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BY ELISHA BARTLETT, M. D., LATE PROFESSOR OF MATERIA MEDICA AND MEDICAL JURISPRUDENCE IN THE COLLEGE OF PHYSICIAN AND SURGEONS OF THE UNIVERSITY OF THE STATE OF NEW YORK, ETC. ETC. Jffliwtjj <8Sbiti0it, $Ufcistb. BY WnJ A. CLARK, M.D., W? PESSOR OF PATHOLOGY AND PRACTICAL MEDICINE IN THE COLLEGE OF PHYSICIANS AND SUIWKOX8 OF THE UNIVERSITY OF THE STATE OF NEW YORK. BLANCHARD AND LEA. 1856. V\JC All diseases, then, ought to be reduced to certain and determinate kinds, with the same exactness as we see it done by botanic writers in their treatises of plants. For there are diseases that come under the same genus, bear the same name, and have some symptoms in common, which, notwith- standing, being of a different nature, require a different treatment.....In writing, therefore, a history of diseases, every philosophical hypothesis, which hath prepossessed the writer in its favor, ought to be totally laid aside, and then the manifest and natural phenomena of diseases, however minute, must be noted with the utmost accuracy, imitating in this the great exactness of painters, who, in their pictures, copy the smallest spots or moles in the originals.—Sydenham. Entered according to the Act of Congress, in the year 1847, by LEA AND BLANCHARD, in the Office of the Clerk of the District Court of the United States in and for the Eastern District of Pennsylvania. PHILADELPHIA: T. K. AND P. O. COLLINS, PRINTERS. TO JOHN ORNE GREEN, M. D., OF LOWELL, MASSACHUSETTS) With whom the early and active part of the writer's life was passed; in a personal friendship which no cloud, for a single moment, ever shadowed or chilled; and in a professional inter- course whose delightful harmony no selfish interest nor personal jealousy ever disturbed; this volume, the best materials for which were gathered during the period thus consecrated by useful labors and social duties, now endeared to us both by many sad and plea- sant memories, is most affectionately inscribed. November 1,1847. PREFACE TO THE FOURTH EDITION. BY THE EDITOR. The distinguished author of this volume had performed his last scientific labor, when his third edition was prepared for the press. Sixteen months ago, he closed his brilliant professional career, after years of growing bodily weakness and pain; his mind not dimmed by his physical infirmities, but bright and comprehensive, glowing with the memories of the past, and the visions of the future. He died too soon for the profession he adorned. The clock had hardly marked twelve-at-noon, on the dial plate of life, when its pendulum strokes grew fain^, and gradually fainter to the ear; and now, at length, when all is still, the hand that notes the hours points sadly upward, to indicate how much of day- time still remained to reap the harvest of affection and honor, in those fields, from which he had already garnered up so many golden sheaves. He died, alas! too soon. The whole profession are his mourners; for conspicuous as he had become by his medi- cal writings, and his extended professional labors; his acknow- ledged worthiness, his innate gentleness and modesty disarmed envy. He left no enemies. His mind and purpose were pure, almost beyond example. His high mental endowments were con- trolled and directed by a considerate judgment and an earnest, benevolent heart; and as the laws of refraction, wrought out into mathematical formulas, enable the lapidary to construct the facets which open the fountains of the many-colored diamond, so for him, cultivation and elegant taste had brought out the varied and winning native lights of his rich intellectual, moral, and social nature. But I need not write his eulogy. His professional influ- ence at least, his opinions, his method, his prudence, his mind live in thousands who have listened to his finished teachings, or have read his thoughtful pages. VI PREFACE TO THE FOURTH EDITION. Dr. Bartlett has written wisely on medical philosophy, but per- haps this book on Fevers is his true "Philosophy of Medical Science." It is the practical application of his own precepts. The question may be fairly raised whether any book in our profession illustrates more clearly the beauties of sound reasoning, and the advantages of vigorous generalization from carefully selected facts. Certainly no author ever brought to his labor a more high-minded purpose of representing the truth, in its simplicity and in its ful- ness, while few have been possessed of higher gifts, to discern, and gracefully to exhibit it. Had I been prepared by previous reading for the duty which the partiality of Dr. Bartlett assigned to me, of preparing this edition for the press, the labor would have been inconsiderable. As it is, I have read extensively, to learn how little that the book contains can be advantageously altered. Scarcely a dozen phrases have been changed, and these chiefly to conform the language to the date of the new issue. Considerable matter has been added, it is true, because new facts have been observed, and new opinions have been expressed, which both add to our knowledge, and suggest new topics for investigation. This I have endeavored to select, and so far as it is original, to write, with the same respect for truth, and desire for usefulness, which influenced the mind of my endeared friend, the accomplished au- thor. These additions will be found enclosed in brackets [—]. A. CLARK. 266 Fourth Avenue, New York. November, 1856. PREFACE TO THE THIRD EDITION. I have very little to say in sending to the press this third edi- tion of my book on fevers, but to express my obligations to the profession of the United States for the very favorable reception which they have given to it. The general literature of fevers has, with one eminent exception, received no very important contribu- tions since the date of the preceding Preface. The exception to which I refer, consists in a series of papers published within the last year or two by Dr. William Jenner, of London. Their leading purpose is to show by careful and rigorous study and comparison the wide and fundamental differences which the author believes to exist between the several forms, as they have generally been re- garded, of continued fever, and especially between the typhoid and the typhus forms. Dr. Jenner's researches have enabled me to add largely to the fulness and completeness of the description of typhus fever; and I have availed myself liberally of his facts and argu- ments in elucidation of the important question of the true relations to each other of the two great forms, or species, of continued fever. I have given no account of the Relapsing Fever of Great Britain, as I do not know that it has ever been met with in the United States. College of Physicians and Surgeons, New York, June 1, 1852. PREFACE TO THE SECOND EDITION. It will be seen by those who have read the first edition of my book on fevers that the present is in some respects rather a new work than a new edition of the former. The History of Typhoid and of Typhus Fever remains much in the same state in the pre- sent as in the first edition, with such additions and developments only as further observation and study have enabled me to make. The History of Periodical, and of Yellow Fever, constituting one- half of the volume, has been added to the present edition; thus rendering the work what it professes to be, a Systematic and Me- thodical Treatise on the Fevers of the United States. November 1, 1847. PREFACE TO THE FIRST EDITION. I have written this book, because 1 thought that I saw a want in medical literature which it might supply. Our science, so far as the great subject of idiopathic fevers is concerned, is passing through a transition period; and many authorities, that were received as standard and classical only a few years ago, are fast becoming obsolete, at least for American readers. This is particu- larly true of the leading English treatises on Fever. Neither the works of Fordyce, Armstrong, Southwood Smith, nor Tweedie, nor the elaborate articles on Fever in the Medical Cyclopedias, Libraries, and Dictionaries, can henceforth be regarded as sufficient or even safe guides for American practitioners; and the remark is applicable to them, not because they are not works of great excel- lence and value, but for other reasons, which will be abundantly vious in the course of the following pages. I may simply say, hdv, that their authors describe principally a fever or form of fever which is rarely met with in this country, and that they do not represent the actual state of our knowledge upon this subject. It must be regarded as especially unfortunate that, until within a few years, the greater part of our information relating to continued fever, has been derived from writers who have treated mostly, and under the same name as that generally used by ourselves, of a dis- ease, or form of disease, differing in many important respects from that which is most common with us, and that in this way so great a degree of confusion has been introduced into our notions of fever. If the radical defect in our literature of continued fever thus indicated had not existed, and if the histories of the disease which have been given to us by Louis, Chomel, and Andral amongst the French, and by Nathan Smith, Dr. James Jackson, Dr. Hale, and some others amongst ourselves, were generally accessible, and gene- X PREFACE. rally read, there would have been no want such as I have alluded to; and, certainly, I should not have added another to the long catalogue of books on fever. A translation, by Dr. Bowditch, of Louis's Researches, was published a few years ago under the auspices of the Massachusetts Medical Society, and has since been in the hands of most of its Fellows. But it is very far from being so generally and thoroughly known as it deserves to be. I may add, that the character of this remarkable work is hardly adapted to the actual wants and tastes of the great majority of our practical men. I may say this, I think, without any risk of giving offence; for no man's admiration of this work can be more unqualified and profound than my own. Constituting as it does one of the few imperishable monuments that have from time to time, and at distant intervals, been raised up along the pathway of our science, it is nevertheless true that, in the present, state of the profession in this country—amidst the daily cares and duties of its active members—there are but few who will devote to this object the time and the labor which are necessary thoroughly to comprehend its principles and to master its accurate and minute details. Chomel's Clinical Lectures, so far as I know, have not been published here; Nathan Smith's Essay, excellent as it is, is still very incomplete; and the Reports of Dr. Jackson and Dr. Hale, besides not professing to treat systematically of the disease, are not generally accessible. These, in brief, are the reasons which have prompted me to undertake the preparation of this treatise. I thought that the wants of medical science, here at least, demanded a history and comparison of the two chief forms of continued fever, as they are now ascertained to exist, fuller and more discriminating than had yet been written; and these wants I have endeavored to supply. My book aims at no other excellence, and no higher merit, than that of being a methodical and compendious summary of the actual state of our knowledge upon two most common and most important diseases. If it has reached this excellence, and if it possesses this merit, I am satisfied. I have only to add in conclusion, that one of my leading pur- poses has been to bring out more clearly and strongly than has hitherto been done our means of diagnosis between the different species or forms of fever, and to ascertain and establish their nosological relations. It cannot be necessary to go into any formal vindication of the importance of this diagnosis. Setting it aside altogether, as a matter of science, it is the first essential condition PREFACE. XI of all sound practice. In the following history it will be noticed that I have spoken of no individual fever excepting the four which are more or less fully described; to wit, Typhoid Fever; Typhus Fever; Periodical Fever, in its three forms of Intermittent, Bilious Remittent, and Congestive; and Yellow Fever. The simple reason of this is, that I do not know anything of any other distinct fever amongst us. There may be such a disease as the Simple Fever of Fordyce, or the Ephemera of many writers. I know that adults, sometimes, in consequence of great or protracted fatigue, and that children still oftener, from inappreciable causes, are attacked with headache, loss of appetite, debility, and general febrile excitement, not referable to any local origin; which symptoms, after rest of from one to two or three days, either with or without medicine, usually subside, leaving the individual in good health. But whether this kind of disorder should be looked upon as a distinct established form of fever, seems to me, to say the least of it, very doubtful. As to an Inflammatory Fever distinct from Typhus or Typhoid Fever, I can only say, with Nathan Smith, and Chomel, that I have no knowledge of any such disease.1 1 Mr. James Moore, Surgeon, says: " Synocha, or pure inflammatory fever is a disease so rare in this country, that many experienced practitioners have doubted its existence." The same writer says that Cullen acknowledged that he never saw the disease. Dr. Thomas Bateman, a sensible and judicious writer, says: " With respect to Synocha, Dr. Cullen's distinguished successor, Dr. James Gregory, asserted that during thirty years' practice, he had never seen a purely inflammatory fever un- connected with acute inflammation of some organ; and my own subsequent ex- perience entirely coincides with that assertion. It cannot be doubted, as Dr. Gregory remarked, that the causus, or ardent fever of the ancients, was the ende- mial bilious remittent of hotter climates, and that no continued fever of this country assumes that character."—J. Succinct Account of the Contagious Fever, etc., p. 25. I may add, further, that the affection described by most of our systematic writers under the name of Infantile Remittent Fever, seems to me to have no existence as a distinct disease. Gastro-intestinal irritation, bilious remittent fever, typhoid fever, and still other diseases are confounded under the foregoing term. September 1, 1842. CONTENTS. PART I. TYPHOID FEVER. CHAPTER I. Preliminary Matters Art. I.—Introductory . Art. II.—Names of the Disease Art. III.—History Art. IV.—Methods of Description CHAPTER II. Symptoms ..... Art. I.—Mode of Access Art. II.—Febrile Symptoms Sec. 1.—Chills Sec. 2.—Heat and State of Skin Sec. 3.—Pulse Art. III.—Thoracic Symptoms . Sec. 1.—Respiration Sec. 2.—Cough Sec. 3.—Physical Signs Art. IV.—Cerebro-spinal, or Nervous Symptoms Sec. 1.—Headache . gec. 2.—Pains in the Back and Limbs Sec. 3.—Mind Sec. 4.—Physiognomy Sec. 5.—Somnolence and Coma Sec. 6.—Vigilance . Sec. 7.—Senses Sec. 8.—Muscles Art. V.—Digestive and Abdominal Symptoms Sec. 1.—Tongue and Mouth Sec. 2.—Appetite and Thirst Sec. 3.—Nausea and Vomiting . ' Sec. 4.—State of Bowels . Sec. 5.—Abdominal Pains . Sec. 6.—Tympanites XIV CONTENTS. Art. VI.—Miscellaneous Symptoms Sec. 1.—Emaciation Sec. 2.—State of the Urine Sec. 3.—Epistaxis . Sec. 4.—Cutaneous Eruptions Sec. 5.—Eschars CHAPTER III. Anatomical Lesions ...... Art. I.—Lesions of the Circulatory Apparatus Sec. 1.—Heart and Aorta .... Sec. 2.—State of the Blood Art. II.—Lesions of the Respiratory Apparatus Sec. 1.—Lungs ..... Sec. 2.—Bronchiae, Epiglottis, &c. . Art. III.—Lesions of the Brain and its Membranes Art. IV.—Lesions of the Digestive and Abdominal Organs Seel.—Pharynx and Oesophagus Sec. 2.—Stomach ..... Sec. 3.—Small Intestines .... Sec. 4.—Large Intestine .... Sec. 5.—Lymphatic Glands Sec. 6.—Spleen ..... Sec. 7.—Liver ..... Sec. 8.—Pancreas ; Salivary Glands ; Urinary Apparatus ; and Sexual Organs .... Art. V.—General Remarks .... Causes CHAPTER IV. Sec. 1—Locality Sec. 2.—Season Sec. 3.—Contagion Sec. 4.—Exemption from Second Attacks Sec. 5.—Epidemic Influences Sec. 6.—Age Sec. 7.—Sex ' Sec. 8.—Race Sec. 9.—Occupation Sec. 10.—Recency of Residence Sec. 11.—Filth, Crowding, &c. Sec. 12.—Exposure ; Excesses, &c. Varieties and Forms CHAPTER V. 112 CONTENTS. XV CHAPTER VI. Duration, March, and Complications Art. I.—Duration Art. II.—March and Complications Art. III.—Peritonitis Art. IV.—Relapses Art. V.—Sequelae page 116 116 117 118 119 120 Mortality and Prognosis CHAPTER VII. 121 Diagnosis CHAPTER VIII. 129 Theory CHAPTER IX. 141 CHAPTER X. Treatment . . . . Art. I.—Dr. Jackson's Method Art. II.—Dr. Nathan Smith's Method Art. III.—Chomel's Method Art. IV.—Louis's Method Art. V.—Bouillaud's Method . Art. VI.—De Larroque's Method 150 151 154 157 162 164 165 166 Definition CHAPTER XL 170 Bibliography CHAPTER XII. 172 PART II. TYPHUS FEVER. CHAPTER I. Preliminary Matters Art. I.—Introductory . Art. II.—Names of the Disease 179 180 181 CHAPTER II. Symptoms Art. I.—Mode of Access 182 182 XVI CONTENTS. Art.* II.—Febrile Symptoms Sec. 1.—Chills Sec. 2.—Heat and State of Skin Sec. 3.—Pulse Art. III.—Thoracic Symptoms . Art. IV.—Cerebro-Spinal, or Nervous, Symptoms Sec. 1.—Headache, Pains in Back and Limbs Sec. 2.—Mind Sec. 3.—Physiognomy Sec. 4.—Senses Sec. 5.—Muscles Art. V.—Digestive and Abdominal Symptoms Sec. 1.—Tongue and Mouth Sec. 2.—Appetite Sec. 3.—Nausea and Vomiting Sec. 4.—State of Bowels Art. VI.—Miscellaneous Symptoms Sec. 1.—Emaciation Sec. 2.—State of the Urine Sec. 3.—Epistaxis . Sec. 4.—Cutaneous Eruptions Sec. 5.—Eschars Sec. 6.—State of the Blood CHAPTER III. Anatomical Lesions .... Art. I.—Lesions of the Thoraeic Organs Sec. 1.—Lungs Sec. 2.—Larynx and Pharynx Sec. 3.—Heart and Blood . Art. II.—Lesions of the Brain . Art. III.—Lesions of the Abdominal Organs Sec. 1.—Stomach Sec. 2.—Intestines . Sec. 3.—Miscellaneous and Secondary Lesions' Sec. 4.—General Remarks . Causes CHAPTER IV. Sec. 1.—Locality Sec. 2.—Season, Weather, &c. Sec. 3.—Contagion . Sec. 4.—Epidemic Influences Sec. 5.—Crowding ; Filth ; Famine, &c. Sec. 6.—Age Sec. 7.—Sex Sec. 8.—Recency of Residence 1 All the paragraphs under the subsection of "Secondary Lesions," are'additions to this editi Til? brackets on p. 222 should have been omitted. CONTENTS. XV11 Varieties and Forms CHAPTER V. page 243 CHAPTER VI. Duration and March . .... 246 Sec. 1.—Duration . .... 246 Sec. 2.—Crisis . 247 Sec. 3.—Sequelse . 251 Sec. 4.—Relapses . CHAPTER VII. 252 Mortality and Prognosis 253 CHAPTER VIII. Diagnosis ........ 260 Sec. 1.—Symptoms ...... 261 Sec. 2.—Lesions ...... 263 Sec. 3.—Causes ...... 263 Sec. 4.—Duration ...... 265 Sec. 5.—Effects of Remedies .... 265 Sec. 6.—Historical ...... 265 CHAPTER IX. Theory 313 Treatment Sec. 1.—Bleeding Sec. 2.—Purgatives Sec. 3.—Affusions a Sec. 4.—Stimulants and Tonics Sec. 5.—Miscellaneous Definition CHAPTER X. 315 ..... 315 . 319 Ablutions .... 319 Tonics .... 320 . 322 CHAPTER XI. 327 CHAPTER XII. Bibliography 329 2 XV111 CONTENTS. PART III. PERIODICAL FEVER. CHAPTER I. Preliminary Matters .... Art. I.—Introductory . Art. II.—Names of the Disease CHAPTER II. Symptoms ...... Art. I.—Mode of Access Art. II.—Febrile Symptoms Sec. 1.—Chills .... Sec. 2.—Remissions or Type Sec. 3.—State of Surface . Sec. 4.—Heart and Pulse . Art. III.—Thoracic Symptoms . Art. IV.—Cerebro-Spinal or Nervous Symptoms Sec. 1.—Headache ; Pains in Back and Limbs Sec. 2.—Mind .... Sec. 3.—Senses and Physiognomy Sec. 4.—Muscular Strength Art. V.—Digestive, and Abdominal Symptoms Sec. 1.—Tongue and Mouth Sec. 2.—Appetite and Thirst Sec. 3.—Nausea and Vomiting Sec. 4.—Epigastrium and Abdomen Sec. 5.—Bowels .... Sec. 6.—Urine .... CHAPTER III. Anatomical Lesions ..... Art. I.—Lesions of the Thoracic Organs Sec. 1.—Lungs .... Sec. 2.—Heart and Blood . Art. II.—Lesions of the Cerebro-Spinal Apparatus Sec. 1.—Brain and its Envelops Art. III.—Lesions of the Abdominal Organs Sec. 1.—Liver .... Sec. 2.—Spleen .... Sec. 3.—Stomach .... Sec. 4.—Intestines .... Art. IV.—General Remarks Sec. 1.—Relation of Lesions to Symptoms . Sec. 2.—Importance, Relative and Absolute CONTENTS. XIX Causes CHAPTER IV. Sec. 1.—Locality Sec. 2.—Season; Temperature ; "Weather Sec. 3.—Age Sec. 4.—Sex Sec. 5.—Race Sec. 6.—Exposure ; Excesses, &c. . Sec. 7.—Malaria PAGE 379 379 382 383 384 384 385 386 CHAPTER V. Varieties and Forms Art. I.—Bilious Remittent Form Art. II.—Congestive Fever Sec. 1.—Names Sec. 2.—Type, and Mode of Attack Sec. 3.—Varieties ; Comatose Sec. 4.—Delirious Variety . Sec. 5.—Algid Variety Sec. 6.—Gastro-Enteric Variety Art. III.—Intermittent Fever . 390 390 391 391 392 393 394 395 397 398 CHAPTER VI. Duration and March Sec. 1.—Duration . Sec. 2.—March Sec. 3.—Critical Days Sec. 4.—Relapses . Sec. 5.—Sequelae Mortality and Prognosis Diagnosis Theory CHAPTER VII. CHAPTER VIII. CHAPTER IX. CHAPTER X. Treatment . Art. I.—Bilious Remittent Fever Sec. 1.—Preliminary Sec. 2.—Bloodletting Sec. 3.—Purgatives Sec. 4.—Cinchona . Sec. 5—Diaphoretics, Refrigerants, &c. 400 400 400 402 403 403 406 413 416 420 420 420 420 421 422 423 XX CONTENTS. Art. II.—Congestive Fever Art. III.—Intermittent Fever . Definition Bibliography CHAPTER XI. CHAPTER XII. PAGE 424 430 434 436 PART IV. YELLOW FEVER, CHAPTER I. Names of the Disease 447 CHAPTER II. Symptoms ....... 448 Art. I.—Mode and Period of Access . 448 Art. II.—Febrile Symptoms . 450 Sec. 1.—Chills .... 450 Sec. 2.—State of Surface ; Sweats . 451 Sec. 3.—Pulse . 452 Art. III.—Digestive and Abdominal Symptoms 454 Sec. 1.—Tongue and Mouth 454 Sec. 2.—Appetite and Thirst 456 Sec. 3.—Nausea and Vomiting 457 Sec. 4.—Bowels ; Abdomen ; Epigastrium 460 Sec. 5.—Urine . 462 Art. IV.—Cerebro-Spinal, or Nervous Symptoms 465 Sec. 1.—Headache and other Local Pains . 465 Sec. 2.—State of Mind 466 Sec. 3.—Physiognomy 467 Sec. 4.—Strength ; Muscles ; Senses 469 Art. V.—Miscellaneous Symptoms 470 Sec. 1.—Color of Skin 470 Sec. 2.—Hemorrhages 472 Sec. 3.—Chest .... 472 CHAPTER III. Anatomical Lesions .... Art. I.—Lesions of Lungs, Heart, and Blood Sec. 1.—Lungs Sec. 2.—Heart Sec. 3.—Blood 474 474 474 476 476 CONTENTS. XXI Art. II.—Lesions of the Cerebro-Spinal Apparatus Art. III.—Lesions of the Abdominal Organs . Sec. 1.—Stomach .... Sec. 2.—-Intestines .... Sec. 3.—Liver .... Sec. 4.—Gail-Bladder and its Contents Sec. 5.—Spleen; Mesenteric Glands; Urinary Org Art. IV.—Miscellaneous Lesions Art. V.—General Remarks Sec. 1.—Relation between Symptoms and Lesions Sec. 2.—Causes of Death . page 479 480 480 485 486 494 496 496 497 497 499 Causes Sec. Sec. Sec. Sec. Sec. Sec. Sec. Sec. 8. Sec. 9. Sec. 10. Sec. 11. Sec. 12. Sec. 13. Sec. 14. Sec. 15. Sec. 16. Sec. 17. Sec. 18. CHAPTER IV. —Locality . . . , —Season .... —Temperature and Weather —Age .... —Sex .... —Race .... —Constitution —Occupation —Acclimation —Exemption from Subsequent Attacks —Epidemic Influences —Sporadic .... —Marsh Miasmata —Decaying Animal and Vegetable Matter —Contagion —Exposure ; Fatigue ; Excesses, &c. —Essential Poison . —Quarantine 501 501 505 506 509 509 511 512 512 513 515 516 517 518 519 521 531 532 533 CHAPTER V. Varieties and Forms Sec. 1.—Season and Locality Sec. 2.—Forms, or Grades . 537 537 538 CHAPTER VI. March and Duration Sec. 1.—March, or Type Sec. 2.—Stages Sec. 3.—Duration . Sec. 4.—Convalescence Sec. 5.—Relapses . Sec. 6.—Sequelae Sec. 7.—Period of Incubation 542 542 545 546 547 548 549 549 XXII CONTENTS. CHAPTER VII. Mortality and Prognosis page 550 CHAPTER VIII. Diagnosis 556 CHAPTER IX. Theory 559 CHAPTER X. Treatment ...... Sec. 1.—Preliminary Sec. '2.—Mercurials See. 3.—Antiphlogistic Method Sec. 4.—Cinchona ; Tonics and Stimulants, and " ment" .... Sec. 5.—Purgatives Sec. 6.—Spanish Method Sec. 7.—Mobile Method ; Dr. Stone's Method Sec. 8.—Prophylactics Sec. 9.—Conclusion . 561 . 561 562 . 564 Abortive Treat 567 568 . 569 569 571 572 CHAPTER XI. Definition 574 CHAPTER XII. Bibliography 576 FEVERS OF THE UNITED STATES. PART FIRST. THE HISTORY, DIAGNOSIS, AND TREATMENT TYPHOID FEVER. )/ PART I. TYPHOID FEVER. CHAPTER I. PRELIMINARY MATTERS. ARTICLE I. INTRODUCTORY. In writing a history of the fevers of the United States, I begin with that of Typhoid Fever, for three reasons. In the first place, my own knowledge of the disease, derived from personal observation, is much more extensive than of the other forms of fever. My attention was early and strongly called to its investigation by the remarkable work of Louis upon the same disease, as it shows itself in Paris. Many years of my professional life have been passed in the midst of a population especially exposed to some of its predisposing causes, and amongst whom it has very constantly, and at times very extensively, prevailed; so that a per- sonal acquaintance with this fever, of twenty years' continuance, has given me sufficient opportunity to become somewhat familiar with its character; more so, at any rate, than with the remaining diseases which I propose to describe. In the second place, there is good reason to think that typhoid fever is more generally and extensively prevalent, in various parts of the world, than the other distinct forms of essential or idiopathic fever. This is a point which requires further and more accurate observation for its settlement; but it is pretty certainly true of the temperate latitudes of Europe and America. The actual extent of its prevalence will be more fully spoken of hereafter. In the third place, typhoid fever has been more minutely, more accurately, more thoroughly studied, than any other distinct form 3 34 TYPHOID FEVER. of essential or idiopathic fever. Although a complex, and in many respects an obscure disease, its diagnosis is, in most cases, easily and positively made out. Its natural history has been very fully investigated, and the results of this investigation faithfully recorded and summed up. Its symptoms, its lesions, its causes, so far as these latter are appreciable, have been very exactly ascertained and settled; and they have been very patiently compared with the symptoms, the lesions, and the causes of other diseases. This more complete knowledge of the disease renders it a very convenient starting-point, and an exceedingly valuable standard of comparison, in our subsequent study of other forms of fever, more or less related to this, but whose history and character have not been so definitively and precisely established. ' These, very briefly, are the simple and obvious considerations which induce me to commence this history with a description of typhoid fever. ARTICLE II. NAMES OF THE DISEASE. I have adopted the term typhoid fever as the name of this disease, simply because it is not particularly objectionable, and because it seems to be coming into general use. It is that which is most commonly given to the disease by the French, although many of their writers have coined other, and, as they think, more appro- priate appellations. Petit and Serres described it, in 1813, under the name of entero-mesenieric fever. This term, as has been observed by Andral, has the advantage of marking the peculiar lesion of the disease, while it is free from the objection of prejudging, by any implication, its nature or character. Bretonneau calls it a dothin- enterite, from the pustular inflammation of the intestine. Cruveil- hier and others have applied to it the name of follicular enteritis. Bouillaud has called it typhoid-entero-mesenteritis. By the Germans it is commonly called abdominal typhus. By some German writers it is called nervous fever, or gastric nervous fever ; by some it is called intestinal ulcerating typhus, or typhous suppuration of the intestines; by others, typhus gangliaris, and so on.1 In New England, it has gene- rally been known under the name of typhus, or typhous fever ; and by many practitioners it still continues to be so designated. Since however, it has been ascertained that the disease differs, in many 1 Edin. Med. and Surg. Journ., vol. xlviii. p. 145. NAMES OF THE DISEASE. 35 important respects, from the typhus of British writers, it has become manifestly necessary to apply to it some other appellation ; and, in conformity to the example of Louis, Gerhard, Jackson, and others, I have chosen that of typhoid fever. It may be well to say a word here in regard to the identity of the continued fever of New England with the typhoid fever of the French pathologists. This identity is very clearly and positively settled. No one familiar with the disease, as it shows itself in Paris, and as it is described by Louis, Chomel, and Andral, and who reads Nathan Smith's description of the typhous fever of New England, can doubt for a moment, so far as the symptomatology is concerned, that such is the case. The identity of the pathological lesions in the fever of the two countries has been more recently established. Dr. E. Hale, Jr., of Boston, published in the Medical Magazine for December, 1833, an account of three dissections of persons, considered by him to have died with this disease. If the diagnosis in these cases could be looked upon as certain and posi- tive, they would constitute, so far as I know, the first published examples of the intestinal lesion of the disease, as it occurs in New England. The diagnosis, however, in all the instances, must be regarded as somewhat doubtful, and the alteration of the intestinal follicles does not seem to have been very clearly or strongly marked. The first authentic and unequivocal cases on record, that I have been able to find, are two, which were published by Dr. Gerhard, in the American Journal of Medical Sciences for February, 1835. In the Medical Magazine for June, 1835, I gave a short account of the entero-mesenteric alterations in five cases of unequivocal ty- phoid fever, which alterations corresponded exactly to those de- scribed by Louis. I have upon my note-book the anatomical history of two similar cases, which occurred during the months of January and February, 1833, but which were never published. Dr. James Jackson, Jr., then a medical student, observed the intestinal lesion in a clear case of the disease as early as October, 1830, al- though the account of the observation was not made public till 1835.1 Dr. Jackson, Jr., after having studied typhoid fever in Paris, aided and guided by the personal instructions of Louis, again saw the disease in Boston; and in two cases, one of which occurred in 1833, and the other in 1834, he found the characteristic lesion of the intestinal follicles and mesenteric glands. An account of 1 Memoir of James Jackson, Jr., p. 222, et seq. 36 TYPHOID FEVER. these observations was published in 1835. Dr. Jackson, Sen., in his Report on Typhoid Fever, communicated to the Massachusetts Medical Society in June, 1838, says, that the alteration of Peyer's glands had been noticed at the Massachusetts General Hospital, previous to 1833, in cases which were carefully examined. Since the period above referred to, more extensive and accurate observa- tions by Dr. J. Jackson, Dr. Hale, Dr. Bigelow, Dr. Bowditch, Dr. J. B. S. Jackson, Dr. Shattuck, Jr., Dr. Holmes, and others of Boston; and by Dr. Gerhard and Dr. Stewardson of Philadelphia, Dr. Swett of New York, and others, have uniformly sustained the correctness of these early conclusions, and demonstrated the entire identity of the typhoid fever of Paris and of the United States. ARTICLE III. HISTORY. By the history of typhoid fever, here, I mean what may be called its literary history—an account of the successive investiga- tions which have led to our actual knowledge of the disease. In order to render this at all full and complete, it would be necessary to go into the history of the entire subject of continued fever, a subject more extensive and more complicated perhaps than any other in the domain of medical science. Neither the design nor the character of my book renders it necessary that I should do this; I shall content myself with touching simply a few of the more salient points of this history. The character of typhoid fever—its symptoms, its lesions, its causes, and so on—was first fully and carefully studied by the physicians of the continent of Europe. The first description of its pathological lesions, at all complete arid satisfactory, was contained in the work of Brost, published in 1804. Some years subsequent to this, Broussais succeeded in establishing his brilliant and power- ful, but transitory dynasty, and under its tyrannous domination, the study of continued fever, on the continent, was cramped and mis- directed instead of being properly guided, favored, and advanced. Everything gave way to the bold effrontery of the dogma that all fevers are dependent upon local inflammations. In looking back now upon the career and achievements of Broussais, it is astonish- ing to see with what meek alacrity our science put on and wore the yoke which he fitted to her neck. The exclusive and hypo- HISTORY. — METHODS OF DESCRIPTION. 37 thetical views of Broussais were controverted ably, and at length successfully, by Andral, Chomel, and other pathologists; but it is to the great work of Louis that we are indebted for the first com- plete and comprehensive description of typhoid fever, a description so complete and so comprehensive that the labors of subsequent observers have hardly added to its materials, or modified its pro- portions to any appreciable extent. Amongst other continental observers, who studied particularly the intestinal lesions of the disease, were Roederer and Wagler, Petit and Serres, and Breton- neau. The original researches of Louis and Chomel were confined to the disease as it shows itself in the adult; within the last few years, the typhoid fever of children has been carefully studied, especially by Barthez and Rilliet, and by Taupin. Dr. Richard Bright has given, amongst his very splendid pathological illus- trations, some excellent specimens of the intestinal ulcerations of this disease. The important and valuable papers of Dr. Jenner, of London, have been referred to in the preface to the third edition of this work. The most important publications upon the subject made in this country are those of Nathan Smith, Dr. James Jack- son, and Dr. E. Hale, of Boston, and Dr. W. W. Gerhard, of Phila- delphia. ARTICLE IV. METHODS OF DESCRIPTION. There are two methods, either of which may be adopted, in the description of a disease. One of these, and that which, with a few exceptions, has been in universal use from the time of Hippocrates to the era of Louis, consists in a general enumeration of the more striking and obvious phenomena of the disease, in their various combinations and progress, constituting a kind of portrait or pic- ture. The other, which has been followed by many writers within the last fifteen years, especially amongst the French, consists not merely in this general enumeration of the phenomena, their com- binations and progress, but in a thorough and careful analysis of these phenomena; in a special and particular study of each indi- vidual element which goes to make up the disease ; and in a strict estimate of the relative value and importance of each and all of these several elements. This analytical process, this "searching operation," is applied in study, as well as in description, not only to the symptoms of a disease, but to a considerable extent, also, to 38 TYPHOID FEVER. its pathology, etiology, and therapeutics. Amongst the best exam- ples of the first method, the physiognomical portraiture of disease, may be mentioned Sydenham's description of measles and St. Vitus's dance, and Dr. Ware's description of delirium tremens. The first, and one of the most perfect examples of the latter, is to be found in Louis's Researches upon Phthisis, published in 1825. Each of these methods has its advantages and its disadvantages, its excellences and its defects. By the first, a more complete and integral picture of the disease is presented at once to the mind than can be done by the second. "We are enabled to see, at a single glance, the form, the outlines, the features, the physiognomy of the disease. But in many very important particulars, this method is inferior to the second. It is merely a picture of disease; like all other pictures, more or less like the original, strongly or feebly colored, according to the peculiar taste or ability of the individual artist. It is necessarily wanting in the scientific accuracy of which the second is susceptible. It is less complete, less perfect. The disadvantages of the latter consist in the absence of that wholeness and unity of impression which are made by the former. The mind, in order to get at the integral and entire picture, must arrange and combine the scattered materials which it has studied separately. As one of the leading purposes of the present work is to point out, as far as our actual knowledge will enable us to do so, the charac- teristic features of each of the four great forms of idiopathic fever; to establish, as far as possible, a clear and positive diagnosis; to ascertain the resemblances and the differences between them; I shall rely almost exclusively upon the last-mentioned method, as the only one capable of leading to these results. 39 CHAPTER II. SYMPTOMS. ARTICLE I. MODE OF ACCESS. There is a good deal of difference in different oases of typhoid fever, so far as the suddenness or violence of the seizure is con- cerned. There is no other acute disease, perhaps, in which the attack is more frequently slow and gradual than in this. In many cases, it is quite impossible for the patient to fix with any accuracy upon the day when his fever commenced. Neither, in many of these same cases, is he able to tell in what his sickness consisted. He can only say that, for several days, he has not enjoyed his accus- tomed degree of health. He may have merely felt a sensation of mental and bodily languor, an indisposition, or an inability to accomplish his usual labor, either of mind or body. He may have had slight and dull pain in the head, or in the back and limbs, with a general feeling of soreness or of fatigue. At the same time he may have experienced some sensations of chilliness, alternating with heat. There may have been, also, diminution or loss of appe- tite, and moderate thirst, with a dry or clammy state of the mouth. The expression of the countenance sometimes becomes listless and dull, the eye loses its animation, and the mind is either indifferent or apprehensive. There may have been moderate diarrhoea, with some pains in the abdomen. This obscure and indefinite condition of ill health may continue for more than a week, occasionally for two or three weeks even, with but slight changes from day to day. Oftentimes there is a slow but steady increase in the severity of these morbid sensations, with a like gradual but regular appearance of other and more characteristic symptoms of the disease—these latter coming out, day by day, one after another, a complete and successive development of the peculiar and strongly marked pheno- mena of the disease. In other cases, after an indefinite continuance 40 TYPHOID FEVER. of this obscure precursory period, there is a sudden supervention of the more violent symptoms. Nathan Smith says: " The disease attacks in such a gradual manner, that we hardly kuow on what day to fix its commencement."1 Dr. James Jackson says : " There is more difficulty, perhaps, in ascertaining the commencement in cases of typhoid fever, than in many other acute diseases."2 In a certain proportion of cases, however, precisely how large I am not able to say, the access of the fever is more violent, and its period much more distinctly marked. Chomel, indeed, says, that most frequently the invasion is sudden, coming on in the midst of perfect health, unexpectedly, and not preceded by any precursory symptoms. Of one hundred and twelve cases, in which this point was exactly observed, the access was sudden in seventy-three; in the others, there were obscure premonitory symptoms.3 Forget thinks the gradual access of the disease is more common than is indicated by these statistics, and this opinion agrees with my own observation. I am sure that, in a large proportion of cases, in private practice, the disease is slow and gradual in its approaches. It will be at once seen that this question can be more readily settled in private than in hospital practice. The mode of attack, in these cases, is various; most frequently, perhaps, by a chill, accompanied by debility and headache, and followed by heat and thirst. In other cases, the mode of attack is different. During a grave epi- demic of typhoid fever, which prevailed in the city of Lowell, in the winter of 1834-5,1 saw two cases, in which the first feelings of ill health, experienced by the patients, so far as could be ascer- tained from them, consisted of severe griping pains in the bowels, accompanied with tenderness on pressure. In these cases, diarrhoea was an early and prominent symptom. In another, and that a fatal case, the patient had been at her usual work during the day, and on getting into bed at night felt lame, this being the first feeling of sickness of which she was conscious. The mode of attack was ascertained in seventeen fatal cases by Dr. Jenner. " In seven of these, the disease began so suddenly that the exact day of its com- mencement could be ascertained; six out of the seven took to their beds respectively on the 1st, 1st, 2d, 3d, 10th, and 16th days; the last two patients, however, were obliged to lie down part of the day from an early period in the disease. No note was taken of the 1 A Practical Essay on Typhus Fever. By Nathan Smith, M. D. 2 Report on the Typhoid Fever. By James Jackson, M. D. 3 Lecjons de Clinique Medicale, Chomel, p. 4. FEBRILE SYMPTOMS. 41 time when the seventh first kept his bed. In the remaining ten of the seventeen cases, the disease began gradually. Of these, four were ailing for a few days, and then became suddenly worse; three of the four took to their beds respectively on about the 7th, 8th, and 11th days of the disease. The other six of the ten, in whom the disease began insidiously, could fix on no particular day as that on which their illness began, but only stated that they became gradually ill from about a given day; of these, four took to bed severally on about the 3d, 7th, 12th, and 17th days of the disease; when the others first kept their bed was uncertain. So that only 28.5 per cent, took to bed before the seventh day."1 [Dr. Flint found that in seventy-three cases of typhoid fever, it was impossible to ascertain the precise period of the attack in more than thirty. A fact which proves, as he says, how gradually and almost im- perceptibly the disease commenced in the greater number of his cases. In four only of these thirty was the invasion in any degree sudden. In seventeen cases, in which he regards his information as exact, the average period between the first symptoms and the time when the patients were obliged to keep their beds, was a little less than four days and a half.2] But, whatever be the mode of attack, whether this be slow, insidious, creeping, and obscure, marked by no obvious and prominent symptoms, or, on the other hand, sudden and violent—in either case, the disease goes on, for a considerable period of time, varying of course according to its severity, and its favorable or fatal termination; during which pro- gress, it is characterized by a greater number and variety of symptoms—in themselves, in their combinations, and their successive appearance, peculiar to this fever—than are to be found in any other form of acute disease. These several symptoms, classified and arranged, I now proceed to describe, as fully and faithfully as the present state of our knowledge will enable me to do. ARTICLE II. FEBRILE SYMPTOMS. Sec. I.— Chills. With but few exceptions, typhoid fever is attended by chills or rigors. These are, generally, not very severe. Dr. Jackson says, that in the Massachusetts General Hospital, rigors 1 Jenner on the Identity or Non-identity of Typhoid and Typhus Fevers, p. 7. 2 [Flint, Resume de Recherches Cliniques sur la Fievre Continue, etc., p. 9.] 42 TYPHOID FEVER. were much less frequent than chills. Nathan Smith observes, merely, that in the commencement there is, generally, some degree of chilliness felt by the patient. Of thirty-three fatal cases, cited by Louis, thirty-one had chills; in one-fourth of which number they were severe, accompanied with trembling. Of forty-five grave cases, recovered, all were marked by chills, excepting three; and of thirty-one mild cases, there were chills in twenty-four. This symptom, in a great majority of instances, is present at the commencement, or very early in the disease. It is one of the most constant attendants upon the formal access of the fever. The chill occurs oftenest in the course of the day, and in a large proportion of cases is repeated more or less frequently during the early period of the disease. It is not less constantly present in cases amongst children, than it is amongst adults. Sec. II.—Heat and State of the Skin. Following the chill or rigor, and in the intervals, when these are repeated, there is almost always increased heat of the skin. This heat varies very much in different respects. In many patients, it is quite moderate in degree, and pretty uniformly diffused over the body. In others, the morbid heat is high and burning, and not unfrequently very unequally dis- tributed. Nathan Smith says: " Sometimes, the head and trunk will be excessively hot, while the extremities are cooler than natural; at others, the extremities will be preternaturally hot, when the body is but moderately so. One cheek will often appear of a deep red color and be very hot, while the other remains pale and cool; as its color and heat subside, they seem to cross over and affect the opposite cheek in the same manner. This color and heat usually extend so far as to include the ear of the affected side." Dr. Jen- ner says: "The natural hue of the face—i. e., of the skin of the whole face—was unchanged, excepting in three cases, in which it had a very slightly marked dusky appearance. There was no flush in three, and no note made of its presence in eight cases. In twelve of the twenty-three cases the face was flushed; in eleven of the twelve the flush was pink, and limited to one or both cheeks; it varied in intensity, disappeared, and returned occasionally, in the same day. " This limitation of the flush to the cheeks was not peculiar to anyone period of the disease; it was well marked in one case when admitted on the eighth day of the disease, and continued so till the twenty-third day, the patient dying on the twenty-fifth. In SYMPTOMS.—HEAT AND STATE OF SKIN. 43 another, admitted on the fifth day, there was a circumscribed flush on the cheeks, on the seventh day, which continued with little change till the fifteenth day, the patient dying on the seventeenth day. " This flush, when conjoined, as it sometimes was, with extreme emaciation, sunken eyes, large pupils, quick breathing, sharp and somewhat anxious manner, forcibly recalled to the mind cases, not of typhus fever, but of phthisis."1 [Huss ascertained the tempera- ture at the epigastrium in 250 cases of typhus and typhoid fever. The maximum in these cases was 104° Fahr. in 13.6 per cent.— 102° in 32.8 per cent—100.4° in 31.8 per cent.—98.6° in 12.4 per cent.—and 96.8° in 9.6. The proportion of these cases to be con- sidered typhoid fever can only be inferred from the statement, that 51' had the petechial eruption, and 141 the lenticular or typhoid eruption.2] In the latter stage of grave and fatal cases, the inten- sity of the morbid heat frequently diminishes; and in mild cases, it is not often very high, even in their early periods. This morbid heat, as one of the elements of the exacerbations, or fever fits, is subject to certain variations in the course of each day. In grave cases, these are of very constant daily occurrence. Sometimes they are irregular in their appearance, coming on at different and uncertain times of the day, although more commonly there are two each day. In the early period of the disease, the most strongly marked exacerbation is usually in the afternoon. During these fever fits, there is increased redness of the cheeks, acceleration of the pulse, and a general aggravation of the severity of all the uncomfortable and painful sensations. Dr. Jackson re- marks, that these exacerbations are much more common in some years than in others.3 The state of the skin, in regard to dryness and moisture, is quite different in different patients. In a small proportion of severe cases, the skin is almost constantly dry, during the whole course of the fever. In others, there is more or less moisture. Sometimes the sweats are limited to a short period following the evening exa- cerbation, or they break out in the night, during sleep. Not un- frequently they are profuse, sometimes confined to certain portions of the body, at others extending over the whole surface. Chomel says that they often exhibit a strong acid odor. Louis observes, 1 Jenner, &c, p. 20. 2 [Stat, et Trait, du Typhus et de la Fievre Typho'ide, p. 89.] 3 Report, &c, p. 135. 44 TYPHOID FEVER. that the sweats are in no degree proportionate to the morbid heat, and that not unfrequently they are prolonged during convalescence, preventing the re-establishment of the strength, and resisting the influence of aromatics and bitters. Nathan Smith speaks of "what has been called the washer-woman1 s sweat, which is extremely profuse over the whole surface of the body and extremities; standing in large drops on the face, and giving to the cuticle, on the palms of the hands and soles of the feet, a corrugated appearance and a light color, as if it had been long macerated in water. In such cases, the perspiration is warm, till a short time before the patient expires." He never saw an instance of recovery after this kind of sweating. [In Dr. Flint's cases of typhoid fever sweating more or less abund- ant occurred, unconnected with favorable crisis, or the agony, in twenty-eight out of fifty-one. In fifteen it occurred more than once —in five twice, in one three times, and in the other nine several times. A moisture less than is usually denominated a sweat was observed in twenty-seven of the fifty-one.] Dr. Smith says, also: "There is a remarkable odor arising from a person affected by this disease, so peculiar that I feel assured that upon entering a room, blindfolded, where a person has been confined for some length of time, I should be able to distinguish it from all other febrile affections." My own experience, in this matter, coin- cides with that of Dr. Smith. This odor, which is not pungent and ammoniacal, like that which is said to arise from the bodies of patients with the grave forms of the British typhus, but of a semi- cadaverous and musty character, I have frequently noticed, espe- cially during the late stages of severe and fatal cases. After recovery, when the case has been one of considerable seve- rity, the cuticle often peels off, in large flakes, from the palms of the hands and the soles of the feet; the hair, also, frequently falls off from the head, and is succeeded by a new growth.1 Sec. III.—Pulse. The circulation is nearly always accelerated; and, in many cases, otherwise modified. The frequency of the pulse during the whole course of the disease, may be said to range between 70 and 140 in the minute. As a general rule, the frequency of the pulse is in proportion to the severity and danger of the dis- ease. The pulse is considerably more frequent in female, than in male patients. Dr. Jackson's Report contains some interesting results in regard to this subject. He found that, in the cases which 1 Nathan Smith. On Typhus Fever. SYMPTOMS. — PULSE. — RESPIRATION. 45 terminated favorably, the average, least frequent pulse was 74.16, and the average, most frequent pulse, 102.68; while in the cases which terminated fatally, the average, least frequent pulse was 91.88, and the average, most frequent pulse was 129.29. Amongst the fatal cases, in the males, the average, least frequent pulse was 85.50, the average, most frequent pulse, 124.29; while amongst the fatal cases, in the females, the average, least frequent pulse was 106.64; and the average, most frequent pulse, 138.58. With the establishment of convalescence, the pulse, generally, though not always, approaches its healthy standard of frequency. [Dr. Flint found that the mean frequency of the pulse, observed once or twice a day throughout the disease, was in those that recovered, 93; in the fatal cases, 110. He has never noticed the maximum frequency in any case of typhoid fever to reach 143, a point at which it was twice marked in the typhus. He regards a sudden acceleration of the pulse as an indi- cation of some serious complication like pneumonia or perforation of the intestines, &c. Dr. Flint has known cases in which the pulse was less frequent than in health. In one instance seen by the Edi- tor, the pulse fell to 44, soon after the disease commenced, and did not rise above 55, till convalescence. It was a mild case, though characterized by the typhoid eruption.] The other variations in the character of the pulse are not suscep- tible of such definite statement, as those of its frequency, but they are still, in many cases, very obvious. Sometimes, especially in mild cases, where the circulation is only moderately accelerated, the pulse preserves its natural softness and volume. This is never the case where it is very frequent. The pulse is then sometimes sharp and jerky, generally small, and pretty easily compressed, and not unfrequently, undulating, or bis-feriens. Distinct intermissions and irregularity of the pulse are not very common, although they occur in a moderate proportion of very grave and fatal cases. Louis thinks that this modification of the pulse is generally connected with a secondary affection of the heart. ARTICLE III. THORACIC SYMPTOMS. Sec. I.—Respiration. Modifications in the character of the res- piration are not often mentioned amongst the phenomena of typhoid fever; but they are of pretty frequent occurrence, and some of 46 TYPHOID FEVER. them are deserving of particular notice. The most common altera- tion of the breathing consists simply in the usual acceleration, which accompanies febrile excitement. Under certain circumstances, how- ever, there is a more marked and peculiar change in the character of the breathing. In high grades of the disease, and. particularly in its later stages, accompanied invariably or nearly so by delirium or stupor, the respiration becomes irregular, noisy, and hissing. Nathan Smith speaks particularly of this peculiarity of the breath- ing. He says: "After the patient has been some time sick, if the disease proves severe, there is a peculiar whistling sound produced wheu he breathes through the nose; and when asleep, or lying in a state of coma, the mouth is generally kept open, and the breath- ing has somewhat of a stertorous sound." I do not think that this irregular, noisy, sibilant respiration depends, in any degree, upon disease of the lungs. It is manifestly connected with and depend- ent upon a morbid condition of the brain. [Dr. Flint calls attention to a kind of breathing which is characterized by a short and precipi- tate, or spasmodic inspiration, not dependent on any appreciable dis- ease of the lungs or air-passages. He regards it as a forerunner of coma. He noticed it in sixteen of his patients, in eight of whom the fever was of the typhoid type. Of these sixteen cases, eight died comatose in twelve hours to four days from the appearance of this symptom; and in some of the others a fatal termination seemed to have been averted by prompt vesication to the back of the neck.1] Positive dyspnoea is not very common. It occurs where there is extensive secondary disease of the lungs, and sometimes it is occasioned by excessive tympanitic distension of the abdominal parietes. Sec. II.— Cough. Typhoid fever, in a large majority of cases, is attended by cough. This is generally slight, and hardly attracts the attention of the physician or the patient. According to Louis, it most commonly commences between the fifth and the fifteenth days of the disease. The sputa are usually small in quantity, some- times tenacious and colorless, sometimes bloody, simply from an admixture with blood from the nares, and sometimes rusty from a complication of pneumonitis. [Huss states that a mild catarrh ex- isted in almost all his two hundred and fifty cases of typhus and typhoid fever, and that it was severe in forty-five. Pneumonia 1 [Resume, &c, p. 24.] SYMPTOMS. — PHYSICAL SIGNS. — HEADACHE. 47 occurred in eleven only. Dr. Flint found cough usually moderate in thirty-two of fifty-nine cases of typhoid fever, and thinks it may have escaped notice in some of the others. Pneumonia occurred twelve times in seventy three cases of the same disease.] Sec. III.—Physical Signs. The most constant and characteristic of the physical signs, connected with the thoracic organs, consists in a dry, sonorous, or sibilant rhonchus. This, in many cases, is very loud, and heard universally over the chest; its extent and severity altogether disproportionate to the dyspnoea. Louis was the first, I think, who noticed, particularly, this sign in typhoid fever. It appears early in the disease. Late in the fever, especially near the close of cases about to terminate fatally, there is often a circumscribed crepitous rhonchus, with other physical signs of local, secondary pneumonitis. Occasionally, instead of the dry, sonorous or sibilant, there is a humid or mucous rhonchus. In many of the grave and fatal cases, there is some dulness on percussion over the most dependent portion of the chest. ARTICLE IV. CEREBRO-SPINAL, OR NERVOUS SYMPTOMS. Having completed the detail of symptoms, to which the term febrile is more particularly applied, and which, with certain modifi- cations and peculiarities, are common to all essential fevers, to all acute inflammatory diseases of considerable extent or severity, and to very many chronic organic alterations, I now proceed to the description of another very extensive group of phenomena, consist- ing in disturbances of the functions of the nervous apparatus. These disturbances occupy a very important place in the natural history of typhoid fever, and serve, in a very considerable degree, to distinguish it from nearly all other forms of disease. Sec I.—Headache. Pain in the head is amongst the most con- stant symptoms of the disease. It is, indeed, very rarely absent. Louis says, that of eighty-seven cases, in which the patients re- covered, there was headache in all but three. It is as common an accompaniment of mild as it is of severe cases. This pain is amongst the earliest symptoms. In many cases, it is the first thing which arrests the attention of the patient, and 48 TYPHOID FEVER. marks the formal access of the fever. Chomel says, that this occurs most frequently on rising in the morning. Sometimes it comes on after the third or fourth day. Its duration is various; but, very generally, after a longer or shorter period, it gradually diminishes in severity and finally disappears. In severe cases which recovered, Louis found its most common duration to be from eight to ten days. The character and degree of this pain are various. Most fre- quently, it is dull, heavy, or throbbing, not occupying very much the attention of the patient. In a few cases, it is intense and acute, occasioning great distress. It is generally continuous, although its severity may be increased during the febrile exacerbations. It is less severe in mild, than in grave cases. Now and then, it is the most prominent and importunate symptom during the whole course of the disease. It occupies, most frequently, perhaps, the forehead and temples, but it often extends over the whole head. It is not unfrequently accompanied with some soreness and stiffness of the eyeballs, felt on pressure and on motion. This symptom is generally present in children. Taupin says that the pain is almost always confined to the frontal region. It is heavy, and not very acute. Sec II.—Pains in the Bach and Limbs. In many cases, the head- ache is attended with pains in the back and limbs. These pains, I think, are more constant and distressing in the legs than in the arms. . They go off with the headache, and frequently, indeed, before the disappearance of the latter. Sec III.—State of the Mind. I have already remarked, in speak- ing of the mode of access of typhoid fever, that one of the earliest and most constant phenomena consists in mental languor or ina- bility. The patient is sometimes impatient and irritable, but more frequently listless and indifferent, or perhaps timid and apprehen- sive of the danger of the approaching disease. He finds it diffi- cult to fix his attention, or to pursue his accustomed train of thought. He is forgetful, and does not measure the lapse of time with his usual readiness and accuracy. This condition of the mind in cases of moderate severity, may continue through the entire course of the fever, up to the period of convalescence. In graver and fatal cases, it is generally lost either in delirium or stupor Delirium is a common symptom of typhoid fever. Its frequency SYMPTOMS. — STATE OF THE MIND. 49 and degree are in pretty direct proportion to the severity and danger of the disease. Of forty-six fatal cases, cited by Louis, there was delirium in thirty-eight. In two of these, the delirium was of short duration; and in two others, it was present only during the last two or three days of life. But it should also be remarked, that seven of these cases were fatal from perforation of the intes- tine; and that .this accident most frequently occurs in cases of moderate severity. I have seen the disease, in its worst form, ter- minating fatally in the course of the second week, without any delirium, but this is certainly not a common occurrence. Of Louis's fifty-six grave cases, terminating favorably, thirty-nine were marked by delirium; while of thirty-one mild cases, there was delirium in only three; and even in these few, it was mild in its character and of short duration. In a small number of cases, this symptom is present at the com- mencement, or very early in the disease. Generally, however, it comes on in the course of the first or second week of the fever. As a general rule, it appears early in proportion to the gravity and to the rapid progress of the disease. Its march and duration are various. In fatal cases, it rarely disappears, after its occurrence, till it is lost either in coma or death. In grave cases, which recover, it goes off with the approach or commencement of convalescence, its subsidence or diminution constituting one of the earliest and surest signs of this desirable event. In many cases, especially of a mild or moderate character, and for the first few days after its appearance, even in severe cases, it is present only during the night, or in the febrile paroxysm, or, perhaps, for a transient period imme- diately after waking. Under such circumstances, the patient can be called back from his incoherent wandering, and, by exciting and holding the attention, his mind kept steady and clear. As soon, however, as this external excitement is withdrawn, the mind at once lapses into its disturbed and irregular action. The delirium is generally of the kind to which the terms low and muttering have been applied. In many cases, however, and espe- cially in such as are rapid in their march, and of great severity, the delirium is attended with wild and violent agitation. Some- times, the patient is in constant and restless motion in his bed, picking at his bedclothes, or pulling them about, and frequently drawing them tightly over his head. Sometimes, he rises suddenlj- from his bed, when, if not restrained, he will sit upon its side, or wander, aimless and incoherent, for a few moments, about the room. 4 50 TYPHOID FEVER. In these cases, the agitation is so violent, that it requires the con- stant presence of attendants, and occasionally no slight degree of force, to keep the patient in his bed. This violent delirium is often attended, also, with cries and screams, particularly during the night. Of Dr. Jenner's twenty-three fatal cases, " there was no delirium in three, but in one of the three there was considerable mental confusion. Delirium was present in twenty cases; in ten of the. twenty, it began severally on the third, sixth, sixth, tenth, fourteenth, fifteenth, twenty- third, twenty-sixth, twenty-eighth, and twenty-ninth days; seven were delirious, when first seen, between the thirteenth and twenty-first days inclusive; in the remaining three of the twenty cases, it was uncertain at what date of the disease the delirium set in. The delirium continued till death in nine cases; in eight of these, the fatal termination occurred on the twelfth, seventeenth, seventeenth, twenty-first, twenty-fifth, twenty-seventh, thirtieth, and thirtieth day of the disease; in one of the nine, the duration of the disease at the time of the patient's death was unknown. In one case, which proved fatal on the twenty-third day, there was no delirium after the twenty-first day, from which time till her death the patient lay in a state of profound stupor. The delirium usually first showed itself at night, the patients sleeping during part of the day. It varied much in amount, sometimes being so violent that patients left their beds, and even ran screaming through the wards; at others, showing itself by slight delusions, only discovered to exist by acci- dent, or again by almost constant chattering. Ten of eighteen pa- tients, i. e. more than one-half, or in the proportion of 55.5 per cent. of those who were delirious after they entered the hospital, and of whom notes on the point were made, left their beds to wander about the ward."1 [Dr. Flint reports that in sixty-four cases delirium was present in forty-seven and absent in seventeen. In the fatal cases this symptom was almost constant, when the death was not caused by perforation or some secondary accident. Among the cases of typhoid fever there was no exception to this rule, and among the typhus cases only one. Those cases of the former affection in which the delirium was violent and persistent had a fatal issue. In two such cases a post-mortem examination of the head revealed no trace of inflammation and little of congestion. Huss regards men as more subject to delirium in both typhoid and typhus fever than women. In the two affections studied together men were delirious in the proportion of 44 per cent., the women at the rate of 33.8 per cent] 1 Jenner, &c, p. 22. SYMPTOMS. — STATE OF THE MIND.—PHYSIOGNOMY. 51 Distinctly monomaniacal delirium is very rare, although it is seen occasionally, after the active period of the disease has gone by. Louis alludes to some cases, where, in the midst of the most danger- ous symptoms, the patients declared that they were very well. He says that he has never known a patient, under such circumstances, to recover. The restoration of the healthy action of the mind, on recovery, is more or less gradual, but nearly always complete. Nathan Smith says, that in some instances it appeared to him that the moral principle was affected after recovery. He speaks parti- cularly of a young man, who, after recovery from a grave form of the disease, had a strong propensity to steal. After repeated thefts, some of them from a young man to whom he was under great ob- ligations, and who had nursed him during his sickness, he was detected and punished. His character before his illness had been good. Dr. Smith says, also, that, after recovery, the whole time that has elapsed, and all the events that have taken place during the fever, are entirely blotted out from the memory, and are never after recovered. This may be true to a certain extent, but not without many exceptions and qualifications. Louis says, in his second edition, that, since the publication of his Researches, he has seen three hundred cases of typhoid fever, and that in only one was there any morbid condition of the mind remaining after the estab- lishment of convalescence. Dr. Jenner says: " A remarkable fatuity remains in some cases, long after recovery; and, in the majority of cases, I think there is some diminution of intellectual power for some little while after convalescence is established. I have seen many cases in which a childishness of mind remained for more than a month after, in other respects, restoration to health." According to Rilliet, delirium rarely shows itself in children before the fif- teenth day of the disease. Sec IV.—Physiognomy. The expression of the countenance is strongly marked and peculiar. Very generally, even in cases of moderate severity, it is dull, listless, and vacant. The eye is heavy and languid. The indifference sluggishness, and apathy of the mind are strongly painted on the face. If there is much suffering, either from pain, or, as more commonly happens, from the indefi- nite and indescribable restlessness of fever, the usual heavy and stupid expression of the countenance is mixed with or supplanted by one of sadness, anxiety, and distress. In many very mild cases 52 TYPHOID FEVER. there can hardly be said to be any other change in the look, than a notable diminution of its animation and quickness. Sec V.—Somnolence [and Coma']. In most cases, preceding the delirium, and often alternating with it after its appearance, there is more or less drowsiness or stupor. This symptom makes its ap- pearance early in proportion to the intensity and to the rapid march of the disease. Louis found it present in nine-tenths of his fatal cases. When the fever was of a mild character, he noticed it in a little more than half the cases, and in these, it was later in its ac- cess, slight in degree, and brief in its continuance. In fatal cases, it generally persists and increases, after its first appearance, unless when interrupted by violent delirium, until it ends in complete coma, or is lost in death. Where the fever terminates favorably, it gradually subsides, and, like the delirium, finally disappears with convalescence. Dr. Jackson found that, in the Massachusetts General Hospital it occurred in one case in 3.81, amongst those which terminated fatally, and in one case in 7.25 only, amongst those which termi- nated favorably. [Coma was observed by Dr. Flint in five cases (6.85 per cent.) of typhoid fever, and in four (6.15 per cent.) of ty- phus. Four others were nearly comatose. Of the nine who were comatose eight died. Dr. Flint remarks that the pseudo-somnolence called coma-vigil, did not predispose to the true coma. This latter was generally developed pretty rapidly, and was preceded or accom- panied by the change in the respiration noticed in Art. III. Sec. I.] Sec VI.— Vigilance. There is an opposite condition, that^of prolonged and obstinate watchfulness, which is common in typhoid fever. This distressing symptom, interrupted perhaps occasionally by a transient, disturbed, and unrefreshing slumber, is more com- mon in the early than in the late periods of the disease, and is much more frequently present in grave than in mild cases. It is often associated with restlessness or delirium. Sec VII.—State of the Senses. Amongst the alterations in the functions of the senses, the most common are dizziness, ringing in the ears, and dulness of hearing. The first of these is often felt amongst the precursory symptoms, before the patient has taken to his bed and it occurs subsequently, especially on his attempting to assume an upright position. Ringing or buzzing sounds in the ears are SYMPTOMS. — STATE OF THE SENSES. — MUSCLES. 53 present, mostly in the early or middle period of the disease, in a majority of severe cases. In mild cases, they also occur, but less frequently. Dulness of hearing was noticed by Louis in two-thirds of his fatal cases, and, in thirty-three of forty-five grave cases, ter- minating in recovery. It is somewhat less common where the fever is moderate. It appears earlier than the tinnitus aurium, and is not unfrequently followed by this latter sensation. Nathan Smith says, in his description of the disease: "The hearing is often impaired, almost from the commencement of the attack. Sometimes false hearing occurs, and the patient imagines he perceives voices and sounds when nothing of the kind exists." The eyes and their functions are more rarely affected. If there is active febrile excitement, there is often increased sensibility to light, mostly in the early stage of the disease. Active injection of the conjunctivas is not often seen. Imperfect and perverted vision occurs occasionally, but it is not common. Like the dizziness and ringing in the ears, this not un- frequently comes on, temporarily, when the patient sits up in his bed. The sense of taste, as might be expected from the state of the tongue, and the loss of appetite, is either dull or perverted. Chomel speaks of patients who chewed, without repugnance, pills composed of medicinal substances, which were very disagreeable during health. The general cutaneous sensibility is not often affected, to any considerable extent. The feeling of soreness, occurring in the access of the disease, which has already been mentioned, appears to have its seat rather in the muscles than in the skin. Sec VIII.—State of the Muscles. Irregular spasmodic contrac- tions, or permanent rigidity of certain muscles, occur in a moderate proportion of cases of typhoid fever. The most common are those of the fingers and wrist, to which the term subsultus tendinum has been applied. Sometimes they affect the muscles of the face, or that of the diaphragm, occasioning hiccough. Wherever they are seated, they are generally present in the late stages, and near the close of the disease. They are much more common in grave and fatal cases than in those of an opposite character. Louis found them present, in some form, either that of spasms or permanent rigidity, in one-third of his fatal cases; while, of fifty-seven cases, somewhat severe, but terminating in recovery, there were spasms in only six. Of Dr. Jackson's cases, subsultus tendinum was noticed 54 TYPHOID FEVER. in one of 3.66, which were fatal, and in one of 10.03, which recovered. Permanent contraction of the muscles, generally of those of the arm, is almost invariably confined to cases which are about to end fatally. Dr. Jackson and Chomel report each one instance of this kind, which terminated favorably. Subsultus tendinum seems to be less frequent in children than in adults.1 One of the most constant and characteristic phenomena of typhoid fever consists in prostration of the muscular strength. In very many cases, this is extreme, even in the early periods of the disease. A great majority of patients take to their beds early in the disease, and remain there almost constantly until the commencement of convalescence. They will suffer themselves to be placed passively in a chair, in order that their beds may be made up and aired, but they are impatient and anxious to be re- turned as quickly as possible. When this prostration is extreme, unless there are great restlessness and distress, or delirium, the patient lies continually in the same position, on his back, entirely passive, with hardly sufficient strength to move his limbs. It is necessary for his attendants to raise him up in bed, and to hold to his lips the cup when he drinks. Conversation, addressed to him, is irksome and fatiguing, and he answers questions with reluctance, and with a painful effort of his exhausted strength. Forget mentions, in very grave adynamic cases, a common position of the patient; his arms extended upon the chest and abdomen, and the hands rest- ing upon the genital organs. Of nineteen fatal cases observed by Dr. Jenner, " two were able to leave their beds unassisted, and with facility, throughout the whole course of the disease. One of the patients died on the twenty-fifth day of the disease, and the other five weeks after her admission. Two were able to leave their beds with tolerable facility respectively up to the fifteenth and twenty-fourth day of the disease, but the former on the sixteenth and the latter on the twenty-sixth day, were unable, without assistance, to reach the close stool placed immediately adjoining the bed. Five patients could, though with great difficulty, get out of bed unassisted, from the thirteenth to the thirtieth day, while ten were quite unable from the fifth to the twenty-sixth day; there was extreme pros- tration in eight cases from the fourteenth to the thirtieth day."2 I have already remarked, that this feeling of debility is early in 1 Barthez and Rilliet. 2 Jenner, &c, p. 26. SYMPTOMS. — MUSCLES. — TONGUE AND MOUTH. 55 its appearance. Chomel says, that patients, in reply to the question put to them at the first visit, how they came to the Hotel Dieu, always answered, " In a carriage, or supported by two friends, for we were not strong enough to come alone on foot." In nearly all the fatal and grave cases, it is very strongly marked; in mild cases, it is still present, but in a more moderate degree. Occasional exceptions are met with. Louis mentions instances, in which the patients kept about for a week, and even a fortnight, some of them continuing their accustomed occupations. Some of these were fatal cases. I have seen one striking instance of this character. The patient did not confine herself to the bed until the occurrence of intestinal perforation. This debility, when it is once present, rarely disappears or diminishes until the close of the disease. A slight increase of muscular strength, shown by turning for a short time upon the side, or by a disposition to sit a little longer than is necessary in the chair, is one of the first and most cheering indications of returning health. ARTICLE V. DIGESTIVE AND ABDOMINAL SYMPTOMS. I now come to the consideration of a group of morbid phe- nomena, not less extensive, various, and important, than those connected with the nervous apparatus. I allude to the symptoms consisting in disturbances of the entire complex function of diges- tion. These symptoms are more characteristic, indeed, of typhoid fever, than those which have just been described. We rely upon them, as one of our surest means of distinguishing between cases of this disease, and those of the analogous form of fever, which will next be described under the name of typhus. For this reason, especially, as well as in accordance with the general plan and object of this history, I shall treat of them particularly, and in detail. Sec I.—Tongue and Mouth. In a certain proportion of cases, the tongue is but slightly altered in its appearance, and this is true of the disease in all its grades of severity. Even in fatal cases, if they terminate early, that is, during the course of the second week, it not unfrequently happens that the tongue is merely covered with a light fur, and is not quite as moist as it is in health. When 56 TYPHOID FEVER. the disease is very mild, the tongue is often almost natural in its appearance, or covered only with a light, yellowish coat. At other times, under the same circumstances, it is smooth, moderately red, and moist with a tenacious, adhesive matter. This glutinous exu- dation is, indeed, very common, in all forms of the disease, the severe as well as the moderate. Besides this, there are other changes, which are found in a majority of cases, especially in those which are grave and protracted. Sometimes the tongue, having been covered with a light, or yellowish, moist coating, for a few days, gradually becomes dry and brown in a stripe along its middle, and red at its tip and along its edges. In other cases, or later in these, it becomes dark over its whole surface; sometimes nearly black, glazed, stiff, and crossed by cracks and fissures. Sometimes this dark, dry crust peels off in flakes or patches, leaving the mucous membrane naked, red, and shining. This process of coating and denuding may be repeated several times in the course of a severe and protracted case. In a small number of instances there is a whitish, aphthous exudation upon the tongue, and also upon other portions of the mucous membrane of the mouth, like that which is often seen in the last stages of phthisis pulmonalis, and some other chronic diseases. It is generally found where the tongue is morbidly red, and only at a late period of the fever, when there is great debility. In these cases, as well as in others, where there is a morbid redness, the tongue is not unfrequently swollen, painful and tender. Now and then, it is the seat of ulcera- tion. The cracked, brown, and blackish tongue is not so common amongst children as it is in adults.1 The patient often finds a good deal of difficulty in protruding the tongue, particularly when it is dry, stiff, and fissured, or covered with the tenacious secretion. Under these circumstances, even if the mind is sufficiently clear, and the will active, the tip and sides stick to the lips, and it is only after repeated efforts that it is finally put out. Not unfrequently, it is protruded with a tremulous motion. The dryness and redness of the mucous membrane often extend to the different portions covering the posterior fauces, giving rise to more or less difficulty of swallowing, and to other disagreeable or painful sensations. The lips are also often cracked and covered with dry crusts, and the teeth, especially near the gums are lined 1 Barthez and Rilliet. SYMPTOMS. — THIRST.— VOxMITING.— BOWELS. 57 with a dark, tenacious sordes. The secretion of saliva is commonly scanty, and its quality changed. Sec II.—Appetite and Thirst. The desire for food is almost inva- riably absent, from the beginning to the end of the disease. The very idea of eating is offensive. A return of the appetite is amongst the earliest indications of recovery. The thirst is, in most cases, proportionate to the degree of febrile excitement. Sometimes, especially during the paroxysm of fever, it is urgent. Cool drinks are commonly preferred, but not always. Sec III.—Nausea and Vomiting. A majority of patients with typhoid fever suffer more or less with gastric symptoms. The most frequent of these are nausea, vomiting, and epigastric distress. Of twenty-four fatal cases mentioned by Louis, there was nausea in thirteen, occurring at various periods of the fever, and continuing for an uncertain length of time. Of twenty-three fatal cases, vomit- ing was present in twelve. Nausea not unfrequently occurs at or near the commencement of the disease; but vomiting takes place more frequently at a later period, especially when the matter ejected is of a greenish color and bitter taste, and when there is also pre- sent epigastric pain or distress. This combination of symptoms was first particularly noticed by Louis, and, as I shall have occasion to say hereafter, was shown by him to be associated with a peculiar lesion of the stomach. Vomiting, at or near the commencement of the disease, is more frequent in cases of children than in those of adults. Pain or distress in the region of the stomach, varying consider- ably in character and severity, is still more common than either nausea or vomiting. Finally, there are many instances, in which patients go through the fever without the occurrence of any one of these strictly gastric symptoms. In regard to this point, Nathan Smith says: "Sometimes, nausea and vomiting take place. Some- times the matter thrown up consists wholly of vitiated mucus; at others, it is mixed with bile of an unhealthy color and consist- ence."1 Sec IV.—State of the Bowels. Amongst the most frequent, and, when taken in connection with other phenomena, amongst the most 1 Smith's Medical and Surgical Memoirs, p. 64. 58 TYPHOID FEVER. characteristic symptoms of typhoid fever, is diarrhoea. This symp- tom varies very much in different cases, in regard to the period of its commencement, its degree, its duration, and so on. As a general rule, it is most common and severe in long continued and grave cases, and least so in those of an opposite character. It was present in all but three of Louis's fatal cases. When the disease is mild, it is frequently wholly absent. It varies in severity, from one or two discharges to twenty or more, in the course of twenty-four hours. It commences at different periods of the fever. Of forty fatal cases, cited by Louis, in which this point was precisely ascertained, diar- rhoea was present on the first day of the disease in twenty-two. In others, it begun from the third to the fourteenth day.1 In mild cases, it is frequently wanting, and,' when present, commonly makes its appearance later in the disease, is less urgent, and of shorter continuance. It is commonly a protracted symptom in severe cases, its average duration, according to Louis, being nearly four weeks. Nathan Smith says: " The latter stage of all severe cases is attended with diarrhoea." [Dr. Flint notes the occurrence of diarrhoea in forty-eight out of seventy-three cases of typhoid fever. The pro- portion of cases affected in this way, varied in different years: thus he reported in 1850, twenty-one in thirty; 1851, fourteen in twenty- nine; 1852, thirteen in fourteen.] In fatal and grave cases, late in the disease, the discharges are often involuntary, and wholly with- out the consciousness of the patient. The stools are generally liquid, somewhat turbid, and of a yel- lowish color, in appearance not unlike new cider. In a consider- able number of cases, they are of a dark brown color. Their smell is fetid and offensive. Occasionally, they contain portions of blood, and sometimes free and repeated hemorrhage takes place from the bowels. According to Dr. Jackson, this discharge occurred, in the Massachusetts General Hospital, in about one-tenth of the cases. In seven out of twenty-one fatal cases observed by Dr. Jenner, there was hemorrhage from the bowels. " In one, discharges of blood took place on the sixth and seventh days of the disease. On the tenth, the stools were healthy in appearance, and well formed; and, although they afterwards became watery, there was no return of the hemorrhage. One man passed a small quantity of blood on the eighth, ninth, and tenth days of the disease, and again from the .twenty-eighth to the thirty-second—i. e. the day o£ death—the 1 Louis's Researches, vol. i. p. 464 2d ed. SYMPTOMS. — STATE OF THE BOWELS. 59 stools between the two attacks of hemorrhage being watery, but free from blood. In one case, blood was mixed or passed with every stool, from the fourteenth to the twenty-first day, the patient dying on the twenty-fifth day. In four cases, hemorrhage from the bowels occurred during the last day or two of life, the patients dying respectively on the seventeenth, twenty-third, twenty-fifth, and twenty-eighth days of the disease. The blood lost varied in quantity from an ounce or two, to two or three pints; in hue, from black to bright red; and in consistence, from a reddish watery fluid to the consistence of treacle, and even solid clots."1 [Dr. Flint met with hemorrhage in three cases out of seventy-three; two recovered, and one died.] It appears, from the researches of M. Taupin, to be less frequent in patients under fifteen years than amongst adults. He met with but one instance, in one hundred and twenty-one cases; and Bar- thez and Rilliet, in one hundred and eleven cases, met with none. A more exact estimate of the importance of this symptom, as well as of others, as a means of prognosis, will be made hereafter. Louis says it is exceedingly rare to find any mucus in the dejec- tions. Dr. Hale, of Boston, thinks that diarrhoea is a more frequent symptom in the typhoid fever of Paris, than in that of New Eng- land ; and the Report of Dr. Jackson seems to corroborate this opinion. This may be so, but I do not think that the data from which the opinion is derived are sufficiently accurate and positive to settle this matter. It seems very probable that the records of the Massachusetts General Hospital do not always call that condi- tion of the alvine evacuations diarrhoea, to which the term is ap- plied by Louis. It is true, at any rate, that such is the case with the great mass of American practitioners. Certainly, as a general rule, they do not, as Louis does, apply the term diarrhoea to that state of the bowels in which only one or two thin discharges occur in the course of twenty-four hours. In this way, the apparent difference may, perhaps, be accounted for. Professor Schonlein, of Zurich, in 1835, found in the intestinal discharges a great number of microscopical crystals, perfectly trans- parent, slightly fragile, soluble in muriatic and nitric acids, and consisting chiefly of phosphate of lime, some sulphate of lime, and a salt of soda. Similar crystals were subsequently found, but in 1 Jenner, &c, p. 32. 60 TYPHOID FEVER. much smaller quantity, and much less constantly, in the intestinal discharges in other diseases.1 Diarrhoea, according to Barthez and Rilliet, is invariably present in the typhoid fever of children. Sec V.—Abdominal Pains. Pain in the abdomen is another very common accompaniment of typhoid fever. Its severity and frequency are in pretty direct relation to the severity of the disease, and to the extent of the diarrhoea. Like the latter symptom, the pains in the abdomen are often present at the beginning of the fever. At other times, the pain appears at different periods of the disease. In some cases, it is only elicited by pressure, but more frequently, it is independent of this. It varies in severity, from a dull heavy ache, or feeling of distress, to a severe, colicky griping. It is not often diffused over the whole abdomen, its most common seat being the iliac fossa3, the hypogastrium, and around the umbi- licus. This symptom, in many cases, constitutes the principal source of suffering to the patient, during nearly the entire progress of the fever. In a certain proportion of cases, generally after the middle period of the disease, and sometimes during convalescence, there is a sud- den supervention of very acute pain in the abdomen, at first con- fined to a small space, but extending pretty rapidly over the entire belly. The pain is accompanied by great tenderness on motion, or pressure; tympanitic distension ; rapid, feeble, and thready pulse; extreme distress; nausea and vomiting; pinched and cadaveric features; and these phenomena are speedily followed by death. These are the signs of an acute peritonitis, the consequence of in- testinal perforation. [This accident occurred twice (2.74 per cent.) in Dr. Flint's cases.] Sec VI.—Tympanites. Flatulent distension of the abdominal parietes is a very common, and, to a considerable extent, character- istic symptom of this disease. Its degree and frequency, like the diarrhoea and abdominal pains, with which it is often associated are, for the most part, proportionate to the gravity of the disease. It is commonly later in its appearance than the other gastrointesti- nal symptoms, showing itself, often, during the second and third weeks of the fever. Dr. Hale, in his very excellent paper, remarks 1 Edin. Med. and Surg. Journ., vol. xlviii. p. 253. SYMPTOMS. — TYMPANITIS. — EMACIATION. 61 that this symptom is found most frequently near the beginning of the disease.1 This is directly opposed to the result of my own observation, and, I think, to the best authorities. It varies in de- gree from a slight rigidity of the muscles and straightness of the parietes to the extremest distension ; in these cases occasioning, as has already been remarked, by its mechanical action on the lungs, no inconsiderable degree of dyspnoea. It generally persists, after its first appearance, till the fatal termination, or the approach of convalescence; although it is not unusual for it to vary consider- ably in degree, at different periods of the fever. The flatus rarely passes per anum, and seems to be but little disturbed by the peri- staltic motion of the intestines. There is another symptom connected with the abdomen, which may be mentioned here. It was first particularly noticed, so far as I know, by Chomel, though it can hardly have escaped the atten- tion, I think, of all who have had much to do with the disease. I allude to the gurgling sound, which is produced by pressure on the abdomen, especially over the region of the cascum. If the disten- sion is not excessive, pretty firm pressure, made alternately with each hand, in the manner of seeking for deeply-seated fluid, will rarely fail, I think, to elicit this sensation and sound. It is chiefly interesting as one of the elements of our diagnosis. ARTICLE VI. MISCELLANEOUS SYMPTOMS. tfnder this head, I have still to enumerate and describe a certain number of morbid phenomena, more or less important, and more or less characteristic of typhoid fever, which could not well be grouped in any other manner. Sec I.—Emaciation. In most cases of the fever, there is a well- marked and gradually progressive emaciation, although it is not often very obvious before the end of the second week. Where the disease is severe and prolonged, this emaciation is often extreme. In cases of great severity, terminating fatally at an early period, this symptom is hardly noticed. 1 Med. Com. Mass. Med. Soc. 1839. 62 TYPHOID FEVER. Sec II.—State of the Urine. Modifications in the urinary secre- tion are generally present. Nathan Smith says: " In the commence- ment of the fever, the urine is not high-colored, and is considerably copious, being often above the natural quantity, and deposits no sediment. In voiding it into a vessel, it often foams like new beer. As the disease advances, the urine becomes more highly colored, and, as it begins to decline, lets fall an abundant sediment. In very severe cases, the patient evacuates his bladder but seldom, allowing the urine to accumulate there in very large quantities."1 Drs. Dobler and Skoda, in a description of the typhoid fever of Vienna, inform us, that whenever the disease is at all severe, the urine deposits no sediment, unless it be a slight cloud of mucus. On the subsidence of the fever, there is often a grajnsh, dirty deposition. Sec III.—Epistaxis. Hemorrhage from the mucous membrane of the nostrils is quite common in the course of typhoid fever. Louis ascertained its occurrence in twenty-seven of thirty-four patients, who had the fever in a grave form, but recovered. It was present in somewhat less than half of his mild cases. [Dr. Flint noticed it in twenty-one of his seventy-three cases.] It may occur at different stages of the disease, but it is most common dur- ing the early period, or in the first half of its duration. It some- times occurs but once, but is, in many instances, several times repeated. It is generally small in quantity, sometimes amounting to only a few drops. At other times it is profuse, requiring the use of the tampon to arrest it. It is rarely, if ever, attended with or followed by any relief. It seems to be much less common amongst children than amongst adults.3 Sec IV.— Cutaneous Eruptions. The most frequent and charac- teristic eruption upon the skin consists in what has been called the lenticular, rose-colored spot. This, indeed, is so common in typhoid fever, and so rarely seen in any other disease, that it has received the name of typhoid eruption. It consists of a small spot, not a pimple, slightly elevated above the surrounding skin, not always sensible to the touch, but generally so, about as large in circum- ference, on an average, as the head of a pin, and of a bright red or rose color. When the skin is made tense, or pressed by the finder 1 Smith's Medical and Surgical Memoirs, p. 64. 2 Louis's Researches, vol. ii. p. 84, 2d ed. SYMPTOMS. — CUTANEOUS ERUPTIONS. 63 the spot readily disappears, returning immediately on the removal of the pressure. There is good reason to think that this eruption is almost an invariable accompaniment of typhoid fever. It is true that amongst thirty-six fatal cases, where the eruption was sought for, Louis found it only in twenty-six. So, in the Massachusetts General Hospital, Dr. Jackson found, during the years 1833, 1834, and 1835, the rose spots in only two-thirds of the patients. But it is very probable that, in many of these cases, the eruption was either overlooked, or that it had disappeared before the patients came under the care of their respective physicians. All the grave cases which recovered, cited by Louis, excepting three, and all his mild cases, without any exception, exhibited this eruption. Dr. Hale found the rose spots in one hundred and seventy-seven of one hundred and ninety-seven cases, and in a greater part of the remain- ing twenty they were not carefully sought for.1 Louis says, in his second edition, that of fifty-four cases, carefully and daily observed, at La Piti£ and the Hotel Dieu, subsequent to the publication of his Researches, the rose eruption was present in all but five. In these it was wholly wanting. I have rarely failed to find it where it was properly sought for. Dr. Jenner says: " My impression is that the rose spots of typhoid fever are more frequently absent from patients more than thirty years old than from those of less mature age. I should say they were rarely absent in young persons. This is, however, the reader must remember, merely a general impression." It appears, from the observations of Rilliet and Taupin, that this sign is as common in early as it is in adult life. It frequently appears a day or two sooner in cases of children. Taupin says that he has never seen this eruption in the course of any other disease amongst children, and he mentions particularly meningitis, of which he has witnessed more than two hundred cases.2 It is found on various parts of the body, but much more fre- quently than elsewhere upon the abdomen and the chest. Now and then, it is seen upon the skin of the extremities and of the face. It is also found upon the back, The spots vary in number. Sometimes they are but fewt—six, eight, or ten. In other cases, they are much more numerous, being sprinkled pretty abundantly over the chest and abdomen. 1 Com. Mass. Med. Soc, 1830. 2 Louis's Researches, vol. i. p. 106, 2d ed. 64 TYPHOID FEVER. Dr. Jackson, of Boston, informs me that he has seen them quite thickly scattered over the entire surface, even that of the limbs. I have this day, August 6, 1842, visited a patient, sick about a fort- night with typhoid fever, who exhibits the spots upon every part of the skin, excepting that of the hands, ankles, and feet. There are not less than twenty upon the face, and as many as forty may be counted on the left arm between the elbow and wrist. Their size varies from that of a small point to a diameter of two lines. Most of them are pretty regular in their oval or circular outline, although a few of the larger ones are less so. They are, many of them at least, slightly but very distinctly elevated above the sur- rounding skin, and can be readily detected by the finger. The most usual period of their appearance is during the second week of the fever. In a few rare instances, they are seen as early as the close of the first week. Of twenty-five cases, in which this point was carefully noticed by Chomel, the eruption appeared between the sixth and eighth days of the disease in two; between the eighth and fifteenth days in thirteen; between the fifteenth and the twentieth days in seven; between the twentieth and the thirtieth days in four; and on the thirty-seventh day in one.1 They generally come out successively, one after another, and after remaining, com- monly, for little more than a week, they successively and gradually fade away and disappear. The following is Dr. Jenner's description of the rose spots. " They are slightly elevated. To detect the elevation, the finger had to be passed very delicately over the surface, as they had none of the hardness of the papulae of lichen, or of the first day's eruption of smallpox. Their apices were never acuminated, never flat, but invariably rounded; their bases gradually passed into the level of the surrounding cuticle. No trace of a vesicle or white spot of any kind was ever detected on them. They were circular and of a bright rose color, the latter fading insensibly into the natural hue of the skin around. They never possessed a well-defined margin. They disappeared completely on pressure, resuminc their characteristic appearances as soon as the pressure was removed; and this was true from first to last, from their first eruption to their last trace. They left no stain of the cuticle behind; they never passed into anything resembling petechiae; the characters they presented on their first appearance continued till they vanished. Their ordinarv size 1 Chomel, p. 20. SYMPTOMS. — CUTANEOUS ERUPTIONS. 65 was about a line in diameter, but occasionally they were not more than half a line, and sometimes a line and a half in diameter. The duration of each papula was three or four days; fresh papulae made their appearance every day or two. Sometimes only one or two were present at first, ran the course above described, and then one or more fresh ones made their appearance, vanished in three or four days, and were followed by others to last as long. The number of papulae seen at one time on the surface was ordinarily from six to twenty; though occasionally there was only one, and sometimes more than a hundred. "They usually occupied the abdomen, thorax, and back, but were occasionally present on the extremities. One was frequently noticed on the thorax, over the cellular interval, at the upper border of the pectoralis on either side. A very pale and delicate scarlet tint of the skin sometimes preceded the eruption of the papulae, but never lasted more than a day or two; the skin resembling in tint that of a person shortly after leaving a hot bath. Rose spots were present in nineteen of the twenty-three fatal cases here analyzed."1 [Dr. Flint found the duration of the eruption in seven well studied cases to be seven days. He met the eruption less frequently than some of the authors here quoted, that is, in forty- nine of his seventy-three cases. About two-thirds showed it in 1850, less than half in 1851, and all (fourteen) in 1852.] Another pretty common eruption consists in transparent vesicles, to which the name sudamina has been given. These vesicles are circular, or oval in their shape, varying in size from that of a small pin's head to that of a split pea. They are formed by the presence of a limpid fluid elevating the cuticle. Their most frequent seat is upon the sides of the neck, and about the shoulders and axillae, though they are sometimes scattered more extensively over the body. Chomel says that he has never seen them on the face. They are most readily seen when looked at in an oblique direction. They appear late in the disease, being rarely seen before the twelfth day. They usually remain for several days, and gradually disappear. ' They were present in two-thirds of Louis's cases, where they were carefully sought for, and in the same proportion, whatever was the severity of the fever. Dr. Hale attaches much less importance to sudamina as a diagnostic sign of typhoid fever than Louis and Chomel. He says: " Wherever the skin is for a length of time 1 Jenner, &c, p. 12. 5 66 TYPHOID FEVER. kept in a state of perspiration, from whatever cause, there sudamina will generally be found." This is far from being in accordance with the observations of Louis and Chomel. Louis says, that of forty patients with other diseases, in all of whom there were copious sweats, only three exhibited sudamina. Sec V.—Eschars, &c. In this place may be properly noticed the tendency which exists, particularly in grave and protracted cases of typhoid fever, to ulceration of the skin. This is occasionally shown in the formation of ulcers upon the sacrum. In similar cases, it not unfrequently happens that blistered surfaces are attacked with ulceration. They become, especially about the edges, covered with a white or grayish exudation, like that which is frequently seen on blistered surfaces, in cases of protracted scarlatina, and which is commonly called canker. The ulceration underneath this matter sometimes becomes deep and extensive, adding, in no small degree, to the irritation of the disease. In some cases, true gangrene occurs, followed by eschars and sloughing. In a moderate proportion of grave cases, typhoid fever is com- plicated with erysipelatous inflammation of the skin. I have known this erysipelatous tendency show itself in a disposition to attack the end of the nose. Biles appear, occasionally, upon different parts of the body, on the approach, or after the commencement of con- valescence. [Large and formidable abscesses occur in a small pro- portion of cases during convalescence. They are not attended by much pain, and are preceded by few of the signs of inflammation, hence sometimes called cold abscesses. Inflammation of the parotid gland, tending to suppuration, is occasionally encountered during the acute stage of the fever. This complication is probably more common in hospital than in private practice. Though a source of much suffering, it does not seem greatly to increase the gravity of the disease. Dr. Flint reports that two of his cases were so affected.] I have now completed the enumeration anft description of the symptoms of typhoid fever. Some of these symptoms are more important, more frequently present, and more characteristic of the disease than others. Some, again, are chiefly interesting and valu- able as diagnostic, and others as prognostic indications. It very rarely happens that, in any single case, they are all united. Under different circumstances, and in different cases, they are very vari- ously combined, constituting different grades and varieties of the SYMPTOMS.—ESCHARS. 67 disease. These varieties might, properly enough, be described in this place ; but I think it better to defer this description until after the anatomical lesions of the disease, and the relations, so far as these have been ascertained, between the symptoms and the lesions, have been given. I shall thus be enabled to present to the reader a more distinct, individualized, and unbroken picture of the dis- ease, with its ordinary and average features, than can otherwise be done. The varieties in its march, in its severity, in the group- ing and combination of its numerous symptoms, will then be con- sidered, in their place, amongst the other complex elements in the natural history of the disease. 63 CHAPTER III. ANATOMICAL LESIONS. Chomel, in his very excellent and full description of the patho- logical alterations^ typhoid fever, divides them into two classes, consisting, respectively, of those which are constant and characteristic, and of those which are occasional. Louis does not attempt to follow any natural or systematic arrangement. In the present history, as a matter of convenience, I shall pursue, as far as this can well be done, the same general order in the succession of subjects, that I adopted in the detail of symptoms; pointing out, under each head, the connections between the symptoms of the disease, and the lesions of the organs, so far as this connection has been ascertained. ARTICLE I. LESIONS OF THE CIRCULATORY APPARATUS. Sec I.—Heart and Aorta. The most striking and common altera- tion of the heart consists in a diminution of its consistence. Louis found this organ natural, in volume, color, and consistence, in one- half of his cases. In seventeen of forty-six cases, the softening was very well marked. Its tissue could be very readily torn and broken down. At the same time, the heart is exceedingly flaccid, assuming, when removed from the body, a collapsed and flattened shape. The softening of the texture, and the general flaccidity, are most com- monly found together, though they may exist separately. Under these circumstances, the cut surfaces of the heart have a dull, dry appearance, and the walls of the ventricles are, in most cases dimi- nished in thickness.1 These changes in the condition of the heart are usually accompanied with alterations in its color. The muscu- lar tissue and the external surface are pale, in many cases with a violet or livid tinge. The internal surface is sometimes pale and 1 Louis's Researches on Typhoid Fever, vol. i. p. 331. LESIONS.—HEART AND AORTA. 69 sometimes of a more or less deep, violet red. The alterations are found more frequently and more strongly marked, in cases which have terminated early, than in those which have been prolonged. Of fifteen cases examined by Dr. Jenner, the heart was firm or healthy in consistence in five; soft and flabby, or flabby only in five; the right ventricle flabby, the left normal, in one. Of four cases no note on this point was made, but the heart was probably healthy. The average duration of the disease in the five cases in which the heart was flabby, was twenty-two days ; in the five cases in which it was healthy, the average duration was twenty-eight days.1 It would seem that, at the Massachusetts General Hospital, lesions of the heart are of less frequent occurrence. Of twenty-eight cases noticed in Dr. Hale's remarks, only two or three are said to have been "rather flaccid." It ought, however, to be remembered, that this term might be applied to the same condition of the heart by one observer, and withheld by another. There have been differ- ences of opinion, amongst pathologists, in regard to the nature of these lesions. I do not think there is any satisfactory evidence that they are inflammatory. The aorta is frequently more or less changed in color, on its internal surface. This change existed in somewhat more than one- half of Louis's cases. It consists of a morbid redness, more or less intense, sometimes in the form of bands or patches, sometimes generally diffused over the whole surface, and extending to the bifurcation of the aorta, or even considerably beyond it. This redness reaches through the inner, and affects, though in a less degree, the middle membrane of the cardiac cavities. The intensity of the morbid color is generally in proportion to the softening and flaccidity of the tissue of the heart. It is always found in connec- tion with the presence of blood in the aorta; and it is important to remark, further, that the most extreme cases of softening of the heart commonly coexist with the presence of a dark, soft, non-fibri- nous clot of blood in its cavities, or with blood not coagulated, but containing bubbles of air.2 The cause and nature of this reddening of the inner coats of the aorta have been the subjects of much investigation and much con- troversy. There is no place for any account of them here. I will 1 Jenner, &c.,p. 80. 2 Louis's Researches on Typhoid Fever, vol. i. p. 333. 70 TYPHOID FEVER. merely say that the opinion of Louis seems to me most in accord- ance with all the phenomena which enter into the solution of the question; and that opinion is, that this redness is the result of im- bibition, by the tissues, of the coloring matter of the blood—the imbibition depending upon a special condition of the blood, or of the tissues, or, perhaps, of both. There is no conclusive evidence, at any rate, that the redness is the result of inflammation. Sec II.—State of the Blood. The most frequent alteration in the character of the blood consists in the diminution of the natural proportion of its fibrin. In some cases, the cavities of the heart, especially the right, contain fibrinous concretions of a whitish or yellowish color; but more commonly, the blood is in the form of dark coagula, or entirely fluid. Of thirty cases, wherein the blood contained in the heart and aorta was carefully examined by Chomel, he found small and scanty fibrinous concretions in six, dark coagula in nine, and dark fluid blood in fifteen. The occasional preseuce of air in this uncoagulated blood has already been noticed. Ac- cording to the observations of Louis, the appearance of the blood contained in the cavities of the heart, as has just been intimated, varies with the condition of this organ. When its consistence was natural, he found, especially in the right cavities, yellowish or whitish fibrinous coagula, more or less firm; when it was consider- ably softened, he found non-fibrinous coagula; and when the soft- ening was very great, instead of coagula, he found only a small quantity of fluid blood containing air. Blood drawn from the veins, during life, rarely exhibits the buffy coat; and when this is present, it is generally soft, gelatinous, or infiltrated, and of a grayish or greenish color. This character of the blood has been particularly noticed by Louis, Chomel, and Bouillaud; and the results of their observations have been abund- antly verified by the subsequent and more accurate researches of Andral and Gavarret. They found that, in typhoid fever, the pro- portion of fibrin in the blood was never increased above its natural standard; but on the contrary that, in many cases, this proportion was very much diminished; and, furthermore, that the degree of this diminution was very uniformly proportionate to the severity of the disease. These observers found a similar alteration of the blood in the eruptive fevers, while in all cases of simple acute inflamma- tion, the quantity of fibrin was above its natural standard. LESIONS.—RESPIRATORY APPARATUS. 71 ARTICLE II. LESIONS OF THE RESPIRATORY APPARATUS. Sec I.—Lungs. Neither the symptoms nor the lesions go to show that the lungs play any very important part in the numerous and complicated phenomena of typhoid fever. Louis found them nearly natural in fifteen of forty-six cases; about the same propor- tion in which he found them so in other acute diseases, excluding, of course, those of the lungs themselves. Chomel found them healthy in ten of forty-two cases. The most characteristic altera- tion is described particularly by Louis, and, so far as I am aware, had not been noticed by other writers. It is of frequent occurrence in the fever of our own country. It has been called splenization or camification of the lung. The latter term may be well enough, but the former is wholly inappropriate; the appearance of the lung being entirely unlike that of the spleen. The portion of lung thus carnified, is of a deep bluish-red color; it has a tough, leathery feel; the finger penetrates and breaks it down with difficulty; it is wholly destitute of air, and sinks readily in water. When it is cut, the smooth surface is directly covered with a thick, red fluid. This peculiar lesion almost always occupies a circumscribed portion of the lower and posterior lobe of one or both lungs. It is quite un- like, in almost every respect, the second stage of inflammation, although the term hepatization has sometimes been applied to it. It is not indicated by any peculiar symptom during life. Dr. Jenner gives the following description of this lesion, which he calls Lobu- lar non-granular Consolidation. " Externally, a portion of lung in this condition has a mottled aspect; here and there are patches, varying in size from a single lobule to half or more of a lobe, of a deep bluish, chocolate, violet, or purplish slate color, bounded by a well-defined angular margin, crossed, if it includes more than one or two lobules; and mapped out into smaller patches, by dull opaque whitish lines. On closer inspection, the outline and the whitish lines intersecting the patches, are seen to be thickened inter- lobular septa. " Scattered in the midst of the larger patches, are frequently found one or more comparatively healthy lobules, of a pale bright- ish pink color, contrasting strongly with the hue of the surround- ing tissue. Here and there, near the border of the large patches, may be seen, occasionally, lobules, the centres of which have assumed 72 TYPHOID FEVER. the dusky purplish tint; the circumference of the same lobules yet retaining their healthy color. The dark patches feel solid and flabby; the pulmonary tissue, at these spots, has lost the resiliency of health. The pleura covering the lungs either retains its natural appearance, or has a slightly milky aspect. On section, the tissue corresponding to the dark patches is found to be of a deep purplish chocolate color, gorged with non-aerated bloody-looking fluid, breaks down with little or no increased facility, nay, sometimes appears tougher than in health; has a uniform or nearly uniform section, i. e. there is no appearance of granules, such as are seen in the consolidation and non-consolidated state of so-called vesicular pneumonia; sinks in water, like the patches seen externally; is bounded by interlobular septa; but these divisions, between the consolidated and non-consolidated tissues are less marked, especially the most superficial tier, so to speak, of lobules. A minute portion can be cut from the middle of a lobule—the centre of which is dark purple, and the circumference brightish pink—which sinks in water; equally small pieces of pulmonary tissue, from the circum- ference of the same lobule, float."1 Other changes, such as inflammation, usually not extensive; simple mechanical engorgement, taking place during the last hours of life; violet red spots or patches in the infero-posterior portions of the lung; circumscribed abscesses and tubercles are present in a certain proportion of cases. The inflammation is often not discoverable during life, except by its physical signs. Sec II.—Bronchia, Epiglottis, &c. The mucous membrane of the bronchial tubes is frequently of a more or less livid red color, sometimes with a violet tinge. That of the trachea is occasionally colored in the same manner, but is very rarely the seat of any un- equivocal lesion. The same thing is true of the larynx. The epi- glottis is more frequently and seriously diseased. In a moderate proportion of cases, it is the seat of ulcerations, extending not only * through its investing membrane, but into the fibro-cartilage itself; occasioning, sometimes,, extensive destruction of the organ. In other cases, it is simply denuded. These ulcerations are not found where the disease is rapidly fatal. They are frequently productive of some difficulty of swallowing. Recent lesions of the pleura are very rare. In many cases there is an effusion of bloody serum, varying in quantity from a few 1 Jenner, &c, p. 86. LESIONS. — BRAIN AND ITS MEMBRANES. 73 ounces to a pint or more, occupying both sides of the chest. This exudation probably takes place near the close of life. ARTICLE III. LESIONS OF THE BRAIN AND ITS MEMBRANES. From the frequency and severity of the symptoms, consisting in deranged action of the brain, it would have been supposed, as a mere matter of a priori reasoning, that this organ would have exhi- bited corresponding alterations in its appearance. Such, however, is far from being the fact. As will be seen by the details which I am about to give, lesions of the brain are far from being universally present, and when present, far from being found in any constant relation to the disturbed functions of the organ during life. Of thirty-eight cases reported by Chomel, in which the brain and its membranes were carefully examined, fifteen presented no appreci- able alterations in these organs.1 The most common changes, in a certain proportion of cases, consist of moderate serous effusion between the arachnoid and pia mater; more or less vascularity of the pia mater itself; a rosy tinge of the cortical substance, and injection of the medullary portion of the brain. Of forty-six cases, Louis found the sub-arachnoid effusion, various in degree, in twenty- eight; vascularity of the pia mater in somewhat less than one-half; the rosy tinge of the cortical substance, uniformly diffused through its entire extent, in seventeen; and more or less injection of the medullary substance in all but eight. This injection is generally proportionate to the red color of the gray substance, and both phenomena are most common and strongly marked in cases which terminate early. The serous effusions, on the other hand, are more frequently found in cases that have been protracted. In rare instances, there is a slight increase or diminution in the consist- ence of the brain, besides some other unimportant and accidental alterations. In regard to the nature of these several lesions, there is, amongst pathologists, a difference of opinion. Those who still cling to the doctrines of the old and exclusive physiological school, and who are haunted by the perpetual presence of irritation, regard the fore- going changes as the evidence and result of inflammatory action. 1 Chomel's Lemons de Clinique Medicale, p. 294. 74 TYPHOID FEVER. Others think that not only is there no satisfactory proof of the action of this morbid element, but that there are many and insuper- able objections to such an opinion. There is no ascertained relation between the cerebral symptoms during life and the pathological conditions of the brain and its membranes appreciable after death. Delirium and somnolence are found to have occurred as frequently, and to have been as strongly marked, in patients whose brains presented no changes, or exceed- ingly slight ones, after death, as in those of an opposite character. Again, it is obvious that these lesions are in no way peculiar to typhoid fever, since they are found almost as frequently in patients dead from other acute diseases, excluding those of the brain itself and its envelops, as in those dead from the fever. ARTICLE IV. LESIONS OF THE DIGESTIVE AND ABDOMINAL ORGANS. Sec I.—Pharynx and (Esophagus. In a large proportion of cases of typhoid fever, these organs are found in their natural state. The only lesion of any considerable frequency which they exhibit consists in ulcerations of their mucous lining. These were noticed by Louis in the pharynx in eight of forty-six cases, and in the oesophagus in nearly the same proportion. They vary in size, from one to six or eight lines in diameter, are circular or oval in shape, and generally quite superficial. In many of these cases, there is difficult or painful deglutition. In others, especially where there is delirium, this symptom is wholly wanting, as it sometimes is, under the same circumstances, in cases of ulceration and partial destruction of the epiglottis. Dr. Jenner found inflammation, with or without ulceration of the larynx and pharnyx, in about half of his cases. His analysis leads him to conclude that the laryngeal is secondary to the pharynweal affection; and that " in typhoid fever laryngitis, independent of pharyn- gitis, is extremely infrequent.''11 Sec II.—Stomach. The mucous membrane of the stomach, unlike that of the pharynx and oesophagus, is generally more or less re- moved from a healthy condition. Louis found it free from any 1 Jenner, &c, p. 49. LESIONS. — STOMACH. 75 obvious lesion, excepting an occasional slight change of color, in about one-third only of his cases. The alterations of which it is the seat are various. The most common consist of changes in its color, its consistence, its thickness, in mamellonation, and ulceration. These alterations may exist separately, or, as happens more fre- quently, two or more of them are found together. The most com- mon change of color consists of increased degrees of redness. This redness is of various shades, occupies different portions of the stomach, most commonly the larger extremity, and seems to be dependent on different causes. Sometimes, even when not connected with any other change in the membrane, it is probably the result of inflammatory action; but, in many instances, there is sufficient evidence that such is not the case. Softening of the mucous membrane, sometimes existing as a sim- ple lesion, is frequently associated with a diminution of its natural thickness. This alteration, either simple or complicated, isrfound in all parts of the membrane, but it is oftenest confined to that of the cardiac extremity. Of fourteen cases mentioned by Chomel, the softening was limited to this region in ten. In some cases, it exists in separate bands; in others, it spreads over a continuous portion of the stomach. The thinning occasionally extends through the membrane, resulting, of course, in its entire destruction. The softening with thinning is found nearly always in those cases which terminate before the twenty-fifth day of the fever.1 Ulcerations of the mucous membrane are present in a few in- stances. Louis found them in four of forty-six cases. Of forty- two cases quoted by Chomel, they were not found in any. These ulcerations are small in size, superficial, and not very numerous. There is another pathological state of the gastric mucous surface, to which the name mamellonation has been applied. This lesion consists of small elevations of the membrane, pretty regularly cir- cular, or oval in their form, and scattered thickly, and in considera- ble numbers over different portions of the stomach. This peculiar condition generally exists, in connection with other alterations, especially with softening, and increased redness. Like most of the gastric lesions, it is oftener present in cases which terminate early, than those which are prolonged. Louis has taken great pains to ascertain the relationship, if any such exists, between these various pathological states of the gastric 1 Louis's Researches on Typhoid Fever, vol. i. p. 173, 1st ed. 76 TYPHOID FEVER. mucous membrane, and the gastric symptoms. The result of his inquiries is this: that in a considerable number of cases the several lesions, separately or combined, are found after death, when there had been no gastric indications of their presence during life; and that epigastric distress, either alone or with nausea, not unfrequently has occurred in cases where the mucous membrane of the stomach was found in a healthy condition. All the cases, however, in which there was epigastric distress, accompanied by repeated vomiting of bile, exhibited more or less extensive disease of the membrane.1 So far as the absence of any constant relationship. between the lesions of the stomach and the gastric symptoms is concerned, the conclusions of Louis are abundantly sustained by the researches of Chomel. Sec III.—Small Intestines. In all cases of typhoid fever, there is lesion of the small intestines. This lesion is peculiar. It is found in no other disease. It is generally extensive. Constituting, as this lesion does, the characteristic, and, of course, the most in- teresting and important pathological element of typhoid fever, I shall describe it with all possible accuracy and completeness. Be- fore proceeding, however, to do this, I will more briefly enumerate certain other occasional changes that are found in the small intes- tines. The duodenum is not often the seat of any very considerable dis- ease. Not unfrequently, it is entirely natural; at other times the mucous membrane is morbidly red, softened, and, very rarely, the seat of a small number of minute superficial ulcerations. The small intestines are moderately distended with flatus, in a few cases. Their contents consist, commonly, of a considerable quantity of mucus, especially in the upper portion, and of liquid bilious matter, of a light yellow or orange color, sometimes tinned with red. In cases where there has been hemorrhage from the bowels, blood, either coagulated or dark colored and grumous is found in the intestines. In many of these same cases, and in some others where there has been no hemorrhage, and where no blood is found in the intestines the mucous membrane is the seat of sanguineous infiltration. This condition has been particularly described by Chomel. I have seen 1 Louis's Researches on Typhoid Fever, vol. i. p. 457, et sen. 2d ed. 2 Lecons de Clinique Medicale. Par A. F. Chomel, p. 247, et sen. LESIONS. — SMALL INTESTINES. 77 it more extensive, and more strongly marked, in two cases of death from acute jaundice, in both of which there were hemorrhagic dis- charges from the bowels, than in typhoid fever. It may exist to the extent of only a few inches, or of several feet. It is generally continuous, not in patches or zones. The color of the membrane ranges from a rose to a very dark red, and it has a peculiarly bril- liant and trembling or quivering appearance, like jelly. Chomel found this lesion in seven of forty-two cases. He is very confident that it is intimately connected with hemorrhage from that portion of the membrane which it occupies.1 The mucous membrane, exclusive of the elliptical plates and the isolated follicles, is, in a majority of cases, more or less changed in color. In many, it is preternaturally red. The redness is some- times continuous, and extends through a large portion of the intes- tinal tract; at other times, and more frequently, it exists in patches or zones. Occasionally, the color is grayish; this is particularly the case when the disease has been protracted to a late period. The consistence of the membrane, like its color, is found, in a moderate proportion of cases, quite natural. Oftener, however, it is more or less diminished; sometimes so much so as to resemble an unorganized pulp, spread, like a layer of paste, over the subja- cent tissue. This softening is in some cases quite simple; that is, it is not connected with any other appreciable alteration. In others, the membrane is, at the same time, reddened or thickened, or both. It is the opinion of Louis, that these two forms of softening are unlike in their character and causes. The latter he considers to be inflammatory; the former he thinks may depend on different causes, but that it is not the result of inflammation. In a part, at least, of the cases, he is inclined to regard it as the result of a post-mortem or cadaveric change. The invariable and characteristic lesion found in the small intes- tines, to which allusion has been made, consists in alterations, differ- ing somewhat in different cases, of the elliptical plates, or Peyer's glands. The condition in which these bodies are found varies with the duration of the disease, with the distance of the plates them- selves from the ileo-ccecal valve, and with other circumstances, the nature of which is unknown. Without entering into so minute and elaborate a description of the several forms of this lesion as has been very properly given in the original researches of Louis 1 Lecons de Clinique Medicale. Par A. F. Chomel, p. 252, et seq. 78 TYPHOID FEVER. and Chomel, I shall enumerate the principal and more striking varieties. In a small proportion of cases, consisting of those which terminate early, the elliptical plates, together with the subjacent cellular tissue, are merely increased in thickness, with redness and softening. This increase of thickness is such, that the edges of the plates have been known [in rare cases] to project to a distance of from one to two or three lines above the surrounding mucous membrane. Sometimes the hypertrophy of the plates and of the subjacent tissue is quite simple, the color and consistence of the membrane remaining unal- tered. This simplest form of the lesion, that I am now describing, like all the others, which are more complex, is invariably found most advanced, and most strongly marked, at the lower extremity of the ileum. Each successive plate, as we go upward along the intestinal tract, from the ileo-ccecal valve, is less and less profoundly altered, till we arrive at those which are in a natural condition. The number of plates, thus changed, is very various; sometimes extending to fifteen or twenty, and at others limited to one or two, and these always in the immediate neighborhood of the ileo-ccecal valve. Louis says that, in two-thirds of the cases, the number of plates, more or less altered, is from twelve to forty. The surfaces of the thickened plates frequently present a granu- lar or finely mamellonated appearance. This condition becomes very manifest when the gland is detached from its subjacent tissue, and held between the eye and the light. At other times, the sur- face of the thickened membrane, corresponding to the plates, is quite smooth and level. In a great majority of cases, the plates, instead of being merely thickened, with or without redness and softening, are more or less extensively the seat of ulcerations. These ulcerations vary very much in size and in number. It frequently happens, for instance, that in proceeding from above downwards, in our examination, after having passed over several plates, simply thickened we come to one of them in which there is a single, circumscribed ulceration, with perpendicular edges, extending more or less deeply into the thickened tissues. As we go on towards the termination of the intestine, the ulcerations become more and more numerous and ex- tensive, till at last, for several inches next to the valve, the plates are entirely destroyed, and we find only ulcerations, corresponding to their sizes and shapes, occupying their places. These intestinal ulcerations are commonly more or less regularly LESIONS. — SMALL INTESTINES. 79 rounded or oval in their shape. Sometimes, however, their borders are irregularly jagged, and angular. So their edges are, in most cases, pretty regularly perpendicular and smooth, but sometimes they are ragged and shreddy. The bottoms of the ulcerations vary, of course, with their depths. They consist, sometimes, of the cellular tissue immediately under the mucous membrane; sometimes of the muscular coat, and sometimes of the peritoneal covering. Occasionally, this covering itself gives way, perforation takes place, and the contents of the intestine are discharged into the cavity of the peritoneum. Louis found this lesion in eight of fifty-five cases. Chomel quotes two instances of its occurrence, in his clinique at the Hotel Dieu ; in one of which, however, the per- foration took place in the large intestine. The perforation is usually single, small in diameter, and near to the termination of the ileum. In one of three cases, mentioned by Dr. Hale, it was at the distance of forty-four inches from the ileo-ccecal valve. It generally takes place at a late period of the disease. Perforation occurred in three of Dr. Jenner's twenty-three cases, respectively on the seventeenth, thirty-first and forty-second day of disease. " The perforation in all three took place through the floor of an ulcer seated on one of the agminated glands. In two of the three, perforation occurred in the lower nine inches of the ileum; in one, three feet above the ileo-coecal valve. In two of the three, the coats of the intestine were destroyed through their whole thickness, at another spot from that at which the perforation, which proved fatal, took place; but the contents of the bowel had been prevented escaping through the aperture first formed by adhesion, in the one case, to the fundus of the uterus, and in the other, to a fold of the intestine. It will be observed that, in one of the three cases certainly, the fatal perfora- tion took place after the termination of the fever."1 It is a very singular fact, that this fatal accident commonly occurs in the course of very mild, or almost entirely latent, forms of the fever. This was the case in ten of twelve instances cited by Chomel. Chomel suggests that the distension of the intestines by gas may frequently be the immediate cause of perforation. This seems hardly pro- bable, since the greatest distension is usually confined to the large intestine, while perforation is most frequent in the small. It has occurred to me that the frequency of the accident in the mildest, and in some degree, latent form of the disease, might possibly be 1 Jenner, &c.,p. 61. 80 TYPHOID FEVER. occasioned by mechanical causes, especially by efforts of the patient while standing and walking. This accident is much less common in children than in adults. Taupin met with it only twice, in one hundred and twenty-one cases; and Barthez and Rilliet only once, in one hundred and eleven cases. There is another peculiar appearance of the diseased plates, which is found in a certain proportion of cases; according to Louis, in somewhat less than one-third. This seems to consist in a morbid change or transformation of the submucous cellular tissue. Instead of being simply hypertrophic, with or without redness and soften- ing, as in the cases already described, there is deposited in the tissue a substance of a yellowish color, destitute of any traces of organi- zation, presenting a surface somewhat glossy when cut, and about as hard and friable as crude tubercle. The term typhous matter has been given to this morbid deposit. This peculiar condition was observed in several subjects, during the grave epidemic of 1833-4, in the city of Lowell; and, in accordance with the fact, previously noticed by Louis, it was most frequent and striking in cases which terminated quite early. This would seem to indicate that the alte- ration in question is connected with the more severe and rapid forms of the disease. M. Forget describes the lesion of Peyer's glands under six different forms. The first of these he calls the form pointillSe, the punctated or pointed form. It was first described by Roederer and Wagler; and its appearance compared with that of the beard newly shaven. This condition of the glands has been noticed by Andral, Chomel, Forget, and others; but there is no satisfactory evidence that it is especially connected with typhoid fever. It is doubted even whether the appearance is really pathological. It is not often met with. The second form is the reticulated. The glands are rarely thickened; their color varies from that of a grayish red to a deep red, and their consistence is greatly diminished. The substance of the glands presents the appearance of a pretty regular network, resembling somewhat the pulp of a cherry. This°appearance is more striking when the glands are examined under water. It has been suggested that this form may be constituted by the first or at least by the earlier, changes which take place in the glands. The third is the honey-comb form. It is the hard form of Louis and has been already described. The fourth form is the pustular. The peculiarity of this form LESIONS.—SMALL INTESTINES. 81 consists simply in the size and shape of the altered glands. These are small and circular, thus occasioning the pustular appearance. Cruveilhier and Forget think that this pustular form is generally connected with very grave and rapidly fatal cases of the disease. The next form is the gangrenous. Forget says it is always the result of the hard or honey-comb form. The substance of the gland loses its vitality; it becomes of a yellowish or greenish color; its edges, growing ragged and shreddy, are detached ; and finally the entire gland is thrown off, leaving the subjacent muscular or serous tissue exposed. The sixth is the ulcerated form. This has been already described with a sufficient degree of minuteness. These lesions of the follicles, both isolated and agminated, can very generally be recognized through the outer or peritoneal coat of the intestine. This coat, at the points corresponding to the thickened and ulcerated glands, is frequently of a reddish or bluish color, sometimes injected, or even covered with a layer of fibrin; and the thickened glands can, in most cases, be distinctly felt by the thumb and finger, as chancres, says Forget, can be felt through the prepuce. Dr. Jenner, after a careful examination and analysis of these lesions in twenty-three cases, sums up the results in the following conclusions:— " 1. That ulceration of the solitary and agminated glands may commence in two modes; on the one hand, by softening of the mucous membrane, abrasion of the extremely softened superficial tissue, and then enlargement of the breach of continuity thus formed, in depth and extent, by simple ulceration; on the other, by sloughing of a portion of the submucous tissue containing the before-described deposit, and of the mucous membrane over it, and then extension of the ulcer in breadth and width, by the separation of minute sloughs from the edges of the breach of continuity, left after the separation of the slough first formed. " 2. That when the whole of the deposit has sloughed out, no fresh deposit is formed; and that, consequently, as the whole of that deposit is seated in the submucous tissue, destruction of the muscular fibres of the intestine must be the result of simple ulcera- tion. " 3. That resolution of the disease affecting the patches may in some cases occur before ulceration has taken place. " 4. That ulcers of considerable size may heal. 6 82 TYPHOID FEVER. "5. That no contraction follows, within a short period, the healing of the ulcers. " 6. That ulcers dependent for their origin on the presence in the system of the fever poison, may, after the fever has run its course, continue to spread, retard recovery, and even cause death by perforation. " 7. That while some of the ulcers are undergoing the healing process, others may be spreading; or, as Rokitansky says, may pass into the state of atonic ulcers. " These atonic or simple ulcers, left after the termination of the fever, are a frequent cause of lengthened duration of illness in cases of ty- phoid fever."1 I have spoken of this lesion of the glands of Peyer, in some of the forms which have now been enumerated, as invariably present in typhoid fever. I have also spoken of it as characteristic of this disease. The question of the absoluteness of this pathological law —of the constancy of the relationship between the intestinal lesion and the group of symptoms by which we recognize the disease, during life—will be further considered, when I come to treat of the diagnosis of typhoid fever. The only remaining alterations found in the small intestine, of which it is necessary to speak, are those of the isolated follicles, or Brunner's glands. Louis found them more or less diseased, in twelve of forty-six cases. They are subject to the same changes which have just been described, in connection with the elliptical plates, and, like the latter, they are most numerously and most pro- foundly altered, in proportion to their proximity to the ileo-ccecal valve. In this disease, as in most others, it sometimes happens that death takes place, unexpectedly, from unknown causes, or from indiscre- tions in diet and regimen, after the establishment of convalescence. These occurrences have enabled us to ascertain the appearances of the diseased glands, during their march towards their original healthy condition. The deep red tint, characteristic of acute in- flammation, is found, in these cases, to have given place to various shades of gray, ash color, brown, and blue. The edges of the ulcer- ations, if such have existed, are smooth and flattened, passing off imperceptibly, each way, into the bottoms of the ulcers and into the adjacent healthy membrane. These cicatrizing ulcers are al- 1 Jenner, &c, p. 60. LESIONS. — LARGE INTESTINE. 83 ways confined to the lower portion of the intestine. Of forty-two cases, Chomel found eleven, in which there was either partial or complete cicatrization of the ulcerated glands; and in all these, the cicatrization was limited to the last six or eight inches of the ileum. It would seem to be very certain that the process of restoration in the diseased glands follows the same march, from the ileo-ccecal valve upwards, which is so evidently followed in the development of the lesions themselves. It is the opinion of Chomel that, where the cicatrization of the ulcers is complete, all traces of the lesion finally disappear. He says that, in the numerous autopsies at the Hotel Dieu, in many of which there was good reason to think that the subjects had for- merly had typhoid fever, there were never found any obvious proofs of old ulcerations, in the form of remaining cicatrices. It is reasonable to suppose that, in many cases, especially in mild forms of the disease, the local lesion terminates in resolution, there having been no loss of substance, either by ulceration or gangrene. Sec IV.—Large Intestine. There are only two alterations of the large intestine, especially connected with typhoid fever. These are its distension by flatus and ulcerations. The flatulent disten- sion is present in a large proportion of cases. It is sometimes very great, pushing up the liver, the stomach, and the diaphragm much beyond their usual positions, and accounting for the extreme tympanitic enlargement of the abdomen during life. Louis found this meteorism of the large intestine most frequently present and most strongly marked in cases which terminated between the twen- tieth and thirtieth days. Ulcerations are found in about one-third of the cases. They were present in twenty-three of seventy-four examinations, made by Louis and Barth. They are generally small in size, more or less regularly rounded, not very numerous, more superficial than those of the small intestines, and occupying, most frequently, the caecum, though not confined to this portion of the large intestine. This lesion is most common in cases terminating late in the disease. In a small number of instances, the submucous cellular substance of the isolated follicles is found to have undergone the same yel- lowish transformation that has already been spoken of as occurring in the elliptical plates. The mucous membrane of the large intestine is sometimes healthy throughout. At others, it is reddened, or thickened, or 84 TYPHOID FEVER. diminished in consistence. There is nothing, however, in these last-mentioned alterations, in any way peculiar to typhoid fever; since they are found as frequently in many other acute diseases as in this. The contents of this portion of the alimentary canal are usually thin, and of a yellow or greenish color. As to the relation between the intestinal lesions on the one hand, and the various abdominal symptoms on the other, I have but little to say. It would be unreasonable to suppose that such a relation does not exist. There can be no doubt that the diarrhoea and the abdominal pains are connected with the different lesions of the intestinal canal. It is, nevertheless, sufficiently evident that this relation is far from being constant and invariable. In this, as in almost all other diseases, the violence of the symptoms, the perturba- tions and perversions in the functions of the disordered organs, are not to be measured, exclusively, by the appreciable pathological alterations which may exist in the organs themselves. Other ele- ments and other influences, many of them obscure and difficult to seize and to estimate, are concerned in the production of the symp- toms. We thus find in typhoid fever that, although there may be a general relationship between the abdominal symptoms and the intestinal lesions, sometimes the lesions are almost entirely latent; they are not revealed by any characteristic symptom during life. Occasionally, extensive ulceration of the elliptical plates, with changes of the mucous membrane, may exist without giving rise to much diarrhoea or to any other prominent abdominal symptom. Sec V'.—Lymphatic Glands. The glands of the mesentery are always found more or less changed; according to their position, and according to the period at which the disease has terminated. Where death takes place before the expiration of the third week, they are increased in volume, diminished in consistence, and of a rosy, or red, color. If life is* prolonged beyond this period, the volume is found more nearly natural, the softening is less marked, and the red color is supplanted by various shades of gray, and violet. In some of them, there are found small yellow points of a purulent deposition. The diseased glands correspond, very nearly, to the altered elliptical plates; those nearest the ileo-ccecal valve being most changed in their appearance. In a few instances, the glands are moderately enlarged, softened, and reddened, opposite the upper plates of the intestine, which continue healthy.' The glands of the mesocolon are also affected in a similar LESIONS.— SPLEEN. 85 manner, but less extensively and less constantly. The same obser- vation, with the same qualification, is true of the other lymphatic glands of the body. It is also true that these glands are rarely changed from their healthy state in any other acute disease. Sec VI.—Spleen. The spleen is almost always more or less altered in its appearance. The most constant change consists in an augmentation of its volume. In many cases, it is three or four times as large as it is in its natural state. It is, also, very generally diminished in consistence. This softening is sometimes extreme, so that the parenchyma of the organ is reduced almost to an inor- ganic, pulpy mass. The increased size of the spleen, and its soften- ing, frequently exist together, but not always. The cases in which this happens most commonly, and in which the two lesions are strongly marked, are those terminating most rapidly. The color of the spleen is very often changed from its healthy appearance, though not so uniformly as its volume and consistence. It is gene- rally darker than natural, of a deep, bluish brown, and sometimes almost black. These changes of volume, consistence, and color generally extend uniformly throughout the whole substance of the spleen. Louis found this organ in its natural condition only four times in forty-six examinations. All the alterations to which it is subject are most strongly marked in those cases which terminate before the thirtieth day. I have avoided, for the most part, the elaborate discussion of questions relating to the nature and causes of the various lesions which are found in typhoid fever. It may be well, however, to observe here that these alterations of the spleen can hardly be attributed to any inflammatory action. The reasons adduced by Louis for this opinion seem to me to be sufficiently satisfactory. Pus, the most unequivocal evidence of inflammation, is never found; the serous envelop of the spleen is unaltered; and the softening and enlargement affect uniformly the whole substance of the organ; which, so far as all analogies enable us to decide, would not be the case, if these lesions were the result of inflammatory action. In the present state of our knowledge, it is enough, perhaps, to say, that these alterations of the spleen, in typhoid, as well as in other fevers hereafter to be described, depend upon some special and peculiar cause connected with the diseases in which they occur, the nature and operation of which are unknown to us; and further, that the lesions seem to be associated with that pathological element, 86 TYPHOID FEVER. so obscure in its nature and causes, but so extensive and fatal in its results, to which the term congestion has been applied; and not with that other element, to which the term inflammation has been applied. Sec VII.—Liver. The only alteration of any considerable fre- quency, in the liver, consists of softening. This existed in about one-half of Louis's cases; but, inasmuch as it was found oftenest during the warm season, it may be that, to a considerable extent, at least, it is a cadaveric phenomenon, resulting from commencing decomposition. In a certain proportion of cases, the color of the liver is paler than natural, and it is less filled with fluids; less fre- quently, it is darkened and reddish, and moderately engorged with blood. Andral found the liver almost constantly healthy.1 There is no constant or uniform alteration in the qualities of the bile contained in the gall-bladder. Oftentimes, it is found reddish, greenish, and abundant; at others, it is darker, of various shades, less liquid, viscid, and less abundant. Occasionally, the mucous membrane, lining the gall-bladder, is manifestly inflamed, and the bladder contains pus. There is nothing in the condition of the liver, or of its secretion, at all peculiar to typhoid fever. Sec VIII.—Pancreas; Salivary Glands; Urinary Apparatus; and Sexual Organs. These several parts are generally found in a healthy state, and the occasional lesions which they exhibit are such as occur in other acute diseases. The accurate and extensive researches of Rilliet and Taupin have shown that the same anatomical lesions are found in patients under fifteen years of age as in adults. The differences in this respect between the two classes of cases are too few and unimportant to make it worth while to notice them in detail. The intestinal ulcera- tions seem to be somewhat less numerous and extensive than in adults; and a little later, perhaps, in their occurrence. The yellow, hard, friable matter is rarely met with. ARTICLE V. GENERAL REMARKS. Such are the conditions of the several organs and tissues of the body in typhoid fever. It will be seen, from the detailed descrip- 1 Andral's Clinique Medioale, vol. iii. p. 579. LESIONS.—GENERAL REMARKS. 87 tions of these organs and tissues which have just been given, that the lesions in this disease are numerous and profound. Its patho- logical anatomy corresponds, in complexity, variety, and extent, to its symptomatology. There are, indeed, few if any diseases of an acute character and of common occurrence, in which this complexity, variety, and extent of symptoms and pathology constitute so promi- nent and so striking a feature as in this. Some of the lesions, as has already been said, are more or less accidental; that is, they do not necessarily constitute any part of the pathological anatomy of the disease. They are not constantly present. Many of these, however, such as the changes in the mucous membrane of the stomach, and the alterations of the spleen, are of very frequent occurrence, and, we have good reason to believe, play generally an important part in the pathology of the disease. Other lesions are not accidental, but essential—necessary to the dis- ease. They always enter into its composition. They make up one of its constituent elements. They are invariably present. This is the case with the alteration of the elliptical plates of the small intes- tine, and the lymphatic glands of the mesentery, corresponding to these altered plates. The real and relative importance of the several lesions, accidental and essential, is a question, in the actual state of our knowledge, not susceptible of absolute and positive settlement. It is a very natural and philosophical conclusion, perhaps, that the essential and constant lesions are more important than those of an opposite cha- racter. This is true, of course, so far as diagnosis is concerned; so far as the fixing and identification of the specific disease is con- cerned ; but it is very questionable whether these lesions exert a more powerful influence upon the rapidity and the danger of the disease than some of the others. It seems, indeed, very probable that, in many cases, life is destroyed, or the disease is rendered dangerous and severe, by the successive development of these secondary alterations, rather than by the extent and gravity of the essential lesions alone. The order of succession in which the several lesions commence and are developed is also a matter not susceptible of very rigorous demonstration. Death almost never takes place, in the disease, before the termination of the first week, and not often so early as this. Still, a careful study and comparison of the pathological appearances which are presented in cases of differing durations will enable us to arrive at a reasonably certain approximation to the S8 TYPHOID FEVER. truth. There can be but little doubt, I think, that one of the first, probably the first pathological alteration which takes place in the solids, consists in the tumefaction of the elliptical plate, or plates, nearest to the ileo-ccecal valve. This tumefaction is accompanied or followed by other changes—an afflux of fluids, softening of the mucous coat, the hard, yellow typhous deposits in the submucous tissue, and, finally, by ulceration ; and these several lesions taking place, first in the plates nearest to the ileo-ccecal valve, gradually and successively extend to those which are further removed from it. Contemporaneous, probably, or nearly so, with these alterations, are the reddening, enlargement, and softening of the mesenteric glands. The enlargement of the spleen, and the diminution of its consistence, occur, also, there is good reason to think, in the early stages of the disease ; and the same thing is probably true, though less constantly, perhaps, of the softening of other organs. The various pathological changes, which are found in thegastro-intestinal mucous membrane, begin and are developed, it would seem, at uncertain and indefinite periods, during the progress of the disease. As to the relation which exists between these appreciable lesions —one or many of them—and the disease itself, if we may so speak, I have but little to say. This is a question which is wholly theo- retical in its character. Its settlement, by different individuals, will depend entirely upon the mode of interpreting the phenomena of typhoid fever, and the relations of these phenomena which they may choose to adopt. One thing, however, we may say, and that with great confidence, and without any qualification; to wit, that typhoid fever is not a gastro-enteritis. It may, correctly enough, be called a peculiar enteritis, or a dothinenteritis, but not a gastro enteritis ; and this, for reasons sufficiently obvious. I do not think, however, that we are justified in referring typhoid fever, considered as a disease —as an integral, though complex, pathological condition, and process or series of processes—to this single local lesion of the intestines. I do not think that we are justified in considering the latter as the exclusive origin and cause of the former, as we consider acute inflammation of the mucous membrane of the large intestine the cause of that other disease—that other integral pathological con- dition and process, or series of processes—which we call dysentery. The most striking analogies are all against this interpretation. It seems to me much more satisfactory and philosophical, much more in accordance with what is seen in many other diseases, to look upon the lesion of the elliptical plates, not as the local cause of all the other LESIONS. — GENERAL REMARKS. 89 appreciable phenomena of typhoid fever, but as constituting one of the pathological elements, in a very obscure and complex disease; all which elements, and this quite as much as the others, are themselves the result of some morbific agent, or influence, or process, the nature, sources, and operation of which are wholly unknown to us. The lesion of the elliptical plates seems to me to bear somewhat the same relation to typhoid fever, considered as a disease, as that which their several characteristic eruptions bear to measles, scarlatina, and smallpox. In none of these, have we any right to regard the cutaneous eruptions as the causes of the symptoms, and of the other various phenomena, which go to make up the several diseases themselves. I shall have occasion to refer to this subject hereafter. 90 CHAPTER IV. CAUSES. The only causes of typhoid fever, the influence of which has been at all positively and accurately ascertained, are these three, to wit, age, recent residence in a given place, and contagion. In using the word cause here, I mean merely to express by it some of those circumstances or conditions amidst which the disease under consideration most frequently occurs. The nature and essence of the actual, producing, efficient cause of typhoid fever, as of most other diseases, are entirely unknown to us. Sec I.—Locality. Typhoid fever is evidently a disease of very extensive geographical prevalence. We have not the means of ascertaining its limits, but there is good ground, I think, for believ- ing that these limits are wider than those which circumscribe the prevalence of any other strictly idiopathic, non-eruptive fever. It is the common fever of the Eastern States. It is questionable, indeed, whether this section of the country is the seat of any other fever, unless it be an occasional sporadic case, or epidemic, of an obscure and doubtful character. The extent of the prevalence of typhoid fever in the New England States may be judged of by the following statistics, derived from the bills of mortality for the city of Lowell for a series of sixteen years, from 1830 to 1846, inclusive. The entire number of deaths from typhoid fever amounted to four hundred and thirty-five. There was only one disease which occa- sioned a larger number, and that was consumption. The population of Lowell during this period increased pretty regularly, from 6477 to somewhat more than 20,800. The number of deaths from typhoid fever annually varied from five, in the years 1830 and 1831, to forty-four, in 1839. From 1832 to 1846, the smallest number in any single year was sixteen. This was in 1841; in the preceding year, it was twenty-six ; in the following year, it was forty-three. In.1846, the mortality went up to one hundred and one. These statements serve to show, at the same time, the importance and CAUSES. — LOCALITY. 91 frequency of the disease, and the variations in the extent of its prevalence in different years.1 It prevails, also, more or less exten- sively, in the Middle and Western States. I have often seen it in Kentucky, where it is sometimes called the red tongue fever. It is probably less common in those portions of the United States which are visited by the various forms of intermittent and remittent fever than in those which are exempt from these diseases, although more extensive and accurate observations than have yet been made are necessary to settle this point. Now that the means for correct and positive diagnosis of the several distinct fevers of our country are becoming more and more generally diffused, there is reason to hope that this, as well as some other circumstances in the natural history of typhoid fever, will soon be satisfactorily established. In December, 1846, I addressed letters to the editors of the medical journals, published in the Southern and Western States, inquiring particularly as to the existence, in their respective neigh- borhoods and regions, of typhoid fever. These letters have been promptly and kindly noticed, and they demonstrate very conclu- sively the prevalence, more or less extensive, throughout many portions of the Southern and Western States, of genuine typhoid fever, its symptoms and lesions corresponding exactly to the com- mon continued fever of France and New England. The interest attaching to this subject induces me to make a few extracts from this correspondence. Dr. Mattingly, of Bardstown, Kentucky, says that typhoid fever prevailed extensively in that town during the fall and winter of 1846. He enumerates the following phenomena as very constantly present in cases of moderate severity: " Chills ; increased local or general heat; accelerated pulse, generally about 100; loss of appe- tite ; muscular debility ; more or less diarrhoea ; pains in the bow- els ; dulness of the intellect; more or less delirium ; frequent epistaxis; dry, brown, or red tongue, trembling, and with difficulty put out of the mouth; rose-colored spots, or typhoid eruption ; twitching of the tendons ; a purplish flush on one side of the face, passing over to the other in the course of two or three hours; a greater or less degree of tympanites; somnolence, or watchfulness; ringing in the ears, or deafness ; one or two exacerbations of fever every day, constantly in the evening, sometimes in the forenoon. These symptoms come on gradually, increasing in violence from 1 An Address before the Mass. Med. Soo. By John 0. Green, M. D, 92 TYPHOID FEVER. day to day, for ten or twelve days, when, after remaining about at a stand for a few days, they gradually give way, and one by one pass off, till convalescence takes place." No one will doubt, I take it, the genuineness of the disease thus described. Dr. M. treated, during the season, fifty-three cases. Of these, twenty-six were between fourteen and twenty years of age, eighteen between twenty and twenty-five, and nine between twenty-five and thirty. The average age was nineteen years and a half nearly. There was hemorrhage from the bowels in nine cases. Death took place in five cases. There was one autopsy, showing ulceration of the elliptical plates, and redness and enlargement of the mesenteric glands. Dr. Sutton, of Georgetown, saw in his own town and neighbor- hood, during the year 1846, forty-three cases. He mentions a few trifling differences between his cases, and the disease as described in my book, but none of any importance. He made two autopsies, both of which exhibited the intestinal and mesenteric lesion. Dr. Wooten, of Lowndesboro', Alabama, says: "There are phy- sicians in our State who contend that we have no fevers except those of a remittent or intermittent type. But my experience justifies me in declaring this to be an error. Typhoid fever does exist here. It appears at all seasons of the year; but I think it is most common in spring and early summer. Its occurrence is far more frequent of late years than formerly. In 1836,1 saw but one case of it. In 1837,1 had a very serious attack of it myself; I was seen by some half dozen experienced physicians, all of whom spoke of it as a very rare case. It has gradually grown more and more prevalent, until it is now looked upon as a rather common disease. It is unnecessary to describe the symptoms of this fever. It is sufficient to say that they are those described by you under the head of Typhoid Fever; and that it is unquestionably the disease for which you inquire." I have a sensible letter from Dr. Core, who practises in William- son Co., Tennessee. There is one locality in his neighborhood, which, from the extensive prevalence of typhoid fever, within the last few years, has received the name of typhoid bottom. Dr. Linton, editor of the St. Louis Medical and Surgical Journal, in a short but excellent letter, says: " The fever, or variety of fever, of which you speak, prevails here as in Kentucky, though I think it is not, either here or in that State, generally recognized as the typhoid fever. It is sometimes called winter fever, or nervous fever, CAUSES.— LOCALITY. 93 and sometimes it is not dignified with any specific name. But of the fact, that we have here a continued fever, commencing with chilly sensations, headache, and general malaise, complicated with diarrhoea, and more or less bronchial irritation, and exhibiting in its course, in many instances, the rose spots, or sudamina, or both, and running a course of from three or four or six or seven weeks, there can be no doubt. I have treated several such cases in this city." Dr. Leake, of Yazoo City, Mississippi, says the disease has pre- vailed more or less extensively, for several years, in his neighbor- hood. Dr. Coe, of Dekalb Co., Georgia, says, in a letter, dated March 17, 1847: "About one year ago, an epidemic prevailed very gene- rally over a small extent of country, which I determined to be typhoid fever. The section in which it prevailed had been pre- viously healthy; it is elevated, with a poor soil, and has only one small stream passing through it. The locality of which I speak was about twelve or fifteen miles square, and almost every family, and nearly all the members of each family, except old persons and young children, were attacked by the fever. It was most exten- sive during May, June, July, and August. The number of cases amounted to two hundred. The following were amongst the most common symptoms: Chills, more or less severe; headache, with pain in the back and limbs, which subsided in a few days; thirst, heat of the skin, acceleration of the pulse, and an evening exacerba- tion; entire loss of appetite; great muscular debility; dulness and confusion of the intellect, passing gradually into delirium; great rest- lessness, subsiding just before day, to some extent, to commence again about breakfast-time; twitching of the tendons; picking at the bedclothes, or at imaginary objects; occasional epistaxis; ring- ing or buzzing in the ears; a dry glutinous, cracked, red, or brown, or blackish tongue, protruded with trembling; dark, thick sordes on the teeth; diarrhoea, the stools thin and watery, dark or yellow- ish, sometimes bloody; tympanitic state of the abdomen ; gurgling of the right iliac region on pressure. The disease was confined to persons between the ages of ten and forty years. There were twenty-two or twenty-three fatal cases." Dr. John P. Mettauer describes a continued fever of Middle and Southern Virginia. From 1816 to 1829, he treated more than four hundred case. He says the disease prevailed in three forms, to wit, those of synocha, typhoid, and typhus. Dr. Mettauer's descrip- 94 TYPHOID FEVER. tion of the disease is not sufficiently minute and detailed to enable us to judge of the reality of these distinctions. The probabilities, however, are that the disease was true typhoid fever, and nothing else.1 Dr. Austin Flint, of Buffalo, has published an account of the disease, as it prevailed at the little settlement of North Boston, in 1843. The disease seems to have been introduced by a traveller from Massachusetts. Of forty-three persons, constituting the entire population of the village, twenty-eight had the fever between Octo- ber 19 and December 7. Ten cases terminated fatally.3 Dr. Samuel Jackson speaks of its frequent and extensive preva- lence in the region of Northumberland, Pennsylvania.3 In the statement of deaths in New Orleans, for the last six months of the year 1844, forty-four are set down to typhoid fever- In the report of the New Orleans Charity Hospital for 1844, ninety- two cases are classed as typhoid fever.4 I do not know how confi- dently the diagnosis, in these cases, is to be relied upon. It would seem that the typhoid is the most common and gene- rally diffused fever of the temperate latitudes of the continent of Europe. Certainly it is so of France, where it has been most ex- tensively and thoroughly studied. It seems to be also the common fever of Germany. In vol. xlviii. of the Edinburgh Medical and Surgical Journal, there is a notice of this disease, as it is described by several writers, prevailing at Brux, in Bohemia, Dresden, Berlin, and at Stangenrod. Burserius describes the disease very fully and accurately, under the title of slow nervous fever.5 Louis saw it at Gibraltar in 1828. It occurs with considerable frequency in the British Islands, although it is not their most common form of fever. The means, however, for ascertaining, with any degree of precision, the actual extent and frequency of its prevalence in the several portions of Great Britain, do not exist, for the obvious reason that no distinction has generally been made between this disease and the contagious typhus. It will probably be found to be of more common occurrence, in certain portions of the country, than in others, and at certain seasons or periods of time. This subject will necessarily come before us again in the account which will be given of the investigations that have been made, within the last few years, in regard to the identity, or the non-identity, of typhus and typhoid fever. It cannot, however, be fully settled, without the aid of 1 Amer. Journ. Med. Sci., July, 1843. 2 Ibid., July 1845. 3 Ibid., Oct., 1845. 4 N. 0. Med. Journ., vol. i. pp. 390, 392. s Inst. prac. Med., vol. i. p. 479. CAUSES.—LOCALITY. 95 observations very much more extensive and discriminating than have yet been made. In the mean time, we can only approximate to the real truth in regard to the matter. Typhoid fever seems to have been of common occurrence at Dublin, from 1826 to 1829. Dr. Kennedy states that he found the elliptical patches more or less diseased in a large proportion of cases during this period, present- ing a striking contrast, in this respect, to the contagious typhus of 1837. Dr. Stokes also says: " In the epidemic of 1826 and 1827, we observed the follicular ulceration, in the greater number of cases. In many instances, perforation took place, and the whole group of vital and cadaveric phenomena corresponded almost exactly to the dothinenteric affection of the French authors."1 In Edinburgh, Dr. Christison says: " The intestinal affection has repeatedly presented itself in groups; the constitutio dothinenterica, to speak in nosogra- phical language, has repeatedly appeared and disappeared, as a sub- ordinate or intercurrent epidemic, in the course of the more general epidemic typhus."2 At Anstruther, in Fifeshire, only thirty miles distant from Edinburgh, this would seem to constitute, as it does in France and in New England, the common form of fever. Mr. John Goodsir, Jr., informed his friend, Dr. Reid, of Edinburgh, that for five years he had attended about one hundred cases of fever, annu- ally, in Anstruther and its neighborhood, amongst which there had been fifteen deaths. In ten of these, he had succeeded in obtaining post-mortem examinations; and in all of them he had found the elliptical plates, and the isolated follicles of the lower portion of the ileum, elevated and ulcerated, and the mesenteric glands enlarged and softened. In four cases, perforation of the intestine had taken place. From the slight sketch of the symptoms, given by Dr. Reid, as well as from the abdominal lesions, there can be little doubt, I think, as to the character of the fever.3 It would seem, also, to be very common at Birmingham. Dr. Ward has published an account of a fever which prevailed in certain quarters of that city in the summer of 1837, in all the fatal cases of which, the lesion of Peyer's glands is said to have been present. Mr. Henry Edmonstone has published, in vol. xix. of the Edinburgh Medical and .Surgical Journal, a short account of the prevailing fever at Newcastle-upon-Tyne, in the years 1821 and 1822; from which it is quite evident that the fever was typhoid. In vol. xli. of the 1 Dunglison's Medical Library. 3 Edin. Med. and Surg. Journal, Oct., 1839. 2 Ibid. 96 TYPHOID FEVER. same journal, there is a pretty full and valuable history, by Richard Poole, Esq., of what he calls an epidemic gastric fever, which pre- vailed in Limerick garrison, during the summer of 1833, and which was clearly typhoid fever. Nearly all the most characteristic symp- toms of the disease were strongly marked. In the same volume, there is another history, by the same gentleman, of a similar epi- demic, which prevailed at Templemore, county Tipperary, Ireland, in the latter part of 1833. Dr. Stewart remarks that, during the summer and autumn of 1836, the cases of typhoid fever received into the Glasgow Fever Hospi- tal were numerous; while from the month of November, in that year, at which time both the type and the amount of typhoid fever became more formidable, till June, 1838, the period at which his connection with the hospital ceased, not more than a dozen cases, and these at long intervals, were admitted.1 Dr. Jenner says: " Typhoid fever is a very common disease, especially in young per- sons; it is the endemic fever of London."2 Hillary, in his account of the diseases of Minorca, describes a slow nervous fever, which was, very evidently, typhoid. He says: " The fever put on and appeared in this warm climate, with all the same symptoms as it usually does in England; and as they are ac- curately described by that learned and able physician Dr. Huxham, in the cooler climate of Plymouth. This slow nervous fever was certainly infectious, for I observed that many of those who visited, and most of them that attended, the sick in this fever, were infected by it, and got the disease, and especially those who constantly attended them, and performed the necessary offices for the sick."3 As to the influence of circumscribed localities upon the preva- lence of the disease, very little is known. It is sometimes absent from large sections of the country, for a considerable period of time. Nathan Smith says that for the first eight years of his prac- tice, which was somewhat extensive in the latter part of the last century, near the Connecticut River, in New Hampshire, he neither saw nor heard of a single case of the disease. Subsequent to that time, for a period of twenty-five years, he " never so far lost sight of the disease as to be unable to follow its changes from one place to another, and to tell where it was prevailing." " It seems to pos- sess," he adds, " a migratory character, and travels from place to place; and after remaining in one village for a longer or shorter 1 Ibid., Oct., 1840. 2 Medical Times, 8th paper, p. 11. 3 Rush's Hillary, pp. 30, 44. CAUSES. — LOCALITY. 97 time, as from one year to two or three, it ceases and appears in an- other."1 It prevails often and extensively in the manufacturing villages of New England. This may, perhaps, be sufficiently ac- counted for by the circumstances favoring the occurrence of the disease, connected with the population of these villages. These are age, duration of residence, and exposure to contagion. In the city of Lowell, the largest manufacturing place in the Eastern States, containing now, 1852, a population of about thirty-five thousand, an unusual proportion of whom are between the ages of fifteen and thirty, and very many of whom are new residents, the disease has been almost constantly present for the last twenty-five years. In some years and seasons, it has prevailed much more extensively than in others: and not unfrequently, for considerable periods of time, the cases have been occasional and few. It is a very common circumstance for it to exist more extensively in certain portions of the city than in others. But there is nothing fixed in these locali- ties ; they are sometimes in one part of the city, and sometimes in another. Instances have frequently been noticed, also, in various parts of the country, in which the disease is confined to a single family in a neighborhood. In these cases, several members of the family are sometimes taken with the disease nearly simultaneously; at others, they are affected in succession, one after another, so that the fever may occupy some months in passing through the family. Dr. James Jackson, of Boston, noticed this circumstance, particu- larly, in a paper in the New England Journal of Medicine and Sur- gery, for July, 1822. He supposes the cause to be in some way connected with the soil of the immediate locality, although not at all depending upon any filth, or decomposing substances, since no such substances could be discovered, and since the houses were often new, clean, in good situations, and occupied by families in easy circumstances. He expresses his disbelief in the agency of contagion, although he says that he has often known the disease to occur°in friends, and hired nurses, who had gone from other families to attend the sick, especially when such persons have remained in the house with the diseased subject, for two or three days at least, and generally for a longer time. A remarkable example of the obscurity in which some of the causes of typhoid fever are envel- oped, and of its singular and inexplicable connection, at certain times, with certain localities, was exhibited during the winter of 1 Smith's Med. and Surg. Memoirs, p. 46. I 98 TYPHOID FEVER. 1834-5, in the city of Lowell. In the course of the winter, there were occasional cases of the disease, in almost every part of the city, but by far the greatest number occurred amongst the female operatives of a single cotton mill; and most of these, even, were confined to two rooms. This mill is situated on a line with five others, and in their immediate vicinity. It is about one hundred and fifty feet in length, and five stories high; the rooms occupying the whole length and breadth of the mill, with numerous windows on every side. The ground room was used for carding, and the average number of hands employed in it was thirty-five. There was not a single case of the disease from this room. The second story was used for spinning. Four females employed in it went out sick during December; one on the 8th, 9th, 10, and 15th, respectively. The one who left on the 10th died on the 27th of the same month. The average number employed in this room was sixty. The third story was appropriated to weaving, and the average number of opera- tives employed in it was sixty-five. Between December 5th, 1834, and January 22d, 1835, twenty six girls left this room ; all of whom, excepting some three or four, were ascertained to have had the fever. They left the mill in the following order: one Dec. 5th, two on the 11th, one on the 13th, one on the 18th, two on the 20th, two on the 21st, three on the 22d, two on the 23d, one on the 24th, 27th, and 31st, respectively. One left Jan. 5th, two on the 8th, two on the 9th, and one on the 10th, 12th, 21st, and 22d, each. The fourth story was used for the same purpose, and had the same num- ber of employed hands as the third. Between Dec. 13th and Jan. 27th, eighteen girls left this room sick. One left Dec. 13th, one on the 17th, two on the 19th, one each on the 20th, 22d, and 23d; two on the 24th, and one on the 27th. Three left Jan. 1st, and one on the 7th, 9th, 10th, 16th, and 27th, successively. From the fifth story, occupied as a weaving-room, and having from twenty-five to thirty girls employed in it, there were but two sick. One of these left the room Jan. 10th, and the other Jan. 17th. Thus, of one hundred and thirty females, employed in two rooms of the same building, nearly one-third were attacked with typhoid fever between the days of Dec. 5th, 1834, and Jan. 27th, 1835. Of this number, nine died in Lowell. There were also two deaths ascertained to have taken place amongst those who left the city immediately on leaving the mill. During this period, there were a few cases of fever in various other parts of the city. Nothing could be discovered about the mill or the two weaving-rooms in CAUSES. — LOCALITY. 99 any way to account for the connection of so many cases with this particular mill, and these particular rooms. There was but a very small number sick from the neighboring mills. The overseer of the room in the third story, where the largest number was attacked, informed me that, for nearly five years, during which he had had the care of the room, there had been amongst those at work in it only three deaths. The weather, at the time when the fever began to show itself, was extremely cold. There did not seem to be any connection between the disease and the situation of the boarding- houses of those who suffered from it. These houses accommodated from twenty to thirty girls each; in a few of them, there were two or three patients sick at the same time, but in many of them only one. An instance of this connection of the disease with circumscribed localities, somewhat similar to the foregoing, took place in 1835 at a woollen manufacturing establishment on the Neponset River, in Dedham; a short account of which was published by Dr. Jackson in the Boston Med. and Surg. Journal. On the 11th and 12th of April, eighteen girls, living in the same house, were attacked with typhoid fever; one of whom died. All these girls worked in one of two mills, near the house. From the other mill, there were no cases; neither were there any cases in the neighborhood, excepting those in this one boarding-house. The entire number of its inmates was fifty-eight. The house had been built only eight years; it was clean, and not crowded; and no death had ever taken place in it till about a week before the appearance of these eighteen cases of fever. On the 5th of April, a girl from the same mill with the others died, after an illness of nearly three weeks, with what was at first considered by her physician, Dr. Spear, as scarlatina; but which he regarded subsequently as typhoid fever. All the females who were attacked on the 11th and 12th of April had seen this first patient; some of them, however, only after death. In May, another girl had the fever; not an operative in the mill, but a domestic in the boarding-house. Dr. AVooten, of Lowndesboro', Alabama, in a letter to me upon the subject of typhoid fever in his neighborhood, says: "There is a circumstance connected with its prevalence here worthy of note. We have a high ridge of land, possessing a sandy and gravelly soil, which affords many springs of good freestone water, and is selected by many planters, who occupy the surrounding country, for their residences. This ridge is about six miles long, and from one to 100 TYPHOID FEVER. three miles wide, and at its nearest point about three miles from the Alabama River. It is surrounded by prairie plantations and prairie sloughs on all sides except that towards the river, where it is bordered by a low, pondy, and malarial country. In all the sur- rounding country, intermittent and remittent fevers are an annual matter-of-course occurrence, whilst the true typhoid is extremely rare, though cases of it do sometimes occur. But upon the ridge, where remittents and intermittents are of very rare occurrence, the typhoid cases are of frequent occurrence, especially during the last few years; so that many planters say they would prefer remaining on their plantations, and having their regular turn of chills and fever, to residing on the ridge and risking this slow fever? There is a pretty common opinion that typhoid fever has a ten- dency to come in and take the place of intermittents and remittents, as these diseases, from the effects of cultivation and from other causes, diminish and disappear. Dr. Austin Flint, of Buffalo, says: " That typhoid fever has, to a great extent, superseded the remit- tent form, has been a matter of frequent remark for some time; and in a brief enumeration of the distinctive traits of remittent, typhus, and typhoid fever, published by us in the first volume of this jour- nal, we mentioned this as a sentiment generally entertained by the profession in this region. That some allowance is to be made from the fact already referred to, that the boundary lines between the two forms are now much more clearly drawn, and have been rendered more familiar to practitioners, we regard as highly probable; yet we think there cannot be a doubt that a striking change has taken place within a few years past, and that typhoid fever, from having been, to say the least, of unfrequent occurrence, has become frequent and is becoming more and more so, remittents diminishing in fre- quency after the same ratio."1 These views are corroborated by some conclusions to which M. Boudin has recently arrived. He says that there exists an anta- gonism between typhoid fever on the one hand, and intermittent fever and phthisis on the other. "Those localities," he says, "in which the producing cause of endemic intermittents thoroughly modifies the constitution, are remarkable for the infrequency of pulmonary phthisis and typhoid fever. The localities in which phthisis and typhoid fever are particularly prevalent are remark- able for the infrequency and mildness of intermittent fevers con- tracted on the spot. The drying up of a marsh, or its conversion 1 Buffalo Med. Journ., Feb., 1847. CAUSES.—LOCALITY.—CONTAGION. 101 into a lake, diminishes or prevents intermittent fevers, but seems to dispose the organism to a new series of diseases, in which pulmonary phthisis and typhoid fever, according to the climate, are particu- larly prominent. After a residence in a thoroughly marshy locality an individual enjoys an immunity from typhoid fever, the degree and duration of which are in direct proportion to the length and degree of the exposure."1 Sec II.—Season. It is not settled how far typhoid fever occurs, with any degree of uniformity, more frequently in one season of the year than in another. The common impression, in New England, is, that it prevails oftenest in the autumn. Dr. James Jackson says, expressly, that such is the fact; although he admits that it may be seen in any month of the year. Nathan Smith does not speak of its occurrence more frequently at one season than at another, and he thinks that he has seen it, not only in every month, but in every day of the year. Amongst the epidemics mentioned by Gendron, one continued from May to October, one from February to May, and one from March to January. The most extensive and fatal visitation of the disease, in the city of Lowell, took place during the winter and early spring. I am very sure, however, that, as a general rule, its annual prevalence is greatest in the autumn. In New England, it is not unfrequently called the autumnal or fall fever. In the Richmond epidemic of 1840, the first case occurred on the 22d of August; there were, in August, six cases; in Sep- tember, seventeen ; in October, ten ; in November, six; in Decem- ber and January, 1841, each two; and in February three—the last case commencing on the 28th of this month. The disease then disappeared till the 16th of August, 1841, when it returned. There were, in August, four cases; in September, six; in October eighteen; in November, seven; in February, 1842, one; in March, seven; in April; one; arid in May two. From May 3d, 1842, to August 4th, there was no new case. The disease then reappeared, and there were, in August, three cases; in September, two; and in October, one. I have the following statement from Dr. Gilman Kimball, illus- trating the influence of season upon the prevalence of typhoid fever. There were admitted to the Lowell Hospital, during seven years, from May, 1840, to May, 1847, six hundred and forty-five patients 1 London Lancet, March, 1847. 102 TYPHOID FEVER. with typhoid fever. They were distributed amongst the twelve months in the following manner, to wit: May, forty-one; June, thirty; July, forty-seven; August, eighty-six; September, ninety- two; October, ninety-eight; November, sixty; December, forty- eight; January, thirty-nine; February, forty-three; March, forty; and April, twenty-one. Two hundred and seventy-six cases were admitted during the months of August, September, and October. The number of deaths was twenty-nine, giving a mortality for the entire period of only one in twenty-two and a quarter. The general treatment is negative and expectant; many of the patients taking nothing but gum Arabic and drinks. One hundred and eighty-three cases at Strasbourg were distributed amongst the four seasons in the following manner, to wit: spring, thirty-eight; summer,forty-nine; autumn, sixty; winter,thirty-six.1 Sec III.— Contagion. The general opinion has been that typhoid fever is not propagated by contagion. Louis, in his first edition, published in 1829, says nothing upon this subject. Chomel, in his Lecons de Clinique Medicale, published in 1834, although he himself was inclined to the opposite opinion, says that not more than one physician of a hundred, in France, regarded the disease as contagious. Andral says he never saw any evidence of its contagiousness. Dr. James Jackson says, if he were to answer from general experience, he should say that instances occur in which there is much in favor of the doctrine of contagion; but that, in the very great majority of instances, there is not any such evidence. He relates some cases, occurring amongst the hospital nurses, apparently attributable to contagion.2 In 1829, M. Bretonneau read to the Royal Academy of Medicine a paper, intended to show that the disease, as it pre- vailed in the country, was often transmitted from one individual to another. Leuret, about the same time, adopted a similar opinion. The subsequent researches of Gendron, Ruef, Putegnat, and others have confirmed this opinion, and Louis has adopted it in the second edition of his work, published in 1841. Many years, however, previous to these publications, Nathan Smith asserted, in the most positive and unqualified terms, the contagious character of this disease. His essay was published in 1824. "That the typhus fever is contagious,"he says, "is a fact so evident to those who have seen much of the disease, and who have paid attention to the subject, 1 Traite de l'Enterite Folliculeuse. Par C. P. Forget, p. 409. 2 Report, &c, p. 144. CAUSES.—CONTAGION. 103 that I should have spared myself the trouble of saying anything in regard to it, did I not know that there are some physicians in this country who still dispute the point; one which I think can be as fully demonstrated as that the measles, smallpox, and other diseases, universally allowed to be contagious, are so."1 Dr. Smith then mentions several instances, which had fallen under his own observation, where the disease seemed to have been communicated through the medium of a contagious principle. From amongst these, I select the following. "A young man, a pupil of mine, was attacked with the typhus fever, from which he recovered with some difficulty. Some of his family, who lived about forty miles distant, came and took care of him during his sickness. Upon his recovery, they returned home in good health, but soon after sickened with the same disease, and communicated it to others, who had not been exposed in the first instance. From this, it spread to numerous other families in the vicinity, who had been exposed to the contagion. In the whole town where this occurred, there had been no case of typhus fever for many years, till brought there by the circumstance above related." "During the prevalence of the typhus fever in Thetford, Vermont, a woman went there from Chelsea, about ten miles distant, to visit and administer to a sister sick of this disease. Upon her return, she was herself attacked by it, and soon after died. Others of her family contracted it of her; and in about four weeks there were thirty persons taken down with typhus, all of whom had been exposed to the contagion."2 Dr. Samuel Jackson, formerly of Northumberland, relates several striking instances, similar to those quoted from Nathan Smith, showing the contagious quality of the disease.3 The memoir of M. Gendron, upon this subject, is very full and elaborate. He adduces a great number of instances, similar to those above quoted from Dr. Smith, many of them very striking and conclusive, to show the contagiousness of the disease. He believes that it is transmissible by direct and repeated contact; by the presence of the sick, without contact; that it may be carried from a sick person, and communicated to another by a third, who does not have the disease; and also, that it may be contracted from exposure to infected clothing, beds, and similar fomites. He 1 Smith's Med. and Surg. Memoirs, p. 47. z Ibid., pp. 47, 84. 3 Amer. Journ. Med. Science., Oct., 1845. 104 TYPHOID FEVER. regards the first-mentioned mode of transmission as altogether the most common. The indirect transmission of the disease from one individual to another, through the intervention of a third, he thinks does not often happen, except when it is prevailing more or less extensively as an epidemic. The disease is most frequently com- municated to those who are in the closest and most constant relation to the sick—their nurses, and immediate attendants. According to the observations of M. Gendron, typhoid fever propagates itself very slowly by contagion. The interval between the successive cases varies from three weeks to a month; so that the fever is often several months in spreading through a village, or neighborhood. The period of incubation, he thinks, rarely exceeds eight or ten days, though it sometimes extends to fifteen, and is occasionally as short as twenty-four hours. He is also led to the conclusion that the power of transmission, or communication, does not exist in the early perio.d of the disease; that it is rarely active before the sixteenth day; and, in general terms, that it continues from the third week to an indefinite period, including convales- cence. He states some facts which seem to show that the con- tagious matter of the disease may remain active in a bed for two or three years. He supposes it probable that certain circumstances connected with the disease in the country, such as small, close rooms, and the more constant presence of their attendants with the sick, may render its contagious character more obvious and certain there than in cities. He acknowledges that, in many instances, he has been wholly unable to ascertain the source and origin of the first case, from which the others have been derived; and he admits, in their fullest extent, the great number of examples of immunity from the disease, after the most marked exposure; but he says, very truly, that all this is as frequently seen in scarlatina, a disease unquestionably contagious, as it is in typhoid fever. It is easy to see that this question is one of great practical im- portance. It can be fully settled only by further and more various observations; and these observations, for obvious reasons can be best made amongst the scattered population, and in the small villages, of the country. The paper of M. Gendron is drawn up with great fairness, and it throws much new and valuable light upon the subject, although he sometimes adopts conclusions favora- ble to his opinions which his facts are hardly sufficient to justify. He is somewhat too ready, in the present state of our knowledge, to consider all cases of the disease, that are in any way susceptible CAUSES. — EXEMPTION FROM SECOND ATTACKS. 105 of being accounted for by the action of a contagious principle, to be, certainly and necessarily, so accounted for. [M. Piedvache1 has written an elaborate paper to prove that this fever is contagious; but he holds that two conditions are essential to its communicability: 1st, neglect to renew the air about the sick person; and 2d, remaining a considerable time near the sick. Contagion is for him incontestable, as well established as any other scientific fact—all the facts, however, go to prove that the con- tagious principle must be concentrated to produce the disease. At the same time that he urges this opinion, he also believes that the affection may be produced and spread through other agencies.] Sec IV.—Exemption from Second Attacks. There is one other circumstance bearing upon this question, which it is important to notice. I mean the immunity from a second attack which seems to be conferred by the occurrence of the disease. M. Gendron gives several remarkable instances of this exemption. The village of Petit-Genes, containing only fifteen persons, was visited by typhoid fever in 1826. Twelve of these persons suffered from the fever, and of the three who escaped two had had it previously. In March, 1829, the disease reappeared in the village, apparently introduced by contagion, and was confined to a single family, who had taken up their residence here, subsequent to the year 1826. Five mem- bers of this family had the fever, and although they were constantly visited, and nursed during the nights, by their neighbors, the sub- jects of the disease in 1826, the fever did not extend beyond the family.2 Chomel says that, of one hundred and thirty patients, at the Hotel Dieu, no one, so far as this point could be ascertained, had previously had the disease. The same immunity was noticed by Nathan Smith. He says: " My own personal experience is strongly in favor of the opinion I have advanced of the non-liability of the same individual to a second attack of typhus ; for during the twenty-five years, since I first attended patients in this disease, and in that time I have visited many hundreds, and have witnessed its prevalence several times in the same village, I have never known nor heard of its recurrence in the same person. 1 [Recherches sur la Contagion de la Fievre Typhoid. Mem. d l'Acad. de M6d., 1850.] 2 Memoir sur les epidemies des petites localites. Par M. Gendron. Journal des Connaissances Medico-chirurgicales. Annee, 1834. 106 TYPHOID FEVER. " I once attended a numerous family, every member of which was sick of typhus, except two, who escaped at that time; but two years afterward, when the disease again appeared in that neigh- borhood, those two individuals of the family, and those alone, were attacked. " In another family which I attended, consisting of eight persons, five of the eight had the disease during the autumn and early part of the winter, and recovered. The next summer, the remaining three, and another person who had been added to the family after the former sickness, were attacked by it, while all those previously affected escaped."1 In 1840, there was an extensive local epidemic of typhoid fever in the town of Richmond, Berkshire County, Mas- sachusetts. It was carefully observed by Dr. Jennings; some of the cases were seen by Dr. Alonzo Clark, and Dr. Willard Parker, so there could have been no doubt as to the true character of the cases. The epidemic reappeared in 1841, and three of forty six per- sons suffered with a second attack of the fever. There were forty- six cases during each year.2 [The observations of M. Piedvache were made in the country, extended over many years, and he often saw the same place and the same family more than once visited by the disease, yet in four hundred and fifty-two cases he did not find a single individual attacked by it a second time. One case of second attack, however, came under his notice while he was preparing his memoir.] It need hardly be said that this character of typhoid fever, if fully established, although not in itself positive evidence, does, nevertheless, constitute a strong ground of belief, resting on analogy, for the contagious nature of the disease. Sec V.—Epidemic Influences. Typhoid fever occurs both in a sporadic and epidemic form. Single, isolated cases are not unfre- quently met with; extensive regions of country are sometimes entirely exempt from the disease, for considerable periods of time; and again it often prevails, as I have already had occasion to say, either in circumscribed neighborhoods, or over wider ranges of country, so generally and extensively as to assume an epidemic character. The disease, in this epidemic form, as I have before stated, becomes migratory in its character, wandering about the country, attacking one neighborhood this year, another the next, and so on. It frequently happens that the disease returns, at nearly 1 Smith's Med. and Surg. Memoirs, p. 52. 2 Dr. Jennings's Letter to Prof. Clark. CAUSES. — AGE. 107 the same season, to the same locality, for two or three years in suc- cession, and then wholly disappears. Sec VI.—Age. The influence of age in the production, or per- haps in the permission, of typhoid fever is very striking, and very accurately ascertained. Setting aside, for the moment, the early period of life, this disease generally occurs between the fifteenth and thirtieth years. It would seem probable that a majority of cases occur during the seven years between eighteen and twenty- five. It is not often seen after the fortieth year, and but few cases are recorded in which it has occurred after the fiftieth year. Of one hundred and thirty-eight cases, analyzed by Louis, fifty-nine were between the ages of twenty and twenty-five years. Of one hundred and seventeen cases, mentioned by Chomel, ninety-one were between the ages of eighteen and thirty years. The average age in two hundred and ninety-one cases, occurring in the Massa- chusetts General Hospital, analyzed by Dr. Jackson, was twenty-two years and a third, nearly. In these cases, the average age of the females was somewhat more than a year greater than the average age of the males. I do not know whether this difference has been noticed elsewhere by other observers. [Piedvache states that in the epidemics which he witnessed, nearly all the old men escaped, but he finds among his cases nine women between fifty and sixty years of age, and five between sixty and seventy.] It may also be stated here, although I shall have occasion to speak of it more particularly when I come to treat of the prognosis in this disease, that the average age of the fatal cases is somewhat greater than of those which recover. Dr. Jenner says: " Of nearly four hundred individuals suffering from typhoid fever, received into the London Fever Hospital, three only have been more than fifty years of age; the ages of these three individuals were respectively fifty-one, fifty-five, and fifty-five years. Two of them were women, one a man. A brief account of the latter case is contained in the present paper. The fact that typhoid fever is very rarely observed after the age of fifty has been confirmed by every observer of the disease." I am inclined to think that this disease occurs more frequently after the fortieth year of life in the country than seems to be the case in cities. Nathan Smith says nothing about its being particu- larly prevalent amongst the young; and in Gendron's memoir upon the disease, as it occurred in one of the French provinces, seven 108 TYPHOID FEVER. cases are mentioned in which the patients were between forty and fifty; three, where they were between fifty and sixty: and four, where they were between sixty and seventy-five years of age. I once saw an unequivocal case in a country-woman sixty-three years old. . M. Lombard, of Geneva, relates a case occurring in a woman seventy-three years old.1 The opinion which I expressed above, in the first edition of my book, finds a striking corroboration in Dr. Jennings's account of the epidemic at Richmond, Berkshire County, Massachusetts, in 1840, 1841, and 1842. The whole number of cases, during this epidemic, was ninety-eight; and the average age was thirty-two years and two-thirds, although in this number are included nine children, from five to twelve years old. Forty-five, nearly half, were thirty- five years old, or over; forty-one were forty years old, or over; twenty-one were fifty years old, or over; and eight were sixty years old, or over. The oldest was seventy-one.2 [The protective in- fluence of the fever itself, undergone at an early age, is not to be lost sight of in considering the comparative exemption enjoyed by the aged, and perhaps the want of this protection was one among the circumstances that may account for the extraordinary high average of age in Dr. Jennings's cases. The town of Richmond has a farming population of about nine hundred persons; though probably not more than three hundred were within the range of this epidemic. This township received its first inhabitants about ninety years before the epidemic of 1840, and until that year had never been visited by fever except in a few sporadic cases; so that in its epidemic form it was regarded by the inhabitants, and by some of the physicians in the neighborhood, as a new disease. Few of the aged had therefore the protection of a previous attack. Still there is good reason for believing that after twenty-five or thirty years of age, the influences which produce typhoid fever are less and less efficient as age ad- vances.] Amongst the young, typhoid fever occurs most frequently be- tween the ages of nine and fourteen years. From five to eight, it is less frequent; and still less so at an earlier period. Of one hundred and twenty-one cases reported by Taupin, ten were in children not over four years old; one case occurred at two years; a few, earlier than this; and one, at seven months. Sec VII.—Sex. The influence of sex in the production of 1 Rep. Ann. de la Soc. Med. de Geneve, 1843, p. 21. 2 Dr. Jennings's Letter to Professor Clark. CAUSES. — OCCUPATION. 109 typhoid fever is not determined. Nathan Smith did not notice any difference in the liability of the two sexes. Dr. James Jackson expresses his belief that the disease occurs amongst men much more frequently than amongst women. M. Tardieu observed that, at the village of Ventenges, in France, in 1835, women and child- ren were most frequently attacked. M. Ruef says that, in the epi- demic of Bischoffsheim, in 1832, females suffered more extensively than males. These facts may, perhaps, be accounted for by the more frequent and constant exposure to the sick, to which females are subject in their capacity of nurses and attendants. Of ninety- eight cases occurring at Richmond, Massachusetts, thirty-eight were amongst males and sixty amongst females. Of Barthez and Rilliet's one hundred and eleven children with the disease, eighty were boys and thirty-one girls; of Taupin's one hundred and twenty-one cases, eighty-six were amongst boys and thirty-five amongst girls. [If we may suppose the disease equally fatal in the two sexes, bills of mortality will aid in resolving this point. The fever of New Eng- land and of the city of New York for several years preceding 1847 was almost exclusively of the typhoid type. The deaths charged to "fever" and "typhus," in the Massachusetts Reports for 1845 and 1846, are thirteen hundred and eighty-three—of these, six hundred and eighty were from the disease in males, and seven hundred and three in females. In the New York Reports, eight hundred and sixty-one deaths appear to have been caused by typhoid fever in five years, four hundred and sixty-one in males and four hundred in females. It seems probable that the influence of sex in pro- ducing typhoid fever is not one of cardinal importance.] Sec VIII.—Race. Whether the liability to typhoid fever is in any degree influenced by race or not, I am unable to say. I have often made the inquiry of practitioners in Kentucky as to the com- parative liability of the two races to the disease, but without any satisfactory result. Dr. Mattingly, of Bardstown, is inclined to think that negroes are somewhat less subject to the disease than whites. Dr. Sutton, of Georgetown, Ky., saw in 1846 forty-three cases; thirteen of these were amongst negroes.1 Dr. Lewis, of Mobile, says: "In the winters of 1835, 1836, and 1837, hundreds of negroes died of a low typhoid fever in the mid- dle part of Alabama. All infectious diseases, which prevail usually in winter and spring, attack them more violently than the whites."2 1 Letters to author. 2 N. 0. Med. Journ., vol. i. p. 417. 110 TYPHOID FEVER. Sec. IX.— Occupation. There is no evidence that any occupation or profession in itself in any way predisposes to this disease, or preserves from it. Sec X.—Recency of Residence. The researches of Louis and Cho- mel show, conclusively, that, in the city of Paris, typhoid fever occurs more frequently amongst new than amongst old residents. This difference is very great. Of Louis's one hundred and twenty- nine patients, all but twenty-seven had resided in Paris only twenty months or less; forty-four only five months or less; and only four had resided there from infancy. Of Chomel's ninety-two patients, at the Hotel Dieu, forty-five, almost one-half, had resided in Paris only one year, or less; and only two had lived there from infancy. I do not know whether this influence has been noticed in our own cities. In the city of Lowell, the disease has generally attacked those who have not been long residents there; but it would not be safe to rely upon this fact alone, since a large part of the young population of that place have been residents, at most, for only a few years. It is very certain, I think, that the influence now under consideration cannot be so obvious in the country as in large towns and cities. No notice is taken of it by that sagacious and careful observer, the late Nathan Smith. I have known the disease to pre- vail extensively, and in a very grave form, amongst the permanent residents of a country village. This, indeed, is a frequent occur- rence in the agricultural regions of our Eastern States, and of France, where the population is generally native and fixed. Sec XI.—Filth, Crowding, &c. In regard to the action of putrid • substances, and to the influence of scanty and unhealthy food, it is sufficient, perhaps, to say that there is no satisfactory evidence of their operation in giving rise to the disease. Piorry is of the opinion that a majority of the patients in the Paris hospitals are received from small and poorly ventilated lodg- ings ; but the influeuce of this cause in giving rise to typhoid fever is not generally admitted, and certainly does not seem to be very evident.1 Sec XII.—Exposure, Excesses, &c. The effect of what are usually regarded as the most common exciting causes of many forms of 1 Clinique Medicale de l'H6pital Pitie. Par P. A. Piorry, p. 175, et seq. CAUSES. — EXCESSES, ETC. Ill disease, such as exposure to cold, strong moral impressions, errors of diet, and excesses, is not very obvious, in the production of typhoid fever. Of one hundred and fifteen patients, at the Hotel Dieu, who were examined by Chomel upon this point, seventy-nine were wholly unable to refer the access of the disease to any appre- ciable cause. It may be added, further, that persons suffering from the disease are generally, immediately previous to the attack, in full health. 112 CHAPTER V. VARIETIES AND FORMS. Typhoid fever, like almost all diseases, exhibits many varieties in its character and appearances, some of which, before proceeding to speak of its diagnosis, it is important to notice. One of these varieties depends upon the degree of severity of the disease. Louis divides his cases into three classes, consisting—first, of those which terminated fatally; second, of those which were grave and severe, but which recovered; and, third, of those which were mild. It is obvious enough that this arrangement is somewhat arbitrary, that the several degrees of severity must run off by imperceptible gra- dations, like the colors of the spectrum, into each other, and that oftentimes the line of demarcation between the classes must be shadowy and doubtful. Nevertheless, the distinction really exists; in a great majority of cases, there is but little difficulty in recog- nizing and appreciating it, and it is one not only of convenience, but of great practical value and importance. It is a very common occurrence for nearly all the more grave and alarming symptoms of the disease to be absent from its com- mencement to its termination in health; and where its diagnosis is not well understood, these cases are often mistaken for some other disease. Under these circumstances, there is frequently but slight febrile excitement, little or no thirst, no affection of the mind, no diarrhoea, no pains in the abdomen. The patient sleeps well; the tongue may be nearly clear, slightly sticky, or covered only with a thin, brownish coat; there is little or no restlessness, or suffering of any sort; and the patient wonders why he is sick, and why he is obliged to lie in bed. But he is obliged to lie in bed. Place him in his chair, and he very soon wishes to get back to his bed. On assuming a sitting or upright position, he finds that he does not feel so well; his muscular strength is gone; his debility, though not extreme, is out of proportion to his other symptoms; and he is troubled, perhaps, with dizziness, or ringing in the ears. It will be found, on inquiry, that either suddenly, in the midst of good VARIETIES. — LATENT FORM. 113 health, or after a few days of vague and indefinite not being well, the patient was attacked with a chill, accompanied or immediately followed by pains, generally of moderate severity, in the head, back, and limbs. None of these symptoms are accounted for by any local disease. In the progress of the fever, the headache goes off; there may be some degree of deafness, slight somnolence, occasional epistaxis, and during the second week the lenticular, rose-colored eruption will probably show itself upon the abdomen and the chest. In this class of cases, after the condition thus described has con- tinued, with but little change, during a period of from two to three weeks, the strength and appetite begin to return, convalescence is rapid, and the patient is soon restored to sound health. Between this, the mildest form of the disease, and those of the gravest and most dangerous character, there are, of course, all possi- ble gradations. It is not necessary to describe them particularly. They are marked, in different degrees, by greater prostration of strength; somnolence, followed by or alternating with delirium: twitching of the tendons ; picking at the bedclothes, or at imagin- ary objects; a dry, cracked, trembling tongue, red,brown, or black; tympanitic distension of the abdomen, and diarrhoea. Dr. Jackson speaks particularly of the predominance of certain symptoms during certain periods of time. In 1828 and 1829, for instance, he had eleven successive cases, in nine of which there was dry tongue ; in 1831, this symptom was present in eleven of fifteen successive cases; in 1834, in ten of twelve successive cases; and in 1835, in twenty-two of twenty-seven successive cases. At one period, epistaxis was very common; at another watchfulness, and so on There is another phasis, under which the mild form of typhoid fever sometimes presents itself, to which Louis applies the term latent. The disease in this form cannot be called absolutely latent, though it is nearly so. The local lesion of the intestine is present; in some cases, it is positively ascertained to have been extensive and profound; but the disturbance and perturbation of many of the functions of the economy, usually accompanying this lesion, and constituting the rational symptoms of the disease, do not take place, or rather they are very obscure. The reason of all this is entirely unknown, and the most we can say about it is that the same thing occasionally happens in other diseases. The latent form of typhoid fever, like the ordinary forms, is commonly marked at ' Report, &c, p. 136. 114 TYPHOID fever. its commencement by chills, headache, and moderate febrile excite- ment. But the patient is often able to sit up, or even to keep about, and there are no prominent symptoms of disturbance in the nervous system or the abdomen. It is very curious, as has already been observed, that the cases of perforation of the intestine have generally been found to occur in this variety of the disease. All these different degrees in the severity of typhoid fever are frequently witnessed at the same time, during its prevalence in a given place. But it often happens with typhoid fever as it does with many other diseases—with the bilious remittent, with true typhus, with scarlatina, with pneumonia, and so on—that during one season, and in one locality, its prevailing character is mild, and its mortality small; while in another season, its character is grave, and its mortality large. Dr. Power, of Baltimore, informs me in a pri- vate letter, dated September 4, 1847, that typhoid fever has been epidemic in that city for the last fourteen months, and that it has exhibited more of the adynamic character than usual, and requiring a more stimulating treatment. I have, more than once, seen the disease pretty extensively prevalent, when nearly all the cases be- longed to the mildest form. In the epidemic of the city of Lowell during the winter and spring of 1834-5, the cases were generally grave, and the mortality consequently great. This difference in the severity of the disease during different years is very strikingly shown in the records of the Massachusetts General Hospital. Dur- ing fourteen years, from 1822 to 1835, inclusive, there were three hundred and three cases of typhoid fever, and forty-two deaths; or one in a little more than seven. In the year 1830, the deaths were one in three and a half; in 1831, they were one in fourteen and a half; and in 1829, one in twenty-five. From 1832 to 1835, inclusive, the number of cases was one hundred an twenty-nine, and the number of deaths twenty-two, making a mortality of one in a little less than six; while from 1836 to 1838, inclusive, the number of cases was one hundred and eight, and the number of deaths seven, making a mortality of one in fifteen. It is still more remarkable that, from November, 1836, to November, 1838, there were fifty-five successive cases, without a single death/ It may be added here that these wide differences in the mortality and severity of the disease in different years, are not to be accounted for by any differences in the treatment. 1 Hale on the Typhoid Fever of New England. Communications of the Mass. Med. Soc, vol. vi. part iii. pp. 254, 255. VARIETIES AND FORMS. 115 Chomel admits several forms or varieties of typhoid fever, not depending upon degrees of severity. These are the inflammatory, the bilious, the mucous, the ataxic, and the adynamic. They depend upon the relative severity, or predominance, of certain symptoms, or groups of symptoms. In the inflammatory form, there are unusual strength and fulness of pulse; great heat and moisture of the skin, urgent thirst, and diminished secretion of urine. These symptoms are especially prominent only in the early period of the disease. According to Chomel, they occur oftenest in the robust, and during the winter months. The bilious variety is characterized by some yel- lowness about the lips and nose; a thick, yellowish, or greenish coat on the tongue; a bitter taste; nausea, and bilious vomiting. Chomel regards this form of typhoid fever—which occurs oftenest, he thinks, during the summer and autumn, and in particular localities—as identical with the bilious fever of authors. There is no doubt, what- ever, that, in the confusion worse confounded which has always pre- vailed throughout the medical world in relation to the diagnosis of fevers, and which is even now but very partially dissipated, typhoid fever has often been described under the name of bilious fever; but it is also quite certain that, if Chomel supposes typhoid fever and bilious remittent fever to be identical diseases, he is widely mistaken. It is easy to see that there may be a bilious variety of typhoid fever, just as there is a bilious form of pneumonia. The mucous variety of typhoid fever is not very distinctly characterized, even in Cho- mel's description of it. It can hardly be said to exist as a dis- tinct variety. The term ataxic is applied to those cases in which there are great severity and predominance of the nervous symp- toms, such as dulness, stupor, perversion of the senses, delirium, and spasms; or to those in which the disease is masked, and ren- dered irregular, by a want of the usual correspondence in degree of severity between the more important symptoms. In these cases there may be little or no delirium, or the pulse may be almost natural when the disease is manifestly hurrying on to a fatal ter- mination. The adynamic form is marked by extreme debility, and prostration of strength, present at the commencement, or coming on in the course of the disease. The mind is lethargic; the pulse is feeble and soft; the urine and the cutaneous transpira- tion are fetid; and the disease is often prolonged beyond the fourth week.1 1 Chomel's Lemons de Clinique Medicale, p. 340 et seq. 116 CHAPTER VI. DURATION, MARCH, AND COMPLICATIONS. ARTICLE I. DURATION. It is not often an easy matter to determine, with accuracy, the duration of a disease. Both extremities of the space to be measured are distinctly defined. This is especially true of typhoid fever. The access of the disease is often gradual, and convalescence esta- blishes itself by slow and almost imperceptible degrees. There is often, also, here another source of difficulty, arising from the state of mind in which the patient is found. His impressions are cloudy, his recollections are indistinct, and he will often date the commence- ment of his illness several days later than it really occurred. Dr. Jenner says the patient always believes that a longer time has elapsed since the commencement of his disease, or since the occur- rence of any given event, than has really passed away. Bearing these circumstances in mind, I proceed to state, as nearly as has been ascertained, the usual duration of the disease. Dr. Jackson, following the example of Louis in regard to pneu- monia, fixes the commencement of convalescence at the time when the patient is able to take a moderate quantity of solid food, the febrile symptoms having subsided for at least two or three days previous to this period. In two hundred and fifty-five cases, at the Massachusetts General Hospital, between the years 1824 and 1835, inclusive, the average duration of the disease was twenty-two days. It was a little less than this in those under twenty-one years old, and a little more in those over. The duration varied in different years, from eighteen to twenty-six days. Dr. Jackson thinks that convalescence commences, in a few rare instances, as early as the seventh day.1 Of one hundred and eighty-six cases, at the same 1 Dr. Jackson's Report on Typhoid Fever, pp. 108,109, 110 111. MARCH AND COMPLICATIONS. 117 hospital, between October 1, 1833, and October 1, 1839, the aver- age duration was thirty-nine days.1 Of sixty-eight cases terminating favorably, cited by Chomel, he says that there was a decided change for the better, in fifty, between the fifteenth and thirtieth days; and in more than one-half of these, it took place between the twentieth and twenty-fifth.2 Nathan Smith says that he has rarely seen the disease terminate under the fourteenth day from its commencement; and that it rarely extends beyond the sixtieth.3 Of the forty-six fatal cases, analyzed in the great work of Louis, ten terminated between the eighth and fifteenth day; seven, between the sixteenth and twentieth; twenty, between the twentieth and thirtieth; and nine, after this period.4 Of forty-six cases occurring in Richmond, Berkshire County, Massachusetts, between August, 1840, and Feb- ruary, 1841, the average duration was nearly forty-one days. It ought to be stated, however, that the duration in three of these cases is stated, respectively, at one hundred, one hundred and seventy-three, and two hundred days. This extreme prolongation was probably caused by some accidental complication. Forty-six cases occurred in the same town, between August, 1841, and May, 1842 ; the average duration in these being a little more than thirty three days. No death took place earlier than the twelfth or thir- teenth day; in no case of recovery, was the duration less than six- teen days/ A.RTICLE II. MARCH AND COMPLICATIONS. The march of the disease is, on the whole, pretty uniform and regular. In cases of average severity, the patients get gradually sicker, from day to day, for two or three weeks; or, after the first week, their condition may continue, with very little change, until convalescence commences. • The disease is not usually marked by great and sudden alterations, either favorable or unfavorable, though these do sometimes occur. Neither is it marked by distinct stages, although Chomel divides it into three septenary periods, dating 1 Hale on the Typhoid Fever of New England, p. 241. 2 Chomel's Lecons de Clinique Medicale, p. 44. 8 Smith's Med. and Surg. Memoirs, p. 56. * Louis on Typhoid Fever, vol. i. p. 134, 2d ed. 5 Dr. Jennings's Letter to Dr. Clark. 118 TYPHOID FEVER. from the distinct and formal onset of the disease. This is arbi- trary, but very well as a matter of convenience.1 Typhoid fever is occasionally, but not often, complicated with other diseases. Nathan Smith says that he has often seen it follow dysentery, and that he has known it to coexist with epidemic catarrh. Chomel gives a case in which it was complicated, at its commencement, with acute pneumonia. Erysipelas sometimes occurs in the course of the disease, and this more frequently dur- ing some seasons than others. During the winter of 1846-7, in Lexington, Kentucky, there were several cases attended with a bright erysipelatous redness of the nose ; and the same redness was seen in some persons not suffering with the fever. ARTICLE III. PERITONITIS. There is one other accident liable to occur in the progress of typhoid fever, of which it is necessary to speak more particularly; I mean acute inflammation of the peritoneum, occasioned by the discharge into its cavity of the contents of the small intestine through a perforation. The lesion itself has already been described. It was first fully investigated, its nature and causes pointed out, and its diagnosis established, by Louis.2 In a majority of instances, it takes place in cases of moderate severity, or in those which have been described as latent, and at a late period of the disease. Its occurrence is marked by the sudden supervention of acute pain in the abdomen. This pain comes on all at once, with no premonitory symptoms, with nothing in the condition of the patient to account for it, and the suffering which it occasions is excessive. The access of the pain is frequently accompanied by chills, the abdomen be- comes rapidly and acutely tender on pressure, and, if it was not so before, hard and tympanitic. The pulse is quick and compressed. An instantaneous change takes place in the physiognomy of the patient. The countenance is expressive of intense suffering; the features are pinched and cadaverous; and the face is covered with a profuse sweat. There is a constant and urgent desire for cold drinks. Nausea and vomiting are present soon after the inflam- 1 Lecons de Clinique Mi'dieale. Chomel, p. 6. 2 Membires sur diverses Maladies, Paris, 1826, p. 156 et seq. RELAPSES. 119 mation has commenced ; the matter ejected from the stomach is of a grass green color, and it continues to be thrown up to the last moment of life. Notwithstanding the constancy and the intensity of the distress,'the patient preserves the same position, lying upon his back, and dreading every movement that may add to the pain and tenderness of the abdomen. Such, in most cases, is the formi- dable array of symptoms which indicate the occurrence and mark the progress of this fatal complication. Occasionally, they are more obscure; and this peritoneal inflammation, like the fever itself, is to a certant extent latent. It is exceedingly rare, how- ever, that there can be any difficulty in ascertaining its existence. Death usually takes place in from one to three days after the occurrence of the perforation. ARTICLE IV. RELAPSES. It seems to be very well settled that true relapses, as they are called, not unfrequently occur in this disease. Dr. Jackson remarks that an error in diet and regimen is often followed by a new train of symptoms, after convalescence from typhoid fever; and that they appear to be such symptoms as belong to the fever, although not always so strongly characteristic as to leave no doubt on the subject. He cites a case in which, during the relapse, there was an eruption of the rose spots. Dr. Stewart reports two cases wherein, amongst many others of the more peculiar symptoms of the disease, the relapses were also attended by a reappearance of the typhoid eruption.1 Indeed, there are probably few physicians extensively conversant with typhoid fever, who have not, more than once, seen convalescence fatally interrupted by a sudden return or an aggra- vation of many of the most characteristic symptoms of the disease, the delirium, the diarrhoea, the subsultus, the tympanites, and so on; constituting, not the supervention of a new accidental affection, but a genuine relapse. 1 Edin. Med. and Surg. Journ., Oct., 1840. 120 TYPHOID FEVER. ARTICLE V. SEQUELS. The most serious sequel of typhoid fever is tubercular consump- tion. This has been particularly noticed by Dr. Gerhard, of Phila- delphia. In patients of a strumous or cachectic habit, it not unfre- quently follows immediately, or very soon, upon the fever, and usually runs on with great rapidity to a fatal termination. Dr. Jackson notices a painful state of one or both legs, coming on after convalescence, attended with more or less lameness in mo- tion, causing much anxiety, and continuing from a few days to several weeks. There were eight cases of this kind in the hospi- tal. Entire recovery took place in all. Dr. Jackson also mentions five cases in which, at a late period of the disease, there was swell- ing of one leg from well marked phlebitis.1 Nathan Smith alludes to the same occurrence.2 I have seen this swelled leg in only one instance. Barthez and Rilliet have met with several cases of ana- sarca during convalescence. 1 Dr. Jackson's Report on Typhoid Fever, p. 133. 2 Smith's Med. and Surg. Memoirs, p. 67. 121 CHAPTER VII. MORTALITY AND PROGNOSIS. Typhoid fever must be considered, on the whole, as a grave disease. I have already had occasion, in treating of its different forms and varieties, to give some instances of its rate of mortality in different seasons and places.1 This depends so much upon the character of the disease, in any particular locality, and during any given period, that it is not an easy matter to arrive at any positive and accurate general or average result. The prognosis, as well as the diagnosis, of this disease, is a complex problem, into the solu- tion of which, in each individual case, there enter a great number of phenomena. Instead of going any further into the question of the average and varying mortality of the disease, I will now endeavor to appreciate, as far as this can be done, the value of the several elements which go to make up our prognosis. In doing this, I shall first briefly pass in review, and, as nearly as this can be done, in the same order in which they have already been described, the several symptoms of the disease; and I will then speak of some other considerations, connected with its degree of severity, and consequent danger. The mode of invasion would seem to have no small degree of influence upon the subsequent character of the disease. This has been particularly shown by the investigations of Chomel. In his wards at the Hotel Dieu, of seventy-three cases in which the access was sudden only twenty-six were fatal; while there were twenty deaths in only thirty-nine cases in which the access was gradual. The strictly febrile symptoms are not, in themselves, of much value in prognosis. A pulse more rapid than one hundred and twenty or one hundred and thirty in the minute constitutes an unfavorable sign; especially if associated with any other grave symptoms. Still, it frequently happens, that cases recover in which this rapidity of the pulse has been present for a con- 1 See page 114. 122 ■typhoid fever. siderable period of time. In two hundred and ninety cases cited by Dr. Jackson in his Report, the average frequency of the pulse in those which recovered was, in round numbers, about twenty in a minute less than in those which ended fatally. It was also from fifteen to twenty in the minute more frequent in females than in males. Dr. Jackson remarks, in his Report, that he has not found chills, at an advanced or late period of the disease, to have been followed by very grave consequences, though he had previously had a different impression. Of twenty-nine cases in which these chills were noted, only two terminated fatally. Louis says that they indicate the commencement of some secondary lesion. The noisy, hissing, and irregular respiration, to which I have applied the term cerebral, is a very dangerous indication; and, as is said by Chomel, when connected with other grave symptoms, renders the case almost utterly hopeless. Delirium, especially if it occurs at an early period, and is of a wild and violent kind, is of very bad augury. Many patients, in whom it comes on late, and in whom it is of a mild, muttering character, recover. Of one hundred and eight cases, mentioned in Dr. Jackson's Report, this symptom was present in two cases in seven of those which terminated favorably ; and in four cases in five of those which terminated unfavorably. Transient and slight delirium, occurring during the night, or immediately after waking from sleep, and easily dissipated by attracting the attention of the patient, cannot, in itself, be regarded as a very serious symptom. There is a peculiar perversion of the mind, occasionally seen, the presence of which indicates great and imminent danger. This consists in a feeling, on the part of the patient, that he is not much sick; when he says, even in the midst of the gravest symptoms, that he feels, and that he is, very well. Louis says that he has never known this state of the mind in a patient who recovered. Somnolence and coma are unfavorable symptoms, in proportion to their degree, and to the early period of their access. If they are present at or near the beginning of the disease, and are at all strongly marked, they are very constantly followed by a fatal ter- mination. Moderate sleepiness or stupor, from which the patient is pretty readily roused, is common in cases of moderate severity; but prolonged and profound coma indicates a very formidable grade of the disease. Watchfulness, restlessness, and agitation are also unfavorable symptoms. Deafness and epistaxis are, neither of - MORTALITY AND PROGNOSIS. 123 them, of any considerable importance as prognostic signs. They occur with nearly the same frequency, and to nearly the same extent, in grave and in mild cases. The same thing is true of dizziness, and noises in the ears. Spasmodic contractions of the muscles, either of the face, or of the arms and hands, constituting subsultus tendinum, or of other parts of the body, are of grave omen. They occur very much more frequently in cases which are fatal than in those which recover. According to Dr. Jackson's Report, they were noted, at the Massa- chusetts General Hospital, in one case in a little less than four of those which terminated unfavorably; and in one case in ten of those which terminated favorably. If these contractions are gene- ral and strongly marked, constituting a kind of epileptiform agita- tion of the whole body, or of all the limbs, the case is almost inva- riably fatal. Such is also the case where there is permanent rigidity of one of the limbs. Louis has never seen a case of this sort recover; and he says that he knows of no one amongst his contemporaries, except Chomel, who has. Barthez and Rilliet saw five cases of rigidity of the muscles of the trunk, in children, all of which terminated fatally; and two cases of convulsions, which ended also in death. Dr. Jackson reports six cases in which this symptom occurred, only one of which ended in recovery. Early and extreme prostration of strength is likely to be followed by a grave and dan- gerous form of the disease. The expression of the countenance may sometimes be of service in our prognosis. It is hardly necessary to say that the pinched, cadaverous, Hippocratic face generally indicates speedily approach- ing dissolution. On the other hand, the reappearance of intelligent expression on the features, from which it had long been banished; the re-illumination of the dull and listless eye; the recognition by the patient of his friends and attendants ; accompanied by the mani- festation of interest in his own situation and safety, and in surround- ing circumstances, are, even in the midst of many grave symptoms, cheering indications of a change that will end in recovery. The appearance of the tongue is of less importance as a prog- nostic sign than has generally been supposed. It is worth some- thing, but in itself not a great deal. In Dr. Jackson's cases, the rate of mortality, with a dry tongue, was 1 in 47.1; with a denuded tongue, 1 in 8; with a dark tongue, 1 in 3.23.x A very dry, cracked, red, or blackish tongue is more unfavorable, certainly, 1 Report, &o., p. 115. 124 TYPHOID FEVER. than one that is moist, with a thin, brownish, or yellowish coat; but the former appearances are not unfrequently present in cases which recover, and, unless accompanied with other grave symptoms, are not much to be regarded. Difficulty of swallowing, especially if great, is an unfavorable sign. Meteorism, or tympanitic distension of the abdomen, constitutes an unfavorable symptom only when it is strongly marked.1 Diarrhoea, if urgent and continued, is a grave symptom. It is much more constantly present in severe and fatal cases than in mild ones, although patients often recover who have suffered greatly and for a long time with it. Nathan Smith says: " The danger of the disease is in proportion to the violence of the diarrhoea; when the patient has not more than four or five liquid stools in the twenty- four hours, it is not alarming, as it does not seem to weaken him much; but if they exceed that number, serious consequences may be apprehended. I have never lost a patient whose bowels con- tinued constipated through the whole course of the disease, and have never known a fatal case of typhus, unattended by diarrhoea." Involuntary discharges from the bowels rarely take place, except in the late stage of very severe cases. Of course, they point towards an unfavorable termination, although they are far from indicating with any certainty such a result. Of thirty cases in which this symptom was present, mentioned by Chomel, thirteen ended in death. Of ten cases cited by Dr. Jackson, only four recovered. Hemorrhage from the bowels is a grave sj^mptom, though far from an invariably fatal one. Of seven cases cited by Chomel, all but one terminated unfavorably. The experience of others, how- ever, is less discouraging. Of seven cases mentioned by Louis, three were fatal; and of thirty-one cases, occurring in the Massa- chusetts General Hospital, eleven only terminated unfavorably. I have certainly seen as many instances of recovery, as of death, in patients who have suffered from this accident. I do not know that the quality of the intestinal discharges, in any other respect, has any constant relation to the danger of the disease. Retention of urine is an unfavorable symptom. Of six cases in which it was present at the Massachusetts General Hospital, three were fatal. Erysipelas occurs oftenest in the course of severe and alarmin^ 1 Louis on Typhoid Fever, vol. ii. p. 341, 2d ed. MORTALITY AND PROGNOSIS. 125 cases. It not only indicates a grave form of the disease, but it adds also to its danger. The rose spots occur with like frequency in all grades of the disease, and are destitute, of course, of any prognos- tic value. The same remarks may be made of eschars upon the sacrum, as have just been made in regard to erysipelas. Before leaving this consideration of the several symptoms of typhoid fever, in their relation to prognosis, it is important to notice one other circumstance, of occasional occurrence, bearing upon this subject. It sometimes happens that a very well marked ameliora- tion of all the symptoms takes place somewhere, usually, between the tenth and twentieth days of the disease; constituting, indeed, an apparent convalescence; and that this amendment is soon after followed by the return, in an aggravated form, of the symptoms which had subsided or diminished, in severity. This species of relapse is almost invariably followed by death. This circumstance is particularly noticed by Chomel, and the truth of his remarks is corroborated by Louis. Besides the foregoing, there are some other circumstances which affect in a general way the question of prognosis in typhoid fever. The principal of these are age, season, and acclimation. Speaking now of adult patients, that is of those over fifteen years old, it seems very certain that the danger to be apprehended from this disease is somewhat in proportion to their increased age. The mortality is smaller between the ages of fifteen and twenty than it is between the ages of twenty and twenty-five; or than it is at any subsequent period of like duration. The mortality at the Hotel Dieu, in Chomel's wards, was one in five, between the ages of fifteen and twenty; one in four, between the ages of twenty and twenty-five; and one in two, over the age of thirty-five. Louis and Chomel agree in saying that they have rarely found cases to terminate fatally, where the patients were between the ages of fifteen and seventeen years. At the Massachusetts General Hospital, Dr. Jackson found the average age in the fatal cases to be a little more than two years greater than in the cases not fatal. He found also, upon a further analysis, that in those patients whose ages were thirty-five years or more, the mortality was one in four; while in those whose ages were twenty years or less, it was only one in nearly eleven. The prognosis is said to be more favorable amongst children than amongst adults; but of Barthez and Rilliet's one hundred and eleven cases, twenty-nine terminated fatally. It would appear, from the observations of Chomel, that typhoid 126 TYPHOID FEVER. fever is more grave and fatal in the cold, than it is in the warm season. At the Hotel Dieu, in 1832, the mortality was one in three during the winter, and one in six during the summer; in 1834, it was one in two and a half during the winter, and one in seven during the summer; and in 1835, the average proportions were the same as in 1832. An exception to this general result occurred in 1831, when the proportion of deaths was one in four during the winter, and one in three during the summer. The number of cases, however, in the hospital, this year, was small. Chomel appears to have no doubt as to the influence of season upon the severity and mortality of the disease.1 I do not know how far his conclusions are sustained by the observations of others. The most fatal form of the disease that has ever been witnessed in the city of Lowell prevailed during a winter of extreme severity. In the Massachu- setts General Hospital, from 1822 to 1835, the rate of mortality during the cold months was 1 in 6.39; while in the warm months it was only 1 in 8.21.2 Of one hundred and eighty-three cases given by Forget, forty- three terminated fatally. The rate of mortality varied with the seasons in the following manner: in "the autumn, it was 1 in 4T3g-; in the winter, 1 in 3T3r; in the spring, 1 in 3,-5r; and in the summer, 1 in 6^.3 It seems, also, and this principally from the results obtained by Chomel, at the Hotel Dieu, that the length of time during which patients have resided wherever they suffer from the disease, has some influence upon its mortality. Between the 1st of November, 1834, and the 1st of August, 1835, there were ninety cases of typhoid fever in Chomel's wards at the Hotel Dieu. Amongst those patients who had resided in Paris less than one year, the mortality was one in three; amongst those who had resided in Paris between one and two years, the mortality was one in five; and of fifteen, who had resided in Paris more than two years, only one died. There is reason to think that this result is not accidental, since the same differences, though to a less striking extent, were noticed during the three previous years, and since they are also in keeping with the observations of Louis.4 Chomel has suggested that a certain degree of general debility, either constitutional or the result of pre- 1 La Lancette Francaise. August, 1835. 2 Dr. Jackson's Report, p. 107. 3 Traite de l'Enterite Folliculeuse. Par C. P. Forget p. 409. 4 La Lancette Franchise. August, 1835. MORTALITY AND PROGNOSIS. 127 vious disease, may act favorably upon the severity and the termi- nation of typhoid fever. Forget says he has often been struck with the rapidity with which the disease has run on to a fatal termina- tion in cases of young persons with rich, vigorous, and fine consti- tutions, so that it was not without a secret terror that he saw these patients enter the hospital.' Whether typhoid fever is any way influenced in its severity by race, I am unable to say. During the year 1846, Dr. Sutton, of Georgetown, Ky., saw forty-three cases of the disease. Thirty of these were amongst whites, and eight of them were fatal—1 in 4; thirteen were amongst negroes, two of which were fatal—1 in 6J. These numbers are of course too small to be in themselves of much value. There is no evidence that the supposed occasional exciting causes of typhoid fever, such as scanty and poor diet, depressing emotions, fatigue, and excesses, have any effect upon the severity and fatality of the disease. It must be obvious enough, from all the foregoing considerations, that the prognosis in any given individual case of typhoid fever, can very rarely, if ever, be absolute and positive. Patients some- times recover from the most desperate condition; they are liable to the most dangerous and fatal accidents, in the mildest cases. But, notwithstanding these contingencies, we may, in a great majority of instances, by a careful study of all the circumstances which can influence the result, arrive at a good degree of approximative cer- tainty in our prognosis. In a moderate proportion of cases, the scales of life and death may hang for many days, so far as we are able to see, in almost exact equilibrium; and no foresight or sagacity can predict, with any degree of confidence, which of the two will finally preponderate. Favorable and unfavorable symptoms will be so combined, and so attempered, as to baffle all the efforts of wisdom and experience to calculate their issues. Hope and Fear are constant an equal watchers by the bedside of the sick. In all the rest, however, the general character of the symptoms will be, one way or the other, so marked and so decided, as to enable us t to judge with a reasonable degree of certainty as to the result. If during the first fortnight, the pulse is not more than one hundred or one hundred and ten in the minute; if there is only moderate drowsiness; if there is no delirium, or even if this, though present, 1 Traite de 1'Entente Folliculeuse, p. 404. 128 TYPHOID FEVER. has not appeared at any early period of the disease, and is easily dissipated, or mild in its character; if there is no twitching of the tendons; if the patient gets some comfortable sleep; if the diarrhoea and tympanitic state of the abdomen are moderate in degree; the chances of recovery are vastly in favor of the patient. Bearing in mind the liability which always exists to a sudden aggravation of the symptoms, to the supervention of some secondary complication, and to the occurrence of intestinal perforation, and the qualification necessarily accompanying this liability, we may in such cases, with great confidence, anticipate a favorable result. On the other hand, if the pulse is more than one hundred and ten or one hundred and twenty in the minute; if there is great stupor or coma; if the delirium comes on early, and is wild and furious; if there are spas- modic contractions of the muscles, picking at the bedclothes, and great prostration of strength; if there is restlessness or agitation; if the diarrhoea is urgent and continued; if the distension of the abdomen is extreme; if the odor from the patient is musty and cad- averous ; if the features are pinched and Hippocratic; especially if there are general epileptiform convulsions or permanent rigidity of one of the limbs; or that peculiar perversion of the intellect which leads the patient, in the midst of this terrible combination of threat- ening circumstances, to suppose and to declare himself free from suffering and danger; if these symptoms, or any considerable number of them, are present, we can have very little ground to look for any but a fatal termination; and this termination we may with great confidence predict. 129 CHAPTER VIII. DIAGNOSIS. It is only since the publication of the work of Louis, by the aid of his and of subsequent researches, that typhoid fever has been distinguished, with any considerable degree of constancy and cer- tainty, from other more or less analogous forms of disease. And even now, there are few problems in diagnosis more complex than this; although, by the application of the requisite knowledge and care, its solution is almost always attainable. The elements which enter into the composition of this problem are many and various. There is no one symptom, there are no two or three symptoms, which, in themselves, are characteristic of the disease. There is no one symptom, there are no two or three symptoms, usually occurring in the disease, which may not be absent during its entire progress. Our diagnosis can never be founded here, as it is in many other instances, on a few positive physical signs. It must always be rational, not absolute. The evidence upon which our verdict is to be rendered is wholly circumstantial. Notwithstanding all this, and although cases sometimes occur, so enveloped in obscurity as to baffle the skill of the most careful and experienced observers; it is still true that there are few general diseases, the diagnosis of which is so well established, and so certain, as that of typhoid fever.1 Perhaps, in the present state of science, a single qualification ought to be affixed to this last remark. The whole question of the diagnosis of the several individual diseases constituting the family of idiopathic or essential fevers, has been undergoing, ever since the publication of the work of Louis, a more rigorous and philosophical 1 A British reviewer of my book gravely cites this admission, of the occasional difficulty, or impossibility, of making an absolute and positive diagnosis, as suffi- cient proof that there is no specific difference between the typhus and the typhoid forms of continued fever—as though there could be no such individual diseases as cancer of the stomach, or softening of the brain, because we are not always able to make them out with entire certainty during life! 9 130 TYPHOID FEVER. scrutiny than it had been subjected to before. Much of the chaotic confusion in which this question had always been involved has been cleared up. Diseases, which had occupied distinct and perhaps widely separated places in the nosologies, have been shown to be identical; and diseases, on the other hand, have been shown to be widely different in their character, which had been regarded as identical. Some of these questions of difference and identity are still unsettled; they are matters not yet finally and definitively disposed of; not yet ranked amongst the established principles of medical science. One of the most important and interestimg of these, and this constitutes the qualification which I wished to make,- is that of the differences between the disease now under consideration and the true typhus fever. By many pathologists, the two diseases are considered to be essentially alike, identical. Until within a few years, this was the general opinion, and even now it is almost universally entertained by the British physicians, who have enjoyed the most extensive opportunities for studying and comparing the two diseases, or the two forms of disease, as the case may be. By other pathologists, these diseases are considered to be essentially and fundamentally unlike each other; unlike in their nature, in their symptoms, in their pathology, and in the mode of management which they require. I believe this last opinion to be the true one; but it cannot be satisfactorly discussed until both diseases have been described. For this reason I shall omit, in what I have now to say upon the diagnosis of typhoid fever, the consideration of the differences between it and the true British typhus. Setting aside, then, as I do for the present, the true typhus fever, there is no disease more readily and positively recognized than a case of well-marked typhoid fever, of extreme or even of average severity, when observed from its commencement and followed through its entire course. It is hardly possible to confound it with any other affection. There is no other in any considerable degree resembling it. Chills, more or less severe, repeated or not; accom- panied with or immediately followed by headache, and pains in the back and limbs; these pains subsiding and disappearing in the course of a few days; thirst; heat of the skin; acceleration of the pulse, with an evening exacerbation; entire loss of appetite • great muscular debility; dulness and confusion of the intellect, passing gradually into delirium; restlessness; vigilance, or somnolence- twitching of the tendons, or picking at imaginary objects; occasional epistaxis; ringing or buzzing in the ears; the appearance of a DIAGNOSIS. 131 scattered, rose-colored eruption, principally upon the skin of the chest or abdomen, during the second week; a dry, glutinous, cracked, red, brown, or blackish tongue, protruded with difficulty, and trem- bling; dark thick sordes upon the teeth; diarrhoea; the stools thin, watery, and dark or yellowish, sometimes consisting of blood; tym- panitic distension of the abdomen; dulness on percussion over the spleen, and gurgling upon pressure upon the right iliac region; with a dry sibilant or sonorous rhonchus over the chest; these symptoms, coming on without any obvious cause, occurring usually in a person under forty years of age and referable to no local disease; more or less regularly and successively developed; increas- ing in severity, and terminating in death, at an indefinite period after the eighth day; or gradually subsiding and disappearing one after another, and giving way to convalescence at an indefinite period after the fifteenth or twentieth day, mark most clearly and unequivocally a disease wholly unlike any other. These symptoms are sometimes during the progress of the disease, and in various degrees of relative severity, all of them present; and in these cases, at any rate, there is no possibility of mistaking typhoid fever for any other disease. The diagnosis, independent of the evidence to be derived from the lesions found after death, in the fatal cases, is easily and certainly made. In other instances, many of the foregoing, and amongst them some of the most characteristic symptoms, may be wanting; and still the diagnosis may remain in no way difficult or doubtful. Some of the most serious disturbances of the nervous system may be absent. There may be no morbid watchfulness or drowsiness, no aberration of the mind, no twitching of the tendons ; but if the other symptoms, above enumerated, are present, there can be no uncertainty as to the character of the disease. Again, it may happen that the abdominal symptoms, the diarrhoea and tympanitic disten- sion, may be wanting, without throwing any doubt upon the diag- nosis. We may go further than this. Let us suppose that a person between the ages of fifteen and thirty is attacked, without any appre- ciable cause, by the febrile symptoms already repeatedly described, attended or followed by loss of appetite, sufficient prostration of muscular strength to confine the patient to his bed, occasional epistaxis, slight dizziness or ringing in the ears, at least on assum- ing the upright position, and that these symptoms cannot be referred to°any local disturbance, and persist for as many as twelve or fifteen days, with but little change, and not much influenced by medicine; 132 TYPHOID FEVER. even under these circumstances, there can be but little question as to the disease. In most cases, there will be found at least as many elements of diagnosis as in that just supposed; in very many, there will be more. Almost always the lenticular eruption will be discovered if it is timely and carefully sought for; if there is no diarrhoea, there may be slight distension of the abdomen, with gurgling on pressure over the region of the caecum, or there may be deafness or sluggish- ness of the mind, or transient and wandering delirium, or, finally, some one or two of the numerous symptoms more or less character- istic of the disease. I do not mean to say by this that typhoid fever can always be distinguished with certainty from other diseases, even when it is watched during its whole course, and by the best observers. Unquestionably, the disease is sometimes so nearly latent, or so poorly defined, as to be overlooked or mistaken; but with ordinary knowledge of its character, its symptoms, and their march, and with careful examination, this will very rarely be the case. It may happen not unfrequently that the disease cannot be posi- tively made out during the first few days after its access. The febrile symptoms, the chills, heat, thirst, accelerated circulation, with the pain in the head and limbs, are amongst the most promi- nent at this period, and they are those least characteristic of this disease. They are, indeed, common to the early period of this and of many other febrile affections, and of the local phlegmasia?, so that until the subsequent and more distinctive and peculiar symp- toms of the disease, whatever this may be, show themselves, it may not be possible to establish our diagnosis. In the same way it may happen that the disease is not seen till it has reached its late stage. Many of its most important diagnostic characters may have disappeared, and no satisfactory history of its anterior progress can be obtained. Under such circumstances, it may sometimes be con- founded with other affections, with dysentery in its late stages, with some diseases of the brain, and with local inflammations, which are strongly marked, especially near to their fatal termination, with what may be called the typhoid element in pathology. Louis' once mistook a case of central softening of the brain, occurring in a boy for typhoid fever. Erysipelas is often attended with many of the symptoms of this disease, delirium, drowsiness, or stupor, red or brown and dry tongue, fuliginous teeth and gums, tympanites, and great prostration of strength, so that, were it not for the presence DIAGNOSIS. 133 from the commencement of the cutaneous inflammation, it might sometimes be confounded with typhoid fever. The diagnosis of typhoid fever in children is sometimes attended with considerable difficulty. The diseases with which it is most likely to be confounded, are gastro-intestinal irritation, accom- panied by fever, and meningitis. The following points of differ- ence between it and these diseases are enumerated by Barthez and Rilliet. Typhoid fever may be distinguished from gastritis, by the presence in the former of a greater degree of debility than usually attends the latter; by a moderate agitation or delirium during the night; by diarrhoea and gurgling on pressure over the ileo-ccecal region; by dulness on percussion over the region of the spleen by the rose spots and sudamina, at least in a large majority of cases; by more intense and prolonged febrile excitement; and by the physical signs of bronchitis. From intestinal or gastro- intestinal irritation, it may be distinguished by the same signs, excepting the diarrhoea. The disease in children with which typhoid fever is more likely to be confounded than with any other, is meningitis. A careful attention to all the phenomena of the two diseases will, however, generally enable us to distinguish between them. In many cases the pulse is more rapid at the commencement of the disease in typhoid fever than it is in meningitis, although this difference is not sufficiently constant to be much relied upon. Spontaneous nausea and vomiting are more common in the latter than in the former; and the headache is generally more severe. There is a very constant and striking difference in the state of the bowels; in typhoid fever, there is diarrhoea; in meningitis, there is con- stipation. The tongue is more frequently dry, brown, and cracked, and the lips and gums covered with sordes in the former than in the latter. The early stage of meningitis is more frequently attended by extreme agitation and delirium than that of typhoid fever; and finally, the latter is more frequently accompanied by slight cough, and a dry sibilant rhonchus than the former. I may add that, while general convulsions are common during the middle and latter stages of meningitis, they seem to be very rare in typhoid fever, since Barthez and Rilliet met with them only twice in one hundred and eleven cases. Typhoid fever, like all other continued affections, is sometimes more or less mixed up with and influenced by the pathological element of periodicity. This will happen most frequently and will 134 TYPHOID FEVER. be most strongly marked in malarious regions, and during the prevalence of remittent and intermittent fever. Dr. Wooten of Lowndesboro', Alabama, in a letter to me, says: "I may remark that I have often seen typhoid fever complicated with regular remittence—that is, typhoid fever and remittent fever existing together; and I have cured the paroxysmal exacerbations, whilst the disease essential to typhoid fever continued; and I have fre- quently found it necessary to do this, before the more formidable disease could be influenced by remedies. I have seen such cases in the practice of physicians, who supposed them to be remittent or bilious fevers, in which the bowels had become diseased as a consequence of the fever. I think this is a very common error. The malarial influence frequently so preponderates in the symp- toms of inflammatory diseases in our latitude, as to obscure the real disease for many days; and in such cases it is easy to look upon such influence as the cause of the structural lesion, whilst, in fact, the latter has acted as the exciting cause to the manifestations of the former." Dr. J. G. Core, of Williamson County, Tennessee, also in a letter to me, speaks of this same blending, occasionally, of the remittent element with typhoid fever. " Remittent fever," he says further, " will certainly run into a typhoid type, unless it is checked early before it becomes complicated; but that is far from being a case of true typhoid fever." I have said nothing, thus far, of the lesion of the elliptical plates, as an element in the diagnosis of the fatal cases. It has already been remarked that this lesion is characteristic of this disease, that it is invariably found in the fatal cases of typhoid fever, and that it is not found in fatal cases of any other acute disease. If this is absolutely true, without exception and without qualification, then the presence or the absence of the lesion ought to be final and decisive in regard to the diagnosis. Let us see what the evidence is upon this matter. I have already spoken of one case, which was regarded by Louis as typhoid fever during life. A post- mortem examination showed that the elliptical plates and mesen- teric glands were healthy, and that death was the result of softening of the central portions of the brain. This, then, was manifestly not a case of typhoid fever. Not only were the usual lesions of this disease wholly wanting, but all the symptoms and the fatal result were sufficiently accounted for by the cerebral lesion. This was a case of disease of the brain simulating, to a certain extent typhoid fever. And even here, it is but justice to say that Louis DIAGNOSIS. 135 now considers his diagnosis to have been precipitate; the diagnosis of a similar case occurring at the present time would, to say the least of it, be qualified and doubtful. Another case is recorded by Louis, in the first edition of his work, which was marked by most of the symptoms of typhoid fever, and on examination after death, no lesion was found in the elliptical plates or the mesenteric glands. But here, again, it is important to remark that the case occurred in 1823, when the diagnosis of typhoid fever was more doubtful than it is at the present time; and, furthermore, that the patient was not seen by Louis till the twentieth day of his illness. If to these circumstances it be added that there was extensive ancient disease of one of the kidneys, fatty liver, and considerable effusion under the arachnoid membrane, and into the lateral ventricles, certainly we are justified in concluding, not that the case was one of typhoid fever, but that the diagnosis was incorrect. The second edition of Louis's work was published in 1841. In that, it is said that no single new case constituting even an apparent exception to the uniform relationship between the group of symptoms upon which the diagnosis of typhoid fever rests and the abdominal lesion had then been met with, either by Louis himself, Chomel, or Bouillaud. One case is briefly reported by Fouquier, which occur- red at La Charite, in 1833, in which the symptomatology of typhoid fever seems to have been pretty clearly marked, and in which the elliptical plates and the mesenteric glands were found almost free from disease.1 A strong case of apparent exception to the law of relationship now under consideration is reported by Prosper Dor. It occurred at the Hotel Dieu of Marseilles, in 1833. The patient was eighteen years old, and died on the eighth day of the disease. There were these symptoms: headache; debility; loss of appetite; sleeplessness; then, epistaxis; great prostration of strength; soft, irregular pulse; dry, blackish tongue; sordes on the teeth; meteor- ism; diarrhoea; delirium; subsultus tendinum, and picking at the bedclothes. There was no cutaneous eruption. Certainly, in this case the diagnosis, during life, would have been sufficiently clear and positive. An examination after death showed the intestines to be healthy, but it showed also extensive disease of the urinary apparatus. The mucous membrane of the bladder was incrusted with a layer of urate of lime, and in the left kidney there was a considerable number of purulent depositions. Now, when it is 1 Journal des Connaissances Medicales, Jan., 1834. 136 TYPHOID FEVER. considered that diseases of these organs are very frequently attended, near to their fatal termination, with strongly marked typhoid phenomena, there can be no hesitation, I think, as to the disposition which ought to be made of the foregoing case; no difficulty in assigning to it its proper position. It was clearly not typhoid fever; but an instance of disease of the urinary apparatus, in which the typhoid symptoms, which often accompany the latter stages of the affections of this apparatus, were more numerous and more closely resembling those of typhoid fever than is often the case. Grisolle says that he has seen only a single exception to the relation of which I am speaking. I have been permitted, through the kindness of Dr. Hale and Dr. J. B. S. Jackson, of Boston, to look over the notes of a case which occurred in 1841 in the Massachusetts General Hospital, and which might seem to constitute an exception to this relationship. The patient was twenty-two years old. He entered the hospital on the 23d of June, 1841, after an illness of two weeks; during the first half of which time he kept about his work. He had pain in the head, back, and limbs; dizziness; tinnitus aurium; prostration of strength; loss of appetite; daily spontaneous diarrhoea; abdo- minal pain and epigastric distress; tenderness over the right iliac region; rigidity of the muscles and tympanitic distension of the abdomen; epistaxis ; the rose-colored spots, and sudamina. He died on the eighth of August, having exhibited for some time symptoms of severe gastritis. The mucous membrane of the stomach was mammellonated, red, thickened, and ecchymosed; there was ulcera- tion of the mucous membrane about the fauces and root of the tongue; and the only alteration of the elliptical plates of the ilium consisted in their great distinctness, and perhaps a slight thicken- ing, with a bright, spotted, ecchymotic redness of two of the plates; one of them two feet and the other four feet from the ileo-ccecal valve. One or two others were similarly affected, but in a slighter degree. A portion of the ileum nearly a foot in length, extending to within six inches of its lower termination, was deeply ecchy- mosed in bands running round the intestine. A single mesenteric gland, directly opposite to the ileo-cceal valve, was nearly as large as the end of the thumb, red and soft. The other glands were scarcely at all enlarged. The spleen was of medium size. This case seems to me to be one of great interest, and suscepti- ble of an obvious and ready explanation. The patient died of gastritis, eight weeks after the accession of typhoid fever. There DIAGNOSIS. 137 is no evidence that the primary affection here was of unusual gra- vity ; there is no good reason to think that positive ulceration of the intestinal follicles usually takes place in mild cases, and perhaps not in many of moderate severity; and in the one before us, sup- posing such to have been the case, sufficient time had elapsed from the commencement of the disease to account for the moderate degree of alteration in the elliptical plates and the mesenteric glands. It was a case of typhoid fever, I think, of moderate severity ; the patient dying of gastritis, at so late a period that the entero-mesenteric lesion had in good part, but not entirely, disappeared. In the discussion of this question, great stress has been laid upon the observations of Andral, by those who deny or doubt the con- stancy of the connection between the diagnostic symptoms of typhoid fever and the peculiar lesion of the elliptical plates.1 A very cursory examination, however, of the facts cited by this dis- tinguished writer, will show conclusively that they justify no such inferences as have been deduced from them. The cases which he has reported are fifteen in number. He arranges these in two classes: the first, consisting of cases of what he calls continued fever with gastro-intestinal lesions, but without any alteration of the elliptical plates; the second, consisting of cases of what he calls continued fever, without any appreciable lesion of the digestive tube. In the first class are contained the histories, generally short and incom- plete, of seven patients. The fifth, sixth, and seventh are the only ones amongst them that can be considered even doubtful. The others are clearly enough not typhoid fevers ; in most of them there was not present even the typhoid state. The sixth case looks like the true petechial typhus, although the history of the patient is too imperfect to justify any confident diagnosis. The seventh case appears to have been one of pneumonia, complicated with erysi- pelas, following upon simple enteritis, and marked by typhoid phenomena. Certainly, there is not one amongst them which, with our present means of diagnosis, would be regarded with any degree of certainty, before death, as a case of typhoid fever. An examination of the eight cases included in the second class is still more conclusive in its bearing upon the question now before us. There is not one amongst them, the diagnosis of which, so far as typhoid fever is concerned, can be looked upon as even doubtful. It is hardly too much to say that neither of them could now be 1 Andral's Clinique Medicale, vol. iii. pp. 222 to 274, 2d ed., Paris, 1830. 138 TYPHOID FEVER. taken, by any possibility, for a case of typhoid fever. I will briefly enumerate the diseases. The first case, forty-sixth of the volume, was phlegmonous erysipelas of the arm, occurring in a soldier thirty-five years of age; the second was gangrene of the right leg in a patient fifty three years old, suffering with organic disease of the heart; the third was inflammation, either chronic or acute, of the i right kidney and the mucous membrane of the bladder in a patient sixty years of age; the fourth was extensive suppuration of the prostate gland; the fifth was latent pneumonia in a woman eighty-one years of age; the sixth and seventh were affections of the brain, one of them in a patient eighty-one years old; and the eighth was gangrene of the lip, accompanied with extensive phle- bitis, and numerous purulent depositions in the lungs. This simple statement of these cases precludes the necessity of any further re- marks upon them. Manifestly, they have no connection with the question of relationship between the usual symptoms of typhoid fever and the alteration of the elliptical plates of the ileum; and yet they have been, more perhaps than any others on record, relied upon to prove the want of any constancy in this relationship. It is certainly very important that this typhoidal state of the system, occurring in connection with many diseases, should be distinguished from typhoid fever. Unless this is done, there is an end to all positive and philosophical diagnosis. Since writing this history, I have seen a patient presenting these phenomena amongst others: prostration of strength ; slight subsultus tendinum; tympanitic distension of the abdomen; diarrhoea; gurgling on pressure; a dry, red, cracked tongue; sordes on the teeth; wandering delirium; and sudamina about the neck. Here were many of the most characteristic ele- ments of typhoid fever; but the disease was clearly and unequivo- cally puerperal peritonitis. These typhoid phenomena, as I have already said, are often present in many diseases: in smallpox; in scarlatina; in asthenic pneumonia; in softening of the brain- in some diseases of the kidneys; in erysipelas; in dysentery, and so on; but under these circumstances, where their connection with these several affections can be discovered, they ought not to be confounded with typhoid fever. It was from disregarding this obvious principle that Andral was led to the conclusion which I have been exa- mining. Barthez and Rilliet, in the course of some observations on the disease as it occurs in children, published in the Journal des Connais- DIAGNOSIS. 139 sances Medico-Chirvrgicales for 1841, report one or two apparent cases not attended by the characteristic lesion. There is one other point in the discussion of this question which it is important not to overlook. It has been said that these intesti- nal lesions, strongly marked and striking as they may be, are by no means confined to cases of typhoid fever—that they are frequently found in other and quite dissimilar diseases; so that, admitting even that they constitute the constant anatomical lesion of typhoid fever, they are still not distinctive and characteristic, since they are com- mon to it and to other diseases. There is a single reply to these objections, which seems to me entirely satisfactory and conclusive. The diseases, other than typhoid fever, in which alterations of the intestinal glands are most frequently found, are tubercular phthisis, scarlet fever, and certain forms of cholera. Now, in all these cases, it is quite sufficient to say that the condition of the glands is obviously and manifestly different from what it is in typhoid fever. In phthisis, the intestinal ulceration is clearly tubercular, depending upon the presence and development of this morbid product in the intestinal glands. Be- sides this fundamental difference in the very nature of the lesion, the inflammation and ulceration in phthisis are chronic in their march, and the appearance of the lesions differs in many other respects in the two diseases. As to scarlet fever, and some of the forms of cholera, it is enough to say that the only changes of the intestinal glands observed in these diseases have consisted in a moderate thickening, with or without redness and softening of the follicles, and that even these changes are far from constant. In none of these diseases are there the peculiar changes of the intesti- nal glands found in typhoid fever, while the mesenteric glands are very rarely at all affected. In the consideration of this question, as of all others which are still legitimate subjects of discussion and controversy, I have sedu- lously endeavored to avoid anything like a partisan or one-sided examination. I have not intentionally overlooked, or put aside, or warped to my mere wishes, if I have any such unfriendly and treacherous guides and counsellors in the search for truth any of the evidence bearing upon the subject. I have adduced all the cases that I have been able to find which might seem to constitute exceptions to this general relationship, or to throw doubts upon its invariableness; and the conclusion to which I am irresistibly led is 140 TYPHOID FEVER. this: That the connection between the diagnostic symptomatology of typhoid fever and the entero-mesenteric lesions is, I will not say absolute and invariable, but as nearly so as the connection between the diagnostic symptoms and the characteristic lesions of any given disease whatever in the nosology, in which this connection is not established by positive physi- cal signs. - 141 CHAPTER IX. THEORY. I believe that it will be a phenomenon in medical writings to find an essay on such a disease as fever unattended by a theory of its proximate cause. Yet were it as well if the professor who spends months in exciting the wonder of applause of a juvenile audience with phraseology which he does not himself understand, would substitute, for all this waste of words and time, the confession of his own and the general ignorance.—John Macculloch. The most positive thing that can be said under this title is, that the materials for a complete and philosophical theory of fever, or theory of any individual fever, using this phrase in its ordinary acceptation, do not exist. Such a theory presupposes and involves a knowledge of the intimate processes and relations of the living powers which has not yet been attained. It is very questionable even whether such knowledge is attainable. In order to see clearly the truth of these observations, and the extent of this truth, let us inquire for a moment what some of the elements are which must go to make up this knowledge; what their nature is, and in what they consist. In the first place, we must know what the actual efficient causes of any given fever, or form of fever, are. We must know what that agency or combina- tion of agencies is, which, being present, brings into existence, originates, sets in motion that concatenation of disordered actions, that complex combination of morbid processes, which constitutes the fever. We must know in what manner these agencies act; where they make their impression; and in what the modifications consist which they work in the living organization and its proper- ties. Of all these things, we are utterly and profoundly ignorant. In the second place, we must know the seat and character of all these processes and modifications themselves; their peculiarities; their tendencies; the differences which exist between them in the several forms of febrile disease. We must know their relations to each other. We must know which amongst them are primary and 142 TYPHOID FEVER. essential; which are secondary and accidental. We must know the parts which they severally play in the production of the integral disease. Of these things, also as of the causes of fever and their mode of action, it is not too much to say that, if we are not wholly and profoundly ignorant, we are so to a great extent. They are but very partially and imperfectly known to us. They are known to us rather analogically, if I may so speak, and by comparison with other morbid processes, than absolutely and positively. We can see wherein they differ in many respects from these other pro- cesses, and wherein they resemble them. With these limitations, and under the conditions implied by these remarks, there is no reason why we may not attempt to commence the foundation of a theory of fever. But in the present state of science, it can only be an attempt at a commencement. We may endeavor to interpret the connection and relationship which observation has shown to exist between certain phenomena or groups of phenomena. We can do nothing more. It ought to be unnecessary to say that even this can be done only by confining ourselves to a single well-defined individual form of fever. Under the simplest conditions, and where alone it is in the nature of things at all possible, we shall find this interpretation or theory sufficiently obscure and difficult. When attempted, as has generally been the case, under dther conditions, it has proved utterly futile; when applied, as these interpretations and theories have generally been applied, to unascertained and imaginary states of the system, they have always degenerated, necessarily, into the idlest of all conceivable speculations. There is no such individual dis- ease as that which has always been expressed, and which is still expressed by the term fever. How then can there be any theory of fever ? There are many separate diseases, to which this generic name is properly enough applied, on account of certain general analogies which exist between them. But the disordered actions and processes which constitute one of these diseases may differ essentially; and, as far as we can ascertain, in most cases they do so differ from those which constitute another of these diseases. The theory of one fever then must be wholly or to a great extent inapplicable to another. The ele- ments which enter into the composition of one problem are not to be found in the other, or they are present in different proportions. The word fever, when used as it commonly is to designate a disease has no intelligible signification. It is wholly a creature of the fancy; the THEORY. 143 offspring of a false generalization and of a spurious philosophy. What, then, can its theory be but the shadow of a shade? If the true theory of disease be such as I have represented it, we should naturally look, in its application to any individual and separate form of disease, first and principally to those phenomena which are most constantly present, and which seem to constitute its most important elements. According to this rule, and in relation to the subject immediately before us, the theory of typhoid fever, the first inquiry would naturally be, what is the nature and what are the relations of its characteristic lesion—that of the elliptical plates of the ileum ? A satisfactory answer to these questions would so far settle the theory of the disease. What is the nature of this alteration of Peyer's glands ? Does it consist in an inflammatory action, and its results? If so, is the inflammation common and simple; or has it something peculiar and specific in its character ? We can hardly hesitate, I think, in at- tributing this lesion to inflammation. We know nothing of any other morbid process that can produce similar results. In its early stages, we find the tissues which are its seat tumefied and reddened; subsequently, ulceration takes place; and if life is not destroyed, there is abundant evidence that the restorative process is set up and the lesion removed by complete cicatrization. Their enlarge- ment, softening, redness, and in some instances the presence of pus in their substance, are equally sufficient proofs that the affection of the mesenteric glands is also of an inflammatory character. But as to the second point, it seems to me that all the analogies in patho- logy tend to show that this inflammation is not common, but specific. It is circumscribed, and not diffused, as ordinary inflammation of the mucous tissues usually is. It does not often lose itself gradu- ally, shading off into healthy membrane. The morbid process almost constantly extends to the subjacent cellular membrane, which is almost never the case in common mucous inflammation of an acute character. Its tendency to rapid ulceration, and the appear- ances of some of its morbid products, would also seem to show that it has something special and peculiar in its nature. Is it not also philosophical and fair to infer something in corroboration of these views from the observations of Andral and Gavarret in regard to the condition of the blood in different diseases ? They have found, from' extensive and careful examination, that, in all diseases con- sisting of common, open, frank inflammation in any of the organs, or complicated with such inflammation, the relative quantity aud 144 TYPHOID FEVER. proportion of fibrin in the blood are increased; while in diseases of an opposite character, and under opposite circumstances—in the exanthemata, for instance—the fibrin either merely maintains its natural proportions, or is diminished in quantity; a condition, as we have already seen, characteristic of the blood in typhoid fever. In regard now to the relation between this lesion of the elliptical patches on the one hand, and the disease considered as a whole on the other, or between the lesion and the symptoms, the simplest view to be taken is that which makes the disease consist essentially in the lesion, and which refers the symptoms to the lesion as their cause. This doctrine makes typhoid fever, not an essential or idio- pathic fever, but an enteritis, or & follicular enteritis, or a dothinenteritis, and assigns to it a nosological position amongst the local phleg- masise. This is a modification merely of the great doctrine of Broussais, and a modification only so far that it does not include the mucous membrane of the stomach in the lesion. It is still held, partially at least, by some French pathologists of the present day. It has been, strangely and unaccountably enough, even by men who have read his books, attributed to Louis. Dr. O'Brien, of Dublin, in one of his hospital reports, when- speaking of this sub- ject, says: " M. Louis, in particular, has adopted the theory of Brous- sais in its fullest extent."1 The same misapprehension has been fallen into even by such a man as Dr. Christison. It is, however, so far from being true that Louis has ever adopted the doctrine of Broussais in relation to the nature of fevers, that no other observer has done so much in overthrowing his peculiar principles. He has even been the most formidable and successful antagonist of that extraordinary man; opposing, in the calm confidence of a truth- loving and truth-seeking spirit, to the arrogant assertions and to the seductive generalizations of the highest genius—maintained and vindicated as they were by a strength and an eloquence of language unequalled in the annals of medical literature—the impregnable and serried array of facts and their relations, carefully and posi- tively ascertained. One objection to this view of the nature of typhoid fever consists in the circumstance that there is no uniform proportion between the extent of the local disease and the severity of the symptoms. There are many fatal cases in which the intes- tinal lesion is very limited in extent; there are others, where the whole character of the disease has been unusually mild and in 1 Dublin Med. Trans., p. 313. THEORY. 145 which, when life has been destroyed by some secondary and acci- dental complication, the alteration of the intestine has been found to be very extensive and profound. This objection, although sound and reasonable, ought not to be considered conclusive. Notwith- standing the exceptions just referred to, it is not certain that there is not, after all, a general correspondence between the gravity of local lesion and the severity of the disease. Besides, even in affec- tions manifestly of a strictly local character, in which the disease consists in the local lesion, it is far enough from true that there is anything like an exact and uniform proportion between the extent of this lesion and the general disturbance of the economy. The degree of this disturbance, constituting the general symptomatology, is influenced by a variety of causes other than the local disease; so that, although we shall find abundant reason, I think, for rejecting the view of which I am speaking, let us be careful not to do so for false reasons, and on wrong grounds. I shall now allude to some of the considerations which go to show that the local lesion of typhoid fever is not primary, but secondary, that instead of being the single cause and origin of the disease, it constitutes only one of its elements, and is itself depend- ent upon some other and ulterior morbid condition as its cause, the seat, nature, and operation of which are not known to us. It may be observed that if the view which has been taken of the specific character of the inflammation entering into the composition of the follicular lesion be looked upon as sound, it constitutes in itself a cogent reason for the correctness of the doctrine above stated. Indeed, it must constitute the principal reason ; and, in addition to what has already been said upon this subject, I will only present one other consideration, which has been much insisted upon, in support and illustration of the view before us, by Chomel. He says that one of the most constant and uniform characteristics of secondary lesions, consisting generally of specific inflammations, is the fact of their being disseminated, of their occupying numerous and circumscribed spots in the tissues and organs of the system. The most striking examples of this pathological law are to be seen in the eruptive fevers, in measles, scarlatina, smallpox, and the ori- ental plague. The same law shows itself, also, in other cutaneous inflammations, in urticaria, in varicella, in the successive crops of furuncles which are sometimes observed, and so on. It is seen further, in some affections of a different character, such as scrofula, syphilis, and the several varieties of scirrhus and cancer. All these 10 146 TYPHOID FEVER. numerous diseases, though they differ very widely from each other in many respects, have this character in common, that the local inflammations which accompany them are disseminated, that they occupy a considerable number of defined and limited localities. There are several other particulars in which the members of this extensive family of disseminated lesions agree with each other, all of which tend to exhibit their specific character and their subordinate relations. They depend upon specific causes. They cannot be produced at will by any of the ordinary excitants of common inflammation. In many cases, these causes are generated by the morbid process itself; and so the diseases are transmitted directly from one individual to another, and are thus perpetuated. In other cases, the origin of the cause is unknown. They have generally a more or less regular march and determinate duration, in many instances going through a series of successive stages, and, if life is not destroyed in the course of the process, terminating naturally in a return to a healthy condition. This march and duration are but very little under the control of art; the first cannot be much modified, nor the second much abridged, by the use of remedies, and so far even as these effects can be produced, they must be produced by means acting not directly upon the lesions themselves, but upon the general system. Now, in every respect, the intestinal lesion of typhoid fever corresponds to this class of pathological alterations. It is disseminated, occupying the same glandular tissue at different points of the intestinal mucous surface; it cannot be artificially produced by any of the common causes of inflammation; it depends upon a specific but unknown cause; it has a regular march and a determinate duration, passing through its several stages, and terminating, if life is not destroyed, in a return to health; and, finally, this process is but little under the control of art. It is strongly corroborative of the soundness of this view that in a disease closely resembling this in many of its symptoms—I mean the contagious typhus—there is no constant local lesion of any sort to which the symptoms can be referred. Certainly, it needs no elaborate argument to show how clearly all these circum- stances indicate that the local lesions in this class of diseases are peculiar in their nature, secondary and dependent in their relations, constituting not the primary and essential cause, but only one of the pathological constituents of the particular diseases in which they severally occur. Some pathologists have adopted the doctrine that the unknown THEORY. 147 cause of typhoid fever acts primarily upon the nervous system, producing some unascertained lesion of innervation, which, in its turn, gives rise to disturbances and alterations in the other organic apparatuses and tissues, and in the fluids; these aggregate disturb- ances and alterations constituting the disease. This doctrine may be the true one; but in the present state of science it must be regarded as wholly hypothetical; and there are some considerations which militate strongly against its probability. Another theory is that which places the primary and fundamental alteration in the blood. We may be justified, I think, in saying that at least this theory has more claims upon our attention, and is more probable, than that of which I have just spoken. It is already demonstrated that, in many cases of typhoid fever, and in other diseases to which it is more or less nearly allied, especially by the common presence in them all of what has been called the typhoid state, or the typhoid element, in pathology, important and peculiar changes have taken place in this fluid. These changes may have been primary and essential. There is good reason to think, at any rate, that they play a very important part in the pathology of these diseases. They deserve further investigation, and they ouglit never to be overlooked; but their actual relations to these diseases are very far from being ascertained. In another class of affections, the acute phlegmasise, we find important alterations in the composition and character of the blood, which are pretty evidently the result of the disease; they are secondary and not primary in their relations. Such may be the case, also, in typhoid fever, and its analogous dis- eases. I am disposed to look favorably upon this partial return of the old humoral pathology, and to hope much from its cultivation and development; but I do not think that we can yet apply it very confidently or extensively to the interpretation of morbid pheno- mena. This, upon the whole, it seems to me, is as far as we can go, safely and philosophically, in our attempt to explain and to account for the morbid processes and alterations which constitute typhoid fever; or to establish, in other words, a theory of the disease. [Certain views regarding the nature of fever in general, not excluding the typhoid, have been lately expressed by the distin- guished German pathologist, Virchow, and by Dr. Parkes, of the University College and Hospital, London, which have been received with so much favor by the profession in England that it will be necessary to refer to them here. These views, as expressed by Dr. Parkes, in his Gulstonean 148 TYPHOID FEVER. Lectures for 1855,1 seem to be, in substance, that a subtile morbific agent enters the blood, and changes, perhaps, gradually, its consti- tution ; that, sooner or later, this changed blood produces a change in the composition of the nerve-centres, particularly those which preside over the nutrition and consumption of the tissues; then occur, he says, " the nervous symptoms of weakness, depression, rigors, contraction of some parts and vessels, speedily followed by relaxation, marking the stage of invasion;" that now muscular and other tissues, deprived of a portion of their innervation, begin to disintegrate, and, by slow combustion, their elements are more or less completely consumed, producing preternatural heat; that the increased action of the heart and the dilated state of the vessels, depend on changes in the nerve-centres and nerves which preside over these parts, and that this condition of the heart and vessels, in its turn, aids in producing these changes of the tissues; that in some febrile states, often in typhoid fever, the products of this combustion are not immediately thrown off by the emunctories, but remain mingled with the blood, still further contaminating it; and finally that the combustion is often incomplete, and " the partially meta- morphosed substances are retained in the body." The points in this theory of fever which can claim consideration for novelty are two, viz: that the heat of fever "arises from an increased consumption of the tissues;" and that this increased com- bustion appears to have its immediate cause in alteration of the nervous system. Dr. Jenner, the reviewer, says that, "taking Vir- chow's definition of fever as the text, Dr. Parkes has brought together a large mass of new and collected facts, for the purpose of proving the truth of each of the three heads into which Virchow's definition naturally falls," viz: elevation of temperature, increased consumption of tissue, and alterations of the nervous system. Dr. Parkes' experiments appear to have been directed mostly to the support of the second of these points. He finds that, in certain cases, the excreta, chiefly in the urine, exceed the normal amount, when the quantity of nourishment taken into the system is little or nothing; and hence he infers that " increase of temperature may be attended with increased elimination, and, therefore, presumably with increased tissue change." But, at the same time, he finds in an unequivocal case of typhoid fever, without diarrhoea, or sweating, or bronchitis, the urinary excretions were for many days below the normal amount, though the elevation of temperature was con- • [B. and F. Med.-Chir. Rev., April, 1856.] THEORY. 149 siderable. He found the same thing also in a girl having acute rheumatism, whose average temperature in the mouth was 102° Fahr. Hence the conclusion, that "the products of metamorphosis, as judged of by the excreta, may be diminished in febrile cases, in which the heat of the blood is intense." Dr. Parkes, however, urges that these latter cases do not disprove the doctrine which the former sustain; but he believes that the excretions are retained in the blood, and refers, among other proofs, to what are called critical evacuations. "It seems," he says, "a reasonable explanation of these sudden discharges to suppose that a large amount of par- tially metamorphosed substances have been retained in the body, and at length have been brought to that point of oxidation or change which permits their elimination by one or other organ. Then, by their discharge, the system is suddenly freed from the noxious compounds which weighed upon it; and the metamorphosis having reached its acme, the temperature immediately falls." Without attempting to follow the argument through, by which Dr. Parkes seeks to support the doctrine of retained excretions, it is sufficient to say that, while this opinion is supported by the respect- able names of Parkes and Jenner, it will not fail to command respect; yet, while the reasoning which supports it is so wholly hypothetical and postulatory, the opinion cannot take rank as a part of our science. Further investigations may prove its truth, and that is all its best friends can ask us to concede to it at present. That the first organic change is in the nervous system, and that that change is such as to diminish the innervation to vessels and tissues, seems not to have been proven any more than the other cardinal proposition of this theory. But if we admit, as everybody seems to be ready to admit, that there may be physical changes in the nerve-centres and in the nerve-tubes, sufficient to produce the gravest alterations in their function, and yet that our means of investigation do not yet enable us to demonstrate those changes, we shall not be too rigorous in our demand for proofs, and shall, perhaps, be ready to admit that the physiological inferences, the analogies, and the facts adduced by Dr. Parkes, go so far, at least, as to render his opinion probable. Yet, regarding this point, as well as that which has been just dismissed, though it may not be fair to use the language of Dr. Parkes, and say that we are still in the " regions lighted only by the dim and treacherous ray of specu- lation," we may properly wait for additional facts to confirm these doctrines.] 150 CHAPTER X. TREATMENT. There are few diseases of equal frequency and importance, the treatment of which is more unsettled than that of typhoid fever; and there is certainly no disease, the therapeutics of which has, within the last few years, attracted more attention than this. Va- rious, and to some extent opposite modes of management have been adopted by different practitioners; they have been conducted on a large scale, for the most part in a fair and impartial spirit, and under circumstances favorable to the discovery of the truth; but they have not yet resulted in the establishment of any uniform and satisfactory method of treatment. There is no unanimity in the opinions and conduct of different practitioners. Under these circumstances, it is somewhat difficult to decide upon the best course to pursue, in treating of the subject, in a work like the present. It is impossible, within any reasonable limits, to describe in detail all the different plans of treatment that have from time to time been adopted, or that are still pursued, together with their actual or alleged results. Still, the completeness of the work and the interests of humanity alike require that the actual state of our science in this respect, the sum and the result of our observa- tions and researches, so far as these can be ascertained, should be fully and fairly stated. I shall therefore endeavor to do this, as far as it is possible. I shall describe the several modes of manage- ment which have been most extensively followed, and most tho- roughly studied, by those leading and distinguished men who have been most favorably situated for the investigation of this subject. In doing this, I shall not often enter into any detailed and parti- cular statement of the effects of individual remedies in single cases or upon single symptoms which different physicians allege that they have seen produced. It will be sufficient for my purposes to state, in general terms, the results of their investigations and analyses. TREATMENT. — DR. JACKSON'S METHOD. 151 ARTICLE I. DR. JACKSON'S METHOD OF TREATMENT. Dr. Jackson, of Boston, after having been for many years an ex- tensive and careful observer of typhoid fever, both in public and in private practice, and after an accurate and circumstantial re-exa- mination and analysis of the effects of remedies upon the disease, as they were exhibited in the wards of the Massachusetts General Hospital, arrives finally at the following conclusions, which it is impossible to give so well in any other way as in his own words. They would suffer by any alteration or abridgment. " First, that, on the attack of this disease, the patient should im- mediately desist from labor and mental exertion, abstain from food, except of the simplest liquid kind, and place himself in bed, or at least in a state of repose. " Second, that free evacuations should be made at the beginning, and that, in doing this, a day is important. It is better that they be made the first day than the second, better on the second than the third; but that it is especially important that they should be made as early as the third day. That an emetic of tartarized antimony should first be given, and then an active cathartic, or the two in combination. If there is constipation at the time, an active enema given at first to disembarrass the bowels, would no doubt facilitate the action of an emetic. If the vomiting and purging are not fol- lowed by great relief, venesection should be practised on the follow- ing day, unless the constitution should be very feeble, or the case very mild. " Third, if the disease has not subsided after the evacuations, tartarized antimony should be given every two hours in increasing doses, after the method of Odier, of Geneva. Meanwhile, the bowels should be kept open, and, for two or three of the first days, it would be well that calomel should enter into the medicine used for this purpose; hot, however, giving more than one moderate dose in a day. It should be noted, however, that usually, after the antimony has been given for forty-eight hours, this will act suf- ficiently on the bowels, and that sometimes it must be restrained by opium. "Fourth, that, when the disease subsides early under any active treatment, it is quite essential that the patient should be restrained from solid food for two or three days, at least, after he has an ap- 152 TYPHOID FEVER. petite for it; and that he then use vegetable food in small quanti- ties, for two or three days more. Likewise, that he should not be allowed to make any efforts of either body or mind until his con- valescence is fully established. By this, it is not intended that he should be confined wholly in bed, but that he shall be confined to his chamber, and not allowed to talk on business, nor on any in- teresting subject. " Fifth, that evacuations, vomiting and purging at least, may be resorted to with advantage in the second week; and that perhaps some benefit may be obtained from antimony in small doses, when commenced in that week. But that, after that period, no active treatment should be employed, or none which will cause any serious inconvenience to the patient. " Sixth, as to diet. There is no point probably on which all practitioners are more agreed than that food should be withheld from persons affected with the disease in its early period, except only the mildest or most bland liquid articles. Probably food would be injurious in its early period, at least, if it could be di- gested. But it cannot be digested perfectly, and often not at all, and that alone should forbid the use of it. When the disease is arrested or mitigated by treatment, it is very certain that an indulg- ence in the use of food is most commonly injurious, and that the cautions already stated are not too severe. When, however, the patient is fully reinstated, he must be allowed some extra food for the recovery of his flesh and strength. This must be done cau- tiously ; but an extreme and protracted abstinence is injurious. When the disease runs its usual course, and the appetite for food returns, is there any danger in the indulgence of it ? To this question I answer, in proportion as the return of appetite takes place early, more caution is necessary. If it takes place at or about the end of the third week of the disease, if it is decided, and if it is accompanied by a cleaning of the tongue, almost any article which the patient craves may be allowed him with safety. The appetite is usually a sufficient guide as to the quality of the food; but not as to quantity. In a large proportion of cases, it will be found a most uncertain guide as to quantity. Hence it is necessary to begin with small quantities, and to increase gradually. It is equally necessary to make the intervals long between the portions of solid food, which are given in the early period of convalescence. At first, there should be one portion of solid food in the day; the next day, if everything is favorable, two portions, with five or six hours TREATMENT.— DR. JACKSON'S METHOD. 153 between them; and two or three days later, watching the effects, three meals may be allowed. But we are not merely to feel the pulse under these circumstances, to see if the fever has increased. The danger is not, I apprehend, that the system will be too sud- denly nourished. It is that the enfeebled organs of digestion may not be able to digest the food. We must, therefore, watch all the signs which refer to those organs. Only, if the head should ache, or other organs be disturbed, we should remember that the promi- nent signs of indigestion are often shown elsewhere than in the stomach, and stop the food till it appears whether this is not now the case. It is also to be constantly remembered that constipation of the bowels will be followed by indigestion, and that evil must, therefore, be guarded against. " Seventh, Cordials. On this, as under the last head, I must give the convictions arising from the most careful observations I have been able to make in many years. I cannot adopt the more accu- rate mode of the numerical system. Nor in this case could this system be usefully followed, unless with the greatest attention to the state of each case. It has appeared to me that we should not adopt the rule to give cordials, nor to withhold them, in every case. When a patient is induced to take cordials reluctantly, they seldom benefit him, and are often followed by injury. When he is greatly enfeebled, at a late stage of the disease, he may be safely asked if he wishes for them, and if he does he may try them; they will seldom hurt him then, if he takes no more than is grateful to him. When he spontaneously demands them, as late as the third week, they will almost always be found useful. Now in following these rules, I have occasionally found a patient who would take a large quantity of some cordial liquor. But this has been rare. Few take them longer than two or three days, and the majority of patients do not take them at all. It is proper to add that by cordials I mean vinous liquors. I have most commonly found cider grateful in the first instance, beginning with an ounce, two or three times a day, and increasing according to the effects. Sound beer or ale is more rarely but sometimes grateful. In patients much exhausted, however, the strong foreign wines, Sherry, Port, and Madeira, are found most useful. These articles may be diluted, or may be employed to season articles of diet, or may be given alone, according to the taste of the patient."1 1 Dr. Jackson's Report on the Typhoid Fever, Med. Com. of the Mass. Med. Soc, vol. vi. part ii. p. 168, et seq. 154 TYPHOID FEVER. It may be added here that Dr. Jackson, during the early period of his practice, in common with most of the New England physi- cians, made use also of calomel in the treatment of typhoid fever. This article generally made a part of the purgative given at the commencement of the disease. It was afterwards continued in small and frequently repeated doses, combined, according to circumstances, with ipecacuanha, or antimony, or opium. Moderate ptyalism was looked upon as a favorable occurrence, although profuse salivation was dreaded. Dr. Jackson's faith in the usefulness of calomel was shaken a few years after the commencement of his practice. When the Massa- chusetts General Hospital was opened, he still resorted to it occa- sionally during the first few days of the disease, and particularly when any secondary inflammation supervened; but confidence in the specific power of the medicine grew less and less, and since 1830 its use in the hospital has been nearly abandoned. Dr. Jack- son informs me that his convictions of the efficacy of early evacua- tions ih the treatment of typhoid fever, founded on his experience in private practice, are not less strong than those which rest on the careful analysis which he has made of the results of his hospital cases. ARTICLE II. DR. NATHAN SMITH'S METHOD. I shall now give a summary of the mode of management followed in typhoid fever by the late Nathan Smith. He begins his remarks on the treatment of this disease by saying that he had never seen a single case in which he was satisfied that he had been able to cut short and arrest its progress, and that in all cases where the disease is going on regularly in its course, without any symptom denoting danger, and without any local distress, active interference will be likely to do more harm than good. Under such circumstances, he thinks no medicine should be given. He also expresses his con- viction that all powerful remedies or measures made use of in the early stage of the disease are very liable to do harm, and that those patients who are treated with them in the beginning of the fever do not hold out so well in its latter stages. He says that he has seen many cases in which persons in the early stages of this disease were moping about, not very sick, but far from being well, and who, upon taking a dose of tartrate of antimony, have been imme- TREATMENT. — DR. NATHAN SMITH'S METHOD. 155 diately confined to their beds.1 He adds, in another place, these remarks : " In cases of simple mild typhus, where there is no nausea at the stomach, no pain in that region, where the heat is moderate, and the pulse not greatly altered in frequency, I am clearly of opinion that we had better leave the disease to cure itself, as reme- dies, especially powerful ones, are more likely to do harm than good. In such cases, the patient gets along better without medicine than with ; all that is required is to give him simple diluent drinks, a very small quantity of farinaceous food, and avoid as much as possi- ble all causes of irritation." Dr. Smith opposes the plan, then adopted by some New England practitioners, of general and almost indiscriminate bloodletting at the commencement of the disease. He would bleed only where there was " uncommon pain in the head, accompanied with great heat in that part, a sense of fulness, and a throbbing of the temporal arteries, or marks of congestion in the viscera of the thorax, such as pain in one or both sides of the chest, increased by a full inspir- ation." Under these circumstances, he thinks that the loss of from twelve to sixteen ounces of blood will often mitigate the severity of the disease, and enable the patient to go through it with more safety. The immediate effects of bleeding have not appeared to him very obvious, and he says that where the pulse is very fre- quent, the operation is seldom or never attended with any advantage. Emetics are recommended by Dr. Smith only where there are nausea and oppression at the stomach, either at the commencement or during the progress of the disease. His favorite articles are ipecacuanha, eupatorium, or sulphate of zinc, given either singly or combined. Tartrate of antimony he looks upon as an inappro- priate and unsafe remedy. The bowels, he says, should be kept open with gentle laxatives, but active and indiscriminate purging he considers hurtful. Blisters, according to his experience, some- times relieve local pains, and are sometimes injurious. They may as well, he thinks, be generally dispensed with. Stimulating reme- dies given internally, with external heat, for the purpose of exciting active perspiration, have always appeared to him to be attended with bad consequences at all periods of the disease. Opium, for the purpose of procuring rest and quietness during the night, when it is not contraindicated by high febrile excitement and pain in the head, and in combination with ipecacuanha and camphor to restrain 1 Smith's Medical and Surgical Memoirs, p. 72, et seq. 156 TYPHOID FEVER. immoderate diarrhoea, he says, may be used to advantage. He has seen, in many instances, very serious evils from the specific action of mercury, but no benefit. Cinchona he has found to produce a good effect in some cases where the surface was cold, and also where there was hemorrhage. The mineral and vegetable acids, the alka- lies, refrigerants, as they are called, such as sulphate of magnesia, super-tartrate and nitrate of potass, he regards as unimportant or questionable remedies. The most effectual refrigerant and febrifuge, in the hands of Dr. Smith, consisted in the free use of cold water externally. He is very warm and decided in his commendation of this remedial measure. He says that there is nothing else so powerful in allaying morbid heat of the surface, in diminishing thirst, and in quieting restlessness and agitation. He directs the body of the patient to be uncovered, and then to be sprinkled or dashed repeatedly with pure cold water. He allows cold water for drink, as freely as the patient may desire, during the whole course of the disease. Dr. Smith closes his account of his expectant and rational system of treatment in typhoid fever with the following directions for the general care of the patient: — " When an individual is first taken sick with typhous fever, we should expect a disease of considerable length, and make our arrangements accordingly. If the thing is practicable, he should be kept in a spacious room, the larger the better. His bed should be of straw, or husks, especially if it is in the warm season; and it should not be placed in the corner, but brought out into the room. We should contrive to have a current of air pass over the bed by means of doors and windows. * * * In the warm seasons of the year, the windows should be kept open night and day. All the furniture should be removed, except such articles as are required for the patient's use. The windows should be darkened, or some- thing opposed to the light, in such a way as to still admit the air. The room should be kept as quiet as possible, since noise is injuri- ous, and no more persons should be admitted than are necessary to take care of the patient, which will, if he is very sick, require the labor of more than one. " The room should not be carpeted, and the floor should be often washed with pure water, or soap and water; and in the hot season, it, as well as the walls, may be kept wet with water during the heat of the day. " Cleanliness is absolutely essential to the patient's comfort, and TREATMENT. — CHOMEL'S METHOD. 157 no dirty dishes or useless medicines or food should be suffered to remain in the room. All excrementitious matter should be removed immediately. In the warm season of the year, the bed and body linen should be changed every day, and in the cold, every other day at farthest. " The patient's body and limbs should be cleansed every day with a piece of sponge and warm water, or soap and water. If a male, he should be shaved every day or every alternate day, and if a female with long thick hair, it should be cut off or thinned so as to leave but little of it the full length."J ARTICLE III. chomel's method. The treatment of typhoid fever has. been, especially for the last twenty years, a subject of great interest amongst the physicians of the large hospitals of Paris. It was in these institutions that the symptomatology, diagnosis, and pathology of the disease were first thoroughly studied; the opportunities which they offer for a careful trial and comparison of different modes of management are un- equalled ; and these opportunities have been very faithfully made use of by a considerable number of cautious, accurate, and philo- sophical observers. Amongst them may be mentioned, particularly, and this without making any invidious distinction, Chomel and Louis. Chomel has been for many years attached either to La Charite or to the Hotel Dieu; he has grown old in the constant and conscientious study of disease; and now, in the ripe maturity of age and experience, is unsurpassed, in the capital of France, as a man of practical sagacity and skill. I shall first give a summary of his practice in this disease.2 His treatment is for the most part what is called rational or symptomatic; that is, it is adapted, as far as common sense and ex- perience enable us to do this, to the varying state and condition of the patient in different forms of the disease, and in the several stages of its progress. Simple and benign cases may be very safely trusted, he says, to refreshing drinks, such as lemonade, currant water, orange water, or pure water, taken at short intervals, and in such quantities as the 1 Smith's Medical and Surgical Memoirs, pp. 95, 96. 2 Lemons de Clinique Medicale. Par A. F. Chomel, p. 449, et seq. 15S TYPHOID FEVER. patient may desire; emollient fomentations or poultices upon the abdomen, when this is painful; sponging the surface of the body with vinegar and water, or cold affusions, if the skin is hot; mucil- aginous injections, several times a day ; cold applications to the head, when this is the seat of pain, and hot poultices or sinapisms, if there is a disposition to drowsiness and disturbed sleep. These measures, combined with fresh air, cleanliness, and quiet, will gene- rally conduct the patient safely through this form of the disease. Still, Chomel is inclined to think that, even in these cases, a single moderate bleeding at the commencement of the fever, while it di- minishes somewhat the severity of the headache and shortens the period of its continuance, may also be of some utility in preventing the development of ulterior complications, and exert some favor- able influence upon the march and termination of the disease. If the headache or the pains in the abdomen are severe, leeches may be applied below the mastoid processes for the former, and near the anus for the latter. If the bowels are constipated, they may be opened by some gentle laxative; if the diarrhoea is troublesome, it may be moderated by rice water, injections of starch and water, and so on. In the inflammatory form of the disease, Chomel adopts a more decided antiphlogistic course, adapted to the intensity of the symp- toms and to the age and vigor of the patient. The bleeding is to be repeated once or twice, leeches applied where they are indicated, and an entire abstinence, even from liquid nourishment, enforced upon the patient. When the disease is marked by bilious symp- toms, a yellow fur on the tongue, a bitter taste, nausea, vomiting of bile, and constipation, the same general course is to be pursued as in its simple form. Chomel has not often resorted, even under these circumstances, to the use of emetics, since he has generally found that the symptoms just enumerated have subsided under the simple hygienic treatment. He thinks, however, that in some of these cases, where the disease comes on suddenly, and there is reason to suppose that the stomach may be oppressed by its con- tents, an early emetic would be useful. Chomel's mucous variety of typhoid fever is too indistinctly marked to make it necessary to notice the slight modifications of treatment which he thinks it may require. In the ataxic form of the disease, there are no uniform rational indications. If it is attended with highly inflammatory symptoms, the active antiphlogistic course is to be pursued; if it is attended with great debility, tonics and cordials are to be given. i TREATMENT.— CHOMEL'S METHOD. 159 In the adynamic form of the disease, Chomel adopts a decided tonic and stimulant treatment, adapted in activity to the degree of prostration and debility. He speaks with great confidence of the propriety and necessity of this course, in these cases. Where the failure of muscular strength is extreme, indicated by the difficulty and languor of all the voluntary motions; the feebleness of the voice; the sinking of the features; the fetor of the breath; sigh- ing and faintness on assuming the sitting posture; smallness and weakness of the pulse; and coolness or coldness of the surface; it is necessary to administer, more or less freely, according to the number and gravity of these symptoms, tonics, aromatics; and cor- dials. Amongst these, the most important are cinchona, wine, camphor, and ether. Chomel prefers the cinchona, in the form of the extract, administered in an aromatic potion, to the amount of one or two ounces in the twenty-four hours. He also employs it in decoction or infusion, sweetened with lemon syrup. He doubts whether the sulphate of quinine is of equal efficacy as a tonic; so that, notwithstanding the inconveniences frequently attending the administration of the extract, especially in large quantities, he still prefers it to the former. At the same time that the cinchona is employed in this manner, he uses it, either in decoction, or in extract, in the form of enemata. While the adynamic phenomena already enumerated are only moderate in degree, and before the necessity for the free use of cinchona has yet appeared, the lighter wines, such as those of Bor- deaux and Burgundy, may be given: when these phenomena are more strongly marked, the stronger wines, such as Madeira, Sherry, and Port, must be resorted to. These may be given to the patient in his drinks; or, as is best in the more grave cases, undiluted. The quantity to be administered must depend, of course, upon the urgency of the symptoms calling for its use. A tablespoonful of one of the strong wines may be given at intervals of from one to three or four hours. The effects of these remedies must be care- fully watched; and if they produce febrile heat, and restlessness, pain in the head, or any other obvious local disturbance, their use must be suspended, or modified. It will not often be either neces- sary or safe to resort to them in the early periods of the disease: although such will sometimes be the case. It is commonly during the second or third week, or even later, that this tonic and stimu- lant medication is called for; and it is often a nice point, m the therapeutics of typhoid fever, to seize upon the exact period when 160 TYPHOID FEVER. it is required and will be borne. Ether is to be used when there is an urgent necessity for rapid and immediate stimulation ; Chomel also occasionally combines it with the mixture of the extract of cinchona. Camphor he rarely uses, except as an ingredient in the tonic injections. In extreme cases, where there is a combination of the ataxic and adynamic elements, he recommends the use of musk in large doses, by the mouth and by injection.1 He speaks more decidedly of the evils attending the application of blisters, than of any benefits to be derived from them. The epistaxis will not often require any special attention. If it is at all copious, the application of a cold astringent solution will generally be sufficient to arrest it. Sometimes, however, it is ne- cessary to resort to mechanical compression, by plugging up the nostrils. To control the hemorrhage from the bowels, Chomel re- commends iced water for drink, in injections and applied upon the abdomen; lemonade, and the extract of rhatany. The formation of ulcers should be guarded against, by avoiding constant pressure upon those points where they are most liable to occur; and when once formed, they should be protected from irritation, and properly dressed. Local inflammations, occurring in the early periods of the disease, or when the debility and prostration are not strongly marked, are to be met by local and general bleeding, adapted to the circumstances of the case. If the patient is in a condition not likely to tolerate these measures, dry cupping and sinapisms in the neighborhood of the inflammation, which is most commonly a pneu- monia, may be substituted. When these complications take place during the adynamic period, or in the adynamic form of the disease, they do not contraindicate the use of stimulants and tonics. The local inflammation under these circumstances will be more surely relieved, or enabled to relieve itself, by a removal of the extreme general debility, through the agency of a tonic medication, than by the abstraction of blood. Perforation of the intestine is to be treated after the manner of Drs. Graves and Stokes, of Dublin; by entire abstinence from drinks and food; absolute rest; and large and repeated doses of opium. In the management of the patient during convalescence, Chomel urges the importance of a mild diet and the avoidance of fatigue; and in cases where there seems to be some obstacle to the entire re-establishment of health, recommends a removal from the city to the country. 1 Gazette Medicale de Paris, March, 1835. TREATMENT.—CHOMEL'S METHOD. 161 In 1831, at the suggestion of a young physician who attended his clinical lectures at the Hotel Dieu, Chomel commenced the trial of chloride of soda in the treatment of typhoid fever. He did not change in any other respect his system of management, but super- added the use of this remedy to the rational plan of treatment which has just been described. He administered the chloride in a sweetened solution of gum Arabic, containing from one grain to one grain and a half to the ounce. Of this solution his patients generally took from fifty to ninety ounces in the twenty-four hours. Injections of the same solution were given morning and night; the body of the patient was freely washed, several times a day, with a solution of the chloride in water; poultices moistened with it were applied to the abdomen; the bedclothing was sprinkled with it; and vessels containing it were placed under the bed. In order to test as nearly as possible the value of this specific medication, it was mostly confined to well-defined cases, at least of sufficient severity to be attended with some danger; and in which it could be applied at the beginning or early in the disease. The results of this plan in the hands of Chomel, from 1831 to 1834, the year in which his work on typhoid fever was published, were various and not very decisive. In that work, however, he expresses himself, at the close of his remarks upon this subject, in the following terms: " Finally, although the results of this treatment have been very dif- ferent in different years, it has still been attended with more suc- cess than any other. Several distinguished practitioners have in- formed us that they have arrived at the same conclusion. We shall continue, then, our trials with a mode of treatment which, combined with the rational method, has thus far given us, notwith- standing its failures, more satisfactory results than any other." Subsequent to this, however, in 1835, with a frankness, a con- scientiousness, a single-minded regard for the truth which it is beautiful to witness, he says: " The hopes which our first trials with the chloride had permitted us to conceive have not been realized. The results which have thus far been obtained are not sufficiently encouraging to justify us in the expectation of continu- ing our trials with much chance of success."1 1 La Lancette Francaise. August, 1835. 11 162 TYPHOID FEVER. ARTICLE IV. LOUIS'S METHOD. Louis, in the second edition of his Researches on Typhoid Fever, published in 1841, seems somewhat undecided in his opinion upon the therapeutics of the disease.1 He hesitates between the rational method which he had generally followed, and the purgative plan adopted by De Larroque. Putting the latter out of consideration for the present, Louis after a very careful and thorough examina- tion and analysis of the effects of remedies, finally fixed upon the following general plan of treatment, as the best that could be pur- sued in the present state of our knowledge upon this subject. Early in the disease, and at any rate within the first ten or twelve days, he resorts to general bloodletting, its extent and repetition to be proportionate to the strength and vigor of the patient and the severity of the disease. If the case is mild, or of moderate severity, and the constitution of the patient not very robust, a single bleed- ing of twelve ounces will be sufficient; in other cases of greater severity, and where the constitution is sound and vigorous, the bleeding should be somewhat more copious, and repeated once or twice. Louis is satisfied that this remedy, within these limits, is generally useful in shortening to the extent of a few days the average duration; in diminishing the gravity, and of course in lessening somewhat the mortality, of the disease. After the fifteenth day, in severe cases, and at an earlier- period in mild ones, where there is but moderate febrile excitement, bloodletting should not be prac- tised. Under these circumstances, the operation does no good, and retards instead of hastening the period of convalescence. Louis has not found the immediate effects of bloodletting, either upon the general severity of the disease or upon any of the single symp- toms, to be very marked or obvious. In some cases, the operation is followed, either at once or in the course of twenty-four hours, by an amelioration of one or more of the most urgent symptoms: in some cases, on the other hand, it is followed by their aggravation; and furthermore, these changes in the severity of the symptoms are such as frequently occur where bloodletting has not been resorted to, and where, indeed, no active medication has been used. This measure is to be aided by suitable drinks, emollient enemata, 1 Louis on Typhoid Fever, vol. ii. p. 379, et seq., 2d ed. TREATMENT. — LOUIS'S METHOD. 163 and cool fresh air. The drinks should consist of sweetened gum water, or of this in combination with artificial Seltzer water, in order to obtain the effects of the carbonic acid gas. They should be given in large quantities, as freely as the patient may desire. Mucilaginous enemata are to be given once a day, during the early period of the disease; and subsequently when the diarrhoea is trou- blesome, two or three times a day. If, notwithstanding their use, the discharges from the bowels continue to be frequent and debili- tating, a small injection containing a few drops of laudanum should be substituted. Tonics are considered by Louis not only very useful, but very necessary, under certain circumstances. When the general febrile excitement has subsided ; when the prostration of strength is ex- treme ; when the pulse is only moderately accelerated, or not at all; when there is slight diarrhoea, and little or no tympanites; they should be at once and freely resorted to. Louis prefers the sul- phate of quinine to any other article, given in an aromatic or mu- cilaginous draught, in doses of from eight to twenty grains. He gives the patient at the same time a sweetened infusion of cinchona for drink; and if there is diarrhoea, he makes use of tonic and astrin- gent injections. Louis dismisses blisters from his plan of treatment with strong and unqualified condemnation. He says there is no evidence that they are of any benefit, and that not unfrequently they add to the gravity, the inconveniences, and danger of the disease. For the last ten or twelve years he has abandoned them entirely. He recom- mends opium, after the method of Graves and Stokes, in cases of perforation of the intestine, though in smaller does. He reports a case, probably of this accident, which occurred at the Hotel Dieu in 1840, and which was cured by this method. Opium, he thinks, is also of use in allaying some of the nervous symptoms; such as twitching of the tendons and slight delirium, when the febrile ex- citement is not very high. When the delirium is violent, he has seen little or no benefit from the use of leeches, or the application of ice to the head; but he recommends, in this case, if the face is flushed, even if the disease has reached its twelfth or fifteenth day, and even if the patient has already been twice bled, another mode- rate bleeding. When the meteorism is extreme, he thinks it may sometimes be diminished by the administration of enemata, consist- ing of magnesia in an infusion of flaxseed. In grave cases, the condition of the bladder should be carefully watched from day to 164 TYPHOID FEVER. day, and retention of urine guarded against. It is unnecessary to repeat his observations upon the importance of rest, cleanliness, and free ventilation, during the progress of the disease; and of light diet and the avoidance of fatigue during convalescence. In concluding this subject, Louis makes use of the following words: " It results from all that precedes, upon the effects of the principal therapeutic agents at present employed in the treatment of typhoid fever, that these agents possess a favorable though limited influence upon the march and termination of the disease; and that an impartial examination of facts points out, with a good degree of precision, the best method of employing the three prin- cipal means which experience has placed in our hands; to wit, bloodletting, evacuants, and tonics. Furthermore, the limited degree of success which has thus far been obtained ought not to discourage the friends of science, nor prevent them from hoping that a more appropriate and successful treatment of this disease will yet be dis- covered. Who could have foreseen the effects of opium, of cinchona, or the preservative power of the vaccine virus ? What accident and observation have hitherto done they are still able to do, with- out doubt they still will do; and therapeutics, like the other parts of science, ought to hope and to expect everything from observa- tion." ARTICLE V. bouillaud's method. Some twenty-five years ago, Bouillaud introduced a mode of practice in the treatment of all acute diseases, and amongst them of typhoid fever, which he claims to be of his own discovery, and which he claims also to have been attended with extraordinary success. This mode consists in copious and frequently repeated abstractions of blood, and in the application of leeches or of scari- fied cups in the intervals.1 The number of his bleedings varies from one to five or six, of from twelve to sixteen ounces each; and nearly or quite an equal quantity of blood is taken from the patient by means of leeches or cups. This lavish waste of the vital fluid is not confined to the earliest period of the disease, since many of the patients who are subjected to it are not received into the hospital 1 Essai sur la Philosophie Medicale, etc. Par J. Bouillaud, p. 412, et seq. Brux- elles, 1836. TREATMENT. — DE LARROQUE'S METHOD. 165 until the second week of the fever. The average day, indeed, is as late as from the ninth to the twelfth. This method he calls that of bleeding coup sur coup, blow upon blow, or dash upon dash, or again and again. He claims to have reduced the practice of blood- letting in acute diseases to an established formula. In connection with this subject, he also announces, in loud and confident tones, that success or cure is the law; failure or death the exception. He claims for his new method an almost infinite degree of superiority over those generally in use ; and that the actual average mortality, under it, is less than half as great as under the old and generally adopted plans. The bold and arrogant terms in which these high pretensions were put forth, the offensive freedom of Bouillaud's remarks upon the practice of his contemporaries, to say nothing of the importance of the subject, and the interests of humaWity and science, soon led to a thorough examination and a discussion, generally warm and sometimes intemperate, of his claims. It is not my intention to enter into a history of these proceedings. It is quite sufficient for my purpose to say that his statistical tables were rectified, his mistaken diagnoses were corrected, and the positive results of his practice shown to be in no degree more favorable than those of other physicians; probably less so. It ought to be said, however, before dismissing the subject, that if Bouillaud has failed to establish the superiority of free and repeated bleeding in the treatment of typhoid fever, he seems at least to have shown that the practice is borne in this disease with a greater degree of impunity, and is attended with less danger than had generally been supposed possible. ARTICLE VI. DE LARROQUE'^' METHOD. r : > There is still another exclusive mode of treatment, very unlike that of Bouillaud, which has been pretty extensively followed within the last ten or twelve years in the hospitals of Paris. I mean that by evacuants, and principally by purgatives. The fifteen or twenty years' reign of the Broussaisian doctrine of fevers, in Paris, had almost entirely banished emetics and purgatives from the treatment of these diseases. Their use was formally and abso- lutely proscribed. It was murderous and incendiary to give either one or the other. After this medico-doctrinal dynasty had had its 166 TYPHOID FEVER. day and gone by, therapeutics became gradually more eclectic and less exclusive. Different modes of practice were adopted by dif- ferent physicians in the same disease; and it could hardly fail to be discovered that the fears which had so universally prevailed, founded upon theoretical considerations of the injurious effects of purgatives, were either without foundation or very much exaggerated. Lerminier, of Paris, and Bretonneau, of Tours, had occasionally made use of purgatives in the treatment of typhoid fever; but M. De Larroque, a physician of the Necker Hospital, was the first to adopt the evacuant or emetico-cathartic plan as a general and almost exclusive mode of treatment, in this disease. He commenced his trial of this method in 1831, since which time it has been more or less extensively followed by Piedagnel at the Hotel Dieu, Andral at La Charite", Louis at La Pitie', and by others. The plan adopted by De Larroque is the following: He usually commences his treat- ment by the administration of an active antimonial emetic; and this is to be repeated until free vomiting is procured. The opera- tion of the emetic is to be immediately followed by the use of purgatives, without much regard to the state of the bowels, the condition of the patient, or the period of the disease ; and these are to be continued regularly up to the time of convalescence. His principal articles are Seidlitz water, castor oil, and calomel. To these remedies, he adds emollient poultices to the abdomen, when there is pain in this region; mucilaginous injections, morning and night; acidulated drinks, and when the febrile excitement subsides, light tonic. Louis, in the second edition of his Researches, expresses himself pretty strongly in favor of the purgative treatment. He himself made use mostly of Seidlitz water, and he thinks that his success with this method was greater than with his former practice. Barthez and Rilliet are opposed to the purgative plan of treat- ment in children ; they think it increases the danger of enteritis. ARTICLE VII. MISCELLANEOUS. [The treatment adopted by Huss, of Stockholm, has little in it pecu- liar. He prefers the rational plan, or as he calls it the expectant and symptomatic. He believes that the fever cannot be cut short by any treatment. He does not rely greatly on emetics, or laxatives, giving them only in particular cases; and bleeding he thinks TREATMENT. — MISCELLANEOUS. 167 decidedly hurtful, excepting only by two to six cups when there are signs of cerebral or spinal congestion, or severe capillary bron- chitis, or much tenderness and tension in the ileo-ccecal region. Blisters he permits only in a single condition, viz., when the head is seriously threatened. He is much attached to the mineral acids. The Solutio acidiphosphoriciof'the Swedish Pharmacopoeia is the basis of his prescription. It contains twenty-five per cent, of phosphoric acid. He gives ten to fifteen drops in mucilage and syrup every two hours, twelve to eighteen parts of the vehicle for one of the solution. He prefers sulphuric acid, used in a similar way, if there is hemor- rhage from the bowels or from any part of the body. He attaches great importance to the use of compresses wet in cold water, applied to the whole abdomen. He recommends that the compress be com- posed of four to eight folds, that it be covered, when applied, with oil cloth or gutta percha, and that it be renewed two or three times a day, or as often as it becomes dry. He thinks that this applica- tion, preceded by sinapisms, or fomentations with turpentine, and continued daily till the approach of convalescence, has great influence in diminishing the severity of the abdominal lesions and symptoms. Stimulants, Dr. Huss regards as of the first importance, when the first sound of the heart becomes enfeebled, the tongue dry, the skin hot and dry; but he uses only wine among the alcoholic drinks, and that very sparingly. He depends chiefly on camphor, carbonate of ammonia, musk, and phosphorus.] In addition to the accounts which have been given of the fore- going systematic methods of treatment, it may be well to mention, in conclusion some few individual remedies, and their application, which have been recommended by different practitioners. M. Bar- thez and M. Fouquier amongst the French, and Drs. Dobler and Skoda amongst the Germans, have made use of alum, supposing that it mi-ht act directly in retarding the progress and in diminish- ing the severity of the intestinal lesion. I am not aware that there is yet any satisfactory proof of its utility. Dr. Gerhard thinks that, in mild cases, gentle purgatives, such as a few grains of blue pill followed by castor oil or Seidlitz powder, should always be given at first, for two or three days; and that whenever constipation fs present, the repetition of the laxative is useful. If the dizziness and headache are troublesome, he says that they may be removed, or greatly relieved, by cupping, by a mustard pediluvmm, or by a blister to the nucha. From the latter application, when properly timed that is, after the active febrile excitement has subsided, Dr. 168 TYPHOID FEVER. Gerhard has never known any injury to result, and he has generally found it to mitigate the severity of moderate cerebral symptoms. In both severe and mild cases, towards the decline of the disease— that is, about the end of the second week if it be severe, and a little earlier if it be mild—he makes use of small doses of calomel, or of blue pill, combined with ipecacuanha, and with a minute quantity of opium, if the diarrhoea is troublesome. One or two discharges from the bowels daily, he thinks, are of service in all stages of the disease.1 In cases of hemorrhage from the bowels, I always make free use of opium and sugar of lead, and generally with entire success. [In 1851, Dr. Robert Dundas, of Liverpool, proposed to treat continued fever with large and frequently repeated doses of quinine, believing that " intermittent, remittent, and continued fever are mere varieties of the same disease." Dr. Peacock, of St. Thomas Hospital, London, sums up the results of this treatment in the January number of the Med. Times and Gaz., 1856, quoting nume- rous authorities, both for and against its use, giving also his own experience with it. His conclusions are that it does not arrest the disease; that it does not even diminish its duration; and that, except in cases with bilious complications, it really does no good, and often does harm?] I have already spoken of the unsettled and discordant state of the professional mind in regard to the therapeutics of typhoid fever. It would be no difficult matter to multiply and strengthen the proofs of this truth, already sufficiently shown by the foregoing details. This, however, would be but an unprofitable labor, in the present state of our knowledge of no practical value. Under the circum- stances in which we are placed, amidst the claims and pretensions of conflicting opinions, it seems to me that we are not now justified in the use of any ultra or exclusive system of treatment; like that, for instance, of Bouillaud, or De Larroque. For the present, our management of the disease must be eclectic and rational, not ex- clusive and specific. In its early stages, unless in cases where there may be special contraindications, it seems to be generally conceded that a moderate antiphlogistic course is the best that can be adopt- ed ; and that active emetico-cathartics, if used at all, ought to be used at this same early period. In the subsequent progress of the disease, a mild alterative and rational plan, keeping the bowels moderately loose by laxatives when this is necessary, and meeting 1 Medical Examiner, vol. iv. pp, 150, 151. TREATMENT.—MISCELLANEOUS. 169 particular symptoms with such remedies as experience has shown to be most suitable, would appear to be most appropriate and suc- cessful. After the first few days, in cases of moderate or average severity, with no special or urgent indication, it is quite clear, I think, that all treatment in any way decidedly active or perturbat- ing is to be avoided. The tendency of the disease in all such cases is towards a natural termination in health; and there is no evidence that the dangerous complications which are liable to occur can be prevented by any active interference. In all grave cases, and espe- cially when stupor or delirium is present, the region of the bladder should be carefully examined every day, in order to guard against the distension of the organ by urine. I may remark in this con- nection, notwithstanding what has been said, that carelessness or indifference in the management of the disease, growing out of the unsettled state of opinion in relation to its treatment, and of the limited control which we possess over it, would be as criminal a dereliction of duty as it would be unbecoming in a cultivator of the science and a practitioner of the art of medicine.1 We may hope that our treatment of this disease will yet become more successful and more uniform; more exact in its application, and more positive in its results. Many " ministers and interpreters of nature," faithful to their high vocation, and competent to its duties, are zealously and patiently occupied in endeavoring to accomplish this end. Guided by a sound philosophy, relying upon the one great means of ascertaining the properties and relations of all forms of matter, inorganic and organic, that of observation, they or their successors may yet find, by persevering experiment or for- tunate discovery, methods of modifying the living organization and of correcting its disordered actions, which shall give us a much greater control over the disease than we are now able to exert. > It is both interesting and gratifying to see the good sense and sound judgment of some of the continental practitioners of the last century in the managemen of this disease. Burserius, after having given a most excellent description of the fever, recommends moderate bleeding where there is much excitement a mild emetic at the commencement, diluent drinks, and then says: "But a simple pan of cure, if it is to be recommended in any case, is certainly to be adopted in the present. For the less the operations of nature are disturbed by art, the milder and safer the remedies we employ are, the more successfully do we restore the patient's health."-Institutions Pract. Med., vol. i. p. 506. And again he adds: - The proper regulation of the diet alone, and time, perform a great part of the cure. The poorer people, generally content with patience and proper attention o the regulation of the diet, despising all kinds of drugs, recover more certamly. - Ibid., 530. 170 CHAPTER XI. DEFINITION. We may, provisionally at least, adopt the following definition of the disease, the natural history of which has now been given. Typhoid fever is an acute affection, occurring most frequently between the ages of fifteen and thirty years, sufficiently often pre- vious to the former period, and but rarely after the fortieth year of life, attacking, at least in cities and amongst adults, in a large majority of instances, persons who are recent residents; occasion- ally, and under certain conditions, capable of transmission from one individual to another; rarely occurring twice in the same person; more common in certain countries than in others, but not confined, so far as is known, to any geographical localities or regions; prevailing at all seasons of the year and in all climates, but more common in the autumn than at other periods, and in temperate and northern than in southern and hot latitudes ; some- times sudden and sometimes gradual in its access; attended at its commencement with chills or rigors, not commonly very severe, and usually repeated, at uncertain intervals, for the first few days; then with more or less feverish heat of the skin ; generally with increased quickness of the pulse; somewhat accelerated respiration; slight, dry cough; an extensive sonorous or sibilant rhonchus, with pain in the head, back, and limbs; loss of the vigor, and, in grave cases, perversion of the faculties of the mind; dull expression of the countenance ; more or less somnolence or watchfulness; giddi- ness or dizziness; ringing, roaring, or buzzing in the ears; occa- sional epistaxis; great loss of muscular strength; in grave cases with spasmodic twitchings of the muscles, especially those of the forearms and hands, with entire loss of appetite, and with thirst; sometimes with nearly a natural appearance of the tongue, and at others with a red, dark, dry, glutinous, cracked, trembling state of this organ; sordes upon the teeth and gums; occasional nausea and vomiting; frequent diarrhoea ; abdominal pains and tenderness, DEFINITION. 171 these latter not unfrequently most marked in the right iliac region; dulness on percussion over the spleen; meteoric distension or rigid- ity of the abdomen; the skin, particularly of the front part of the body, being usually the seat, in the course of the second and third weeks of the disease, of a peculiar eruption, not commonly abundant, consisting of small circular or oval spots of a bright rose color, slightly elevated above the surrounding surface, and readily dis- appearing under pressure; coming out successively, one after another, for several days, remaining usually for somewhat more than a week, and successively and gradually fading away, and finally disappearing; the blood, when drawn from the body, having its proportion of fibrin diminished in a degree closely correspond- ing to the gravity of the affection, which symptoms differ very widely in their duration, in their march, in their severity, and in their combinations in different cases, no one of which is invariably met with, and several of which are frequently wanting, but enough of which are almost always present to characterize the disease; which symptoms, furthermore, may either gradually diminish in severity, and finally disappear between the twelfth and the thirtieth day of the disease, or may increase in severity, and terminate in death between the seventh and the fortieth day from their access, the bodies of patients exhibiting, on examination after death, in only a certain proportion of cases, various pathological changes in the brain, heart, lungs, stomach, and liver, but in most cases enlarge- ment or softening, or both, of the spleen, and in all cases thickening or redness, or a morbid deposition in the subcutaneous cellular tissue, or ulceration, or all these changes of the elliptical plates of the ileum, with enlargement, redness, and softening of the mesenteric glands, corresponding in their position to the altered intestinal follicles; which disease, thus characterized and defined, differs essentially from all others in its causes, in its symptoms, in its lesions, and is, in the present state of our knowledge, only to a limited extent under the influence or control of art. 172 CHAPTER XII. BIBLIOGRAPHY. The bibliography of typhoid fever, as a distinct and specific dis- ease, may properly enough be said to have commenced with the publication of Louis's Researches, in 1829. I do not forget the earlier works of Eoederer and Wagler, in Germany ; and of Prost, Petit and Serres, and Bretonneau, in France, on the same subject; nor the description of Huxham in England, and of Nathan Smith in America: but these publications, compared with that of Louis, were fragmentary and incomplete. Other continental writers have also given very good general descriptions of the disease, under the names of typhus, adynamic, ataxic fever, and so on. These descrip- tions are now of but little value, for the reason that no clear dis- tinction was made between true typhus and typhoid fever. It indeed remains to the present moment a question undecided, whether the camp, the jail, and the typhus fevers of the continent of Europe, previous to the thorough study of typhoid fever, were identical with this disease, or constituted a distinct and different species. My own opinion is, as I have already stated, that both parties are partly right and partly wrong. It is probable that both typhoid and true typhus fever made up these diseases; and it is quite impossible to determine now, in many cases, to which of the two any particular epidemic belonged. Besides the few but very important works which are hereafter briefly mentioned, Andral, Bouillaud, Cruveilhier, and others amongst the French ; and Schonlein, Skoda, Rokitansky, and others amongst the Germans, have written more or less extensively and systematically upon this disease. Several important papers have also been published in the French medical journals. Medecine eclairee par I1 observation et Vouverture des corps. Par P. A. Prost. Paris, 1804. In connection with the history of the re- searches in relation to typhoid fever, this is a very remarkable book. Prost may be fairly regarded as one of the far forerunners BIBLIOGRAPHY. — PROST. 173 of Louis. He seems to have devoted himself for a considerable period of time with great assiduity and faithfulness, and almost exclusively to the observation of disease, in its most extended sense, in the large hospitals of Paris. Before publishing his book, he had made more than four hundred autopsies, many of them requiring an entire day, and none less than several hours. One of the first fruits of his arduous and conscientious study of nature was the dis- covery that, in the ataxic fevers of Paris, there always existed in- flammation, with or without ulceration, of the mucous membrane of the intestines. Bouillaud, in speaking of Prost's work, says: "This fine commencement of a revolution, which ten years later was destined to shake the temple of medicine to its deepest founda- tions, was suffered to pass almost unnoticed. Truly, Prost might have said of his epoch, as Tacitus said of another: 'Nostra oetas oblivia suorum.1 " There is a curious fact in medical literature, connected with this portion of the history of fever. Prost's book, as Grisolle says, fell stillborn from the press. Almost the only one of his contempo- raries who took any special notice of it was Broussais; and a sin- gular notice this was, coming as it did from a man whose highest title to glory—subsequently claimed for him, both by his disciples and by himself—consisted in a fuller development of this very doc- trine of Prost. Broussais, in the first edition of his History of Chronic Inflammations, after citing the opinion of Post, relative to the influence of inflammation of the digestive mucous membrane in the production of ataxic fever, says: " I have too often found this membrane in good condition after the most malignant typhus; I have seen too many patients improved by the employment of the most energetic stimulants, to share the opinion of this physician on the cause of ataxic fever." And still, the truculent and unscrupu- lous reformer, after having thus summarily rejected, as worthless, the materials which had been laboriously quarried from the great primary formation of nature, did not hesitate to make use of them as corner-stones for the temple which he himself strove to build. Prost's work is in two volumes, and the greater part of it is made up of short histories of disease, with an account of the several organs after death; only a small proportion of these being cases of fever. ' The preliminary observations are to a great extent speculative and hypothetical. A Practical Essay on Typhous Fever. By Nathan Smith, M. D. The author of this modest and unpretending essay was an extensive 174 TYPHOID FEVER. and distinguished teacher and practitioner of medicine and surgery throughout many portions of the New England States during the first quarter of the present century. He was a remarkable man; and his name stands worthily and fitly by the side of those of Hux- ham, Pringle, and Blane. My opinion of the value of the essay above mentioned has been already sufficiently attested, by the in- corporation into my book of a large portion of its matter. To an American practitioner, it is worth infinitely more than all the mod- ern English treatises on fever put together; for this simple reason, if for no other, that it deals with the form of disease with which he is familiar—which the English treatises do not do. Nathan Smith was a shrewd, clear-headed, patient, and careful student of nature—his vision undazzled and his judgment never perverted by fanciful speculations; and the labor of my book will not be wholly lost if it succeeds in some degree in calling back the attention of my countrymen to his neglected and almost forgotten pages. The essay was published in 1824. Anatomical, Pathological, and Therapeutical Researches upon the dis- ease known under the names of Gastro-Enteritis; Putrid, Adynamic, Ataxic, and Typhoid Fever. By P. Ch. A. Louis, 2 vols. Paris, 1829. This is the great work of Louis, to which reference has been so constantly made throughout the preceding history. An American edition was published from a translation by Henry J. Bowditch, M. D., in 1836. A second French edition was published in 1841. The work at the time of its first appearance was entirely without a parallel, if we except the Researches on Phthisis, by the same writer. These works of Louis have become the established models for all similar undertakings; they are the standards by which all analogous labors are to be tried. Here and there, a single individual has attempted to depreciate their value and under- rate their importance—a value and an importance which every successive year since their appearance has only served to strengthen and confirm. Like new planets added to a solar system, they have quietly but irresistibly wheeled into their orbits, from which they are henceforth no more to be jostled than the planets are from theirs. Lecons de Clinique Medicale, etc. Par A. F. Chomel. Filvre Typhoide. Paris, 1834, pp. 548. Next to the great work of Louis, this is perhaps the most valuable original treatise on typhoid fever that has been published. It is not so methodical in its plan and arrangement as it might have been, and the anatomical details are somewhat prolix, extending as they do to nearly two hundred and BIBLIOGRAPHY. 175 fifty pages; still, as I have just said, the work is second only to one in value. It is rich in solid material, and is marked throughout by the clearness, good sense, and sound philosophy of its distinguish- ed author. A Report, founded on the Cases of Typhoid Fever, or the Common Continued Fever of New England, which occurred in the Massachusetts General Hospital, from the opening of that Institution in September, 1821, to the end of 1835. By James Jackson, M. D., pp. 93, 1838. There is no need of my speaking at any length of this Report; the preceding pages bear ample and conclusive evidence of the richness and value of its materials. It consists mostly of a careful and accu- rate numerical analysis of three hundred and three cases of typhoid fever treated in the Massachusetts General Hospital. It is alto- gether the most important contribution which has been made to the history of the continued fever of New England, and it is in every way worthy its distinguished author, the elder Louis of the New World. Remarks on the Pathology of the Typhoid Fever of New England; as exhibited in its Physical Signs and its Anatomical Appearances. By Enoch Hale, M. D., 1839, pp. 68. This paper, like the Report of Dr. Jackson, is published amongst the communications of the Mas- sachusetts Medical Society. It is a very excellent and sensible paper; and it is particularly valuable for its minute and careful description of some of the more characteristic physical signs of typhoid fever—such as the meteorism, and the rose spots; and of the intestinal lesions; and further, for its full and clear state- ment of the differences between typhoid and typhus fever. TraitS de TEnUrite Folliculeuse—Fievre Typhoide. Par C. P. For- get. Paris, 1841, pp. 846. This is a work of very large promise, and of very moderate performance. It is a full and systematic monograph of more than eight hundred solid pages, in which the author has contrived neither to give us a compact and clear sum- mary of the researches of others, nor to add any important know- ledge of his own. As Sir James Mackintosh said on another occa- sion, it is one of the most unnecessary books in the world. One of its leading objects is to vindicate the strictly local and inflammatory nature of typhoid fever, and the consequent rational antiphlogistic treatment. On the Identity or Non-Identity of Typhoid and Typhus Fevers. By William Jenner, M. D. London, 1850, pp. 102. On the Identity or Non-Identity of the Specific Cause of Typhoid, 176 TYPHOID FEVER. Typhus, and Relapsing Fever. By William Jenner, M. D. London, 1850, pp. 20. Typhus Fever, Typhoid Fever, Relapsing Fever, and Febricula ; the diseases commonly confounded under the term Continued Fever. Illus- trated by Cases collected at the bedside. By William Jenner, M. D. London Medical Times, 1850. I have already alluded to these publications, and expressed my opinion of their value. It is not necessary that I should give any detailed account or analysis of them here. The more important portions of their contents are introduced into the present edition. Dr. Jenner is Professor of Pathological Anatomy in University College, London; his observations were made in the London Fever Hospital; and that these observations were extensive, thorough, careful, conscientious, and complete, no one who reads the record of them will for a moment doubt. [Clinical Reports on Continued Fever, based on Analyses of one hundred and sixty four Cases, &c. By Austin Flint, M. D., Buffalo, 1852, pp. 390. Also Resume de Recherches Cliniques sur la Filvre Continue, &c. Par Austin Flint, M. D. Paris, 1854, pp. 112. The cases here reported are partly the typhoid fever brought to Buffalo by German immigrants, and partly the typhus brought there by the Irish immigration of 1847, and afterwards. Dr. Flint recognizes the distinction between these forms of disease, and treats them under separate heads. The Reports are drawn up under the guidance of a sound judgment, and the true medical philosophy. They are frequently quoted in the first and second parts of the present edition of this work. Siatislique et Traitement du Typhus et de la Fihre Typhdide, &c. Par Magnus Huss, M. D. Paris, 1855, pp. 240. This book is val- uable as showing the character of the fever which prevails in Sweden. The author lives at Stockholm. Attached to the Sera- phim Hospital, he has given a general account of a larger number of cases (3,186) than has before been collected in a single volume, and at the same time he has furnished an analysis of two hundred and fifty of these cases. The author recognizes the common dis- tinction between typhus and typhoid fever, but is so fully persuaded that they are substantially the same disease that he generalizes from the two without discrimination. Those holding the doctrine of this book will feel that this is a material fault, and will deprive the treatise of a portion of the influence to which the large collection of cases would otherwise entitle it.] PART SECOND. THE HISTORY, DIAGNOSIS, AND TREATMENT TYPHUS FEVER. 12 PART II. TYPHUS FEVER. CHAPTER I. PRELIMINARY MATTERS. ARTICLE I. INTRODUCTORY. I now proceed to the description of Typhus Fever. The natural history which I shall be able to give of this disease will be some- what less complete than that which I have already given of typhoid fever. The reason of this is twofold: in the first place, I have seen much less of the disease myself; and in the second place, but few entire and elaborate histories of the disease have been published. We have many excellent general descriptions of it, especially as it has shown itself in certain localities, and during certain epidemic periods; but we have had no thorough and detailed histories of its symptomatology and lesions; like those which Louis, Chomel, and others have furnished us of typhoid fever. To these remarks it may be added that the diagnosis of typhus fever, by most of the observers upon whose records we must depend for our materials, is much less accurate and positive than that of typhoid fever is, as this disease shows itself in New England, and in France. Typhus fever is more frequently confounded and mixed up with other diseases, by its best historians, than typhoid fever is; and in this way, another element of incompleteness and confusion is introduced into its his- tory. The foregoing remarks, contained in my second edition, need some qualification in consequence of the recent appearance of the papers of Dr. Jenner. The materials for the following description will be derived mostly from British physicians, and from Dr. Gerhard, of Philadelphia. 180 TYPHUS FEVER. The accounts of typhus fever which have been published from time to time, and mostly in the form of Hospital Reports, by the Scotch and Irish practitioners, constitute our richest and most authentic sources of information in the study of this disease. This remark is especially applicable to the Hospital Reports of Dublin, made subsequent to the year 1812, by Edward Percival, John O'Brien, F. Baker, William Pickels, John Cheyne, and others. I know nothing of a like character in the English language superior to the Hospital Reports of John Cheyne ; and one of the most valu- able histories of the disease now under consideration which have ever been published, is to be found in the account given by Dr. Barker, and Dr. Cheyne, of the great epidemic of typhus fever which overran Ireland during the years 1817, 1818, and 1819. One reason for this reliance, which I am disposed to place upon the observations of Irish and Scotch writers, rests upon the belief, the grounds of which will be fully stated hereafter, that true typhus fever is more exclusively the prevailing fever in Ireland, and in the northern portions of the British empire, than it is in the middle and southern regions of England. Dr. Gerhard has published, in the American Journal of Medical Sciences, a very valuable history of an epidemic typhus fever which prevailed in Philadelphia, during the spring and summer of 1836, and which was carefully studied by himself and Dr. Pen nock. I am aware of the danger of trusting to the phenomena presented by any single epidemic in making up the history of a disease, and I do not intend in the present instance to be guilty of this fault. I look upon the papers published by Dr. Gerhard as of inestimable value; but it is only by a careful examination of many histories of typhus fever, and by a methodical arrangement of the materials which they may furnish, that I can hope to make out even a tolerably complete and satisfactory descrip- tion of the disease. I shall follow, as far as this can conveniently be done, the same general plan, in the disposition of the several subjects of inquiry and description, as has already been adopted in the fore°-oino- his- tory of typhoid fever. PRELIMINARY MATTERS. 181 ARTICLE II. NAMES OF THE DISEASE. The term typhus, from the loose manner in which it has been used, and the various morbid conditions to which it has been applied, has become somewhat indefinite in its signification. It is only important for me to say here that I mean by it an idiopathic, contagious fever, prevailing generally amongst crowded populations, and in badly ventilated localities, and not marked by any constant lesion of the solids. The other most common names by which it has been known are the following, to wit: Hospital Fever, Jail Fever, Camp Fever, Malignant Fever, Putrid Fever, Petechial Fever, and Contagious Typhus. It should be added that these latter terms have not been invariably and exclusively confined to true typhus; they have been sometimes applied to typhoid fever. [Recently it has been denominated, in this country, the Ship Fever, on account of its fatal prevalence on board emigrant vessels, and its evident importation from Ireland in 1846, and subsequently.] 182 CHAPTER II. SYMPTOMS. ARTICLE I. MODE OF ACCESS. Typhus fever is sometimes sudden and sometimes gradual in its access. I am unable to state, with any degree of certainty, the proportion between these classes of cases. In six of eight cases reported by Dr. Gerhard, the patients complained, for a period of from three to seven or eight days, of various uncomfortable feel- ings, such as languor, loss of appetite, soreness of the muscles, sleeplessness, wandering pains in different parts of the body, and so on. In the other two cases, the disease came on suddenly. Dr. O'Brien says that these premonitory symptoms continue generally for a few days, but sometimes for a week or two. Amongst these symptoms, he enumerates lassitude and fatigue on the least exer- tion : dulness of the eyes; sallowness, and dejected expression of the face; heavy, dull pain in the head; slight nausea ; anxiety without any apparent cause; slight chills, frequently repeated, especially towards night, and imperfect, disturbed sleep.1 Dr. Pickels speaks of the disease as being nearly always preceded by trembling and nausea.2 Dr. John Cheyne, in his description of the fever of the spring and summer of 1818, as it showed itself at the Hardwicke Hospital, Dublin, says: " Some patients felt an unaccountable dejection of spirits for several days before seizure; some continued at work or labor for several days after their illness began in the shape of a headache, which frequently intermitted; in a few, the disease began with intense headache without rigor, the patients being, as they said, at once knocked down."3 Dr. Jenner says: " Of sixteen of forty-three fatal cases, no parti- 1 Trans, of Phys. of Ireland, vol. i. p. 410. 2 Ibid., vol. iii. p. 196. 3 Dub. Hosp. Rep., vol. ii. p. 4. MODE OF ACCESS. 183 culars as to whether the disease began suddenly or insidiously could be obtained. Of the remaining twenty-seven cases, twenty- three were taken ill suddenly; nineteen of these twenty-three cases first kept their beds as follows:— Four on the first, six on the second, five on the third, three on the fourth, and one on the sixth day. Thus, all these patients were confined to their beds before the seventh day. Of these twenty-three cases, when four took to their beds was not learned. In four of the twenty-seven cases of which a correct history was obtained from the patients or their friends, the disease began insidiously, so that the day of its commencement could not be exactly ascertained, but they took to their beds on about the second, third, fourth, and sixth days; so that if this group be added to the first, every patient may be said to have been confined to bed by the sixth day.1 [The sudden attack was less frequently observed by Dr. Flint. Among his sixty-four cases of typhus, he was able to learn the early history in twenty-five. In eight of these the attack was sud- den. For eighteen of these twenty-five, studied separately, the average period of invasion was between four and five days; for the other seven, it was just three days.2] Many writers, who have seen much of the disease, mention cases in which persons in full health, while standing by the bed of the sick, and breathing the infected atmosphere from the body and bed of the patient, have been instantaneously seized with nausea, giddiness, faintness, and so on, and these symptoms have been immediately fol- lowed by the gravest form of the fever. These sudden seizures are more common in typhus than they are in typhoid fever; indeed, I do not know that they are ever seen in the latter disease. [Dr. Upham and a nurse were seized with sudden giddiness, faintness, and nausea while plugging the posterior nares of a patient in the last stage of malignant typhus; but in neither did the symptoms of the fever follow. Their escape, Dr. Upham ascribes to immediate change of clothing, a warm bath, and pure air.3 Such occurrences suggest a doubt whether these symptoms are the effect of the real typhus contagion; and if typhus does really follow the disgust or fear pro- duced by breathing the nauseous breath of the patient, or foul air from his foul bed, the latter should probably be regarded only as 1 Dr. Jenner on Typhoid and Typhus Fever, p. 8. 2 [Resume de Recherches Cliniques sur la Fievre Continue, p. 9.] 3 [N. Y. Journ. of Medicine, July, 185-2, p. 12.] 184 TYPHUS FEVER. an exciting cause, the specific poison having been previously received into the system. Similar stories are told of the sudden production of yellow fever from the overpowering odor of filth ; but it is opposed to all known rules of incubation that either disease should be produced instantly, and without previous exposure to the specific poison.] ARTICLE II. FEBRILE SYMPTOMS. Sec. I.— Chills. I do not know that there is anything peculiar or characteristic in the initiatory chill of typhus. Many writers speak of it very indefinitely, or not at all. Sometimes it is of some severity, and well marked; but in many cases it seems to consist merely of a sense of chilliness felt over the whole body, or especially perhaps along the back, and continuing not unfrequently for two or three daj's. Sec. II.—Heat and State of the Skin. After the disease is fully formed, the surface of the body becomes preternaturally hot. The heat of the skin is peculiar and pungent, constituting what has been called "calor mordicans." Dr. Gerhard says that this burning heat of the skin was so remarkable in the Philadelphia epidemic of 1836 that the resident physicians and others could frequently diagnosticate the disease from this symptom alone. This morbid heat is generally accompanied by dryness of the skin. It is increased towards night, forming a well-marked evening exacerbation. [Dr. Flint reports that this calor mordicans was noticed in very few of his cases, and he asserts that it is not to be regarded as a distinctive sign of typhus fever. He further remarks that the increased heat of skin in some of his patients continued, without remission, through the whole course of the disease; in others, it appeared at intervals of irregular duration, and in certain cases the temperature did not at any time exceed that of the surface in health.] Dr. Edward Percival observes that the strongly marked exacerbation occurs more frequently in the first than in the second or third week of fever. During the spring and summer of 1817, the temperature of the surface on the day of admission to the Hardwicke Fever Hospi- tal, Dublin, was ascertained by the thermometer in two hundred and fifty cases. It ranged from 96 to 100 deg. Fah., inclusive, in eighty-three cases; from 101 to 106 deg. Fah., inclusive, in one SYMPTOMS.—HEAT AND STATE OF THE SKIN. 185 hundred and sixty-three cases; and from 107 to 109 deg. Fah., inclusive, in four cases.1 During the winter and spring of 1818, a similar examination was made of ninety-nine cases, with similar results. The temperature ranged from 95 to 100 deg. Fah., inclu- sive, in twelve cases; and from 101 to 106 deg. Fah., inclusive, in seventy cases; and from 107 to 109 deg. Fah. in seventeen cases. Towards the termination of the disease, the skin not only loses this acrid and burning heat, but frequently becomes cooler than natural. Sir Gilbert Blane, in his excellent description of typhus, studied mostly on shipboard, says: " The symptom next to be taken notice of, though a minute one, is very constant and characteristic in this sort of fever. It is a peculiar heat in the skin, communicated to the hand of another person. It is usual to grasp the wrist of the patient after feeling his pulse, in order to examine the state of the skin in point of heat and moisture; and in doing this, a glow of heat is impressed on the palm of the hand, which lasts for some hours if one should neglect so long to wash the hands."2 In con- nection with the same subject, a still older, and equally careful observer, Sir John Pringle, remarks : " In the beginning, the heat is moderate; even in the advanced state, on first touching the skin, it seems inconsiderable, but upon feeling the pulse for some time, I have been sensible of an uncommon ardor, leaving an unpleasant sensation on my fingers for a few minutes after. The first time I observed this, I referred it to the force of imagination; but I was assured of the reality by repeated experiments, and by the testimony of others, who, without knowing of my observation, had made the same remark."3 Most writers upon this disease speak of the odor from the body of the patient. Southwood Smith calls it peculiar and characteristic, but does not attempt to describe it. John Cheyne mentions the offensive fetor from the patient. Dr. Gerhard is more explicit upon this point. He says that this peculiar odor was pungent, ammoni- acal, and offensive; especially in severe cases, and in fat, plethoric individuals; sometimes, for a few days before death, the smell re- sembled that of putrid animal matter. The bodies of these patients ran into decomposition very rapidly after death, although, before putrefaction, the odor was less pungent than it was during life- Dr. Pickels says that, upon entering the room of a patient, the pre- ' Dub. Hosp. Rep., vol. ii. p. 10. 2 Obs. Dis. of Seamen, p. 355. 3 Obs. Dis. of Army, p. 259. 186 TYPHUS FEVER. sence of typhus fever was indicated, previous to any examination, by this peculiar fetor from the skin. Sec. III.—Pulse. The pulse is generally very frequent. In severe and fatal cases, it is often more than one hundred and twenty in the minute, and not unusually as high as one hundred and fifty. Of two hundred and thirty-seven cases, in the Hardwicke Fever Hospital, the average frequency of the pulse, on the day of admis- sion, was from fifty-two to seventy-eight in twenty-seven; from eighty to one hundred in seventy-nine; from one hundred and two to one hundred and twenty in ninety-five; and from one hundred and twenty-four to one hundred and eighty in thirty-six.1 The rapidity of the circulation was generally, but not uniformly, pro- portionate to the excess of temperature. Sometimes, though rarely, the frequency of the pulse, even in very grave cases, is below the natural standard. It is generally, but not always, regular. Dr. Gerhard says that the peculiar undulation in the motion of the artery, so frequent in typhoid fever, was rarely felt in the Philadel- phia typhus of 1836. The pulse very rarely, if ever, exhibits the strength, hardness and sharpness of inflammatory diseases. Sometimes, early in the fever, it may be somewhat full, but even then it is easily compressed; and after the first few days it is almost always small, soft, and feeble. Dr. Jenner says, in speaking of his fatal cases: " From the earliest period of the disease that any of the forty-three patients came under my observation, the pulse was decidedly soft, gradually became weak, then very weak, and in many cases during the last few days of life imperceptible. Generally small, it was occasionally full, but still retained its extreme softness."2 In this connection, better than anywhere else, I may speak of the feeble action of the heart. This feebleness in the contraction of the central organ of the circulation is particularly mentioned by Dr. Stokes, of Dublin, and other writers on typhus fever. Dr. Ger- hard found it extreme in many cases, even from the earliest period of the disease. [Dr. Stokes, in his lectures on Fever lately published in the Med. Times and Gazette, renews his instructions to listen to the beatings of the heart, to learn whether the first sound has become enfeebled, or be not altogether wanting. Such feebleness in the 1 Dub. Hosp. Rep., vol. ii. p. 4. 2 Dr. Jenner on Typhoid and Typhus Fever, p. 37. THORACIC SYMPTOMS. 187 heart's action he regards as one among the marked indications for the administration of wine. He speaks also of a " true muscular murmur," first observed in the hospital to which he is attached, " produced when the heart does not contract per saltern, but, as it were, vermicularly." Dr. Huss urges the auscultation of the heart in fevers, arguing that as " the feebleness of the muscular system is an index of the general depression of the vital forces, so the feebleness in the action of the heart, perceived in the alteration of its sounds, becomes the most exact measure which we possess of the general state of depression."1] ARTICLE III. THORACIC SYMPTOMS. In most cases of typhus, there is some lesion of the respiratory organs, manifesting itself by signs or symptoms during life. Dr. Gerhard found, early in the disease, a feeble and imperfect respira- tory murmur over the posterior portion of the chest, with cor- responding dulness on percussion. These signs were frequently but not always combined with a subcrepitant or mucous rhonchus. This latter was more common during the cold than during the warm weather. The sibilant rhonchus, common in typhoid fever, was rare in this epidemic. Pneumonia constituted the most fre- quent accidental complication, especially in the winter. It was indicated by a loose mucous rhonchus, instead of the fine dry crepitus and bronchial respiration of simple pneumonia, and was unattended by pain. Dr. Pickels says that, in the typhus fever of 1817,1818, 1819, in Cork, next to the affection of the head, the most prominent and constant feature was the affection of the chest, as marked, during the first days, by oppression of the precordia, sighing, and in the course of the disease by cough. The cough was generally accom- panied by a copious and viscid expectoration, and was especially urgent early in the disease during the winter months.2 The frequency of respiration, during the active period of the disease, is increased. Of one hundred and seventy-one cases admitted into the Hardwicke Fever Hospital, during the spring and summer of 1817, the average frequency of the respiration on 1 [Statistique et Traitement du Typhus, &c., p. 171.] 2 Trans, of Phys. of Ireland, vol. iii. p 198. 188 TYPHUS FEVER. the day of admission was about thirty in the minute. It ranged from twenty to thirty in eighty-four cases: from thirty-two to forty in seventy-seven cases; and from forty-four to sixty in ten cases.1 Of two hundred patients, treated by Dr. Henderson at the Edinburgh Royal Infirmary, in 1838 and 1839, there were symptoms of thoracic disease in seventy-three. In a large majority of these cases, the symptoms were bronchitic.2 Of Dr. Jenner's forty-three fatal cases, there was cough, generally slight in amount, and accompanied by little expectoration in twenty- one. " Sonorous rale was present in seven of these cases; three had mucous rale more or less abundant, without sonorous; and in nine there was during life some want of resonance of the most depending part of the chest, i. e., the portion corresponding to the most depending portion of the lung, the patient being in the recum- bent position, and on his back; this region does not, it will be observed, include the extreme base, the root or apex of the inferior lobe; the respiratory murmur at the same point was accompanied by an intensely congested condition of the corresponding pulmonary tissue, occasionally passing into absolute consolidation. Doubtless the same physical signs were present in many other cases, but from the state of the patients very many were unable to be raised in bed sufficiently for the posterior parts of their chest to be examined."3 [Dr. Stokes thinks that the most common disease secondary to typhus fever and complicating it, is in the bronchial tubes. In this country we usually call this complication bronchitis. Dr. Stokes doubts the propriety of calling it by a name that suggests the idea of inflammation, or the treatment of inflammation. He thinks it the "result of the typhus deposit, or vascularity with tumescence." What of inflammatory action there is, he looks upon as " reactive or specific." It furnishes the same physical signs as inflammatory bronchitis, except that the increased resonance on percussion often met with in the latter is not found in the bronchial, or as he sometimes calls it, the pulmonary complication of typhus. The rational symptoms are less marked, and often the tumefaction and mucous accumulations in the tubes become so considerable as to threaten suffocation before the physician's attention is drawn to the state of the lungs. Dr. Stokes suggests that this secondary bronchial disease may hold the 1 Dub. Hosp. Rep., vol. ii. p. 11. 2 Edin. Med. and Surg. Journal, Oct., 1839. 3 Dr. Jenner on Typhoid and Typhus Fever, p. 37. SYMPTOMS. — HEADACHE; PAINS IN BACK AND LIMBS. 189 same relation to the Irish typhus, that the follicular disease of the intestine, in France, bears to the fever of that country. Rokitansky recognizes a broncho-typhus, and points out alterations which occur in the bronchial glands.1] ARTICLE IV. CEREBRO-SPINAL, OR NERVOUS SYMPTOMS. Amongst the most constant and prominent symptoms of typhus fever, are those connected with the nervous apparatus. They obtrude themselves urgently upon our observation; they are strik- ing, and strongly marked in their character; they are many in number; they are present at the earliest period of the disease; and they accompany its various stages up to the time of convalescence. Not- withstanding all this, for the very reason, perhaps, that it is so, I am unable to give anything like so full and discriminating a history of this extensive and important class of symptoms, as I have given of the corresponding symptoms, in typhoid fever. The British writers upon typhus fever do not seem to have considered it at all necessary to speak with any considerable degree of particularity of these symptoms; so that it is impossible, in the actual state of our knowledge, to make so satisfactory a comparison in this respect between typhus and other fevers, as is desirable. Sec. I.—Headache; Pains in the Back and Limbs. Pain in the head is almost always present during the early period of typhus fever. Dr. Gerhard does not speak of it in his general description, but it is mentioned in all his reported cases, eight in number. It is very commonly amongst the premonitory symptoms of the dis- ease; and if not present at this time, is very sure to constitute one of-the signs of its formal and more decided attack. Dr. Henderson found it in one hundred and fifty of one hundred and fifty-nine cases; it was present on the first day, in ninety-two of one hundred and eight cases; and its mean duration was ten days.2 Dr. Pickels says of the Cork epidemic, in 1817, 1818, and 1819: "The most distressing source of uneasiness was the headache; the patient, when questioned, complaining, in almost every instance, particularly 1 [Lectures on Fever, Med. Times and Gaz., 1854.] 2 Edin. Med. and Surg. Journ., vol. iii. p. 432. 190 TYPHUS FEVER. of this pain, and often using some comparison illustrative of its acuteness. It was commonly referred to the forehead, more par- ticularly over the eyes; rarely to the occiput. In a few instances it was dull and vertiginous." Dr. Stewart informs us that, of one hundred and thirty nine cases occurring at Glasgow, the headache was present after the fifth day in ninety-eight; that in between one- sixth and one-seventh of this number it ceased before the tenth day; but that in the remaining five-sixths it continued throughout the advanced stages of the disease, and in eleven throughout the whole course of the affection.1 The headache is usually accom- panied by pains, more or less constant and severe, in the back, and in the extremities, particularly the legs. Sec. II.—State of the Mind. The mind is almost always more or less affected, from the commencement of the disease. This affec- tion may consist, for the first few days, merely in a diminution of its usual strength and activity. The patient feels himself confused and cloudy, and hesitating in his thoughts. His accustomed apti- tude for intellectual effort is lost. Dr. Gerhard says that, in the Philadelphia epidemic of 1836, "the alteration of the intelligence was so slight at first as to escape the attention of an inexperienced observer; but when the fever had fully set in, there was at least confusion of the intellect, and nearly always delirium. This last symptom was absent in only a few cases. The delirium was not noisy, except in about one patient out of twenty. In the immense majority of patients, it was dull, muttering, and incoherent. The delirium became more tranquil, and was exchanged for ordinary stupor, or coma, when the fever was at its height. It did not cease entirely until the complete establishment of convalescence. Even after recovery, the intellect of the patient was more enfeebled than it is in ordinary diseases, and regained its usual strength but slowly." In the Irish epidemic at Cork, already spoken of, Dr. Pickels says: " The patient commonly raved of those objects which had principally engrossed his attention during health. A cow-herd, who had been brought in from the country, fancying that the patients who lay around him were those animals which he had been accustomed to attend, endeavored at intervals to rouse them into motion by a particular cry, which is usual for this purpose in the 1 Edinburgh Med. and Surg. Journ., Oct., 1840. SYMPTOMS. — STATE OF THE MIND. 191 country. A thief raved of his thefts and accomplices. A faith- ful steward refused, with many acknowledgments, to take his wine, as he had his master's keys and it might render him unfit to per- form his business." Hildenbrand says: "During the septenary stage of an attack of typhus, my mind was constantly engaged in removing an awkward ornament from my stove, which stood di- rectly opposite to me; and, being of course unable to remove it, it tormented me in the most cruel manner. One of my pupils, who, having been taken with an attack of typhus a short time previously, had assisted at the opera called the Mirror of Arcadia, performed, during the whole septenary of the nervous stage, the character of viper-catcher; and as he was obliged to swallow these disgusting reptiles, he experienced the most inexpressible anxiety. Another labored under the painful and fantastic idea, during the whole course of his disease, that he was not only suffering for himself, but for all his comrades in the clinical ward."1 Dr. John Cheyne informs us, in his account of typhus fever at the Hardwicke Hospital, Dublin, in the summer of 1818, that, in severe cases, delirium came on at the end of the first or at the beginning of the second week. " At all times, such patients were incapable of any stretch of atten- tion ; they answered questions satisfactorily, though with a falter- ing voice, but soon wandered from-the subject. In many cases, the delirium was of a very troublesome kind; first it was only oc- casional; then, it continued all night; then it was uninterrupted. We had many patients who created great disturbance by wandering about the wards all night, prying into the closets, and looking under the beds. Some of these were full of their usual occupa- tions : one man, by trade a cooper, endeavored to pull his bed to pieces, in order to make a tub of the spars." It ought, perhaps, to be stated here, that many of the patients in the Irish hospitals were habitual spirit drinkers;-and it is very probable that, in some of these cases, the elements of delirium tremens may have been com- bined to some extent with those of the fever itself. In twenty-three cases amongst females, noticed by Dr. Hender- son, at Edinburgh, the delirium began on an average about the eleventh day. Dr. Henderson found no appreciable relation between the disturbance of the mental powers and the degree of pain in the head. The average date at which delirium showed itself amongst male patients was about the tenth day: it occurred, also, in a 1 Gross's Hildenbrand, p. 45. 192 TYPHUS FEVER. greater proportion of cases amongst males, and was oftener of a violent character. The following is Dr. Jenner's account of the state of the mind in his forty-three fatal cases : " The mind of one patient was perfect throughout the disease. This was a very mild case in every particular; the patient died of phlebitis after he had once left his bed. In another case there was only slight mental confusion; this patient also survived the fever. Although there was no actual delirium in thirteen other cases, yet there was in them such extreme mental confusion that the patients could give no account of their past state, ' felt bothered,' had no idea how long they had been in the hospital, nor in some cases where they were. Delirium began in ten cases respectively, on the fifth, eighth, tenth, tenth, tenth, eleventh, eleventh, eleventh, twelfth, and thirteenth days. It was present when five cases first came under observation, severally on the sixth, eighth, ninth, ninth, and fourteenth days. In every instance in which the delirium commenced after the patients entered the hospital, excepting one, it was preceded by a varying amount of mental confusion. It was uncertain how long nine patients had been ill, who were delirious when I first saw them. Four patients were admitted into the wards in a state of complete stupor. The delirium continued till the death of the patients in thirteen cases, nine of which proved fatal, severally on the ninth, eleventh, eleventh, fourteenth, sixteenth, seventeenth, seventeenth, nineteenth, and twentieth days. The remainder of the forty-three patients either sunk into a state of absolute coma, or survived the termination of the fever. The character of the delirium was usually far less active than that of the delirium of typhoid fever; the patients displayed less vivacity, and fewer of them, seven only of the twenty-four, i. e. at the rate of 29.2 per cent, of those who were delirious after they were admitted into the hospital, attempted to leave their beds to roam in the wards."1 [In Dr. Flint's cases, delirium appeared in forty-nine, and was absent in fourteen. Its character was ordinarily passive consist- ing in incoherent words, murmurs, and in efforts to rise from the bed. In no case was it so violent as to require restraint.2] Another very constant symptom belonging to this group consists of somnolence, or stupor, in its various degrees. This is amongst the earliest phenomena of typhus fever. Dr. Gerhard says: "It 1 Jenner en Typhoid, &c, p. 23. 2 [Rgsumgj &Ci> p> u^ SYMPTOMS. — STATE OF THE MIND. 193 was perceptible in our patients, from the moment when they com- plained of their first symptoms. It was frequently slight, but could always be recognized by a little attention, and gradually increased until the middle period of the disease, when it was most intense; nor did it cease entirely until the strength of the patient had returned. There were usually some traces of it during con- valescence. The stupor rarely passed into complete coma, except in fatal cases; hence coma was always a most unfavorable sign. Still, to a moderate extent, it was occasionally witnessed, without being followed by the same danger as in ordinary diseases." Dr. Pickels observes that, in cases marked by stupor, even where there had been no delirium, the patients, upon recovery, seemed to have lost all recollection of what length of time they had been sick. Somnolence was present in twenty-seven of Dr. Jenner's forty- three fatal cases. Nine patients had coma vigil, from one to four days immediately preceding death. " By this term," says Dr. Jenner, "I mean to express that peculiar condition in which the patient lies with his eyes open, evidently awake, but indifferent or insensible to all going on around him, and not what some writers on fever have meant by the expression, viz., that state in which the patient lies asleep for hours, and yet declares, on awakening, that he has never closed his eyes."1 [The following remark of Dr. Flint is important: " The state called coma vigil does not predispose to true coma. The develop- ment of the latter is usually rather sudden, and, so far as the pre- liminary cerebral symptoms are concerned, unexpected, and it is preceded and accompanied, according to my observation, by the change in the respiratory rhythm," referred to in the first part of this work.2] The sleep is imperfect, unrefreshing, and disturbed; and it con- tinues to be so until it lapses gradually into coma, or until the patient falls into the deep and sweet repose of commencing con- valescence. [Dr. Stokes3 expresses the conviction that the nervous or cerebral symptoms of typhus fever are more and earlier developed when the disease attacks persons in the elevated classes of society ; and that the disease is more fatal in the higher than in the lower classes. With the exception of physicians, the ship fever in New York has 1 Jenner on Typhoid Fever, &c., p. 24. 2 [Resumg, &c., p. 15.] 3 [Clin. Lect., Med. T. and Gaz., July 22d, 1854.] 13 194 TYPHUS FEVER. hardly reached \he higher classes. Since 1846 it has produced a very large mortality, in a single year more than five thousand deaths, but it has been confined almost wholly to emigrants from Ireland, the Irish inhabitants of the city, and to those whose duties brought them in contact with the sick. Among the latter class physicians are, of course, prominent. In the editor's circle of pro- fessional acquaintance, about fifty took the fever, and nearly one- third of that number died. The mortality among hospital patients has not probably exceeded one-tenth, except temporarily when the wards have been over full. The cerebral symptoms among the hospital fever patients were more frequently noticed than Dr. Stokes appears to have met them in the same class, while among the phy- sicians attacked, in almost every instance they appeared early, and formed the leading features of the disease. Dr. Upham refers to the greatly increased ratio of mortality among physicians and medical attendants, who become the subjects of the typhus fever. He says: " Statistics will show that no epi- demic, or contagious malady has ever visited our shores, or sprung up among us, which has proved so fatal to the ranks of our pro- fession according to the number exposed ;'n but he does not inform us whether his observation confirms the opinion that in the studious and thinking the cerebral symptoms are most frequently met with.] Sec. III.—Physiognomy. Besides the dull and stupid expression of the countenance, common both to typhoid and to typhus fever, there are other appearances of the face more characteristic of the latter disease. These consist in a peculiar state of the skin and the eyes. They are very generally mentioned by writers on typhus fever, and are particularly described by Dr. Gerhard. " A constant symptom," he says, " observed in every case, was a dull, livid, red hue of the countenance, extending nearly over its whole surface. Sometimes, this color approached a purple. It coincided with a strong, dark red suffusion of the capillary vessels of the conjunctiva, which appeared at the same time with it; but it usually disappeared at an earlier stage than the injection of the eyes. The conjunctiva never presented the bright red tinge, or the brilliant aspect, observed in acute inflammatory diseases of the brain, or of the eye itself. 1 [N. Y. Journ. of Med., July, 1852, p. 12. The mournful history of yellow fever as it visited New York in 1798, and the martyrdom of professional men at Norfolk, Va., in 1855, furnish saddening exceptions to this statement.] SYMPTOMS.—PHYSIOGNOMY.—SENSES. 195 Dr. Jenner says: "The conjunctivae were more or less intensely injected in twenty-five cases; and in all of those in which the opportunity occurred of observing the date of the first appearance of this increased vascularity, it began during the second week. * * * In eleven of the cases, the pupils were contracted. The expression was dull, and the bloodvessels had a dark-red tinge, instead of their usual scarlet hue. The suffusion of the face and eyes was so con- stant, and so well marked, in the fully formed disease, that it served almost as a pathognomonic sign. It was generally most evident in patients of a full habit of body. Towards the close of the disease, the reddish color was gradually changed into a dull ashen tint, which remained until the entire recovery of the patient."1 Dr. Jenner says: " In none of the forty-three cases was the expression natural throughout the disease. In a large majority of the cases, both the expression and the manner of the patient were so peculiar that from them alone the diagnosis might have been formed. They were dull, heavy, oppressed, confused, like those of a drunken man just disturbed from sleep. The mind was rarely intelligent enough after the commencement of the second week to be disturbed as to the final issue, and as the disease in itself is free from serious organic lesion, all automatic, as well as mental expression of anxiety was absent. The hue of the face after about the sixth day was, like the expression and manner, peculiar—it was thick and muddy looking; the change from this condition to the clearness of health was most remarkable. * * * The muddy hue had no relation to the flush of the face, for it was often present when the face was pale; moreover, though only noted in the face, it affected more or less the whole skin. The face was flushed in eighteen cases, and in every case the flush covered the whole face, though in some it might have been somewhat more intense on the cheek than elsewhere. The color of the face when flushed was dusky red, and never pink, as the cheeks were in the cases of typhoid fever."2 Sec. IV.—State of the Senses. Several of the senses are com- monly more or less perverted in the course of typhus fever. Some confusion of vision is frequently present from the beginning of the disease. This is often associated with dizziness, especially on assuming the sitting or upright position. Dulness of hearing, 1 Jenner on Typhoid, &c, p. 28. 2 Ibid., p. 20. 196 TYPHUS FEVER. commonly connected with ringing in the ears, is also an early and a very common symptom. Dizziness was present in five of nine cases observed at London by Dr. Shattuck, Jr., and dulness of hearing in only one. Dr. Stewart mentions great intolerance of light as one of the most constant symptoms of the disease. There is often a morbid sensibility of the entire surface of the body. Dr. Gerhard observed, in the Philadelphia epidemic of 1836, that " the sensibility of the skin was universally augmented when the stupor was not so great as to render the patient insensi- ble, or nearly so, to all external impressions. The tenderness upon pressure was so much increased as to induce us to refer the external soreness at the epigastrium, when pressure was made upon the abdomen, to an affection of the internal organs; but on more care- ful examination, the sensibility was nearly equally increased in every part of the body, and was evidently external. " The cutaneous tenderness was preceded by muscular soreness, which lessened as the skin became more sensitive." Sec. V.—State of the Muscles. Amongst the earliest and most constant accompaniments of typhus fever is loss of muscular strength. This is almost invariably present from the beginning to the close of the disease. Even during the premonitory stage, when this exists, it is with much difficulty and effort that the patient succeeds in keeping from his bed. Dr. Pickels, in his Report on the Typhus Fever at Cork, says: " The debility was such that the patient was unable, from the commencement, to rise from the bed, or to walk without assistance, and in some instances, even without the effort of rising, fainted in bed. In a few. syncope appeared, as the first symptom of the onset of the disease. In thirty-four of Dr. Jenner's forty-three fatal cases, there was extreme prostration; and in a large majority of these cases, this extreme prostration came on from the ninth to the twelfth day of the disease.1 "There is a secondary and still more extreme prostration of strength, which comes on, on the subsidence of the fever, and is attended with coldness of the extremities, and a feeble, fluttering pulse."2 Spasmodic twitchings of the muscles are very common in typhus as they are in typhoid fever. Their positive frequency I am not able to give. Dr. Gerhard observed subsultus of the tendons at 1 Jenner, &c, p. 27. 2 Amer. Journ. Med. Sciences, Aug., 1837. SYMPTOMS.—TONGUE AND MOUTH. 197 the wrist in three-fourths of his patients. "In the more severe cases," he says, " the subsultus extended to the muscles of the legs and face. When it appeared at the face, the corners of the mouth were drawn rapidly to one side or the other, giving a singular expression to the countenance. In the worst cases, the subsultus extended to nearly all the muscles of the body, keeping the patient in a constant state of tremor, not unlike a severe chill. The smaller muscles were much more affected than the larger ones, and there was no constant rigidity observed in any case; neither was there any paralysis." It will be seen, from what has now been said, that the symptoms connected with the nervous system are even more constant and more strongly marked in typhus than in typhoid fever; but that there is no very constant or important difference between them, unless it be in the greater degree of stupor attending the former, in the lower grade of the delirium, and in the earlier and more rapid development of these symptoms. ARTICLE V. DIGESTIVE AND ABDOMINAL SYMPTOMS. Sec. I.—Tongue and Mouth. The appearance of the tongue in this disease is very various. In mild cases, it frequently con- tinues moist, and is merely covered with a light-colored, thin coating; this may become brownish, as the disease proceeds. In other and in grave cases, the tongue is dry, cracked, glazed, trembling when protruded from the mouth, and of various shades of color, from the light brown already mentioned to black. It may be of a deep glossy red color. Sometimes, and in certain stages of the disease, it has a dark, yellowish or brown, dry stripe along its middle, while the edges are nearly clean and moist. Dr. Henderson studied the state of the tongue very carefully in a large number of cases at Edinburgh, in 1838 and 1839. " It very early became covered," he says, " with an increased and altered secretion; white, yellow, or ash-colored; viscid, and adhering to the surface, becoming commonly thicker and darker as the disease advanced. A dry state of the tongue began chiefly in the second week of the fever, and continued for the most part without change, until, along with other symptoms of convalescence, the tip and edges assumed a moist and clean appearance, which gradually extended to the rest. The dryness was often confined to the centre of the tongue 198 TYPHUS FEVER. extending in a brown streak from the point backwards."1 Accom- panying these morbid states of the tongue, there is very frequently an accumulation of dark sordes upon the teeth and gums, and fetor of the breath. Dr. John Cheyne, in his Hardwicke Hospital Report, for 1818, says, that there was often an inability to protrude the tongue, which very awkwardly obeyed the will of the patient. " He would open his mouth, and after various unsteady motions, at length force out his tongue; and when this was accomplished, it was not again drawn within the mouth until he was repeatedly admonished to that effect." Dr. Jenner says the tongue is more uniformly dry and brown in typhus than it is in typhoid fever.2 Sec. II.—Appetite. The appetite is generally destroyed, although it would seem to be less constantly and entirely wanting in typhus than in typhoid fever. Amongst the blacks at Philadelphia, in 1836, the appetite sometimes continued, and some of them asked for and ate solid food. At the Cork Street Fever Hospital, 'during the summer of 1816, when the prevailing character of the fever was very mild, Dr. William Stokes noticed, as a remarkable pecu- liarity, the continuance of a considerable degree of appetite, even whilst the fever was urgent. In two fatal cases, a desire for food was expressed a few hours before dissolution. Sec. III.—Nausea and Vomiting. Nausea and vomiting are occasionally present at the commencement of the disease; but the proportion of cases in which they occur, and the difference in this respect, if any such exist, between typhus and typhoid fever, I have no means of ascertaining. In the Philadelphia epidemic of 1836, both nausea and vomiting were extremely rare. Dr. Ger- hard says that he scarcely found either of these symptoms noted in a single case. There may be a good deal of difference in their frequency, in different seasons and localities. I have already stated, that Dr. Pickels says the fever at Cork, in 1817, 1818, and 1819, was, in almost every instance, preceded by nausea, or, as the patient expressed it, by an empty straining. Dr. Anderson says that nausea was present in fourteen of eighteen cases observed by himself, on the first day of the disease. In nine cases observed by Dr. Shattuck, at the London Fever Hospital, there was neither nausea, vomiting, nor epigastric pain. Amongst one 1 Edin. Med. and Surg. Journal, Oct., 1839. 2 Jenner, &c, p. 29. SYMPTOMS. — STATE OF THE BOWELS. 199 hundred and thirty-two female patients treated at the Royal Infir- mary of Edinburgh, in 1838 and 1839, nausea and vomiting were ascertained to have been present in only twelve, chiefly at the beginning of the fever. Sec. IV.—State of the Boivels. In a majority of cases, there is very little if any obvious change either in the shape or feel of the abdomen. When it is at all tympanitic, it is only slightly so. Dr. Gerhard says that, in many patients, it was either retracted or altogether of the natural form. Dr. Stewart found moderate meteor- ism in only seventy-four of four hundred and sixty-three cases. Tenderness on pressure, either over the whole abdomen or over the epigastrium, is frequently spoken of by writers on typhus fever; but it is probable that, in many cases, this has depended upon the morbid sensibility of the skin. Of Dr. Shattuck's nine cases, there was meteorism in only one; and in this, but for a single day. Of Dr. Jenner's forty-three cases, there was tenderness of the abdomen at some period of the disease in nine cases, but in eight of them it was trivial and transient. Gurgling was detected in only a single case. The abdomen in twelve of forty-one cases was full and reso- nant, in three only of these twelve was it unnaturally distended, and in neither of the three was it noted to possess the peculiar shape of the typhoid abdomen. In twenty-two cases there was neither fulness, resonance, tenderness, nor gurgling; in these twenty- two cases the abdomen presented all the physical signs of health, and in two of them it was noted to be somewhat concave.1 [Yet Dr. Flint found tympanitic distension of the abdomen almost as frequent in typhus as in typhoid fever. In typhoid fever he ob- served it in fifty out of seventy-one cases, and in typhus in forty- six out of sixty-four.] Oftener than otherwise the bowels in typhus fever are constipated. This is as true of grave as it is of mild cases; and it is also as true of the late as it is of the early periods of the disease. Spontaneous diarrhoea is as rare a symptom in typhus as it is a common one in typhoid fever. It is hardly seen, indeed, in the former disease, except- ing during certain seasons, especially in the summer and autumn, when there exists a general predisposition to intestinal irritation and inflammation. Under such circumstances typhus fever feels, as any other disease might, the influence of the prevailing pathological Jenner, &c, p. 31. 200 TYPHUS FEVER. tendency. Dr. Stewart found diarrhoea in only twenty-three of one hundred and thirty-nine cases. Dr. Henderson, in one hundred and fifty-four cases of typhus, found the bowels easy in ninety-ninei loose in five, and costive in fifty. Dr. West, in his paper on Ex- anthematic Typhus, says: " The action of the bowels was not dis- turbed, in the great majority of cases; in fact, the administration of mild laxatives was necessary, in most instances, in order to obtain an evacuation once in forty-eight hours; and in some of the most severe cases, the bowels were very constipated. Diarrhoea occurred in only ten of sixty cases; in three of which the patients died, and it was only four times that it lasted longer than forty-eight or sixty hours." " The intestinal evacuations," says Dr. Henderson, "in their most disordered state, were very dark, slimy, and offensive; and in a more or less considerable degree they possessed these characters in almost every case ; a few only of the mild and one or two of the protracted cases having had throughout stools of a light yellow color." Dr. Edward Percival speaks of the stools in a certain number of cases, as being " unctuous or pitchy, of a black or green- ish hue, and either preternaturally fetid or unusually inodorous." Many of Dr. Jenner's patients required aperients. The discharges were rarely watery, and in only one case was there any considerable diarrhoea. Hemorrhage did not occur in a single case.1 [Dr. Flint records the existence of diarrhoea in eighteen of his seventy-three cases of typhus, and in forty-eight of his sixty-five cases of typhoid fever. He did not meet with hemorrhage in typhus fever.2] Epigastric distress and tenderness are spoken of by Dr. Cheyne and by many others as frequently present, especially during the summer and autumn, when there are other symptoms of disturbance of the stomach. Of one hundred and thirty-nine cases reported by Dr. Stewart, there was abdominal pain, somewhat permanent, in ninety-six; and in sixty of these it continued throughout the greater part of the illness. In most cases the pain was general, in thirty-two it was chiefly or entirely confined to the region of the liver, and in half of these it was associated with great tenderness on pressure. In eleven instances only was there any pain in the right iliac region. Dr. Stewart observes that, while in typhoid fever the pain accompanies the diarrhoea, in typhus the pain is often most severe when the bowels are costive, and is relieved by the exhibition of a purgative.3 Dr. Stewart found, indeed, that of 1 Jenner, &c, p. 33. 2 [Resume, &c, p. 19.] 3 Edin. Med. and Surg. Journ., Oct., 1840. SYMPTOMS. — EMACIATION. — STATE OF THE URINE. 201 seventy-seven cases of typhus in which diarrhoea either spontaneous or consecutive was noticed, there was accompanying abdominal pain in only thirty; while of sixty-two cases in which the bowels were confined, abdominal pain and constipation coexisted in no less than twenty-one. A similar relation between these two symp- toms was noticed by Dr. West. It can hardly be necessary for me to call attention to the very wide and striking difference between the abdominal symptoms in typhus and typhoid fever. Hemorrhage from the bowels is of extremely rare occurrence. Dr. Henderson saw only one instance of this, amongst two hundred patients, at the Royal Infirmary of Edinburgh, in 1838 and 1839. ARTICLE VI. MISCELLANEOUS SYMPTOMS. Sec I.—Emaciation. There is not much obvious wasting of the body, in the early periods of typhus fever. Dr. Gerhard did not find it to become very evident until the fever began to decline. Sec. II. State of the Urine. I am not aware that the changes in the quantity and character of the urine in typhus fever have been to any great extent accurately studied. Dr. Gerhard says that, in the Philadelphia epidemic, the urine " was examined very attentively, and was remarkable merely for its extraordinary freedom from brick-red deposit, or the changes so frequently observed during the course of fever." Dr. Edward Percival says that the quality of the urine is too variable to place any dependence upon it. This, however, is in reference to prognosis. Dr. William Stokes says that, in the early stages of the disease, the urine is scanty and high-colored. Retention of the urine is not uncommon in bad cases, constituting a distressing, and, if overlooked, as it is very likely to be, a dangerous complication. This seems to be more common in typhus than in typhoid fever. It was present in eleven of Dr. Jenner's forty-three fatal cases. " Either retention or involuntary discharge of urine was a symptom in twenty-one, or in nearly one-half of the patients; and as no notes on the point were taken in seven cases in which the prostration was extreme, it is probable that considerably more than one-half were thus affected."1 1 Jenner on Typhoid, &o., p. 26. 202 TYPHUS FEVER. Sec. III.—Epistaxis. Hemorrhage from the nostrils, so common in typhoid, seems to be not a very frequent occurrence in typhus fever. Dr. Gerhard does not mention it at all. By some writers, however, it is spoken of as a more common and important symptom. Dr. Pickels, in his report on the Cork epidemic, says: "Bleeding from the nose, though often occurring separately, in a majority of instances appeared in petechial cases. The discharge did not usually exceed a few drops, but continued to recur during some days. In two cases, however, which proved fatal, the discharge was so profuse as to fill vessels of considerable size. Bleeding from the nose came on in a majority on the second day, rarely appearing later than the seventh; it was much more common amongst males than females." Dr. F. Barker speaks of its occurrence occasionally, and adds that no other hemorrhage is common. It was not present in any of Dr. Jenner's [or of Dr. Flint's] cases. Sec. IV.— Cutaneous Eruptions. Typhus fever is very generally attended with a peculiar and characteristic eruption upon the skin. The name of the disease has often been derived from this circum- stance; hence it has been called petechial fever, spotted fever, macu- lated fever, and so on. As to the exact frequency of the occurrence of this eruption, it is impossible to speak with entire certainty. In many cases it has probably been overlooked; and besides this, it is to be remembered that the diagnosis of typhus fever, by many who have written most extensively and most magisterially upon the subject, has been anything but rigorous and careful. Dr. Stewart remarks, " that the eruption of typhus was unnoticed at Edinburgh, until the attention of physicians was called to it by Dr. Peebles in 1832." He says further: "It is also well known to many that, previous to a visit which Dr. Peebles made to the Glasgow Fever Hospital in the spring of 1835, the exanthema of typhus, then found to be of general occurrence, had neither been looked for nor registered in that institution, and was received as a new discovery." These considerations may help to account for the differences which are to be found in different histories of the disease in relation to this particular subject. In the Philadelphia epidemic, Dr. Gerhard says: " It was present in thirty-two of thirty-six whites. Of the four cases in which it was not visible, one died upon the seventh day of the disease, and the others presented slight symptoms of fever, which disappeared in the course of four or five days. It was also visible, though less distinctly, in mulattoes; and we may infer SYMPTOMS.— CUTANEOUS ERUPTIONS. 203 that the color of the skin alone prevented its development in the negroes." [Dr. Flint met with typhus eruption in fifty-seven of his sixty-four cases of typhus fever.] This eruption differs in many respects, and in a very striking degree, from that of typhoid fever. Its color, especially after the second or third day of its appearance, is that of a duller and darker red. The spots are of a dun, dusky, purplish hue; in some cases, they become almost black. They vary in size, from that of a minute point to a diameter of a line, or even of an eighth of an inch. They are less regularly circular or oval than the rose spots of typhoid fever. They are not elevated above the surrounding skin, and disappear but very partially, or not at all, on pressure. They are almost always much more numerous than the spots of typhoid fever, covering, in many cases, the entire trunk and the extremities. Sometimes they are spread over the skin almost as thickly as the eruption of measles. Dr. Pickels says that in the Cork epidemic " the spots were principally observed upon the breast, neck, shoulders, arms, and thighs, rarely upon the face. From their resemblance, in some instances, to freckles, the friends of the patients, in their descriptions at the dispensary, sometimes compared the appearance of the skin covered with them to that of a turkey's egg. The mottled or marbled efflorescence, resembling measles, occurred in several."1 Huxham says: " We frequently meet with an efflorescence, also, like the measles, in malignant fevers, but of a more dull and lurid hue, in which the skin, espe- cially on the breast, appears as it were marbled or variegated." Pringle's description of the eruption is in these words : " There are certain spots, which are the frequent but not inseparable attendants of the fever in its worst state. These are less usual on the first breaking out in the hospitals; but when the air becomes more corrupted, the spots are common. They are of the petechial kind, of an obscure red color, paler than the measles, not raised above the skin, of no regular shape, but confluent. The nearer these spots approach to a purple color, the more ominous they are, though not absolutely mortal." The eruption sometimes fades suddenly, or changes in its color. Dr. Stewart, amongst others, has, within a few years, studied with great care and particularity the character and appearances of this eruption. He says that the rash is permanent, that is, that it does not consist of successive 1 Trans, of Phys. of Ireland, vol. iii. p. 199. 204 TYPHUS FEVER. eruptions of spots; that in all cases it presents the two periods, longer or shorter, of increase and decline; and that, in the more severe cases, it may exhibit during the period of increase four different states, being florid, dark, livid, and petechial. When the hue of the eruption is florid, it disappears readily under pressure; when dark, it still disappears, but more slowly; when livid, semi- petechial, or pseudo-petechial, as it has been called, it is only par- tially effaced; and when petechial, it is not in the least affected by pressure. In many cases, it remains florid throughout; in others, it presents one or more, and in not a few all these alterations; and after it has reached its height, the process is inverted, and it passes through the various phases of lividity, darkness, redness, and paleness before its evanescence." Of one hundred and thirty- nine cases of typhus observed by Dr. Stewart, the eruption was pale in about one-fourth, florid in between one-sixth and one- seventh, darkish in between one-eighth and one-ninth, livid in rather less than one-ninth, and petechial in about one-eighth. Dr. Stewart ascertained the exact time of the appearance of the eruption in fifty-two cases. This time varied from the second to the thirteenth day ; but in twenty-nine cases, more than half of the entire number, it appeared on the fifth or sixth day; and in three- fourths it appeared from the fourth to the seventh day. In forty- eight cases, the eruption began to decline at different periods, from the eighth to the nineteenth day. It was still more irregular in the time of its disappearance, since this ranged from the thirteenth to the thirty-first day. The average duration of the eruption was eleven and a half days.1 Dr. Henderson, of Edinburgh, has also observed, with an atten- tion and thoroughness not inferior to those of Dr. Stewart, the appearances of the cutaneous eruption, and very generally with similar results. Dr. Henderson noticed that, as a general rule, the progress and development of the eruption corresponded with the increasing severity of the other symptoms of the disease, and that in like manner, the decline of the eruption was nearly simultaneous with the first signs of convalescence. He found, also, that the mortality and duration of the disease were very noticeably pro- portionate to the abundance of the eruption. Convalescence was more protracted in those cases where it was abundant than in those where it was scanty.2 1 Edinburgh Med. and Surg. Journal, Oct., 1840. 2 Ibid., Oct., 1839. SYMPTOMS.—CUTANEOUS ERUPTIONS. 205 In Dr. Gerhard's cases, the eruption appeared from the sixth to the eighth day after the commencement of the disease, and gradu- ally faded away and disappeared from the fourteenth to the twentieth. The importance of this eruption, as one of the diagnostic marks of typhus, induces me to add to the foregoing the minute and precise description of Dr. Jenner. He calls it the mulberry rash, peculiar to typhus fever. " The eruption was never papular. Its characters varied with its duration. On the first appearance of the rash, it consisted of very slightly elevated spots of a dusky pink color. Each spot was flattened on the surface, irregular in outline, had no well-defined margin, but faded insensibly into the hue of the surrounding skin, disappeared completely on pressure, and varied in size from a point to three or four lines in diameter. The largest spots appeared to be formed by the coalescence of two or more smaller, and the shape of the former accordingly was more irregular than that of the latter. " Second Stage.—In one, two, or three days, these spots under- went a marked change; they were no longer elevated above the surrounding cuticle; their hue was darker and more dingy than on their first appearance; their margins rather more, but still imperfectly defined, and now they only faded on pressure. In this stage, they were usually darker, less affected by pressure, and their margins more defined on the posterior than on the anterior surface of the body. In some cases, the spots after this grew paler, passed into faintly-marked reddish-brown stains, and then disappeared. " Third Stage.—In others, a third stage was reached; the centres of the spots became dark purple, and remained unaltered by pres- sure, although their circumferences still faded ; or the entire spots, the circumferences as well as the centres, changed into true pete- chias, i. e., spots presenting the following characters, a dusky crimson or purple color, quite unaffected by pressure, a well-defined margin, and total want of elevation above the level of the cuticle. This alteration was most frequently observed to take place on the back, at the bend of the elbow, and in the groin. At the bend of the elbow they were generally oval, their long axis lying in the direc- tion of the long axis of the arm. In a large majority of the cases, the spots were very numerous, close together, sometimes almost covering the skin. In a few instances, however, they were com- paratively few in number, very pale, and situated at some distance 206 TYPHUS FEVER. from each other.1 The usual situation of the spots was the trunk and extremities ; but occasionally they were limited to the trunk, and now and then were observed on the face. Their number reached its maximum on the first, second, or third day, no fresh spots appearing after the latter date, and each spot remained visible from its first eruption till the whole rash vanished. " When very numerous, the whole of the spots seen together on the surface had not an equal depth of color; many were much paler than the others, and had a dull appearance, as if seen through the cuticle. In my notes, I have been in the habit of distinguish- ing these collectively as the subcuticular rash. It often, by its abundance, gave a mottled aspect to the skin, on which ground the darker spots were seated. Variations in the absolute or relative amount of the subcuticular rash and of the spots, as well as in the depth of their respective color, cause much difference in the general appearance of the rash. Sometimes it resembles measles so closely as to be distinguished from it with difficulty; at others, it presents that appearance which has been called spotted rash; and, again, it is sometimes so pale that, unless carefully looked for, it might be passed over altogether. When the spots on the back were of a much deeper hue than those on the anterior surface of the trunk, the skin covering the posterior surface was generally considerably congested. Slight pressure of the finger, leaving a white mark, which slowly returned to its previous dusky red color, " To sum up:— " 1. The mulberry rash was present in all the cases. " 2. The rash usually appeared from the fifth to the eighth day of the disease. " 3. Fresh spots never appeared after the second or third day of the eruption. " 4. The duration of each spot was from its first appearance till the death or recovery of the patient from the attack of typhus. " 5. The rash disappeared between the fourteenth and twenty - 1 In these cases, on the first day of their appearance, they occasionally bore so close a resemblance to the rose spots that although they were never altogether identical with the best-marked specimens of the latter, yet the most tutored eye might be in some doubt as to the order to which they belonged; and when the gene- ral symptoms were at the same time equivocal, the diagnosis was impossible till a day or two had elapsed, when some or all the spots passed into their second stage; whereas, if they had been the spots peculiar to the typhoid fever, they would have retained the characters they presented on the first day till they disappeared altogether on the third or fourth day after their eruption. SYMPTOMS.—CUTANEOUS ERUPTIONS.—ESCHARS. 207 first days of the disease; when death ensued after the latter date, it was the result of local disease, which either complicated the pro- gress of the fever, and continued after that had run its course, or sprung up anew, connected or not with the enfeebled state of con- stitution, the consequence of the fever. " 6. In no case was there any return of the eruption, and, there- fore, no true relapse."1 [Dr. Thomas B. Peacock, assistant physician to St. Thomas's Hospital, London, in a short series of Lectures,2 now in the course of publication, confirms this description of Dr. Jenner. He is emphatic in re-stating the facts, that during the first day or two, the eruption is slightly elevated above the skin, and is of a rose tint; and that the spots at first disappear on pressure. He was able to ascertain the date of the eruption in twenty-eight cases. In two, it appeared on the second or third day of the disease; in three, on or before the fourth; in five, on or before the fifth; in seven, on or before the sixth; in six, on or before the seventh; in two, on the eighth and ninth, each; and in one, on the ninth or tenth. In thirteen of these, its disappearance was also noted, its duration having been five, seven, nine, twelve, nine, eleven, twelve, thirteen, seventeen, seven, thirteen, six, and ten days, in the several instances. Dr. Peacock, however, does not corroborate Dr. Jenner's statement that, in favorable cases, the eruption continues till recovery com- mences. The interval between its disappearance and convalescence was from two to fifteen days; in those whose fever terminated on or before the twentieth day, the average interval was three days and a half. These, it may be assumed, were uncomplicated cases. In the others the interval was longer, though nothing is said of complications.] Other eruptions, but none of them at all constant or character- istic, are occasionally observed in this disease. Amongst them is that of sudamina, which is sometimes seen, but not so frequently as in typhoid fever. A miliary eruption now and then shows itself over the whole body, remains for a few days, and then disappears, the elevated cuticle falling off in a fine, branny desquamation. Vibices are occasionally, though rarely, seen near the fatal close of the disease. Dr. Stewart met with them in only two of one hundred and thirty-nine cases, and with purpura spots in only 1 Jenner, &c, pp. 14-17. 2 [Lectures on the Varieties of Continued Fever, &c.—Med. Times and Gaz., August, 1856.] 208 TYPHUS FEVER. three. Dr. Henderson saw only one vibex amongst two hundred patients, and sudamina in only three. In grave cases, there is sometimes noticed a dark livid or purple color of the skin of the extremities, oftenest in the early, but some- times continuing through the entire period of the disease. Sec. V.—Eschars. Gangrenous sloughs and ulcerations seem to be common in some epidemics of typhus fever, and rare in others. At Philadelphia, in 1836, they were present in only three or four cases in a hundred. Dr. Pickels says that gangrene of the hips, nates, and shoulders was frequent during the epidemic at Cork in 1817, 1818, and 1819. Dr. O'Brien, in his Cork Street Hospital Report for 1820, informs us that ulcerations and gangrene of the hips, nates, and sacrum were of very common occurrence, few of the malignant and protracted types of fever being exempt from them. Dr. Percival, of Dublin, says: " Gangrenous extremities were extremely rare amongst my patients." Sec. VI.—State of the Blood. Amongst these miscellaneous symptoms may be mentioned the condition of the blood when drawn from the body. In the epidemic at Philadelphia, the blood was examined in various stages of the disease, except where the state of the patient was such as to render the operation of blood- letting clearly improper. " At a very early period, it was dark, without the buffy coat, and offered a large but soft and dark- colored coagulum. At a more advanced stage, it presented, in some patients, the dissolved appearance described by various authors as characteristic of the typhus or putrid fevers." Dr. O'Brien says: " In those instances where blood was taken in the advanced period of the disease, I have always found its texture broken down and dissolved, changing rapidly into a greenish, watery fluid, with little coagulum, indicating great dissolution of the animal fluids, and consequent great debility."1 Huxham has described quite fully, in his usual rich and excellent manner, the altered state of the blood in typhus.2 1 Trans, of Phys. of Ireland, vol. i. p. 424. 2 Huxham on Fevers, p. 41, et seq. 209 CHAPTER III. ANATOMICAL LESIONS. The pathological alterations in fatal cases of typhus fever have not been so thoroughly and accurately studied as in those of typhoid fever. Our knowledge of the anatomical lesions and of the condi- tion of all the organs after death, in the former disease, is of course much less complete than in the latter. Although the morbid ana- tomy of typhus fever has by no means been neglected by British observers, who have the best and most extensive opportunities for its investigation, it is nevertheless true that it has not been sub- jected by them to such comprehensive, numerous, and detailed examinations, as the lesions in typhoid fever have undergone, at the hands of Louis, Andral, Chomel, Bouillaud, and others.1 Amongst the most valuable and authentic materials for this portion of my history of typhus fever, are the results of the investigations of Drs. Gerhard and Pennock, during the Philadelphia epidemic of 1836. The number of autopsies made by these gentlemen during the prevalence of the disease was about fifty, and the fruits of their researches are especially valuable, on account of the entire confi- dence which we may feel in their competency as pathological observers, a confidence which we are forced to withhold from very many reporters of the morbid appearances in this as well as in other diseases. The paper of Dr. Gerhard does not contain any particu- lar and formal description of the state of the several organs, and this description I shall be obliged to make up from the six indivi- dual cases, the anatomical lesions in which he has minutely detailed. During the years 1838 and 1839, Dr. John Reid, of Edinburgh, made careful and thorough examinations of the bodies of between forty and fifty patients who died with typhus fever at the Royal 1 This remark, made in my second edition, is much less true now than it was then. The remarkable researches of Dr. Jenner have added very largely to our minute and accurate knowledge of the anatomical lesions of typhus. 14 210 TYPHUS fever. Infirmary of that city. These examinations are reported and analyzed and compared with the symptoms in a spirit the most philosophical, and with a completeness as rarely met with as it is worthy the highest praise. They constitute a very valuable addi- tion to our knowledge of the lesions in this disease.1 With the materials derived from these sources, and with such others as are accessible and trustworthy, I shall endeavor to make out as full an account of the pathological anatomy of typhus fever as, in the present state of science, it is possible to do. ARTICLE I. LESIONS OF THE THORACIC ORGANS. Sec. I.—Lungs. The morbid alterations which are found within the cavity of the chest seem to be not less constant and important in typhus than in typhoid fever. The lungs were more or less changed from their healthy condition in all the cases reported by Dr. Gerhard. This change generally consisted in a somewhat pecu- liar condensation of a portion of one or both lungs. The tissue of the lung was more solid and heavy than in its natural state; quite or nearly impermeable to the air, sometimes friable and sometimes not so; of a dark and sometimes a livid red; not granular, like hepatization, but resembling in some degree, when torn, the struc- ture of the spleen. This alteration was most frequent in the lower and posterior portions of the organs. The mucous lining of the trachea and bronchial tubes was in many cases of a rosy red color, sometimes of a livid tinge; but it was rarely changed, either in thickness or consistence. In only two or three of thirty-five cases, examined by Dr. Jenner, were the lungs found free from disease. In three cases, there was simple congestion of the posterior part of the lungs. In three cases, there was congestion with diminished consistence. In eleven cases, there was congestion of the posterior part of the lung, with non- granular consolidation of the most depending layer of pulmonary tissue; in some cases, extending to both lungs, in most limited to one. In four cases, there was more or less oedema. In eight cases, 1 Between 1839 and 1841, Dr. Reid made careful dissections in one hundred additional cases of continued fever. The results of these examinations will be found in the present edition. LESIONS. — LARYNX AND PHARYNX. 211 there was lobular consolidation, granular or non-granular. In two cases, there was gangrene. The following is Dr. Jenner's description of the congestion of the posterior portion of the lung, with non-granular consolidation of the most depending part of the organ, a condition that he did not find after death from typhoid fever. " The posterior portion of the lung was congested, and its consistence diminished; the most depending layer of pulmonary tissue (the subject being on its back) which extended in different cases from a quarter of an inch to two inches into the substance of the lung, was solidified, very dark- bluish chocolate in color, gorged with non-aerated dark claret sero- sity, which flowed freely from the cut surface; it was scarcely softened; the whole of the solidified layer sank in water. The solidified portion was limited to the part of the organ which lies in the hollow formed by about the fourth, fifth, and sixth ribs. * * * The solidified and crepitant tissue passed imperceptibly the one into the other."1 Of forty-three cases examined by Dr. Reid, in 1838 and 1839, there was more or less lesion of the lungs in all. In fifteen of these the lesion consisted of simple congestion, at the most depending portion of the organs; in thirteen cases, the posterior and middle parts of both lungs were gorged with blood and frothy serum, and some portions were so dense as not to crepitate when cut, though they did not present any granular appearance; and in ten cases, there was increased effusion into the bronchial tubes.2 In thirty- nine of these cases, the brain was also examined; and it appears, from a careful comparison, that extensive engorgement and conges- tion of the lungs were more frequently found associated with those cases in which there was increased serous effusion within the cranium than with those where this condition did not exist, indicating some special relationship between the two phenomena.3 Sec. II.—Larynx and Pharynx. Dr. Jenner found unequivocal traces of disease of the larynx or pharynx, or of both, in nine of twenty-six cases. "The larynx and pharynx were deep purple, and covered with slimy mucus in one case. In four, there were unequivocal traces of inflammation in both organs; thus, in one of 1 Jenner, &c, p. 50. 2 Between 1839 and 1841, Dr. Reid examined the lungs in eighty-eight fever cases, with much the same general results.— Edin. Med. Journ., Aug., 1842. 3 Edin. Med. and Surg. Journ., Oct., 1839. 212 TYPHUS FEVER. the four, the mucous membrane of the pharynx was deep red, of the larynx vivid scarlet, the redness on minute inspection being found to be punctiform; in another of the four, the lining mem- brane of the pharynx was of a dirty-yellowish color, and so soft that it was removable by the gentlest scraping; the cordae vocales swollen, the rima glottidis a mere chink, the mucous membrane of the larynx generally vividly injected and covered with muco-pur- ulent fluid, and on the chordae vocales, and on the mucous mem- brane lining the larynx above the chords, were numerous shreds of white, opaque, lymph-like matter, readily removable. In the third case, the lining membrane of the pharynx was covered with thick mucus, felt rough, apparently from enlargement of its folli- cles, and was of a dull purple color; there was a small ulcer on either chorda vocalis, but no other trace of inflammatory action within the larynx. The pharynx in the fourth case was studded with small yellowish spots, from which, on section of the mucous membrane covering them, a drop of purulent-looking fluid exuded. The lining membrane of the larynx in the same subject was dusky red, the chordae vocales and arytaeno-epiglottidean folds distinctly thickened from effusion of serosity into the submucous cellular tissue."1 Sec. III.—Heart and Blood. The heart was found in some of Dr. Gerhard's cases softened, flabby, and easily broken down; in others, it was in its usual condition. The appearance of blood, contained in the heart and in the large vessels, was striking and peculiar. It was of a very dark color, often almost black, thick in its consistence, and sometimes oleagin- ous. In one case, the blood in the cavities of the heart, in the aorta, the vena cava ascendens, and in the femoral vein, is described as being like molasses, in color and consistence, with minute fatty globules floating in it. The substance of the heart in Dr. Shattuck's cases was not altered. In the right ventricle, there were from one to three ounces of black, liquid blood; and in three cases, a somewhat smaller quantity in the left. In all Dr. Reid's cases, the blood appeared to be in a fluid state, or nearly so, in the large veins; but in several a greater or less number of coagula, generally small and soft, were found in the 1 Jenner, &c, p. 50. LESIONS. — BRAIN. 213 right side of the heart. In two subjects the blood, in the same situation, was in a grumous state. Of twenty-nine cases, Dr. Jenner found the heart flabby in fifteen, and firm in fourteen. In twelve cases the lining membrane was stained of a dusky-red color. The staining of the endocardium, and the flabby condition of the heart were generally found together; and they were frequent in proportion to the length of time that had elapsed after death, before the bodies were examined."1 "The fluid condition of the blood generally," says Dr. Jenner, " was observed in about equal proportions in the subjects dead from typhoid and typhus fevers: but with this exception there was a marked difference in the blood in the two diseases; it was far more profoundly diseased, i. e. it deviated far more from its healthy con- dition, in the cases of typhus than in those of typhoid fever."2 ARTICLE II. LESIONS OF THE BRAIN. In all the cases reported by Dr. Gerhard, there was unusual en- gorgement of the sinuses and the larger vessels of the brain. These were filled with dark-colored fluid blood, in some cases, in the large sinuses, surrounding a soft, greenish coagulum. Inflammatory in- jection of the pia mater is not mentioned. Varying quantities of serum, from one or two drachms to one or two ounces, were found, in a certain proportion of cases, under the arachnoid, or within the ventricles. The medullary portion of the brain was frequently of a violet tinge ; otherwise, the substance of the organ was unaltered. In Dr. Shattuck's cases, observed at the London Fever Hospital, the organs in the cranial cavity presented no remarkable lesions. In three of them, there was slight sub-arachnoid infiltration. Of forty-three cases in which the brain was examined by Dr. Reid, in 1838 and 1839, there was increased effusion of serurA in twenty- five. This effusion, in a majority of instances, was situated between the arachnoid and the pia mater, and was commonly moderate in quantity, in many cases elevating the arachnoid above the surface of the convolutions only at the depending portions of the brain. Nearly all these patients exhibited more or less prominent cerebral symptoms; such as delirium, coma, subsultus tendinum, &c; but 1 Jenner, &c, pp. 80-82. 2 Ibid., p. 84. 214 TYPHUS FEVER. these symptoms were as frequently present, and as strongly marked, in the class of cases where there was no increased effusion of serum as in the others. Of course, it is impossible to attribute the cere- bral symptoms to the serous effusion. In every case but one, the bloodvessels of the brain are said to have been " well filled," and their congested condition was indicated by the number of bloody spots which appeared upon the cut surfaces of the organ, although these may have depended in part upon the fluidity of the blood.1 Dr. Reid examined the brain in eighty-two additional cases of con- tinued fever, between the years 1839 and 1841, and the general results corresponded very nearly with those just stated.2 In five of thirty-nine cases examined by Dr. Jenner, coagula of various sizes were found within the cavity of the arachnoid. " In every case the coagulum was in the form of a delicate red film, varying in thickness, and consequently in hue, in different cases and in different parts of the same clot. It was almost colorless where thinnest, bright red where a little thicker, and deep purple at the thickest parts. It was in every case situated on the convex surface of the brain, and in one stretched from the anterior lobe to the tentorium, and from the median fissure to a point corresponding to a line drawn transversely, just above the external auditory fora- men. In one case it consisted of two or three delicate fibrinous films only. When the dura mater was reflected, part of the clot adhered to the layer of arachnoid covering the pia mater. In three of the five cases the clot was double, i. e. existed on both hemi- spheres of the brain. In two cases it was confined to the right side. In one of the five it was accompanied by effusion of blood into the substance of the rectus abdominis. The substance of the brain was firm in four of the five, and apparently healthy in all. The vessels of the cerebral substance, and its meninges were not particularly congested; the blood in the vessels of the pia mater fluid, but unable to be pressed out of them into the cavity of the arachnoid. No aperture could be found from which the blood had escaped—the sinuses were perfectly healthy; the sources of the hemorrhage could not, consequently, be discovered."3 [The typhus fever was imported into New York, as into most of the commercial towns of the United States, by the emigrants that left Ireland in great numbers during and after the famine of 1846. 1 Edin. Med. and Surg. Journ., Oct., 1839. 2 Ibid., Aug., 1842. 3 Jenner, &c, p. 47. LESIONS.—BRAIN. 215 In 1847 Bellevue Hospital was crowded with that disease, and from that time till the Autumn of 1855, the type of fever admitted into that Institution was almost without exception typhus. It was known as the ship-fever. In the large number of post-mortem exa- minations made during those eight years, there was a remarkable uniformity in the cerebral lesions, almost every death was imme- diately preceded by coma, and the coma in the greater number of instances was preceded by at least a few hours of delirium. The coma had a duration in some instances of a few hours, in others of three or four days. The morbid condition of the cerebral mem- branes corresponded remarkably with the severity and duration of the coma. In almost every instance there was serous effusion under the arachnoid. The quantity of this fluid varied from an ounce to four or five ounces. It was transparent in almost all, slightly milky in a few only. In every instance it was most abundant over the convex surface of the brain, and frequently it appeared in a layer half an inch and more in thickness at, and for some inches around the vertex. The accumulation at this point appeared to be the effect of gravitation after death, and probably after the removal of the upper portion of the cranium, aided by the traction, from before, backwards, necessary in re- moving the calvarium. The vascularity of the surface of the brain, as a general rule, was greatest in those in whom the serous effusion was least, and not considerable when the effusion was abundant. But it is believed that nearly every brain examined displayed either increased vascularity with slight serous effusion, or serous effusion sufficient to oppress the cerebral functions during life. This was certainly true of more than one hundred examinations made by the author of this note, and he can recall no instance in which the membranes appeared entirely healthy. He thinks it necessary to insist on this point, as it does not appear that any author, since Clutterbuck has met with similar appearances so frequently. It was a peculiarity of the epidemic of 1847-8 in New York, and the same characteristic continued to mark the disease, or rather the fatal cases of it, until it gave place, in the autumn of }Sdo, to the indigenous typhoid fever. Besides the changes here described, the arachnoid membrane in many instances bore the marks of disordered action. It rarely possessed its natural trans- parency, and many times it appeared as if it had imbibed a certain quantity of milk, being in portions almost opaque. This was most frequently noticed in the upper and parietal regions. In 216 TYPHUS FEVER. many instances, besides this opaline appearance, the membrane was dotted over with opaque white or yellowish white spots, without perceptible elevation, sometimes with distinct elevated grains. The white spots terminated somewhat abruptly, but irregularly, in the surrounding membrane, and varied in size from a mere point to a line and a half in diameter. They were not very numerous. The elevated grains had somewhat the appear- ance of small opaque miliary tubercles. They were seen, however, only on the convexity of the brain, and were not associated with tubercles in the lungs. They were usually numerous, irregularly grouped, and in one instance many of the grains were united two and two, by a short bar of the same material, so as to resemble dumb-bells. The white spots were noticed in almost all, the yellowish grains much less frequently. The brain itself seemed to have undergone but little change. In a few instances, some slight softening of the external layer; in most a deeper color of the cortical portion, a pretty free discharge of blood from the cut vessels of the white structure; moderate serous effusion into the ventricles, with fulness of vessels on the walls of these cavities, were the principal departures from the healthy condition of its tissues. When, however, the watery effusion was considerable, the surface of the brain almost always bore the marks of forcible com- pression. The sulci were deepened, and the convolutions com- pressed and attenuated; consequently there were broad furrows between the convolutions. In some instances, pits were formed large enough to receive the first joint of a finger. These appear- ances were noticed only on two or three inches of the upper part of each hemisphere, and backward a little below the vertex. It has been suggested that this effusion of serum in typhus fever is the result of an anemic state of the system, but several facts seem to forbid such a supposition. The analogies between the state of the brain and membranes just described, and that seen in the meningeal inflammation which so often proves fatal in Bright's disease of the kidneys; indeed the correspondence of this state with the condition called by the French Secondary Meningitis, from whatever cause; the absence of fluid effusions in other serous cavities; the absence of every thin & like general hydremia; the condition of the arachnoid and pia mater; and perhaps more than all the altered shape of the surface of the brain when the serous effusion was abundant, suggest the idea of an action more energetic than a mere passive effusion.] LESIONS.—ABDOMINAL ORGANS. 217 ARTICLE III. LESIONS OF THE ABDOMINAL ORGANS. Sec. I.—Stomach. The mucous membrane of the stomach was more or less altered in all the cases reported by Dr. Gerhard. The most constant change consisted in softening of the membrane in the cardiac extremity, or grand cul-de sac. This softening was sometimes confined to a small portion of the membrane; sometimes it was quite extensive. It varied in degree, from a moderate dimi- nution of the consistence of the membrane to its pulpy disorganiza- tion. In some instances the softening extended to the other coats of the stomach. Mamellonation of the mucous membrane, espe- cially towards the pyloric extremity, was not uncommon. In some cases there was blue engorgement of the large veins; in some a pointed redness, and in others a continuous dull slate color of the mucous coat. Dr. Jenner found the mucous membrane of the stomach pale, or healthy in color, in twenty-three of thirty-seven cases. It was of a uniform dusky gray hue in two cases. There was some redness, or minute hemorrhagic spots in a small number of cases. In one case there was recent ulceration. Mamellonation was noted in fourteen cases. The consistence of the mucous membrane was normal, or nearly so, in twenty-two cases. In four cases there was extreme softening of the great cul-de-sac, so that it ruptured in the removal, or in the washing of the organ. Sec. II.—Intestines. The intestinal canal in all its tissues, and throughout its entire extent, was very constantly and remarkably free from disease in all Dr. Gerhard's cases. In the reported cases no appreciable lesion is mentioned, excepting occasional spots or patches of ecchymosis. The examinations were thoroughly made, and especial solicitude was felt, and corresponding carefulness was taken, to ascertain accurately the state of the small intestine, and its elliptical plates. Amongst the entire number of autopsies there was but a single case, and that of doubtful diagnosis, in vjhich there was the slightest deviation from the natural appearance of the glands of Peyer. " In the case alluded to, in which there had been some diarrhoea, the agglomerated glands of the small intestine were reddened, and a little thickened; but there was no ulceration, and no thickening or deposit of yellow puriform matter, in the submucous tissue. The 218 TYPHUS FEVER. disease of the glands resembled that sometimes met with in small- pox, scarlet fever, or measles, rather than the specific lesion of dothinenteritis. " In all other cases, the glands of Peyer were remarkably healthy in this disease, as was the surrounding mucous membrane, which was much more free from vascular injection than it is in cases of various diseases not originally affecting the small intestine. " The mesenteric glands were always found of the normal size, varying, as in health, from the size of a small grain of maize1 to three or four times these dimensions. With the exception of a slightly livid tint, common to them and the rest of the tissues, they offered nothing peculiar either in consistence or color. "The spleen was of the normal aspect in one-half the cases; in the other half, it was softened, but not enlarged, and in one case out of five or six enlarged and softened. " Thus, the triple lesion of the glands of Peyer, mesenteric glands, and spleen, constituting the anatomical characteristic of the dothinenteritis, or typhoid fever, although sought for with the greatest care, evidently did not exist in the epidemic typhus. In- deed, it was a subject of remark that, in the typhus fever, the intestines were more free from lesion than in any other disease ac- companied by a febrile movement. This exemption extended to the large intestine, until the summer heats began, when a few scat- tering cases offered some symptoms of diarrhoea, during the pre- valence of an epidemic dysentery ; and, where they terminated fatally, softening and other signs of inflammation of the mucous coat of the colon were observed."1 The liver was found sometimes moderately softened ; sometimes engorged with dark, fluid, oily blood, and sometimes spotted with ecchymosis. In many cases, however, it was the seat of no ap- preciable lesion. The contents of the gall-bladder differed in different cases: in some the bile was viscid; in some it was thick, dark, grumous, and so on; in others it was healthy. The kidneys, in some instances, were of a darker color than natural, but com- monly they were free from disease. It is hardly necessary to give in detail Dr. Jenner's account of the condition of the bowels. With three exceptions, Peyer's glands were perfectly healthy, i. e. neither elevated, reddened, softened, nor ulcerated. The exceptional cases did not present the lesions 1 Am. Journ. of Med. Sci., Feb. 1837. LESIONS.—ABDOMINAL ORGANS. 219 of typhoid fever. With two exceptions, occurring in tuberculous children, the mesenteric glands were entirely free from disease. Dr. Jenner found the average weight of the spleen in thirty-four subjects, aged more than fifteen years, and who died before the termination of the fourth week of the disease, to be seven ounces and five drachms. In Dr. Shattuck's cases, the small intestine was generally healthy. The thickness and consistence of the mucous membrane were na- tural, and there was no lesion whatever of Peyer's patches or of the mesenteric glands. In three of four cases there was either red- ness or softening of the mucous membrane of the upper portion of the large intestine. In all the cases, the fecal matter contained in the large intestine was small in quantity, pultaceous, soft, and yel- lowish. In two cases the mucous membrane of the stomach was unaltered; in two others it was reddened, softened, or mamellonated. There was no constant lesion in the other abdominal organs.1 Of twenty-one cases examined by Dr. Stewart, at the Glasgow Infirm- ary, the aggregated follicles were distinctly elevated in two; very slightly so in eight, not elevated in five, and scarcely visible in six. In none of them was there any ulceration. Of thirty-three cases examined by Dr. Reid, in 1838 and 1839, in the Edinburgh Infirm- ary, only two presented the follicular lesion of typhoid fever, and even these doubtfully. These had been protracted cases, and came from the country. Of the remaining thirty-one cases, Peyer's glands were distinctly elevated in four; visible, but not elevated, in nine; scarcely visible in seven; and not visible in eleven. In none were they ulcerated.2 Between the years 1839 and 1841, Dr. Reid examined the intestines in ninety-one cases of continued fever. The result is very remarkable, and corresponds in a very striking manner with that of his previous investigations. The elliptical patches and solitary glands were found in the following conditions, to wit: not visible to the naked eye in six cases, scarcely visible in seventeen, distinct but not defined in four, defined in eight, neither reddened nor elevated in forty-four, elevated but not ulcerated in six, elevated and ulcerated in six. In all these last cases the mesen- teric glands were enlarged and more or less softened. In two of them, there was perforation of the ileum, producing rapid and fatal periton- itis. Five of these cases occurred in laborers on the Glasgow railroad; and they had been for a short time previous to their illness located in 1 Med. Exam., vol. iii. p. 150. 2 Ed. Med. and Surg. Journ., Oct., 1S39. 220 TYPHUS FEVER. Linlithgow or its neighborhood, about seventeen miles west from Edinburgh. Their average age was twenty-five years; the youngest was eighteen and the oldest thirty-five. Dr. Reid says: " During the whole three years and a half that I conducted the post-mortem exami- nations in the Edinburgh Infirmary, in no single case did I observe, in any individual who had been seized with fever while residing in Edinburgh, anything resembling the changes described as occurring in the lower part of the ileum in the typhoid fever of Paris."1 " Whether or not," adds Dr. Reid, " the typhoid and typhus fever be identical or different diseases, we shall not venture at present to give an opinion; but if it should turn out that they are specifically the same disease, it would prove an interesting subject of inquiry to endeavor to ascertain why the typhoid fever should, for several years past, never be found in Edinburgh, while it existed at Lin- lithgow, Anstruther, and other places in Fifeshire." An interesting subject, indeed! And is the inquiry any less interesting why, if the diseases are specifically the same, one of them, with no constant lesion of the solids, should be the common disease of Scotland and Ireland, and the other, with a profound and peculiar anatomical lesion, should be almost the sole continued fever of France and of the United States of America ? Is there any other disease that exhibits such a character? The Register of Dissections at the same Insti- tution, kept by Dr. John Home, from 1833 to 1837, showed that, of one hundred and one cases, only seven presented ulcerations of the elliptical plates. In two there was perforation. These were probably instances of typhoid fever. Thickening, mamellonation, and other lesions of the mucous membrane of the stomach, were found in about one-fourth of the cases. The spleen was generally larger than usual, soft, and in some cases almost diffluent. In one instance this organ weighed eleven, and in another fourteen ounces. [The intestinal lesions at the Bellevue Hospital, New York, during the late prevalence of typhus fever, differed but little from those here described. In about one-third of the post-mortem exami- nations the Peyerian patches were not only visible, but had under- gone obvious change. Many of them, particularly those in the lower part of the ileum, were slightly raised, of a light gray color, dotted over with bluish or dark brown points—"the shaven beard" appearance. Ulcerations were not met with except in a few instances, in the autumn of the three or four last years. When 1 Edin. Med. Journ., Aug., 1842. LESIONS. — ABDOMINAL ORGANS. 221 ulcerations were found, the mesenteric glands were observed to be enlarged and changed in the same manner as in typhoid fever. In the greater number of examinations the intestines were found in a healthy state. It is worthy of remark that in no one of six or eight cases in which ulcers were found after death, did the symptoms lead the physician to suspect their existence during life. The number of ulcerated patches in any one case did not usually exceed five or six; in one or two cases only were they more numerous.] Sec. III.—Miscellaneous. The petechial eruption frequently con- tinues visible after death. In three of four cases examined by Dr. Shattuck, the spots penetrated the thickness of the skin to the sub- cutaneous cellular tissue, and communicated to the parts they occupied a purplish color. Amongst the pathological phenomena of typhus fever, may be mentioned the tendency which manifests itself, in a certain propor- tion of cases, to early and rapid decomposition. Dr. Pickels, in his Report on the Typhus Fever at Cork, says that this tendency was shown by the rapid putrefaction of bodies after death, rendering necessary their almost immediate interment. In many instances the skin of the arms, thighs, and of almost the entire body, changed to a deep livid or black color, somewhat of the appearance as if scorched by gunpowder, several hours before death.1 Dr. Gerhard noticed that rapid putrefaction took place, especially in the bodies of those patients from whom the offensive ammoniacal odor, already spoken of, had been most strongly perceived during life. Dr. Jenner noticed that, in subjects examined within twenty-four hours after death, cadaveric rigidity was found much less constantly in cases of typhus than in those of typhoid fever.2 [Secondary Lesions.—Here, perhaps, better than anywhere else, can be introduced some remarks regarding the accidents likely to attend typhus fever, not usually regarded as the direct effects of that dis- ease. Foremost among what may be called the secondary lesions, stands that condition of the bronchial mucous membrane already referred to on page 188. Very few post-mortem examinations have been made by the editor, in typhus fever, that have not revealed a highly vascular state of the lining membrane of the bronchial tubes. The color is often a bright red, often a very deep brown, almost black, or a venous hue, and the tissue appears to be slightly 1 Trans, of Phys. of Ireland, vol. iii. p. 202. 2 Jenner, &c, p. 40. 222 TYPHUS FEVER. thickened. The tubes generally contain frothy mucus, and if the examination be long delayed, often bloody. These appearances. though sometimes confined to the larger tubes, extend frequently as far as the diminishing branches can be conveniently opened with the scissors. Rokitansky states that in the variety of fever which he has denominated broncho-typhus, beside these changes in the tubes, the bronchial glands are enlarged; purple, afterwards of lighter color; friable and infiltrated with a medullary typhous matter, and he compares their condition to that of the mesenteric glands in abdominal typhus, or typhoid fever. The common occur- rence of bronchial complications in the ship fever (or Irish typhus), and the enlargement, hyperaemia, and softening of the bronchial glands, are facts well known to the hospital physicians of New York, but it is believed that they have not verified the conjecture of Stokes, that typhous matter may in such cases be deposited in the mucous membrane; or the assertion of Rokitansky, that it is found in the enlarged bronchial glands.] Dr. Stokes recognizes the laryngo-typhus of Rokitansky, in which there is a change in the mucous membrane of the larynx and trachea similar to that which occurs so commonly in the bronchial tubes, though he says that he has not met with it often. [It is the condi- tion described in Sec. II. of this Article.] Tuberculosis.—Dr. Stokes is still disposed to regard typhus as one of the exciting causes of tubercular deposits in the lungs and else- where.1 He states that he has seen a few cases in which they were rapidly deposited both during the fever and during convalescence from it. In one case, "large quantities of soft gray tuberculous matter, in isolated masses, varying from the size of a pea to that of a small hazel-nut, were found after death loading the rio-ht lunc," and all, he believes, was deposited during fourteen days of petechial fever. In another case he thinks that eight days of what he re- garded as a relapse of fever, was sufficient to sprinkle thousands of miliary tubercles throughout the lungs, liver, spleen, uterus, and kidneys, and over all the serous surfaces. Such occurrences, of which he recites several more, though none that ran their course so rapidly as these, he regards not as an accident, but as the direct effect of the fever. He thinks also that tubercles are often deposited in the lungs during fever, and are not discovered by the physician, and that their progress is arrested by the convalescence, so that the 1 [Med. Times and Gaz., 1854.] LESIONS. — ABDOMINAL ORGANS. 223 principal evidence of their existence is found in the subsequent ex- pectoration of calcareous concretions. Probably most physicians who have seen much of this disease have noticed the occasional de- velopment of the symptoms of phthisis, during the later stages of the fever and during convalescence. Phlebitis of the extremities, Dr. Stokes has found often enough to induce him to place it among the secondary lesions of fever. It is not always painful, and he is led to look for it in cases where the pulse continues frequent after the usual period of the fever has passed. This condition of pulse he thinks most commonly attends and indicates this complication, or tubercles, or in the typhoid fever perhaps ulcerations of the intestines. Prostration of strength and frequent pulse, protracted long beyond the usual duration of the disease, in either of its types, is probably in all cases the effect of some complication or secondary lesion. Muscular Softening.—Dr. Stokes believes that softening, such as is known to affect the heart in typhus and typhoid fevers, may affect also other, even the voluntary muscles. This he thinks may be the case with the muscular layer of the bronchial tubes, permitting accumulations of mucus, and inducing asphyxia, which sometimes comes on suddenly in typhus fever. He suggests also that the same change may take place in the muscles of the ear, so that they no longer preserve the contact necessary for the proper communica- tion of the atmospheric vibrations to the inner chambers, thus explaining the deafness of typhus and typhoid fevers. Mental Imbecility.—In several instances it was remarked, during the late prevalence of typhus fever at Bellevue Hospital, that, though the body gained strength, and all the general symptoms indicated convalescence, yet the mind did not clear up with the improvement of the body. The delirium which had existed at the height of the fever, continued more or less markedly after the fever had entirely subsided. This was noticed in some cases, even after the patients could leave their beds. In all these, however, the mental health was at length restored. Two instances are known in which patients recovered their bodily strength, but remained idiotic up to the time of their discharge from the hospital. It can hardly be doubted that this mental imbecility, almost complete, was the result of some change in the brain itself, produced by fever. The nature of that change, there was no opportunity of ascertaining, yet we are led to seek its explanation in the cerebral lesions already described. Inflammation of the parotid gland may with some license be placed 224 TYPHUS FEVER. among the secondary accidents of typhus fever. It appears before the fever begins to abate. It is usually painful, attended by much swelling of affected region, after a day or two by redness, and sup- puration is usually evident after the third or fourth day. Resolu- tion without suppuration is rare. The inflammation, however, usually subsides pretty rapidly, after the evacuation of the pus. It commonly affects but one side, though it has been known to affect both, either at the same time or one after the other. This lesion, for such it is, though we study its history, for the most part, at the bedside, occurred as often as once in eight or ten cases, at the Belle- vue Hospital, during the eight years above named, and yet it did not seem to increase materially the mortality of the principal dis- ease. Abscesses.—There is a kind of suppuration peculiar to typhus and typhoid fever, and probably most frequently seen in the former. It occurs during convalescence, or at least after the fever has passed its highest intensity. Commonly the first thing the physician notices is a tumor on the back, chest, neck, or shoulders, or about the hips or sacrum. It already contains pus, and often a great deal. It is not very tender, and hardly at all painful. It is not red, and to the hand it scarcely feels warmer than other parts of the body. These accumulations of pus have been called cold abscesses. They sometimes occur single, but often there are two or more. They show little tendency to a spontaneous opening, but often burrow and extend widely. They always demand the lancet as soon as they are discovered. In the early and severest period of the late epidemic in New York, they were of rather frequent occur- rence, and were the cause of death in several instances, after, and sometimes long after, all the fever symptoms had subsided. The death in some was the result of profuse suppuration; in some it was caused by the pus penetrating the cavities, as the thoracic. From 1850 to 1855, the cases of typhus were not very numerous at the Bellevue Hospital, though the number of deaths from that disease was, in 1851, ninety-six, falling off, in 1853, to thirty-four, and so diminishing to about twenty-five. In these years cold abscesses were rarely met with. Erysipelas of the head and face was a frequent complication of the typhus at Bellevue, most frequent during the severest of the epidemic, when the editor had in his ward from two hundred to two hundred and fifty cases of this disease continually, and his col- league as many more. At that period, he believes that it occurred LESIONS. — ABDOMINAL ORGANS. 225 to at least one in five of all who were under treatment. He remembers to have found, one morning, that five of his patients, lying side by side in adjoining beds, had been attacked by erysipe- las during the preceding night; yet the ward was large and well ventilated—one of the two best in the hospital, and it was not over- crowded. There was, at the time, little or no erysipelas in the hospital out of the fever wards. As the typhus epidemic lost some of its virulence, this secondary accident became less frequent; but under all circumstances, it appears to be not very unfrequently the companion of typhus, as it is known to be of typhoid fever. The occurrence of this accident, as seen at Bellevue, did not seem to increase, in any great degree, the mortality of the fever; indeed, the writer cannot now recall an instance in which a patient died during the continuance of this local inflammation. Occurring almost uniformly in the second or third week of the fever, it may have added its own weight to the agencies that were overwhelming the vital powers, but its immediate and direct effects in increasing the mortality were not very obvious.] Sec. IV.— General Remarks. The most striking^ fact in the pathological anatomy of typhus fever consists in the absence of any constant and characteristic lesion. One of the most uniform and probably one of the most important alterations is that of the blood. It seems to me, in the present state of our knowledge, quite idle and useless to attempt to trace any obvious connection between the symptoms and the lesions, or, in other words, to refer the former to the latter. The broad and fundamental difference in the state of Peyer's glands, and the mesenteric glands, in typhus and typhoid fever, will, of course be noticed. [Many writers, particularly on the continent of Europe, prefer to characterize these affections by terms which imply some affinity between them. Typhus abdominalis is their appellation for the typhoid affection of Louis, and typhus cerebralis, or nervosus, for the typhus of English writers; and it is necessary to admit that the greater severity of the head symptoms, and the greater frequency of the cerebral lesions in the latter disease, compared with the Peyerian lesion of the former, furnishes some ground for the dis- tinction. Yet it is not claimed that the cephalic changes in one are met with as uniformly as the intestinal alterations of the other.] 15 226 CHAPTER IV. CAUSES. I shall enumerate under this head some of the principal cir- cumstances which appear to favor the occurrence and spread of typhus fever. Our knowledge of its efficient causes, excepting that of contagion, is very limited and imperfect. Sec. I.—Locality. It is very evident that the geographical boundaries within which typhus fever prevails, as a common and more or less constant disease, are much less extensive than those of typhoid fever. The actual extent to which typhus fever has heretofore prevailed in different regions and countries, owing to the imperfect histories which have been left to us of this and of analogous diseases, and the consequent doubtfulness and uncer- tainty of our diagnosis, is a matter which it is now impossible to determine with any considerable degree of precision. One thing is very certain, and that is that typhus fever has always been of very rare occurrence in New England. Nathan Smith, one of the great observers of New England diseases, says expressly that he never met with any other form of continued fever than that which he has so well described under the then common name of typhus fever, and which was evidently the typhoid fever of this work. Very few of the New England country physicians now living, I presume, have had an opportunity of seeing typhus fever on their own soil, excepting now and then a few instances, in cases of foreigners recently arrived from Britain. A continued fever, which seems to have been evidently conta- gious, prevailed in the Boston Almshouse in 1817. The account of it, however, which was published in the New England Journal of Medicine and Surgery, for April, 1818, by Dr. John P. Brown is not sufficiently detailed and particular to enable us to decide whether it was typhus or typhoid fever. Many cases are annually received into the hospitals of our large cities, especially those of CAUSES. — LOCALITY. 227 New York, from the British emigrant vessels. The ship Eutaw arrived at New York March 6, 1842, forty-two days from Liver- pool, with about two hundred passengers, mostly Irish, seventy of whom were sick with typhus on her arrival. Amongst these there were eight deaths. The bark Barlow arrived at New York from Greenock May 15, 1842, after a passage of forty days, with nearly fifty typhus patients, there having been three deaths before her arrival. These are instances of what occurs nearly every year.1 In August, 1840, twenty-one cases of typhus were admitted, from a single vessel, into the Boston Almshouse. Four of the cases were fatal. Dr. Butler informs me that the dulness of the mind, deafness, stupor, suffusion of the eyes, and dinginess of the skin, were amongst the most prominent symptoms. The bowels were usually torpid, and there was slight meteorism in only two or three cases. Dr. Doane, physician at the New York quarantine establish- ment, informs me that amongst the most striking and constant phenomena of the disease, he has noticed the injection of the eyes, the fuliginous aspect of the skin, and deafness. Diarrhoea is rare, and the alvine discharges, when procured by medicine, are dark colored and offensive. The evidences of the contagious character of the disease observed by Dr. Doane are very positive; during his connection with the institution, a period of about three years, no less than fifteen or sixteen individuals connected with the hos- pital having died with typhus fever, which had been contracted from the emigrant patients. The disease which was commonly called spotted fever, and which prevailed in many parts of New England, principally between the years 1807 and 1816, is supposed by some writers to have been the true typhus fever. Dr. Gerhard says that it was similar in its nature to the British typhus. Dr. James Jackson thinks that it was a dif- ferent disease. It is very certain that, in many important particu- lars, it bore a very striking resemblance to true typhus. This re- semblance is noticed by most writers upon the disease. Dr. Elisha North called it a new petechial malignant typhus. Dr. Hale, of Boston, whose description of the disease, as it prevailed at Gardiner, Maine, in the spring of 1814, is the fullest and best that has been published, regards it as a congestive fever. He speaks of the many points of 1 The number of these cases during the present year, 1847, has been immensely greater than it ever was before. The hospitals of most of the commercial cities from the St. Lawrence to New Orleans have been crowded with typhus patients, coming mostly in emigrant ships from Scotland, England, and Ireland. 228 TYPHUS FEVER. resemblance which exist between it and Dr. Armstrong's typhus; but he says, also, that there are many strong points of difference between the two diseases. It is not easy, at the present day, upon such evidence as we possess, to decide with any confidence upon the precise character of the spotted fever of New England. With- out going any farther into the consideration of this question here, I will merely observe that an examination of most of the records that have been left us of this disease, has induced me to believe that it belongs to that class of new and more or less temporary epidemics, each having its peculiar character, marked by its pecu- liar phenomena, and depending upon new and peculiar combinations of unknown morbific influences—which have always from time to time made their appearance, rather than to the class of established and permanent maladies. Dr. Gerhard thinks that some of the epidemics which overran the Middle States, between the years 1812 and 1820, were typhus fever; and that it was of this disease that three distinguished pro- fessors in the University of Pennsylvania—Rush, Wistar, and Dor- sey-T-died. He says that Dr. Parrish, one of the most experienced physicians of Philadelphia, who practised very extensively amongst all classes of inhabitants in the winter of 1812-13, when he saw some of the cases at the Philadelphia Hospital, in 1836, immediately recognized their identity with those of the former epidemic. A pupil of Dr. Gerhard's, from North Carolina, informed him that he had witnessed a similar fever amongst the negroes. It seemed to be contagious, and, from the absolute disregard of cleanliness and the crowded state of the negro cabins, it frequently spread exten- sively. It is hardly necessary to say that these and similar opinions are to be received with a good deal of caution ; and that the extent and frequency of the prevalence of true typhus fever in the United States can only be determined by the accurate and continued ob- servations of the future. Upon this question, as upon so many others connected with epidemic disease, the past sheds but a con- fused and uncertain light. It is very clear that, for the:last thirty years, at least, true typhus fever has been almost or entirely unknown in France. In the years 1813 and 1814, there appeared at Paris a severe epidemic fever, which was first noticed amongst the troops who returned from Napoleon's campaigns in Germany, and in the east of France; and which afterwards spread amongst the inhabitants of Paris, and other large cities, and was everywhere extremely fatal. This epi- CAUSES.—SEASON, WEATHER, ETC. 229 demic,Dr. Gerhard is disposed to believe was typhus fever; although Louis, Chomel, and other French physicians who observed it, are inclined to regard it as identical with their prevailing typhoid fever, or dothinenteritis. A writer in the October number of the British and Foreign Medical Review, for 1841, thinks that the fever which devastated Italy in 1816 and 1817 was identical with the typhus of Great Britain. The fixed and constant residence of typhus fever is to be found in the British Islands. The mud cabins of Ireland, and the damp dark cellars of the cities of Great Britain, are its true habitat. These are its perpetual lurking-places, and here it is always to be found. The terms Irish typhus and British typhus have, indeed, come to be its most distinctive appellations. The number of deaths in England, except the metropolis, from typhus, in 1841, was 13,795 ; of these, 6,618 were males, and 7,077 females. The number in 1842, was 15,027 ; of these, 7,056 were males, and 7,971 females.1 According to the Report of the Registrar-General, there is no marked difference in the mortality from typhus in town and country districts in England ; the annual mortality to one million living, in 1841, being for the town districts, nine hundred' and eight; and for the country districts, nine hundred and twenty-nine. Dr. John Hunter says he never met with the disease in the West Indies.2 Sec. II.—Season, Weather, &c. Typhus fever prevails at all seasons of the year. Several of the Irish writers have remarked, in general terms, that the disease is found to prevail most extensively during the early part of summer. It seems probable, however, from extensive and accurate researches, that the difference in the extent to which the disease prevails in the different seasons of the year is not very great. Illustrative of this point, so far as a single locality is concerned, I copy the following table from Dr. Mateer's statistics of fever, during a period of eighteen years at the Belfast Fever Hospital. It shows the aggregate number of admissions into the hospital, arranged according to the four seasons, for this long and continuous series of years, with the average rate of mortality for the several seasons:— 1 Rep. Reg. Gen. 2 Hunter's Diseases of the Army, p. 83. 230 TYPHUS FEVER. Summer 2596 1 to 17|| for Summer. Autumn 2482 1 to 15?£ for Autumn. Winter 2359 1 to 14,]7 for Winter. Spring 2412 1 to 13|4 for Spring. It appears from this table that the influence of season, in favor- ing the prevalence of typhus fever, is small. It appears, also, that the rate of mortality is highest in the spring and winter.1 The deaths from typhus in England, in 1841, were distributed in the following manner through the quarterly periods of the year; in spring, 4218; in summer, 3498; in autumn, 3197; in winter, 3941.2 In the following year, 1842, there was a wider difference; the deaths in spring, being 3910; in summer, 3480; in autumn, 3680; and in winter, 5131.3 As to the effects of the sensible qualities and changes of the weather, nothing very positive seems to have been ascertained. These effects are doubted by some observers, and not agreed upon by others, who admit their existence. Thus Dr. Percival says: " It has long been observed that protracted dry weather is pecu- liarly productive of fever in Dublin ;" and Dr. Cheyne says: "More than thirty years ago, it was remarked by a very eminent physi- cian, the late Dr. Quin, that wet and cold summers always proved healthy ones in Dublin." Still, the same excellent observer informs us that the summers of 1816 and 1817, when fever was extensively prevalent, were wet, cloudy, and cold; and Dr. Barker makes the following remark : " The state of the weather, as to moisture, has been said to have affected the progress of this fever in other parts of Ireland. I cannot say that I have observed this in Dublin, although I have kept a register of the weather during several years past."4 Dr. Henderson, in his account of the epidemic at Edin- burgh, in 1838 and 1839, says that cold weather had commonly the effect of increasing the number of admissions into the Infirmary, which declined again when the temperature was moderate.5 Dr. James Arrott, of Dundee, remarks that all his inquiries tend to prove that great vicissitudes of the weather, and especially that great degrees of cold and wet, are powerful causes of typhus.6 The great epidemic of 1741 was coincident with two very severe winters and two very dry summers, one of which was very hot; 1 Dub. Journ. of Med. Sci., vol. x. p. 34. 2 Rep. Reg. Gen., 1843. » Ibid., 1844. 4 Trans, of Phys. of Ireland, vol. ii. p. 527. 5 Edin. Med. and Surg. Journal, Oct., 1839. 6 Ibid., vol. Ii. p. 127. CAUSES. — CONTAGION. 231 that of 1817 was attended by mild winters and very wet and cool summers. Rutty says: " Whenever we observe the usual harmony and proportion of the winds and attendant weather to vary much, we may expect an unhealthy season."1 Sec. III.— Contagion. Typhus fever has been almost universally regarded, by those physicians who have enjoyed the best and most extensive opportunities for observing it, as a disease capable of direct transmission from one individual to another, by means of contagion. Amongst others of the older British writers who main- tained this opinion, may be mentioned Willis, Huxham, Grant, and Pringle; and amongst the moderns, there are but few who dissent from it. Different observers differ, it is true, amongst themselves, in regard to the extent to which the principle of contagion operates in the propagation of the disease, and in regard to some other points connected with this subject; but they very generally admit the fundamental fact, of its contagious transmissibility. Dr. O'Brien, in a Dublin Fever Hospital Report, for 1819, in allusion to this matter, says: " That the skepticism of one or two individuals has gone so far as to deny the existence of contagion altogether in the fevers of our climate, but that the opinion is so singular, and so contrary to the general sense of mankind, that deservedly little attention has been paid to it." The extreme doctrine in regard to the contagiousness of typhus fever is, that the disease is exclusively and invariably the product of contagion ; that it never arises from the action of other causes alone; that it is never spontaneous, as it is called, in its origin; that it resembles in this respect smallpox, and not scarlatina. This opinion is not generally entertained, and must have been always the result rather of philosophizing than of observing; for, certainly, the evi- dence of direct observation is altogether against this exclusive opinion. It is easy to see that the accurate settlement of a question of this character is exceedingly difficult, and that where a consider- able number and variety of influences are or may be acting together in the production of disease, it must be often quite impossible to determine, with any degree of certainty, the actual and comparative agency of each. One thing, however, in regard to the present matter, is perfectly clear; and that is, that, in very many cases, there is no positive evidence, whatever, of the action of contagion. 1 Harty's Sketch, p. 142. 232 TYPHUS FEVER. Dr. Edward Percival says: " Having made it my business to inquire into the origin of most cases of fever that were admitted to the Hardwicke Hospital, during several years, I found the results to point less frequently and precisely to a contagious source than I should have anticipated."1 Dr. F. Barker observes that, of ninety patients in the Cork Street Fever Hospital, in October, 1817, of whom minute inquiry was made in relation to this point, only twenty-four could refer their cases to the effects of contagion.2 From a pretty careful and certainly an unprejudiced examination of this subject in the observations and opinions of British writers, I think we may look upon it as well settled, that the morbid actions con- stituting typhus fever are capable of generating in the body a poi- son, which, when concentrated, and aided in its operation by favoring circumstances, will produce the same disease in persons exposed to its influence. We may consider it also as not less certain, that the same poison may be generated by other agencies, amongst the most active of which seem to be the crowding together in close, unven- tilated apartments, amidst accumulated personal filth, of the wretched and suffering poor. I shall state the more obvious grounds upon which these conclusions rest. Dr. O'Brien, in his Cork Street Fever Hospital Report for 1816, states that, of- nine physicians who bad been permanently attached to the Institution, five had had the disease, in two of whom it proved fatal. Of the four who escaped, two had had contagious fever before their connection with the hospital. All the nurses employed in the hospital had suffered from the disease.3 Of the medical men connected with the South Fever Asylum, at Cork, during the epidemic of 1817, 1818, and 1819, seven physicians, the apothecary, and his apprentices, contracted severe fevers. Two of the physicians died. Nearly all the other persons connected with the hospital, and who, from the nature of their occupations, were in frequent and close communication with the sick—the hair- cutter, the porters, the nurses—were attacked with the fever.4 At the Hardwicke Fever Hospital, Dublin, in 1816, all the nurses and other residents in the hospital, amounting to twenty-three persons, escaped the disease. Dr. Cheyne attributes this exemption to the cleanliness and free ventilation of the Institution.5 Still, it appears that, in the following year, many of the officers of the same estab- 1 Trans, of Phys. of Ireland, vol. i. p. 287. z Ibid., vol. ii. p. 530. 3 Ibid., vol. ii. p. 485. * Ibid., vol. iii. p. 224. 3 Dublin Hosp. Reports, vol. i. p. 55. CAUSES.—CONTAGION. 233 lishment caught the fever. Amongst them were eight or nine medical gentlemen, the steward, all the servants, in succession, whose business it was to remove the clothes of the patients upon their first admission, and most of the unseasoned nurses.1 The opinions of the celebrated Dr. Armstrong, upon this point in the history of typhus, are well known. In the early part of his life he adopted the popular doctrine of the contagious nature of the disease. In a paper on the origin, nature, and prevention of typhus fever, communicated to the Medical Intelligencer in May, 1822, he expresses some doubts as to the correctness of his former opinions in relation to this question. His scepticism in regard to the conta- gious character of typhus, under any circumstances, continued to increase with his advancing years and experience; and in a lecture on the disease, published in 1825, although he does not deny the possibility of the transmission of typhus by contagion, he is unwil- ling to admit the existence of any positive evidence that such is ever the case. It ought, however, to be stated here, that Dr. Arm- strong's conclusions upon this subject were evidently somewhat influenced by his singular doctrine of the essential identity of inter- mittent, remittent, and typhus fevers, and of their dependence upon a single common cause? It may be added in connection with this subject, that nothing is more cqpmon, during the prevalence of typhus fever, than for a considerable number of individuals residing in the same room to be successively attacked with the disease. In many instances all the members of a large family, and even of several families, inhabit- ants of the same house, have, one after another, become its subjects. This common occurrence is noticed by most of the Irish writers upon fever. Of nine thousand five hundred and eighty-eight patients received into the Belfast Fever Hospital, from 1818 to 1835, two thousand three hundred and forty-two came in single cases, while seven thousand two hundred and forty-six came in numbers of two or more from the same family. They came from one thousand eight hundred and fifty-six families, thus giving an average of nearly four patients to a family.3 One of the circum- stances which early attracted the attention of Dr. Gerhard in the Philadelphia typhus of 1836, was the fact that the patients came in 1 Dublin Hosp. Reports, vol. ii. p. 53. 2 Memoir of the Life and Medical Opinions of John Armstrong, by Francis Boott, vol. i. pp. 149-171. 5 Dub. Journ. of Med. Sci., vol. x. p. 35. 234 TYPHUS FEVER. groups, and several from the same house. Amongst the first admitted into the hospital were seven negroes, the entire population of a cellar, in the lower part of the city. This occurrence of several cases in the same house has been but very rarely observed amongst the comfortable and rich classes in Ireland. Under these circum- stances, the fever has not usually extended to more than a single member of a family. The latent period of the contagious principle has not been accu- rately ascertained. It is probably different "in different cases. Dr. Barker says that, in many instances, it seems to extend to two or three weeks. Dr. Perry, of Glasgow, intimates incidentally, in his letter on typhus fever, published in the Dublin Journal of Medical Science, for January, 1837, that the disease rarely if ever makes its attack in less than eight days from the time of exposure. The same gentleman says that numerous observations and experiments have satisfied him that typhus fever does not communicate its con- tagious principle before the ninth day of the disease, and perhaps not till a later period. Many very striking instances are recorded, however, by different writers, in which the disease seems to have been directly and immediately received from a patient laboring under it, and to have instantaneously manifested itself. Dr. Henry Marsh, of Dublin, in an admirable paper upon the origin and latent period of fever, published in Volume IV. of the Dublin Hospital Reports, enumerates twenty cases of this sort. He says that they constitute a few amongst many facts of the same kind, which he has been able to collect, and that every day's observation adds to their number. In most of these instances, the persons, many of whom were nurses or physicians, while in the act of rendering some service to the sick, which exposed them to the strong, offen- sive odor arising from the beds or bodies of the patients, were immediately seized with headache, great prostration of strength, and with nausea, perhaps, or rigors; and these symptoms were soon followed by the full development of the disease, in many of which cases it proved fatal. He mentions the deaths of three physicians, Dr. Crawford, Dr. James Clarke, and Dr. Waring, under such cir- cumstances. Two cases of a similar kind are reported by Dr. Ger- hard, in his account of the Philadelphia typhus of 1836. He says: " The nurse was shaving a man, who died in a few hours after his entrance; he inhaled his breath, which had a nauseous taste, and in an hour afterwards was taken with nausea, cephalalgia, and ring- ing in the ears. From that moment the attack of fever began, and CAUSES.—CONTAGION. 235 assumed a severe character. The assistant was supporting another patient who died soon afterwards; he felt the pungent sweat upon his skin, and was taken immediately with the symptoms of typhus." It would be easy to multiply, and that to a great extent, similar examples. Sir John Pringle says of the jail fever: " I have observed some instances of a high degree of contagion attending it; but the common course of the infection is slow, and catching to those chiefly who are constantly confined to the bad air, such as the sick in hospitals, and their nurses, and prisoners in jails."1 In connection with this subject it should be stated that, even during the prevalence of very general epidemics, certain circumscribed localities sometimes are nearly or quite exempt from the disease. Thus, in the House of Industry at Cork, and in the Foundling Hospital of that city, in 1817, 1818, and 1819, the disease scarcely showed itself, when very prevalent amongst the inhabitants in general. The jail at Cork also remained free at the same time; and in the Marine School, and the Royal Hibernia Military School, in Dublin, there were but few cases.2 The occasional exemption of the inmates of these and similar institutions has been generally attributed to their seclusion, and consequent freedom from exposure to contagion. Another important quality of the contagious poison seems to be very well ascertained, to wit, that, as a general rule, it must be concentrated and abundant, so to speak, in order to excite the disease. A few cases in a large, cleanly, and well-ventilated ward, do not often communicate the disease to the other occupants, nor to the medical attendants and nurses. Dr. Christison's testimony on this point is very explicit and direct. He says: "The infection of continued fever is for the most part by no means virulent. This is contrary to universal prejudice among unprofessional persons, and to the opinion entertained even by some members of the medical profession. But it is nevertheless certain, so far as minute observa- tions of several violent epidemics during the last twenty years can determine the point, that moderate precautions will render the in- fectious atmosphere inert. Cleanliness and ventilation will speedily extinguish any epidemic. For it is well ascertained that fever, communicated to an individual in the better ranks by attendance on the sick in hospital, is very rarely propagated in his own station, or to any of his attendants. Among numerous instances known 1 Dis. of Army, p. 256. 2 Account, etc. By Barker and Cheyne, vol. i. p. 96. 236 TYPHUS FEVER. to the writer, of young practitioners and medical students who have caught fever in the prosecution of their practical studies, not a single case has occurred where the disease was communicated in their families at home or in their lodging-houses."1 [Dr. Peacock, however, states that, in the Royal Infirmary at Edinburgh, the managers, observing evils to result from concentrating the poison of typhus in the fever wards, distributed some of the fever cases through other wards. They put four patients in different parts of each ward of thirty beds, giving each fever patient the space usually occupied by two beds, and placing them between the piers of open windows. The fever spread to the adjoining beds, so that in a month no less than twelve cases of infection occurred; and the experiment was abandoned. Dr. Peacock is disposed to fix the incubation period of the typhus poison at ten to fourteen days; and it seems to him that the disease is most contagious during convalescence.2 At the beginning of the typhus epidemic in New York, late in 1846, the wards at Bellevue were greatly crowded, and almost all who were in immediate communication with the sick took the disease. In 1847 Dr. Reese took charge of the institution, and from that time there has been no ground for complaint in this respect. He erected tents in the hospital inclosure, and removed to them many of the patients. Temporary wooden buildings were raised for the cold season, as it approached, and from that time to the present, though the wards were for a long time full, they have never been crowded. They were always clean, and generally as well ventilated as the construc- tion of the buildings would permit. Yet very little difference was noticed in the communicability of the fever. The new nurses and the young physicians took it as before. From 1847 to 1852 the number of young physicians attached to the hospital was thirty-six; of these all but nine had the typhus fever. Of those who escaped, four had had the disease previously in some other hospital, and 1 Tweedie's Library of Practical Medicine. I cannot refrain from asking here, in a note, how far this dependence of fever upon a want of cleanliness and ventila- tion is applicable to typhoid fever ? Do my friends who believe in the essential identity of these two diseases, and who are familiar with the continued fever of this country, believe that any cleanliness and any ventilation will arrest the latter disease ? Let them try it, when typhoid fever prevails as it so often and so exten- sively does during the beautiful and breezy Indian summer, amongst the most cleanly, the most temperate, the best clad, the best fed, and the best sheltered people that this world has ever seen—the rural population of the Eastern States. * [Med. Times and Gaz., Aug., 1856.] CAUSES. — CONTAGION. 237 three had had typhoid fever some time before. From 1852 to the autumn of 1855 the fever still preserved the same type, but the number of cases was reduced, so that the average for any one time did not exceed twenty-eight in four well ventilated wards, and in this period of nearly four years, though the new and unseasoned nurses have not escaped, the writer has not been informed of any case among the young physicians. Dr. Flint states that the Buffalo Hospital is attended by Sisters of Charity, and that the five who took the fever were in imme- diate attendance on the fever cases; and he adds, that the sickness in all these began during the Lenten season. "The exposure was not greatest at this portion of the year, nor were the duties more arduous, and therefore it seems fair to suppose that the abstinence and increased devotional exercises of this period must have had some agency in the causation of the disease, rendering the system, probably, less able to resist, or eliminate the miasm of contagion."1 Dr. Upham says: "No doubt there are certain conditions, mental and physical, that strongly predispose to the reception of contagion, and its subsequent development. Irregularity of any of the func- tions, and fatigue of mind or body act thus."2 The physicians of Bellevue Hospital think that they can refer to a considerable num- ber of facts that illustrate this opinion.] Sec. IV.—Epidemic. The entire history of typhus fever shows, conclusively, that it is often very intimately dependent upon that unknown influence, or combination of influences, to which the term epidemic has been applied. After estimating, as nicely as our means will enable us to do, the agency of the several supposed causes, exciting and predisposing, of the disease, we are still unable to account for its general prevalence, during certain periods, and over more or less extensive regions, without resorting to this ancient hypothesis of an occult influence, or agent, coming, we know not whence—whether from the earth, the air, or the stars—and acting, we know not how, in the production of its results. In the case of typhus fever, as of many other diseases—of scarlatina, of measles, of smallpox—it is evident that, independent of all the circumstances which are admitted to favor its occurrence and its extension, there exists at certain times a predisposition or tendency to the disease which we are wholly unable to account for, or explain. Like the 1 [Clinical Reports on Continued Fever, p. 148.] 2 [N. Y. Journ. of Medicine, July, 1852, p. 12.] 238 TYPHUS FEVER. smallpox, and like scarlet fever, it is always present in Ireland; but at considerable intervals, we find it increasing immensely in the extent of its prevalence, and after the lapse, usually, of from one to two or three years, again subsiding to its permanent and average standard. Several of the great Irish epidemics have been already frequently alluded to. Barker and Cheyne are inclined to think that the plagues, as they were called, which accompanied the two great civil wars in Ireland—the first in Queen Elizabeth's time, and the second, that which commenced in 1641—were epidemics of typhus. There are subsequent histories of epidemics, more or less complete, in 1708 and 1709; in 1718, 1719, 1720, and 1721; from 1728 to 1731; in 1740 and 1741; in 1762; from 1797 to 1802; in 1817, 1818, and 1819, and so on. Barker and Cheyne estimate the number of cases during the epi- demic of 1817, 1818, and 1819, at one million and a half. It is remarked by Barker and Cheyne, that the duration of epi- demics has in many instances been about two years. This was the case in 1740 and 1741; in 1800 and 1801; and in 1817, 1818, and 1819.1 Sec. V.— Crowding; Filth; Famine, etc. Amongst the circum- stances which, to say the least of them, are very frequently asso- ciated with the presence of typhus fever, are the crowding of persons together in dark, damp, and badly-ventilated apartments; anxiety; fatigue ; excesses; exposure to the inclemencies of the weather, and scanty and poor food. The real and relative agency of these seve- ral influences, in the production of the disease, has not been very minutely and carefully studied, but there can be little doubt that they are often amongst its most powerful and prolific causes. The very intimate connection of typhus fever with crowded, ill- • entilated, and filthy apartments, has been universally admitted. This is the pestilence which dogs the footsteps of retreating and discomfited armies, and takes up its dwelling in their tents; which hides itself within the dark and noisome walls of ancient prisons; which lurks amidst destitution and vice, in the narrow lanes and unlighted cellars of great cities, and which has been, for many generations, the perpetual inmate of the low mud-cabins of the Irish poor. Of jail fever, Sir John Pringle observes: " This disorder is inci- dent to every place ill-aired and kept dirty; that is, filled with 1 Account, etc., vol. i. p. 133. CAUSES.—CROWDING, FILTH, FAMINE, ETC. 239 animal steams from foul or diseased bodies. And upon this ac- count, jails and military hospitals are most exposed to this kind of pestilential infection; as the first are in a constant state of filth and impurity, and the latter are so much filled with the poisonous efflu- via of sores, mortifications, dysenteric and other putrid excrements. I have seen instances of its beginning in a ward, when there was no other [?] cause but one of the men having a mortified limb."1 The connection of the great typhus epidemics of Ireland with a general scarcity of food has long been noticed. It has been esti- ♦ mated that, during the years 1740 and 1741, eighty thousand per- sons died in Ireland, of fever, dysentery, and famine. Dr. Rutty, then a practising physician in Dublin, informs us that, "in the autumn of 1740, there was a great dearth of provisions in Ireland, which proceeded almost to a famine in winter, the potatoes having failed, whilst other provisions bore double or treble their usual price." A subsequent epidemic of 1800 and 1801 was also at- tended by a great scarcity of provisions. Again, the terrible epi- demic of 1817, 1818, and 1819, was preceded, and during a portion of the time at least, and in many places accompanied, by a dreadful deficiency of even the commonest food. There are few darker pages in the long, sad annals of Irish poverty and disease, than that upon which is written the history of this epidemic.2 The crops of 1816 had almost entirely failed, and the same thing was true to a considerable extent of the following year. Not only was a large portion of the grain destroyed by the unfavorable weather, but the little that was saved was of a poor quality. It would be wrong, however, to attribute this or any of the pre- ceding epidemics to famine alone. Typhus fever is constantly present in various parts of Ireland, and it has more than once extensively prevailed when the harvests had been good, and food unusually abundant. This is only one of many co-operating in- fluences, to which the wide-spread prevalence of the disease is to be attributed. 1 Pringle's Dis. of the Army, p. 255. 2 Let me add, in a note, that many of these otherwise gloomy pages are made radiant and luminous with affecting examples of the patient resignation of the poor sufferers; and of the self-forgetfulness and devotion of the Roman Catholic clergy, the physicians, and other benevolent friends of the sick. Few incidents in medical biography are more touching and beautiful than the sketch which is given of the early death of young Gillichan, of Dundalk, one of the many martyrs to science and humanity, whose brief lives shed light and glory on the history of our art. 240 TYPHUS FEVER. Many of the Irish writers often speak of having seen typhus fever occurring several times in the same individual. Dr. Stoker speaks of the poor as having frequent attacks of fever, in the course even of a short life, and thinks that few adults have escaped these attacks, although he has no doubt that the succeeding attacks are milder than the first. Dr. O'Brien, in one of his hospital re- ports, says: " Some of the nurses have had the disease three or four times." Others have remarked that a second attack of the disease is very rarely witnessed when the first had been severe, or when it had been attended by an abundant eruption. And there seems good reason for believing that such is the case. Dr. Barker, in his Report of the Cork Street Hospital, Dublin, states that he has for some time entertained the opinion that sufferers from fever, attended with the petechial eruption, if they are not altogether secured by it from a second attack, are not at least so liable to it as those who have had a fever of the ordinary kind. " Though I have frequently made the inquiry," he adds, " I have not found a patient in whom this symptom was distinct, who had suffered from the same fever on any former occasion. But, whatever may be the result of more minute inquiry, it may be asserted that the chances of the recurrence of fever diminish in proportion to the continu- ance and severity of the first attack." Dr. Bracken, of Waterford, after quoting the above, says: "It appears to me that this opinion is supported by experience, as well as by reasoning from similar facts. Since I first observed this remark, I have kept the subject in view, and, after some attention to it, I have not been able to ascertain that more than three persons, out of many hundreds who came within my observation, have had relapse or recurrence of fever, after being previously affected with the symptoms in ques- tion."1 Dr. Trotter says: " During our extensive and long experi- ence of the origin, progress, and extinction of contagion, in ships, and everywhere else, I have entertained a strong suspicion that typhus infection very seldom affects a person more than once in a lifetime."2 Dr. Perry, of Glasgow, in a letter to the editors of the Dublin Journal of Medical Science, says: "I have for some years entertained the opinion, founded upon an extensive series of obser- vations, that contagious typhus is an exanthematous disease, and is subject to all the laws of the other exanthemata; that, as a general rule, it is only taken once in a lifetime, and that a second attack of 1 Barker and Cheyne's Account, etc., vol. i. p. 241. 2 Medecina Nautica, p. 213. CAUSES.—AGE.—SEX. 241 typhus does not occur more frequently than a second attack of smallpox; and, judging from my own experience, less frequently than a second attack of measles or scarlet fever." Sec. VI.—Age. There is no evidence that this disease is con- fined to any period or periods of life. , During its prevalence at Philadelphia, in 1836, children were rarely attacked by it; but after childhood, age seemed to exercise little or no influence upon the susceptibility to the disease. Amongst the whites, where the age could be better ascertained than amongst the blacks, there were as many patients over thirty-five years old as there were under this age. Dr. Edward Percival, in his Report on the Epidemic Fevers of Dublin, at the Hardwicke Fever Hospital, during the year 1813, 1814, and 1815, says that the disease prevailed continually amongst the boys and girls of the Bedford Asylum; characterized by petechias, great failure of strength, a turgid countenance, and con- siderable stupefaction.1 Eleven hundred of these children were crowded together in a building originally intended to accommodate only six hundred. Of three thousand nine hundred and seventy patients, received into the Cork Street Hospital, Dublin, in 1817 and 1818, there were under ten years of age three hundred and sixty-two ; from ten to twenty years, fourteen hundred and seventy- four; from twenty to thirty years, twelve hundred and sixty five; from thirty to forty years, five hundred and eight; from forty to fifty years, two hundred and forty-one; and over fifty years, one hundred and twenty.2 Dr. Barker says that, in the course of the epidemic of the above-mentioned years, he witnessed the disease in many children under the age of four or five years, and in its most exquisite form—that of petechial fever. It will be found from ex- tensive observations, that a large proportion of the cases of typhus fever occur in persons who are between the ages of fifteen and thirty years; but it would be very unsafe to infer from this fact anything positive as to the liability of different ages to the disease, unless we have first ascertained the whole number of persons of these different ages exposed to the causes of the fever. From not attending to this and other circumstances in these calculations— from not taking into account all the elements of the problem to be solved—many writers have lost themselves on what Dr. Arrott, of Dundee, calls the "quicksands of false arithmetic" 1 Trans, of Phys. of Ireland, vol. i. p. 288. 2 Ibid., vol. ii. p. 533. 16 242 TYPHUS FEVER. The average age of forty-seven patients, in whom the disease proved fatal at the Royal Infirmary of Edinburgh, in 1838 and 1839, was thirty-five years and a half, nearly.1 Sec. Yll.—Sex. The influence of sex in predisposing to typhus fever is not very great. It has been generally remarked by Irish observers, that the disease is somewhat more common amongst females than it is amongst males. This fact may be in part, per- haps entirely, accounted for, by the more constant exposure of the females to many of the most active causes of the disease. From Dr. Mateer's statistics, it appears that, of 9588 patients admitted into the Belfast Fever Hospital between May, 1813, and May, 1835, inclusive, 5130 were females and 4458 were males. Dr. Harty gives a table of the admissions and deaths of the two sexes, at some of the principal hospitals of Ireland, from 1817 to 1819. The number of males admitted was 32,144; the number of females 34,398. The male mortality was one in 19.40; the female, one in 24.75.2 In connection with this subject, Dr. Harty remarks that, " though it is well ascertained that the epidemic spared neither age, sex, nor condition, and that all were indiscriminately exposed to its attacks, it is yet certain that there were particular periods of the epidemic season, during some of which children, during others adult females, and during others adult males predominated in number."3 Sec. VIII.—Recency of Residence. New residents in any given locality seem to be somewhat more liable to typhus than others, although this circumstance has so little influence that it has not been often spoken of by British writers. According to a table published by Dr. Davidson, of five hundred and sixty-eight patients with typhus, admitted into the Glasgow Fever Hospital, in 1838 and 1839, one hundred and seventy-six, or one-third, nearly, were natives of the city; one hundred and ten had been residents less than six months; fifty-five, from six months to a year; ninety-seven from one year to five; and one hundred and thirty, from five years to twenty and upwards. Thus more than half of the whole number had lived in the city five years or upwards.4 1 Ed. Med. and Surg. Journ., Oct., 1839. 2 Historic Sketch, etc., p. 29. 3 rbid., p. 31. 4 Dunglison's Medical Library. 243 CHAPTER V. VARIETIES AND FORMS. The most common varieties of typhus fever are such as depend upon different degrees of severity, and such as are more or less constantly connected with the different seasons of the year. The proportion of mild to grave cases varies considerably under different circumstances, but it is almost always very great. Cases of all de- grees of intensity, from the mildest to the most severe and malig- nant, just as happens so frequently with scarlatina and smallpox, are often found together, under the same circumstances, and appa- rently depending upon similar causes. During the winter and spring, the disease is more likely to be seriously complicated with pulmonic affections. In the summer and autumn, it is frequently associated with gastro-intestinal irrita- tion. The disease, in certain places, and for a limited period of time, is occasionally marked by certain peculiarities. Dr. John Cheyne remarks that he never witnessed continued fever with so many inflammatory symptoms, as in the spring and summer of 1816, at Dublin ; and that the blood was sizy in nearly one-half of the patients who were blooded. In August and September, the cases were often complicated with dysentery, and with symptoms of gastro-hepatic derangement. A distressing nausea was common, with a bitter or foul taste, and a yellow tongue. After this period, the fever became more severe in its character, and was frequently complicated with an inflammatory state of the bowels.1 In Decem- ber, and the following January, many cases were attended with in- flammation of the bronchial mucous membrane. The same writer says that, of one hundred and seventy-five patients admitted into two wards of the Hardwicke Hospital during the months of April, May, and June, 1818, at least three-fourths had cough, with pains or stitch, oppression in the chest, and quickened respiration."2 But these varieties are in no degree more numerous or more important 1 Dub. Hosp. Rep., vol. i. p. 15, et seq. 2 Ibid. 244 TYPHUS FEVER. than those which are observed in the history of all epidemic diseases. Certain individual symptoms or phenomena may be frequent at one time and place, and rare at another. The occurrence of epistaxis, for instance, or of relapses, or of some consecutive affection, may be much more common in one season than in another. Dr. John Cheyne says of the fever at Dublin in 1816: "Relapses, which rarely occurred in summer, were uncommonly frequent in winter." During the years 1843 and 1844, there prevailed very exten- sively, at Edinburgh, a form of fever marked by such strong pecu- liarities as to excite some question as to its true character. Dr. Alison believed it to be specifically distinct from typhus. A very elaborate history of the disease has been published by Dr. Halliday Douglas, in the Northern Journal of Medicine. It was generally sudden in its attack, and rapid in its progress. One of its most striking peculiarities consisted in its tendency to terminate suddenly, after a certain period, by a critical evacuation—commonly by sweat- ing—and after an apyretic interval to relapse. This sometimes happened twice. Of one hundred and twenty-one cases admitted into the Edinburgh Royal Infirmary during the primary attack, the period of the first crisis was ascertained in eighty-three. It occurred on the fourth day, in two; on the fifth day, in twelve; on the sixth day, in twenty-five; on the seventh day, in twenty-seven; on the eighth day, in nine; on the ninth day, in four; and on the tenth day, in four. Only six of the remaining thirty-eight are said to have recovered gradually, and not by an abrupt crisis. The crisis was in most instances preceded by a rigor or chilliness; and, in all but two cases, accompanied by a sweat more or less profuse, lasting generally for a few hours, in a few cases for two or three days. .Sometimes, during the sweat, the pulse increased in frequency, but not always. The apyrexial period or intermission was quite com- plete in all but fifteen cases. Its usual duration was from five to seven days. The relapse was almost universal. Of one hundred and forty cases in which the time of its occurrence was ascertained, it took place between the ninth and thirteenth days of the fever, in seventeen; on the thirteenth, fourteenth, and fifteenth days, in eighty-one ; and subsequent to the fifteenth day, in forty-two. The relapse was generally ushered in by a rigor, and followed by febrile symptoms, less urgent, however, and of shorter duration than in the primary attack. This relapse usually terminated by a second crisis, between the second and the fifth day inclusive, from its commencement. In eleven cases, there was a second relapse, VARIETIES AND FORMS. 245 occurring at different periods, from the eighteenth to the thirty- sixth day of the disease. The duration of the second relapse varied from one to five days. The access was generally accompanied by epigastric distress and bilious vomiting. In a certain proportion of cases the patients became jaundiced. Dr. Douglas says the frequency of this occurrence has been exaggerated. He met with it in only twenty-nine of two hundred and twenty cases. The epidemic was marked by some other minor peculiarities. The disease referred to in the above paragraph, has attracted a good deal of attention in Great Britain, during the last few years. Dr. Jenner, has described it carefully and minutely under the name of Relapsing Fever. He regards it as a specific disease, differing, clearly and distinctly, from both typhus and typhoid fever. The following is Dr. Jenner's definition of the disease: " Sudden rigors, headache, skin hot and dry, tongue white, urine high-colored, bowels regular, occasional or frequent vomiting, loss of appetite, absence of abnormal physical abdominal signs. In severe cases, jaundice, profuse sweating on about the seventh day, followed by apparent restoration to health ; on from the fifth to the eighth day, reckoning from the apparent convalescence, repetition of the original symptoms, with greater or less severity; again terminating in sweating, and then permanent convalescence."1 [Dr. Peacock recognizes the relapsing fever, and says that it is characterized by its "almost constant association with evidence of biliary derange- ment, and by the absence of any eruption on the skin, and definite morbid changes after death in itie alimentary canal."2] I have said nothing about the old Cullenian division of continued fever into synocha, synochus, and typhus, for the sufficient reasons that this division is altogether arbitrary and conventional; and that, although some few of its illustrious author's countrymen still cling to it, it is very generally and very properly abandoned. 1 Jenner on the Identity or Non-Identity of the specific causes of Typhoid, Typhus, and Relapsing Fever, p. 4. 2 [Med. Times and Gaz., July, 1856.] 246 CHAPTER VI. DURATION AND MARCH. Sec. I.—Duration. The duration of typhus fever varies very considerably in different cases, and under different circumstances. Death often takes place at an earlier period than ever happens in typhoid fever. Dr. O'Brien says that death is not unfrequent on the fifth or sixth day of the disease. Dr. Pickels remarks that the disease, when fatal, rarely exceeded the eleventh or thirteenth day, and in many cases that it was much shorter. Dr. Edward Percival noticed that death was most common between the eleventh and seventeenth days. Dr. Bracken, of Munster, in a communication to Drs. Barker and Cheyne, says that, in the epidemic of 1817, 1818, and 1819, the greatest number of deaths took place on the ninth day; and then successively, on the tenth, twelfth, eleventh, seventh and eighth. The statements of most of the Irish writers, in regard to the average duration of the disease, are not, I think, to be very confi- dently relied upon. They do not tell us in what manner the duration was estimated, nor what n*)de was adopted for fixing the commencement and the termination of the cases. Dr. Lyne, of Fralee, says that, in the epidemic of 1817, 1818, and 1819, the duration of the disease ranged from five to twenty days, the average period being fourteen days.1 Dr. Bracken, of Munster, estimates the average duration in the same epidemic at nine days before puberty, and at fourteen days for adults.2 Dr. Pickels, in his Report of the South Fever Asylum, at Cork, for 1817, 1818, and 1819, says that, of fifty-nine cases taken in succession under the age of sixteen years, and which recovered, thirty-seven did not exceed the tenth day, and twenty-two did; and that of sixty cases, over the age of sixteen, which recovered, nine did not exceed the tenth day, and fifty-one did.3 The testimony of the Irish observers is very unanimous as to the shorter duration of the disease amongst 1 Barker and Cheyne's Account, etc., vol. i. p. 164. 2 Ibid., vol. i. p. 304. 3 Trans, of Phys. of Ireland, vol. iii. p. 203. DURATION AND MARCH. — CRISIS. 247 the young than amongst adults. It is less, also, in mild than it is in grave cases. Dr. Stoker found at the Cork Street Hospital, Dublin, in the summer of 1818, that of four hundred and seventy- one cases, mostly mild, nearly three-fourths terminated on or before the seventh day. Dr. Alexander P. Stewart says that the mean duration of typhus fever at Glasgow, calculated from the results of many thousand cases during successive years, is about twenty-one days.1 Dr. Henderson says that the average date of commencing con- valescence at the Royal Infirmary of Edinburgh, in 1838 and 1839, was the thirteenth day. The average period at which death took place, calculated by Dr. Reid from one hundred and forty-three cases, was between the twelfth and the thirteenth day.2 [No record has been preserved from which we can now learn the exact duration of the fever at the Bellevue Hospital, but it was the confident expectation of all the physicians who treated it, that the severe symptoms would begin to abate at least by the end of the third week, in the cases that recovered. The average stay of the patients in the hospital but little exceeded one month, being usually admitted from the fifth to the seventh day of the disease.] Sec. II.— Crisis. Many of the Irish writers on typhus fever allege that, in very frequent instances, the disease terminates in what has been called a crisis. That the commencement of con- valescence, in this as well as in many other diseases, should be formally and pretty clearly marked by certain phenomena of a decided character, is what we can easily understand, and what we frequently see. The coming on, after its long absence, of quiet and protracted sleep, accompanied as this grateful and refreshing visitation often is, with a diminution in the frequency of the pulse, a restoration of the integrity of the mind, and a change in the state of the skin, from an arid heat to a warm, gentle, and equable moisture, most certainly indicates a great and radical revolution in the condition of the system, which may well be called a crisis. But something more than this formal and obvious change in the state of the living tissues from a morbid to a healthy action is often meant, I think, by writers who speak of these crises in typhus and other fevers. They tell us of a violent struggle in the suffer- ing economy, which precedes and accompanies the transition of the 1 Edin. Med. and Surg. Journ., Oct., 1840. 2 Ibid., Oct., 1839, and Aug., 1842. 248 TYPHUS FEVER. functions from their diseased and perturbed action to their natural and easy play. They speak as though the recuperative powers of the system, almost worn out or overcome by the morbific influences which have obtained possession of the organs, had now gathered up and concentrated all their remaining energies; had now taken their desperate and final stand against the further inroads and ravages of disease; and as though the perturbation resulting from this conflict constituted the critical struggle, terminating, as the case may be, either in recovery or in death. This is neither an unfair nor an exaggerated statement of the views of these observers. Thus Dr. Percival, in his Hardwicke Fever Hospital Report, for 1813, 1814, and 1815, says: " The critical period was often a scene of severe struggle, the issue of which was for many hours doubtful. An obscure rigor would set in on the eve of the fourteenth day, or later; delirium and jactitation would increase, the extremities become cold, respiration hurried and oppressed ; the countenance pale and anxious; and the pulse, by its frequency, smallness, and irregularity, scarcely numerable. The patient would often moan loudly, from pains referred by him to the bones of his back and limbs. This struggle usually increased for some hours, and then subsided into relief or the gradual extinction of life."1 Dr. Per- cival, also, expresses the opinion that the term of convalescence was lengthened or shortened, in proportion as the crisis was fully or obscurely formed. Dr. Cheyne, in his Hospital Reports, makes very frequent mention of crises, marked by rigors succeeded by sweats. He noticed this termination of the fever much oftener during some periods than in others. Thus he says that, between the 12th and the last of May, 1817, amongst fifty-nine patients admitted into the Hardwicke Hospital, there were twenty instances of this form of critical resdlution, although, previous to this time, he had good reason to think that such a termination was exceed- ingly rare. " The rigor of crisis," as Dr. Cheyne calls it, he says rarely lasts long; perhaps only a few minutes, perhaps half an hour or an hour. Another form of crisis is thus characterized by the same accurate observer: " A state of restlessness and anxiety, with flushing of the face, rapid pulse, frequent, laborious breathing, and increased heat of the surface, with great distress at the pit of the stomach from heat, tenderness, or pain ; which distress was not unfrequently relieved by vomiting. The patients were in a state of universal uneasiness, which would have been truly alarming 1 Trans, of Phys. of Ireland, vol. i. p. 299. DURATION AND MARCH. — CRISIS. 249 had we not known its tendency; but this state is well understood, even by the servants of a Fever Hospital, who soon come to know by these symptoms that the patient is near ' the cool.1 This state sometimes lasted for the greater part of a day, during which time one of our experienced nurses, who was fond of figurative lan- guage, would generally remark that lthe cool was hovering round1 the patient."1 Whatever was the form of this "salutary effort,11 it was generally completed by a warm perspiration flowing from the whole surface of the body. Dr. Cheyne enumerates many other occasional modes of crisis, which seem to have consisted merely in the occurrence of some more or less striking symptom, such as diarrhoea or expectoration, or a simple, chill, just preceding or at the commencement of convalescence; and concludes the subject by saying that, in many instances, he could not discover any critical effort, the disease gradually terminating, as some of the older authors have remarked, by " insensible resolution.11 Dr. Stewart, of Glasgow, in reference to this subject, says: "All that I insist upon is the frequent, I may say the common, occurrence of a perceptible crisis, or what is vulgarly termed a turn in typhus. I think I may appeal to the experience of every physician, and more especially of every resident clerk in a fever hospital—for they have more constant opportunities of observation—whether they have not often been struck at seeing, during their morning visit, the glassy eye, the haggard features, the low, muttering delirium, the stupor approaching to coma, the tremor, the subsultus, the carphology, the rapid, thready, tremulous, and intermittent pulse, of the previous evening; the formidable array of symptoms, in short, which seemed to indicate a speedy and fatal termination, exchanged for the clear eye, the intelligent countenance, the steady hand, the comparatively slow and firm pulse, and the returning appetite of approaching convalescence. To such cases as these, we might almost apply the Scripture phrase, 'At such an hour, the fever left him;' and if the crisis is not very frequently so marked, we can, in the great majority of cases, point with precision at least to the day on which amendment began to take place."2 The following is Hildenbrand's description of the stage of the disease, immediately succeeding to the crisis. It constitutes his seventh period: "The first striking symptom that disappears is the delirium. The patient awakes as it were from a dream, or a fit of 1 Dub. Hosp. Rep., vol. ii. p. 17. 2 Edinburgh Med. and Surg. Journal, Oct., 1840. 250 TYPHUS FEVER. intoxication; his head becomes free, and in some instances he has an instantaneous and perfect recovery of his former knowledge- The memory, however, is still peculiarly affected; so much so that the patient has great difficulty in recalling to mind the circumstances that passed before and during his illness. The mind also experi- ences a considerable change, and the indifference which was pre- viously observed in the patient now begins to disappear. The eye becomes more attentive and expressive; surrounding objects begin to excite an interest, and the patient takes more notice of what is going on; the insensibility of the soul is dissipated; and the feelings of gratitude, of love, and of friendship, as well as of every other sentiment of the soul, are gradually awakened and displayed in the most exalted degree. " While the nervous system resumes its ordinary functions, and the locomotive powers become more energetic, the functions of the circulation are re-established, and the pulse becomes calm, regular, and open, though it is frequently weaker than in the preceding stages of the disease; the heat and perspiration of the body become mild and uniform; the thirst completely disappears, and the drinks which formerly afforded so much comfort to the patient now become disgusting."1 Hildenbrand also notices particularly the extreme muscular debility which accompanies this stage of the disease. [There are few diseases in which the transition from unfavorable to favorable symptoms is more marked than in typhus fever. In a period of eight, or twelve, or twenty-four hours, convalescence, in the majority of those who recover, is fully promised, is even com- menced. The peculiar dusky suffusion of the face subsides; the tongue becomes moist, though perhaps clammy; the mind is re- stored ; the patient feels his weakness and exhaustion, and com- plains of it, for the first time in many days; the pulse falls in frequency; and the skin becomes cool. This is a crisis, for in its etymology, the word means only something decided. Such a crisis was noticed hundreds of times in the late epidemic of typhus fever, in the Bellevue Hospital; but crisis by sweating, or other evacua- tions, was very rarely seen; while that by a violent struggle of nature was not noticed at all. Dr. Peacock says that the resolution of fever does not seem to be effected by means of critical evacua- tions, and he further remarks, that he has not learned to attach much importance to critical days in this disease.] 1 Gross's Hildenbrand, p. 52, DURATION AND MARCH. — RELAPSES. 251 Sec. III.—Sequela:,. Typhus fever is not often followed by chro- nic affections which can be referred to the previous disease. Dr. Cheyne and some others speak of an occasional case of phthisis, chronic rheumatism, hydrothorax, and so on, as amongst the sequelae of typhus fever; but the general testimony of the Irish physicians is against the frequency of such results. This is very striking in the reports from many districts of the country, which are published in Barker and Cheyne's account of the epidemic of 1817, 1818, and 1819. They almost all agree in saying that the disease rarely left any dreg behind it. Sir Gilbert Blane noticed that ships arriving in the West Indies, from England, with their men suffering from typhus, were more liable than others to exten- sive visitations of dysentery.1 [Dr. Upham wrote the paper, from which extracts have been already made, in part to record the occur- rence of " a peculiar intestinal affection" allied to dysentery (though the diseased action often extended to the ilium), during convales- cence from fever, as it appeared at the Quarantine Hospital, Boston. Dr. Upham states that he found " the secondary dysenteric affection" existing in the Quarantine and Emigrants' Hospitals of New York, and that it was there "of a similar intractible and fatal type." Little or nothing of this complication was seen at Bellevue Hospital, while it seems to have existed in the New York hospitals named above. The reason for this difference may, perhaps, be found in the fact that recent emigrants are not admitted into the institution at Bellevue. Regarding phthisis, and other sequelae, the reader is referred to the section entitled Secondary Lesions, p. 221 of this volume.] Sec. IV.—Relapses. The statements of British writers in regard to the frequency of relapses are quite contradictory. In most of the communications contained in Barker and Cheyne's history of the epidemic of 1817, 1818, and 1819, relapses are stated to have been of very frequent occurrence. At Cork, the number of per- sons who relapsed was estimated at two thousand. At Waterford, the relapses amounted to one-fifth or one-sixth of the whole number of the sick.2 This tendency to relapse was most striking during the latter period of the epidemic. It would seem to exist during certain periods, and to be absent during others. Dr. Stewart says that, however long may be the period of excitement, however long the adynamic stage, however tedious the period of convalescence, 1 Obs. Dis. of Seamen, p. 356, 1 Barker and Cheyne's Account, etc, vol. i. p. 439. 252 TYPHUS FEVER. he has never, amongst thousands of cases, seen a single case of relapse, in the proper sense of the term, after the symptoms had begun to decline.1 Dr. Edward Percival says that relapses were extremely rare at the Hardwicke Fever Hospital; while Dr. Pickels speaks of them as common, though mild, at Cork. Dr. Alfred Hudson, in his elaborate Inquiry into the souces and mode of action of the Poison of Fever, informs us that, in five hundred cases of fever admitted into the Navan Hospital in 1840, only two instances of true relapse occurred.2 These differences of statement may depend, in part at least, upon relapsing fever having been confounded with typhus. [Relapses were not uncommon at Bellevue. During convales- cence, and usually after the patient had left his bed, he would be seized, often suddenly, with a chill more or less severe, more or less prolonged. This would be followed by an ardent fever, with furred tongue, suffused face, prostration of strength, headache, marked increased frequency of pulse, in short, with a repetition of the symptoms by which the primary fever is ushered in, when the attack is sudden. Its progress for a few days differed from that of primary typhus, chiefly in the absence of the graver cerebral symp- toms. Its duration was, however, much shorter, usually ending in convalescence, in from five to eight days; and its mortality was so inconsiderable that an attack excited little apprehension for the patient's safety. A few cases were more protracted, but it is believed that the fever of relapse, in no instance, reached the average dura- tion of the primary fever. In two instances which can be distinctly remembered (probably in more), both the first attack and the relapse were marked by the peculiar typhus eruption. These cases will be remembered by many physicians, and by many who were then medical students, for they attracted considerable attention. The cases in which relapse occurred did not seem to differ from those in which it did not, and though after 1850, the physicians of Bellevue had the advantage of Dr. Jenner's views on Relapsing Fever, they did not find reason, in their subsequent observations, to change their former opinions regarding the new attacks. The author of this note still holds to the opinion that relapses, if the disease above described deserves that name, do occur after typhus fever, and if there be a distinct febrile affection to be called Relaps- ing Fever, he believes that it has not been his fortune to see it.] 1 Edinburgh Med. and Surg. Journ., Oct., 1840. 2 Dunglison's Medical Library. 253 CHAPTER VII. MORTALITY AND PROGNOSIS. The average mortality of typhus fever, deduced from large or considerable numbers, like that of most other epidemics of a grave character, differs very greatly in different seasons and localities. Before proceeding to estimate the elements of our prognosis in individual cases, I will endeavor to ascertain, as nearly as our materials will allow this to be done, the general rate of mor- tality in this disease, and some of its variations under different cir- cumstances. It is estimated by Drs. Barker and Cheyne, in their admirable history of the great Irish epidemic of 1817, 1818, and 1819, that the number who suffered from typhus fever in that country, be- tween the commencement of the first-mentioned year and the mid- dle of the last, embracing a period of only two and a half years, amounted to fifteen hundred thousand; and that the aggregate num- ber of deaths was sixty five thousand, making the average mortality one in twenty-three. The number of patients received into the Cork Street Fever Hospital, of Dublin, between the 14th of May, 1804, and the 5th of January, 1816, embracing no remarkable epidemic period, was twenty thousand two hundred and seventy eight. The highest mortality was one in ten, in the year 1805; the lowest was one in nearly twenty, in the year 1815; and the average mortality, for the entire period, was about one in fourteen. Dr. O'Brien, in the Report from which these results are obtained says, that the hospital necessarily received an undue proportion of grave and dangerous cases; so that the rate of mortality amongst fever patients was somewhat higher in the hospital than in the city at large.1 The whole number of patients received into the several fever hospitals of Dublin, from the 31st of August, 1817, to the 1st of October, 1819, was forty-one thousand seven hundred and seventy-five; and the deaths, during this period, were one thousand nine hundred 1 Trans, of Phys. of Ireland, vol. i. pp. 446, 461. 254 TYPHUS FEVER. and seventy-one; making the rate of mortality one in twenty-two, nearly.1 The highest rate, for any single quarter, was one in fif- teen ; the lowest, for any single quarter, was onejn thirty-two. The average mortality, during the same epidemic, in the South Fever Asylum at Cork, was one in twenty-five. The influence of age, sex, season, and the condition and constitu- tion of the patient upon the danger of the disease, and upon our consequent prognosis, constitutes an interesting and important subject of inquiry. Typhus, like typhoid fever, is less severe and fatal in early than in middle life. Dr. Percival says that amongst the children who were timely removed from the crowded apartments of the Bedford Asylum to the cool and ventilated wards of the hospital, and who were properly treated, the fever seldom continued longer than seven days in any case, and hardly ever proved fatal.2 Dr. Baker observes that very few children became the victims of the epidemic in the years 1817 and 1818. Amongst the numerous cases of children which came under his care, he recollects but one which terminated fatally; and in that instance, death was occasioned by the supervention of another disease.3 Dr. John Cheyne says of the fever of 1818, at the Hardwicke Hospital, that persons under twenty-five years of age had the disease mildly. This influence of age upon the mortality of typhus fever is placed in a very clear and striking light by the statistical researches of Dr. Mateer. I copy the following table from a paper of his in the tenth volume of the Dublin Journal of Medical Science, exhibiting the effects of age upon the mortality of the disease, at the Belfast Fever Hospi- tal, from September, 1817, to May, 1835 :— Age. No of Cases. Death From 1 to 5 years 301 12 5 to 10' t< 979 13 " 10 to 15 ii 1709 36 " 15 to 20 (1 2225 90 From 20 to 25 II 1384 74 " 25 to 30 l< 1033 81 " 30 to 35 II 677 70 " 35 to 40 II 553 76 From 40 to 45 II 418 82 " 45 to 50 II 302 60 " 50 to 55 II 188 45 " 55 to 60 II 135 29 Mortality. n 25 Jj n 75 T% a 24|f n 241 & ' n 12ff n 9*3 * m n 5 4& f 1 Trans, of Phys. of Ireland, vol. iii. 3 Ibid., vol. i. p. 2*8. a 4if J p. 456. Admitted, 5214—died, 151, being a mortality of nearly 3 per cent., or 1 in 34 84- 151. Admitted, 3747—died, 301, being a mortality of 8 per cent, and a fraction, or 1 in 12 135-301. Admitted, 1043—died, 216. being a mortality of nearly 21 per cent., or 1 in 4 179- 216. 2 Ibid., vol. ii. p. 572. MORTALITY AND PROGNOSIS. 255 Age. No. of Cases. Deaths. Mortality. From 60 to 65 years 86 31 1 in 2|f 1 Admitted, 171—died, 60, " 65 to 70 " 36 12 1 in 3 I being a mortality of 35 " 70 to 75 " 25 11 1 in 2?% J 15-171 per cent., or 1 in " 75 to 80 24 6 1 in 4 J 3 ^^ly. Results very similar to the above are shown by an examination of the cases received into the Royal Infirmary of Dundee in 1836 and 1837. It has been very generally observed amongst the hospital patients in Ireland and Scotland that the rate of mortality is much influ- enced by the period of the disease at which the patient is received, it being much less in those cases that are received in the early than in those that are received in the late stages of the fever. This may depend in part upon the circumstance that the severity of these cases, sent late to the hospital, would be likely to be greater than that of the general average. This influence is very well shown by the following calculation made by Dr. Mateer, and founded upon a grand total of 9588 patients treated in the Belfast Fever Hospital, during a series of seventeen consecutive years. admitted."1 \ 2d 3d 4th 5th 6ih 7th 8th 9th 10th nth 12th 13th 14th Total- No. of ) 544 1081 1669 1106 927 594 i067 302 539 187 247 167 700 9588 cases. J No. deaths. 13 41 82 52 39 40 112 30 57 13 25 7 150 664 Ratio of "] mortality percent.; 1 2 3 4 4 4 6 11 10 10 6 10 4 20 fractional f Nos. omit- I ted. J It has been observed, as a general rule, in Ireland, that the mortality is considerably greater amongst men than it is amongst women. During certain periods, and in given localities, this differ- ence is very obvious. Thus, at the Cork Street Fever Hospital, Dublin in 1817 and 1818, the rate of mortality amongst the males was one in sixteen, while amongst the females it was only one in twenty.1 During the same epidemic, however, at Cork, the mor- tality in the South Fever Asylum was, amongst males, one in twenty-eight and a half, and amongst females one in twenty-three.2 During a period of eighteen consecutive years, from 1818 to 1835, at the Belfast Fever Hospital, the ratio of deaths was for females one in fourteen nearly, and for males one in seventeen.3 The rate 1 Trans, of Phys. of Ireland, vol. ii. p. 568. 2 Ibid., vol. iii. p. 230. 3 Dublin Journ. of Med. Science, vol. x. p. 40. 256 TYPHUS FEVER. of mortality in the Royal Infirmary of Dundee, omitting fractions, in 1836 and 1837, was for females one in eighteen, and for males one in eleven. It ought, however, to be remembered, in partial explanation of this difference, that in many places the average age of the female is less than that of the male patients. Barker and Cheyne say: " We believe that at all times fever, particularly when it assumes a severe form, is more fatal to men than to women."1 Although the poor are very much more subject to typhus fever than the rich, and those who are well provided with the material comforts and luxuries of life, it is a singular fact that the disease, when it does occur in the latter class, is more severe and dangerous than when it occurs in the former. The testimony of the Irish physicians to the truth of this circumstance is almost unanimous. Old Rutty, in speaking of the great epidemic of 1740 and 1741, says: " The poor, abandoned to the use of whey, and God's good provi- dence, recovered; while those who had generous cordials, and great plenty of sack, perished11 Barker and Cheyne say: " In every part of the country, fever was reported to have been much more fatal amongst the upper than the lower classes."2 Of eleven physicians at Cork, who had the disease in 1819, four became its victims. At Water- ford, at Fermoy, and at Cork, the mortality amongst the upper classes ranged from one-third to one-fourth of the whole number attacked.3 The mortality amongst the young physicians attached to the New York hospitals has been very great.4 Mental anxiety and distress seem to predispose to a grave form of the disease. The Irish writers have generally observed that fathers of families, and others, whose character and circumstauces in life were such as to occasion great depression of spirits, and apprehension for the future, were more subject to severe and danger- ous attacks than those of a different temperament, and in different situations. Dr. Bracken, of Waterford, says: " In the winter and spring of 1806-7, the attention of the writer was forcibly directed to the fatal effect of fever on the fathers of families. Several fami- lies with fever were admitted during that period into the Royal Infirmary of Edinburgh, of which the heads, almost without excep- tion, became victims, while the rest escaped. Similar coincidences have since that time been repeatedly observed by him. Scarcely 1 Account, etc., vol. i. p. 90. 2 Ibid., vol. i. p. 95. 3 Ibid., p. 435. 4 [See remarks added to this edition at the end of Sec. 2, Art. IV., Chap. II.; also Sec. 3, Chap. IV., Typhus Fever.] PROGNOSIS. — ERUPTION. 257 any medical person needs to be informed that the age, habits, pro- bably bad, or diseases derived from them, together with the greater mental anxiety and solicitude, naturally belong to persons in this relative situation in life, must materially enter into the prognosis in all cases, and frequently have the worst effects on the termination of the disease."1 Dr. Edward Percival remarks that " fevers which had been preceded by great bodily fatigue and mental anxiety were uniformly hazardous." Dr. Pickels says: " The disease was very fatal amongst the old, and those who were debilitated by previous diseases, especially asthma. Of six or seven blacks who had the fever in Cork, all died but one." Dr. Arrott, of Dundee, thinks that, of all circumstances increasing the danger and mortality of typhus, the previous habitual use of intoxicating drinks is the most powerful. Barker and Cheyne say: " It is a general remark that epidemic diseases are most fatal on their invasion; and in conformity with experience we find that the late epidemic fever—that of 1817,1818, and 1819—was most mortal at its commencement. This is proved by reference to various documents. Thus it appears, from a tabular view of the admissions to the Fever Hospital in Cork Street, that the mortality decreased from 62 in 1000, to 31 in 1000."2 A similar difference was observed in the epidemic of 1800 and 1801. Our prognosis in individual cases must depend upon a careful appreciation of all the foregoing circumstances, and especially upon the degree of severity of a certain number of the symptoms. Great prostration of strength at an early period of the disease, profound coma, and dark purple or livid petechia, are amongst the most un- favorable symptoms. Dr. Gerhard says that, in the Philadelphia epidemic, when the stupor was extreme, so as almost to amount to coma, the prognosis was nearly always fatal. Dr. Edward Percival says: " The worst symptoms of fever are pervigilium, tympany, singultus, and coma; the most favorable in all cases are sleep, a moist tongue, and solvent bowels; a deficiency of urine is also an unfavorable sign, and its suppression very commonly a fatal one. When the patient lies at ease on his side, and especially if he is observed to relieve himself by spontaneous changes of position, after the fever is much advanced, the augury is favorable; on the contrary, when he continues extended and supine, lethargic and muttering, the prognostic is adverse."3 Dr. Bateman speaks thus 1 Barker and Cheyne's Account, etc., vol. i. p. 198. 2 Ibid., vol. i. p. 88. s Trans, of Phys. of Ireland, vol. i. p. 296. 17 258 TYPHUS FEVER. of the tongue: " The most important indications afforded by the appearance of the tongue are perhaps to be deduced from its changes; that is, from its tendency to return to the natural state, whatever the character which it usually maintains throughout may be. If the clammy tongue becomes cleaner, the parched one begins to lose its shining appearance, and to exhibit its papillae surrounded with moisture, or the crust of the coated one to soften and loosen, we may generally anticipate a favorable change in the other symp- toms, if it have not at the same time occurred. Perhaps we may with equal confidence prognosticate favorably of the issue of a fever, in which the tongue retains much of its natural appearance in the midst of many untoward symptoms; a circumstance which not very unfrequently occurs. The same observation, I believe, is applicable to the pulse; and when both these favorable symptoms concur, that is, when the tongue is moister and cleaner, and the pulse less frequent and softer than the severity of other symptoms would lead us to expect, we commonly see the patient recover, though the general indications of danger may be extremely great."1 " It is a consoling symptom," says Hildenbrand, " when the tongue, which was before dry and parched, becomes in the least moist and supple." Amongst the circumstances to be considered, in the prognosis of individual cases, are the amount and the character of the eruption, the danger of the disease being somewhat in proportion to the abundance and the dark color of the spots. Dr. Henderson found the mortality amongst those with an abundant eruption to be one in five; while amongst those with a scanty eruption, it was one in eight and a half, nearly. Of Dr. Stewart's one hundred and thirty- nine cases, the eruption was universally copious in ninety-six, and the rate of mortality was one in five; it was partially copious in thirty-two, and the rate of mortality was one in six and four-tenths; it was scanty in eleven, amongst whom there was only one death. Of fifty-nine cases, wherein the eruption was light-colored, the deaths were one in twelve, nearly; while of eighty cases, wherein it was dark-colored, the deaths were one in four nearly.3 Dr. Henderson found, at the Royal Infirmary of Edinburgh, in 1838 and 1839, that subsultus tendinum, to any considerable extent, was almost always followed by death.4 1 Succinct Account, etc., p. 43. 2 Gross's Hildenbrand, p. 107. 3 Edin. Med. and Surg. Journ., Oct., 1840. 4 Ibid., vol. lii. p. 434, Oct., 1840. PROGNOSIS.—HEAT OF SKIN. 259 Dr. Graves, in a paper published in the Dublin Journal for July, 1838, speaks of contraction of the pupil as a very unfavorable sign in typhus. He says: "In fever with cerebral disease, one of the most alarming symptoms is marked contraction of the pupil; and were I called to a case in which every other symptom was favora- ble, but great contraction of the pupil was present, I would sav that it was a case of extreme danger. A tendency to even mode- rate contraction of the pupil is a very dangerous symptom in typhus; but a pupil extremely and permanently contracted, or, as it has been called, a pinhole pupil, is or used to be a fatal sign." Heat of the skin, according to the observations of Dr. Cheyne, would seem to be rather a favorable indication than otherwise. He found that, amongst two hundred and fifty patients who were ad- mitted to the Hardwicke Fever Hospital in the spring and summer of 1817, and in whom the temperature of the skin was ascertained on the day of admission, the rate of mortality was larger in those where the temperature was low than in those where it was high. Amongst eighty-three of these patients, in whom the temperature ranged from 98 deg. to 100 deg. Fah., inclusive, there were seven deaths, or one in twelve, nearly; amongst one hundred and twenty- seven, in whom the temperature ranged from 101 deg. to 104 deg. Fah., inclusive, there were five deaths, or one in twenty-five; and amongst forty, in whom the temperature ranged from 105 deg. to 109 deg. Fah., inclusive, there was only a single death. " It was not uncommon," says Dr. Cheyne, "to find the thermometer gradu- ally rising from 98 or 99 deg. to 102 or 103 deg., or even higher, while the severity of the disease was abating; and, on the other hand, we frequently observed the temperature declining while the patient was getting worse; thus the patient was often in great danger when the temperature of the body did not exceed 98 deg. In some instances, for a day or two before death, the mercury did not rise above 96 or 95 deg. Indeed, in severe cases, after the tem- perature fell to par or below it, and that without any critical effort, we considered its rising again as a favorable change. In examining the disordered state of the vital functions, he adds, during the sum- mer of 1817, with a view to the prognostics of continued fever, we derived more information from the state of the breathing than from the pulse, and more from the pulse than from the temperature of the body."1 1 Dub. IIo-p. Reports, vol. ii. p. 13, et seq. 260 CHAPTER VIII. DIAGNOSIS. I cannot conclude this Essay on Fevers, without taking notice of the very great ■difference there is between the putrid malignant and the slow nervous fever; the want of which distinction, I am fully persuaded, hath often been productive of no small errors in practice, as they resemble one another in some respects, though very essentially different in others. John Huxham. It is plain that there are at least two species of continued fever, both in Europe and this country, and further researches may very possibly show more. James Jackson. Typhus fever may be confounded with various other diseases; with pernicious intermittent or remittent fever, with some cerebral affections, with typhoid pneumonia. The most important point, however, in connection with its diagnosis, is that which refers to its relations to typhoid fever. It may be remembered that, in ray obser- vations upon the general diagnosis of the latter disease, I alluded to this subject, and expressed the opinion that the two affections constituted radically dissimilar fevers, with the further remark that this question could be best considered after the natural history of both diseases had been given. We are now prepared to enter upon this particular matter, and to establish, as far as this can be done, the differential diagnosis of the two fevers. There is, however, one preliminary remark which ought to be made here, and that is, that even if we should come to the conclusion, as a question of strict scientific and philosophical nosology, that these two affections are essentially and fundamentally alike; that they are forms merely of one individual disease, it would still be hardly less important that ice should be able to distinguish between them as forms or varieties of disease. In a practical point of view, the necessity of an accurate diagnosis is not removed, even by the conclusion which I have supposed. These forms of fever, if we choose so to consider them, are still so dis- tinctly marked; they differ, in many respects, so constantly and so widely from each other, that their diagnosis is none the less im- DIAGNOSIS. — SYMPTOMS. 261 portant than it would be under the other supposition, that they are essentially dissimilar diseases. After pointing out their principal points of resemblance and of dissemblance, I will endeavor to exhibit, as fully and as faithfully as I can, the present state of the question in regard to their identity or non-identity, by a reference to the opinions and the investigations of those observers who have paid especial attention to this subject, constituting as it does one of the most interesting and important which is now occupying the attention of medical men. Sec. I.—Symptoms. In their mode of access, typhoid and typhus fevers, in many instances, very nearly resemble each other. It is pretty evident, however, that, as a general rule, the access of the disease is more gradual in the former than it is in the latter: typhoid fever creeps on treacherously and obscurely more frequently than typhus does; and the latter makes its onset suddenly, and without any lingering premonitions, more frequently than the former does. The seizure of the typhoid fever, in grave cases, is much more frequently accompanied with abdominal pain and diarrhoea than is that of typhus. The chief difference between the two diseases, in regard to the strictly febrile symptoms, consists in the more pungent and burning heat of the surface which characterizes typhus. Perhaps it is more frequently the case, also, in this disease than in typhoid fever, that the temperature of the skin falls manifestly below its natural stand- ard as the febrile excitement declines. I am not aware that there is anything in the chills, or in the character of the pulse, to dis- tinguish the two fevers. Perhaps the latter is more uniformly soft and compressible in typhus than in its related disease, and Dr. Gerhard found it more rarely bisferiens, as it is called. The odor from the body seems to differ in the two diseases. In typhoid fever, when perceived at all, it is usually in the latter period of grave cases, and is then of a stale, cadaverous character; in.typhus it is pungent and ammoniacal, more common and more striking. The thoracic symptoms are subject to greater variety in typhus than in typhoid fever. In some seasons, they are frequent and well marked; in others, they are nearly wanting. In the former dis- ease, they consist generally of dulness on percussion, and feeble- ness of the respiratory murmur over the lower and back parts of the chest, and of loose mucous rhonchi; in the latter, of dry, sono- 262 TYPHUS FEVER. rous, or sibilant rhonchi. The cerebral respiration is common to both fevers. There is a pretty close correspondence in the number, the severity, and the constancy of the nervous symptoms in the two diseases. Taking in all grades of severity, they may be somewhat more con- stant and .prominent in typhus than in typhoid fever; the pain in the head may be more intense and distressing; the stupor may be more marked; the morbid sensibility of the surface seems to be more common and striking; and the prostration of muscular strength, on the subsidence of the febrile symptoms, is more in- variable and profound. There is one other difference in regard to the existence of which I think there can be no reasonable doubt. The nervous symptoms in typhoid fever almost always creep on more stealthily and gradu- ally than they do in typhus. This is especially true of the dul- ness and stupor. In the latter disease, this symptom is generally more marked and profound at the commencement than it is in the former. In the abdominal symptoms of the two diseases there are nume- rous and important differences. In typhoid fever, where the affec- tion is at all severe, there is generally spontaneous diarrhoea, with liquid, yellowish, ochre-colored stools; in typhus, there is commonly constipation; and the stools, when procured by purgatives, are often dark, slimy, or pitchy, and offensive. Hemorrhage from the bowels is not unfrequent in the former; it hardly ever occurs in the latter disease. Abdominal pains are often present in both fevers, but in the former they almost invariably accompany the diarrhoea; in the latter they are attended by constipation, and are relieved by cathartics. In the former they are more frequently confined to the right iliac region, accompanied by tenderness on deep pressure, and gurgling, than in the latter. Tympanitic distension of the abdomen is very common in typhoid fever ; it is very rare in typhus. The cutaneous eruptions, characteristic respectively of the two affections, are very unlike in many respects. In typhoid fever, the spots are pretty uniformly oval or circular, varying but little in size; often distinctly though slightly elevated ; readily disappearing under pressure; generally not very numerous; confined, for the most part, to the skin of the chest and abdomen; and of a bright rose color. In typhus, they are more irregular in their shape and size; not elevated above the adjacent skin; partially disappearing under pressure, or not at all; often abundant, and even confluent; DIAGNOSIS. — LESIONS. — CAUSES. 263 in many cases occupying the skin of the extremities as well as that of the entire trunk; and usually of a duller and more dusky color than in the former disease. Not unfrequently, also, they consist of true petechias, or cutaneous ecchymoses, which in fatal cases persist after death. The average period of their appearance seems to be rather earlier in typhus than in typhoid fever. The dingy color of the skin, the dusky suffusion of the face, and the dark injection of the conjunctiva, are, to a considerable extent, peculiar to typhus. Such are the principal points of likeness, and of unlikeness, in the symptoms of these two diseases. I shall now institute a similar comparison between their respective lesions. Sec. II.—Lesions. There are some differences in the pathological alterations which are found in the thoracic organs in the two fevers. The differences in the abdominal lesions in the two diseases are very striking and constant. They are so well marked, and so invariable, that they are easily stated. In typhoid fever, there is a peculiar and constant alteration of the elliptical patches of the ileum, consisting of various degrees of thickening, changes of con- sistence and color, and especially of ulceration. In typhus, these plates are very rarely altered, and when so at all, only to a very trifling extent. In typhoid fever, the isolated follicles both of the small and the large intestines are found to have undergone, in many cases, the same changes that occur in the aggregated follicles; in typhus, they are in a healthy condition. In the former disease the mesenteric glands, corresponding to the altered and ulcerated fol- licles, are reddened, softened, and augmented in volume; in the latter they are unchanged in any respect. The large intestines are usually more or less distended with flatus in typhoid fever; they are not so in typhus. The spleen is enlarged and softened in a considerable proportion of cases of both diseases, but these changes are greater and more frequent in the former than in the latter. Alterations in the thickness, color, consistence, and so on, of the mucous membrane of the stomach and intestines are frequent but not invariable in both affections; there is nothing of any diagnostic value in their differences. Sec. III.— Causes. In connection now with the causes of these fevers, there are several circumstances in which they differ very considerably from each other. Typhus, although occurring most freq uently in early life, is not so exclusively confined to this period 264 TYPHUS FEVER. as typhoid fever is. The former attacks individuals more than forty years old much oftener than the latter does. Recency of residence in any given place, although it seems to favor the occur- rence of typhus, does so much less powerfully and manifestly than of typhoid fever. The unknown causes of the latter disease con- nected with locality are less circumscribed, geographically, than those of the former; at any rate, they seem to be more constantly and uniformly present over more extensive regions of the earth. In other words, typhoid fever is widely and continually prevalent in many places where typhus is very rarely if ever seen. The sporadic character of the former is more marked and evident than that of the latter. Typhus prevails more frequently in an epidemic form than typhoid fever. The latter disease may be to a certain extent, and under certain circumstances, contagious; but it is much less evidently and decidedly so than the former. The connection of crowded, filthy, and poorly ventilated apartments, with the origin and propagation of typhus, is more manifest and unequivocal than with those of typhoid fever. This latter point deserves to be much more strongly and em- phatically stated than it was as above in my first edition. It seems to me to constitute a broad, unequivocal, and most striking differ- ence between the two diseases. Typhus fever is very intimately connected, in its etiology, with crowding, impure air, filth, and poverty; it is, to a very great extent, dependent upon these causes for its primary origin. There is no point in its natural history more positively settled than this. Many of the British writers allege that the entire removal of these causes would exterminate the disease. Now all this is entirely otherwise, so far as typhoid fever is concerned. I do not mean to say that crowding, impure air, filth, and destitution may not sometimes give rise to typhoid fever, and favor its prevalence, although there is very little evidence if any that they ever act in this manner. But I do mean to say that, as a general rule, the disease is in no way and in no degree dependent upon these causes. In a vast majority of instances it is entirely impossible to trace any connection between them; nay, more than this, it is entirely manifest that there is no such connec- tion. The poison of typhus fever is generated in a stagnant and depraved atmosphere, rank with the thick corruptions of concen- trated emanations from the living human body; the poison of typhoid fever, like that of epidemic cholera, and like that of scarlatina, comes we know not whence; it is generated as readily DIAGNOSIS. — DURATION.—EFFECTS OF REMEDIES. 265 amidst cleanliness and purity as amidst filth; and it floats as freely in the fresh breezes under the open sky, as in the close and stagnant atmospheres of crowded cabins and lanes. Sec. IV.—Duration. The average duration of typhus is consider- ably less than that of typhoid fever, and death from the former dis- ease occurs in many cases earlier than from the latter. The termi- nation of the disease by a more or less well-marked crisis is also much more common in the former than in the latter. Sec. V.—Effects of Remedies. Finally, it is very evident, I think, that these two diseases differ from each other in the effects which are produced upon them by remedies. The immediate influence, for instance, of treatment, is much more obvious in typhus than it is in typhoid fever. General or local bleeding, when it is indicated, is more uniformly followed by mitigation or removal of local pain, especially of that of the head. So the administration of stimulants and tonics, under circumstances that call for them, is more frequently followed by a strong and manifest impression upon the morbid actions than is often seen in typhoid fever. It is pretty clear also that, as a general rule, typhus requires a more tonic and supporting treatment than the latter disease. M. Bouillaud may have failed to show that typhoid fever is more successfully treated by repeated bleedings, general and local, even at periods of the disease somewhat advanced, and independent of any special local indication, than by any other plan ; but he has at least demonstrated that this treatment may be borne with a good degree of impunity. We rarely hear of the sudden and often fatal sinkings, and collapses, which have so frequently followed a single moderate abstraction of blood in the middle and later stages of typhus. Sec. VI.—Historical. If this alleged and well defined difference between typhoid and typhus fevers really exists ; if these two dis- eases are radically and fundamentally diverse, and unlike each other, and if the diagnosis between them can be generally established, it becomes a matter not only of scientific interest, but of great prac- tical moment, for us to inquire how far this distinction is recognized, either in form or in fact, by the leading and classical British writers, who have long been, and who still continue to be, to a very great extent at least, our guides and authority on the subject of continued fever. What do they mean by the terms typhus fever, common con- 266 TYPHUS FEVER. tinned fever, slow nervous fever, and so on ? Do they describe a single disease, essentially identical in its nature, and differing only in its form, under these several appellations ? If so, what is this disease ? Is it the typhus fever, or is it the typhoid fever of this book ? On the other hand, do they describe distinct and separate diseases under these several appellations ? If so, what are these diseases ? Are they typhoid and typhus fevers, or are they something else? Certainly, I need not say how necessary it is to all sound science, and to all successful or even safe practice, that we should understand each other upon this primary and fundamental point of diagnosis. Cer- tainly, I need not say what contradictions and what inextricable confusion must inevitably grow out of the want of this understand- ing. In order to determine, as far as may be, the questions above indicated, I will briefly examine the opinions and observations of some of those British authors whose works are most generally in the hands of our own practitioners, and whose writings have most extensively influenced their doctrines and their practice. Amongst these I may mention particularly John Armstrong, Southwood Smith, and Alexander Tweedie. In Dr. Armstrong's "Practical Illustrations11 there is a great deal of gratuitous generalization, and of loose diagnosis; but he never- theless admits, very distinctly, the existence of two distinct forms of fever. One of these he calls typhus fever, and the other common continued fever. He uses the term typhus, he says, not, as has often been the case, to designate the combination of malignant symptoms which may take place in the last stage of any acute disease, but "to denote a specific disease, that, like the epic poem of ancient critics, has a beginning, a middle, and an end." The common continued fever of Dr. Armstrong is, I think, the typhoid fever of Paris, and of New England. Some of the leading and prominent distinctions between the two diseases, already so fully pointed out in the foregoing pages, can hardly fail of being recognized in the following extract: " The disturbance of the sensorial functions, and the prostration of the moving powers, are remarkably characteristic of true typhus. In the most frequent forms of the common continued fever, the patient has uneasiness in the head; but he has a bright eye, and a counte- nance indicative of no mental depression or despondency; and he lies in a position which displays some command of muscles, and can move about the bed, or get up, with a tolerable effort. On the contrary, in genuine typhus, the eye always wants animation; the countenance has a dull, wearied, depressed, and often desponding DIAGNOSIS.—HISTORICAL. 267 expression, and the patient lies in a comparatively relaxed position, and moves himself more languidly, almost like one worn out by loss of sleep, and from some unusual fatigue. In the common con- tinued fever, the patient commonly has not much inaptitude of mind, often answers questions readily, and in a pretty firm voice, without much increased agitation of the breathing; whereas, in typhus, the answers are mostly given with languid slowness and reluctance, and much speaking obviously disturbs the respiration. In the common continued fever the skin is generally of a brighter red than natural, especially on the cheeks; on the contrary, the skin is always more or less of a dusky color in typhus, and an admixture of it may be best observed in the flush of the face. This duskiness of the skin' is one of the proper symptoms of typhus, and seems to arise from some change in the constitution of the blood, which I have almost invariably seen darker than in ordinary fevers. In the worst cases, the duskiness increases in the progress of the disease, and lessens in those that assume a mild aspect. So very characteristic is this cutaneous duskiness, that I think I could distinguish typhus by it at any time, if two patients were presented to me, the one laboring under that disease, and the other under the common continued fever. In typhus, the tongue has an early tendency to become brown and dry; in the common continued fever it is always white, and often even somewhat moist for the first week; in typhus, the pulse is variable as to force and frequency, but it is seldom very resisting to pressure; but in the common continued fever, it mostly resists firm pressure of the finger, from the freer stroke of the heart. The above remarks are certainly most appropriate to the first and mid- dle stages of the ordinary instances of typhus, and of the common continued fever; for, in the last stage of both, many of the symp- toms so approximate as to make them more nearly resemble each other.'" Dr. Armstrong also speaks of the peculiar odor from the body in typhus fever, of the appearance of petechiae, and of the frequency and gravity of pulmonic complications. Amongst the occasional symptoms of the common continued fever, he mentions epistaxis and diarrhoea; and in most cases, he says death occurs at the end of the second or middle of the third week, but sometimes later. Now when it is remembered that the diagnosis between this common continued fever of Dr. Armstrong, and many local inflam- 1 Practical Illustrations of Typhus Fever, etc. By John Armstrong, p. 234, et seq. 268 TYPHUS FEVER. mations, was but very imperfectly established when his book was written; that its characteristic features had been but partially ascer- tained ; that other diseases must necessarily often have been con- founded with it, we shall have no difficulty, I think, in coming to the conclusion that, with these qualifications, the disease described by Dr. Armstrong as the common continued fever, is identical with the typhoid fever of the present day, and that his typhus fever is the typhus of the present day. Dr. Armstrong thinks that there is a third form of fever, occa- sioned by the crowding together of a great number of persons in filthy and close apartments, differing from both the preceding fevers. •His notice of it is too short and imperfect to enable one to judge of the correctness of this opinion, but the disease which he describes was probably a form of typhus. Dr. Southwood Smith denies the existence of more than one con- tinued fever. To the several forms and varieties of this single fever, depending upon degrees of severity and complications, he applies different terms; merely, however, as a matter of convenience. "The more we investigate the subject," he says, " the more satisfied we shall become that continued fever is one disease, and only one, however varied or even opposite the aspect it may present; but that it differs in intensity, in every different case; and that this, and this alone, is the cause of the different forms it assumes."1 Notwithstanding this opinion of Dr. Smith, an attentive study of his book, with our present knowledge upon this subject, will lead us, I think, to the conclusion that the two diseases which I have described, the typhus and the typhoid fever, both fell under his observation, and both helped to furnish the materials for his work; although he failed, as his predecessors and contemporaries had done, to discover and to distinguish clearly the differences between them. It must, however, be added that his histories of the several varie- ties of fever are not sufficiently full and accurate to enable us always to make a satisfactory diagnosis. His descriptions are glowing and vivid enough, too much so, perhaps; but they are not diagnostic, they are not discriminating, they are not complete. Like those of almost all English writers upon fever, they are not pure; they are mixed up and corrupted with a priori and hypothetical explanations and interpretations of the symptoms. 1 A Treatise on Fever. By Southwood Smith, M. D., Boston, 1831, p. 41. DIAGNOSIS. — HISTORICAL. 269 His synochus mitior seems to be a mild form of typhus, although it is impossible to speak with any confidence, from his description. The same remarks may be made, excepting as to the severity of the disease, of his synochus gravior, with subacute and with acute cerebral affection, and with thoracic affection. His synochus gravior, with abdominal affection, corresponds more nearly to typhoid fever. Some of the cases included in this subdivision certainly belong to the latter disease. His several varieties of typhus, corresponding to those of synochus, and excepting that with abdominal affection, are pretty evidently, for the most part, made up of cases of true typhus. His typhus mitior, with abdominal affection, looks more like typhoid fever. Now, taking the evidence derived from the symptomatology alone, in these descriptions by Dr. Smith of his several forms and modifications of continued fever, one thing at least we may look upon as settled. If, on account of the incompleteness and vague- ness of Dr. Smith's general and particular histories of the disease, we are not justified in deciding positively that the two distinct fevers, as I have described them, were both present in the London Fever Hospital, we may with entire confidence assert that these histories contain no evidence whatever that such was not the case. So far as the evidence derived from this source goes at all to settle the question, aided and interpreted as it now is by our present knowledge, it goes to show that both typhoid and typhus fever, but principally the latter, constitute the disease which Dr. Smith describes; and this conclusion we shall find singularly corroborated by an examination of his cases illustrative of the pathology of the disease. His general description of the lesions found after death is too loose and imperfect to be much relied upon. He speaks of the dusky color of the skin, the large purple petechiae, and the dark color of the muscles and the internal viscera. The brain is described as usually morbid, either increased vascularity of its membranes and substance or serous effusion constituting the most common alteration. We may, however, well feel the necessity of caution and scepticism, when we find it stated, as it is, that "the pituitary gland is very constantly softened, and often in a state of suppura- tion." The mucous membrane of the bronchial tubes was very generally thickened, and of a dark red color. The lower portion of the small intestine is said to have been found, in many cases, more or less extensively diseased ; its mucous membrane sometimes 270 TYPHUS FEVER. only reddened and vascular, and at others the seat of ulcerations. These ulcerations, with alterations in the mesenteric glands, seem to have been identical with the entero-mesenteric lesion which I have described as characteristic of typhoid fever. In a large num- ber of cases, on the other hand, the intestine is said to have been free from disease. Now, the point to which I wish more particu- larly to refer, illustrative of the question before us, is this; the ave- rage age of the patients constituting the two classes of cases ; those which did and those which did not exhibit, after death, the peculiar lesion of the elliptical plates found in typhoid fever. I find, for instance, that there are thirty-five cases reported of fever with prominent cerebral affection, and with absence of intestinal ulceration ; and that the average age of these cases is thirty-four years. Of these patients there were thirteen who were over thirty-five years of age; ten of them were as high as fifty, and the oldest was sixty-five. There are eight cases reported of fever with prominent thoracic affection, and with no ulceration of the intestine. The average age of these cases is somewhat more than thirty-six years. There are three cases reported of fever with prominent abdominal symptoms, but without ulceration of the ileum, and the average age of these is forty-five years. There are eight cases reported of mixed disease, without ulceration, the average age of which is twenty-two years and a half. The average age of these fifty four cases is about thirty- three years. I find, furthermore, forty cases reported wherein the intestinal ulcerations characteristic of typhoid fever were present; and the average age of these cases is twenty-two years and a third. Only four of them were over thirty five, and the oldest was fifty years of age. The bearing of this result upon the question of the existence of typhus and typhoid fevers amongst Dr. Smith's cases, and of the diagnosis between them, is too obvious to require any further remark.1 Dr. Alexander Tweedie's Clinical Illustrations of Fever were published in 1830. This work is more fragmentary in its character, and less systematic, than the treatise of Dr. Smith; but it bears many marks of sound judgment and careful observation. Dr. Tweedie seems to be very strongly impressed with the fact that 1 Dr. Reid's one hundred fatal cases have already been spoken of. There were only six of them which presented the lesion of typhoid fever; the average age of these six cases was twenty-five years ; the average age of the one hundred cases was thirty-six years and a third; seventy-seven were over thirty, and forty-two were over forty.—Edin. Med. Journ., Aug., 1842. DIAGNOSIS.—HISTORICAL. 271 different and diverse fevers prevail in London; but he has failed to point out, with any degree of accuracy or completeness, their distinguishing characteristics. His work, like that of Dr. Smith, is thus rendered almost valueless, by the fatal and fundamental defect of a want of all clear and well-defined diagnosis. This is true in relation not only to the separate kinds of fever, but also to other and widely different diseases. Thus, under the head of continued fever, we find many cases which are manifestly not fevers of any kind. These are instances of peritonitis, pneumonia, phthisis, and so on. Under these circumstances, and from such imperfect data, it would be worse than idle to attempt to settle the important question of the kind and character of the fever, or the fevers, which are described by Dr. Tweedie. I wish merely to remark that an examination of his cases in reference to their average age, furnishes the same singular' corroboration of the correctness of the opinion which I have given in regard to the existence amongst them of both typhoid and typhus fever as has already been deduced from a similar examination of those of Dr. Smith. For instance, of fifteen cases which, as far as I can judge, seem to have been cases of fever, and in which there was no intestinal ulceration, the average age was about forty years; while of sixteen other cases, in which the lesion characteristic of typhoid fever seems to have been present, the average age was less than twenty-six years. By some of the older British physicians, however, amongst whom may be mentioned, especially the incomparable Huxham, the difference between these two forms of fever was distinctly noticed. I have already given an extract from this writer's Essay on the Difference between a Slow Nervous and a Putrid Malignant Fever ; in which, considering the time when it was written, and the compara- tively imperfect study of diagnosis which was then common, the peculiar features of the two diseases are very well delineated. In a letter from Dr. Darwin to Dr. Lettsom, dated Derby, October 8, 1787, the following passage occurs: " If your Society proposes questions, I should wish to offer for one, ' Whether the nervous fever of Huxham (or fever with debility, without petechiae or sore throat, or flushed countenance, or pungent heat), be the same as the petechial fever, or jail fever?' The former of these, viz., the nervous fever of Huxham, prevails much over all the country at this time."1 Dr. Vaughan, also, of Leicester, in a letter to Dr. Lettsom, dated 1 Life and Correspondence of Dr. Lettsom, vol. iii. p. 118. 272 TYPHUS FEVER. July 27, 1783, in reference to the same subject, observes: " There is surely a peculiarity in the species of fever you had the goodness to send me an account of, protracting itself to such a length as thirty-five or forty days: it certainly agrees very much with Hux- ham's Febris Nervosa, which, notwithstanding Dr. Cullen, is a very different disease to the Febris Carcerum, in its attack, progress, termina- tion, and cure.111 Contemporary with these authorities, and inferior certainly to none, is that of Sir John Pringle, who very distinctly recognizes the difference between jail fever or typhus, and the low nervous, miliary, or typhoid fever. " In the description," he says, " I have endeavored to distinguish them," i. e. malignant or pestilential fevers, " from all others, as far as I could do it in distempers whose symp- toms are so much alike. The nervous fevers are frequently accom- panied with miliary eruptions, which have no resemblance to the petechial; nor have I ever happened to see miliary eruptions in this malignant kind."2 In reply to some strictures of De Haen, he says, still more explicitly: " I have never considered the jail or hospital fever, and the miliary fever," meaning the low nervous, or typhoid, " as similar; and indeed I may venture to say that, as the symptoms of the two are so much unlike, they ought to be treated as different in species ; and, consequently, that neither the theory nor the practice in the one ought to be regulated by analogy from the other."3 Again, he says: " I have, therefore, all along considered the jail or hospital fever (in regard to others, that commonly occur in these parts), as a fever sui generis, at least as different from either the scarlet, the miliary, or any other eruptive fevers which are known."4 The strictures alluded to above, by De Haen, had reference par- ticularly to the treatment of fever, by Huxham and Pringle. De Haen charged these great British observers with bad practice, with a too stimulating and incendiary method in the management of fever. Pringle, in his reply to De Haen, says, expressly, that the fever treated by the latter at Vienna was of a different kind from that treated by himself; and in a note to this reply, he makes the following very interesting remarks in regard to the dissimilarity of the cutaneous eruption in the two diseases. " After publishing what is above, relating to the distinction which I conceived was to be made 1 Life and Correspondence of Dr. Lettsom, vol. iii. p. 161. * Observations on the Diseases of the Army. By Sir John Pringle. Philad. ed., p. 298. 3 Ibid., p. 384. * Ibid., p. 385. DIAGNOSIS. — HISTORICAL. 273 ' between De Haen's petechias, and mine, I was confirmed in my opinion by Dr. Huck, who in the year 1763 was at Vienna, and was favored with admittance into all the hospitals there, and in particular had the satisfaction of attending Dr. De Haen himself, and seeing, with that celebrated physician, some of his patients in that very fever which he calls petechial. Dr. Huck examined those spots in Dr. De Haen's presence, and assured me that they had hardly any resemblance to those which I have called petechial, and which he himself had so often seen in the hospitals of the army; but that they were so like flea-bites, that he was apt to believe that one must be often mistaken for the other."1 Let me add, here, that I do not know anything in the annals of medical polemics, imbued with a finer temper, or a more philosophical spirit, than this reply of Pringle to De Haen. It is every way equal—and there is no higher praise than this—to Louis's defences against the attacks of Broussais and Bouillaud. In place, or out of place, I cannot forego the pleasure of gracing a page of my book with the following golden words from the reply of Pringle. " In fine, Dr. De Haen may be assured, that the regimen which I propose stood at first on no other foundation than experience, after my having seen the bad effects of a contrary method, whether by too large or too frequent bleedings in the beginning, or by giving hot things too early, in order to raise the pulse when it began to sink, or to force a crisis before the common period of the disease. Some of the medicines are superfluous, but I am pretty sure that none of them are hurtful. * * * But having once got into a method, which brought about as many cures as seemed otherwise consistent with the circumstances of my patients, lying in a foul air, amidst a con- stant noise, and often neglected by the nurses, I did not attempt to reduce my practice to more simplicity than what is mentioned. Yet, whatever confidence I may have in the directions which I have published, I am still ready to alter any part of them, upon a fair _ representation from those who have had equal opportunities with myself of seeing and treating this fever. But to oppose either mere theory or analogy from other fevers, where the similarity is so disputable, or to oppose some general maxims from Hippocrates or Sydenham to the observations which I have offered as the result of a long and painful experience in a distemper that no physician 1 Observations on the Diseases of the Army. By Sir John Pringle. Philad. ed, p. 390. 18 274 TYPHUS FEVER. could well know but in such circumstances as mine, is a manner of writing, I must say, more fitted for disputations in a school of medicine than for the instruction of a practical physician."1 Dr. Macbride, of Dublin, says that the " Putrid Continual Fever, before Dr. Langrish's2 time, was confounded with the nervous; but though both nervous and inflammatory fevers, towards the close, often show that by that time the crasis of the blood is destroyed, yet we are not to confound them with this," the putrid continual, " wherein, from the very beginning, there is some peculiar acri- mony, which dissolves the bond of union among the insensible particles, and allows them to run into combinations opposite to the mild, smooth, and emollient nature of blood in the healthy state."3 Dr. Willan, in speaking of the contagious typhus of London, in 1799, says: "To this contagious fever, alone, Dr. Cullen ought to have applied the denomination of typhus mitior; he has improperly comprised under it the slow or nervous fever, described by Hux- ham and Gilchrist, which may rather be considered as a species of hectic, and is not received by infection."4 Dr. James Sims, of the county of Tyrone, Ireland, although dis- posed to doubt the existence of the distinctions between the slow nervous and the putrid fever, insisted upon by Huxham, still says: " I would not by this be understood to mean that there is no differ- ence in reality between a low nervous fever, as it is called, and a putrid malignant one; I am well aware that there is; but am afraid that, in the last stage of the nervous one, as described by Dr. Hux- ham, a change is brought about by his treatment of it that he little suspects, which is its degenerating into a truly putrid malignant fever in nothing distinguishable from the other described under that appellation."5 In the 4th volume of the Edinburgh Medical Essays and Observa- tions, 1734, there is an Essay on Nervous Fevers, by Dr. Ebenezer Gilchrist, of Dumfries. The disease described by Dr. G. is evidently 1 Observations on the Diseases of the Army. By Sir John Pringle. Philad. ed., p. 395. 2 " The Modern Theory and Practice of Physic, by Brown Langrish, M. D., Lond., 1735." 3 A Methodical Introduction to the Theory and Practice of Physic. By David Macbride, M. D. London, 1772, p. 324. 4 Med. and Phys. Journ., vol. ii. p. 412. 5 Obs. on Epid. Dis., p. 248, 1776. DIAGNOSIS.—HISTORICAL. 275 typhoid fever. "I take this fever,11 he says, "to be very different in its nature and changes from other fevers11 In a continuation of the same essay, in the 6th volume, Dr. G. thus describes the disease. "The fever runs out to the twentieth, twenty-fifth, thirtieth, and sometimes to the thirty-fifth day. The symptoms upon seizure are generally such as are common to all fevers—coldness, trembling, and frequent alternations of heat and cold, nausea, headache, and vomiting; while at other times it draws on more insensibly. * * * From the seventh or eighth day, sooner or later, a delirium comes on, which is constant, and lasts through the fever, but for most part is not very high; the tongue is black, chapped, and parched. The sick are faint, highly dispirited, sigh heavily, and, when the fever is vehement, have a nervous or inter- cepted breathing. * * * A symptomatical looseness, or deafness, or both, accompany it to the end. What deserves a serious con- sideration, is the frequent hemorrhages or bloody appearances that happen. I have known them bleed four or five pounds by the nose in a few hours: bloody or sanious stools, and very fetid, are observed. * * * Seldom do they die soon in the disease, though it has been fatal before the fourteenth day." * * * "The disease, before it makes its attack, gives sufficient warning sometimes. Two or three weeks before they are laid down, they are low-spirited, inappetent, loaded, sleep ill, sigh frequently, groan involuntarily, and feel inexpressible disorder, accompanied with great fear, con- cern, and dejection, and perhaps, slight alienation of mind." The essay is long and tediously stupid, with d priori reasonings. Twenty-five years ago, an interesting paper was published in the Edinburgh Medical and Surgical Journal, by Dr. Autenrieth, Jr., on the Sporadic Abdominal Typhus of Young People, as the disease showed itself in the South of Germany. The difference between it and the typhus is distinctly recognized; although, as the author remarks, the two diseases had generally been confounded. Dr. Autenrieth, Jr., says expressly, and in so many words, that the dis- ease which constitutes the subject of his essay is essentially distin- guished from typhus; by arising independently of any contagion; by the particular time of life in which it spontaneously occurs; and by the seat of the complaint being in the abdomen, rather than the brain. Amongst the symptoms which the author enumerates, and which show very clearly its identity with typhoid fever, and its difference from typhus, are watery diarrhoea, abdominal pains, tympanites, and epistaxis. Dr. Autenrieth's sketch of the disease 276 TYPHUS FEVER. was written from memory, while he was residing in Edinburgh, and at the close of his paper, he refers to a more exact and com- prehensive description of the disease, to be expected from the hand of his father. " If," he says, in conclusion, " by the present attempt, I should be so happy as to excite the attention of the British medical profession to the knowledge and cure of this disease, I enter- tain the hope that, in a short time, the science may be enlarged, and my design completely attained." It is not a little remarkable that the attention of British observers should have been especially called to this particular subject—the distinctions between these two forms of fever—fourteen and sixteen years subsequent to the pub- lication of Dr. Autenrieth, Jr.'s, paper, by two other young con- tinental physicians—Dr. Lombard, of Geneva, in 1836; and Dr. Staberoh, of Berlin, in 1338. I shall now give a summary of the investigations which have been made, and of the opinions which have been advanced, in regard to this very important question, during the last few years. Dr. E. Hale, Jr., of Boston, in a paper on the typhoid fever of New England, published in the Medical Magazine for December, 1833, speaks very decidedly of the want of correspondence between the descriptions of typhus, given by Dr. Armstrong and Dr. South- wood Smith, and the phenomena presented by the common fever of our own country. These phenomena, he says, are " widely dif- ferent11 from those enumerated by the foregoing writers, as charac- teristic of the typhus which they describe ; but whether this want of likeness depends upon various modifying circumstances con- nected with the prevalence of the disease in the two countries, or upon an " intrinsic difference11 in their nature, he does not stop to inquire. The Dublin Journal of Medical Science, for September, 1836, con- tains two short letters, written by Dr. H. C. Lombard, of Geneva, and addressed to Dr. Graves, on the relation of the typhus fever of Britain to the typhoid fever of the continent. Dr. Lombard had for six years been familiar with the latter disease in France and in Switzerland, and, in the fatal cases, had invariably found the pecu- liar lesion of Peyer's glands. On Dr. Lombard's arrival in Glasgow, in 1836, he was allowed by his friends to examine the body of a fever patient, in whom he had said no doubt could exist as to the presence of follicular disease. He was not a little astonished at finding the elliptical plates wholly unaltered. On his arrival in Dublin, he was again furnished with an opportunity of making two DIAGNOSIS. — HISTORICAL. 277 similar examinations—one at the Meath, and one at the Hardwicke Hospital—and here again he was disappointed in not finding any lesion of the elliptical plates. Dr. Lombard alleges that he found the symptoms of the British typhus almost identical with those of the typhoid fever of the continent, but he immediately proceeds to mention the great difference in the appearance of the eruption in the two diseases, or forms of disease, the frequent occurrence of typhus in old subjects, the absence of prominent abdominal symp- toms, and its strongly-marked contagious character. He does not speak very positively upon the subject, but is unwilling to admit that the two diseases are specifically distinct. Dr. Lombard, on his way home, visited the Fever Hospitals of Liverpool, Manchester, Birmingham, and London; and on his arrival in Geneva, wrote a second letter to Dr. Graves, bearing date about one month subsequent to his first communication. At Liverpool, Manchester, and London, he found the same state of things as he had seen in Dublin and Glasgow ; prominent cerebral symptoms, an abundant cutaneous eruption, infrequency of abdom- inal disorder, many patients of advanced age, and strong evidences of the contagious character of the fever. It does not appear that he witnessed any autopsies anywhere in England. At Liverpool, he was told that ulcerations of the ileum and caecum were occa- sionally but by no means constantly met with, and that their frequency varied in different seasons. At Manchester, he was informed, merely, that the ulcerations of the intestines were by no means always to be found in the fatal cases. At Birmingham, he saw no patients, but was told by the medical attendants of the fever wards in the General Infirmary, that, in examinations, after death, ulcerations of the lower part of the ileum were always present. At the London Fever Hospital, he saw but very few patients, but concludes, from Dr. Tweedie's researches, that ulcerations in the lower part of the ileum are not to be found in more than one-fourth of the fatal cases, and that their frequency varies with different seasons; it being much greater in autumn than at any other period of the year. This constitutes the whole sum and substance of Dr. Lombard's personal knowledge of the typhus fever of Great Britain. In his second letter, he expresses, very decidedly, the opinion that there are two distinct and separate fevers prevalent in Great Britain ; one of them identical with the contagious typhus, the army and jail fever of the French pathologists ; the other a sporadic disease, identical with 278 TYPHUS FEVER. the typhoid fever, or dothinenteritis, of the French. He considers Ire- land as the source of the former disease; and supposes it to be carried by the Irish, in their annual migrations, to the several large towns and cities of the sister island.1 In Glasgow, it constitutes, he says, one-third of the total number of fever cases; in Dublin, much less; and in London, one-fourth; these proportions varying in dif- ferent seasons, but being greatest in autumn. Many of the suggestions contained in these letters were, at the time when they were made, exceedingly important; and it seems somewhat singular that they should not immediately have received a greater degree of attention from British observers. The conclu- sions, however, in regard to the exact degree of proportion in the prevalence of the two fevers, or forms of fever, in different cities of Great Britain, and in regard to the exclusive origin of typhus in Ireland, and its subsequent diffusion through Scotland and Eng- land, are, to say the least of them, premature and gratuitous. This precipitancy of judgment would seem to be a prominent character- istic of Dr. Lombard's mind; for we find him, in 1839, imagining that he had demonstrated the existence of a new disease, a true bilious fever, differing both from typhoid and from the bilious remit- tent fever, from this worthless and utterly inadequate evidence— the occurrence of two cases of prolonged bilious vomiting and purging, one of them in a female seventy-four years old, the other in a female fifty-eight years old, both terminating fatally; in only one of which was there an examination of the body, and in this no apparent lesion of any of the organs I2 In the 48th volume of the Edinburgh Medical and Surgical Journal, there is a very interesting notice of several papers, by recent German writers, on the abdom- inal typhus of that country, in which the question of the identity of this disease, clearly and manifestly typhoid fever, with the true British typhus is at least admitted to be a legitimate subject of doubt, and of further investigation. Macculloch insists very strongly that the typhus mitior of Cullen, the low, nervous fever, as it is commonly called, is essentially different from true contagious typhus.3 One of the most important documents in the history of this in- 1 As an offset to this opinion, it may be remarked that Dr. Barker, many years ago, attributed the great increase in the prevalence of fever which took place throughout Ireland, during and after the year 1810, to its introduction from the Continent by the return of the Walcheren troops, and in other ways. 8 Gazette Medicale, March, 1839. 3 Macculloch on March Fever, p. 35. DIAGNOSIS.—HISTORICAL. 279 vestigation is the paper of Dr. Gerhard's, to which reference has been so frequently made. The leading facts contained in that paper, so far as they bear upon the question before us, have already been embodied in the preceding account; it can be hardly neces- sary, therefore, to repeat them here. It is enough to say that the disease observed by Dr. Gerhard, and Dr. Pennock, prevailed some- what extensively, there having been admitted to the hospital with it, between March and August, 1836, nearly two hundred and fifty patients; that it corresponded very exactly in its symptoms to the true typhus; that it was clearly transmissible by contagion; and that the elliptical plates and the mesenteric glands were found uni- formly free from the lesion of typhoid fever. Dr. Gerhard and Dr. Pennock had both been familiar with the latter disease, and they were struck with the wide difference between it and the typhus of 1836; and to them belongs the credit of having first fully pointed out, and clearly established, the most prominent and essential points of dissemblance between the two diseases. Dr. Staberoh, of Berlin, after four or five years' study of contin- ued fever in Vienna and Paris, and after passing six months in Great Britain, where he had extensive opportunities for observing both typhus and typhoid fever, adopted the doctrine of the specific difference between the two diseases.1 Mr. Henry Kennedy, in a paper contained in the Dublin Journal for March, 1838, says that while his mind was in a state of suspense, in regard to the conflicting opinions of the French and British pathologists, as to the connection between intestinal lesions and continued fever, an opportunity was presented to him of seeing the common fever of Paris and of Geneva; and to his surprise he found it in many particulars different from the typhus of his own country. Two years of subsequent uninterrupted- study of the subject convinced him "that the fevers of the two countries are of different types, and that typhus may in the great majority of instances be distinguished from the gastro-enteric fever of the French." In the early part of 1839, Dr. George C. Shattuck, Jr., of Boston, had an opportunity of studying under favorable circumstances a small number of cases of continued fever in England. Dr. Shat- tuck had been already familiar with the typhoid fever of Paris, where he had then recently been engaged in its investigation, under 1 Dublin Journ. of Med. Science, July, 1838. 280 TYPHUS FEVER. Louis. It was at the particular request of Louis, as well as from his own warm interest in this very important question of diagnosis, that his observations were made. He saw thirteen cases of contin- ued fever, at the London Fever Hospital, where he says, through the kindness of Dr. Tweedie the attending physician, and of Mr. Goodfellow the resident medical officer, every facility for the exam- ination of the patients and for anatomical researches was afforded him. An account of these cases was communicated by Dr. Shattuck to the Medical Society of Observation of Paris. They were subsequently made the groundwork of an elaborate memoir of nearly seventy pages, by M. Valleix, which is contained in the October and No- vember numbers of the Archives Generales de MSdecine, of Paris, for 1839. Dr. Shattuck's own history of his observations was pub- lished in the Medical Examiner for February 29, and March 7,1840. As M. Valleix's analysis and comparison are founded entirely upon the cases furnished by Dr. Shattuck, it is unnecessary to take any further notice of the former, excepting to say that the author arrives at the conclusion that the typhoid and typhus fevers are both to be met with in England, and that they are distinct diseases. Dr. Shattuck's paper contains histories, more or less complete and extensive, of six of the thirteen cases. The first of these was clearly enough identical with the typhoid fever of Paris and New England. The patient was twenty-two years old ; and, in addition to many symptoms common to both diseases, there were meteorism and diarrhoea, and on examination after death, the characteristic lesion of the elliptical plates and the mesenteric glands, although moderate in extent, was present. Nothing is said in the report of this case of any cutaneous eruption. The second case corresponded in its most prominent features to the typhus fever of the Irish writers, and of Dr. Gerhard. There was no meteorism, and the skin of the trunk and limbs was covered with numerous spots of a dark red color, imperfectly disappearing on pressure, of the size of the head of a pin or of a small pea, grouped together. The elliptical plates and the mesenteric glands were in a healthy condi- tion. In the third case, the disease does not seem to have been so clearly marked. The symptomatology was rather that of typhoid than of typhus fever; but along with four or five lenticular rose spots on the abdomen, slightly raised above the surface of the skin, and disappearing on pressure, there were other spots grouped together, not raised above the surface. The history of the case is not very full. The fourth case was evidently enough, I think, one DIAGNOSIS. — HISTORICAL. 281 of typhus fever. The abdominal symptoms were very slightly marked ; there were redness and suffusion of the eyes, and the deep red grouped eruption over the skin of the body and arms. In the fifth case, which is briefly described, the diagnosis is uncer- tain. There were no abdominal symptoms, and both eruptions seem to have been present, as in the third case. The sixth and last case is reported more at length. It resulted fatally, and after six days of mild and damp weather, the abdominal viscera were removed from the body and examined. There was no appreciable alteration of the elliptical plates or the mesenteric glands. Dr. Shattuck seems disposed to consider this case as one of typhoid fever. There was diarrhoea, and the abdomen was somewhat swollen. It was tender on pressure, but so also were the limbs. There were few lenticular rose spots upon the abdomen, but they were followed by an abundant petechial eruption, of a deep red color, scarcely disappearing on pressure, not raised above the skin, and extending over the body and limbs. It ought to be added that this patient, who up to that period had been in good health, was seized with the disease the day after she had been employed in washing the clothes of the porter of the hospital, who had just died of fever. It is not my purpose to follow out in detail Dr. Shattuck's ana- lysis and comparison of the phenomena presented in his cases. Throwing out one of the cases, he divides the remaining twelve into two series, the first corresponding in its general features to typhoid fever, and the second distinguished from the first by the absence of abdominal symptoms, of the lesions of the glands of Peyer, by presence of a peculiar eruption, and by the liability to the disease on the part of older persons. The first series consists of three cases, one of which terminated fatally; the second consists of nine cases, four of which were fatal. These observations, although few in number, are very valuable. They were made, under interesting circumstances, by a competent and accomplished observer; and they show conclusively, so far as they go, that many cases at least of the continued fever of Britain may readily be distinguished during life from the typhoid fever of France and our own country, and that they are not characterized by the same anatomical lesion which is present in the latter. The forty-fifth volume of the Edinburgh Medical and Surgical Journal contains some observations on Continued Fever, as it occurs in the city of Glasgow hospitals, in the form of a letter to 282 TYPHUS FEVER. the editors, by Dr. Robert Perry. The only thing in these obser- vations which it is at all important for me to notice is the view which Dr. Perry takes of the relations between dothinenteritis and typhus fever. He looks upon the intestinal lesion as an accidental complication of typhus fever, and not less frequently, also, of small- pox, and says that in the latter disease the morbid appearances in the intestine are the same as those which occur in dothinenteritis itself, which disease, he says, may also exist as an affection per se, characterized by its peculiar symptoms; and from his enumeration of these symptoms, it is very certain that he has reference to typhoid fever. It is quite clear that Dr. Perry's observations, notwithstand- ing their extent—and he speaks of having made three hundred autopsies—have not been sufficiently accurate and discriminating to aid us much in the settlement of nice and difficult questions of diagnosis, like the one under consideration. In the month of April, 1840, Dr. Alexander P. Stewart read, before the Parisian Medical Society, a valuable paper upon the question of the identity or non-identity of typhoid and typhus fevers. This paper is contained in the Edinburgh Medical and Surgical Journal, for October, 1840. Dr. Stewart says that when he began, in 1836, the practical study of fever, he was much struck with the simultaneous occurrence, in the wards of the Glasgow Fever Hospital, of two sets of cases, in which the symptoms, however little most of them might seem to differ, when viewed individually, pre- sented, when taken collectively, characters so marked as to defy miscon- ception, and to enable the observer to form with the utmost precision the diagnosis of the nature of the disease, and the lesions to be revealed by dissection. In one class of cases, the affection, when it was mild in its character, and of short duration, was not attended by any eruption; while those cases in which it was fatal presented an abundant and generally a profuse eruption; but in the other class of cases, which equally, and even in a much higher proportion, went on to a fatal termination, there was rarely any and at most only a very scanty eruption. Dr. Stewart also noticed that the disease, in the latter class of cases, was much more gradual in its progress and prolonged in its duration than in the former; and, finally, to complete the contrast, already so striking, dissection proved the existence in the one disease of most extensive local lesions, and in the other the absence of all prominent local lesions, whatsoever. Dr. Stewart then proceeds to consider at some length the leading features of difference between these two diseases, in regard to their DIAGNOSIS. — HISTORICAL. 283 origin, their proximate causes, their course and duration, some of their symptoms, some of their anatomical lesions, and their treat- ment. He considers it settled that the poison of typhus is fre- quently generated by the crowding together of great numbers of individuals in close and unventilated places, while the similar origin of typhoid fever is, at least, very doubtful; that typhus is eminently contagious, while typhoid fever is so to a much more < limited extent, and only under peculiar circumstances; that the mean duration of typhus is much less than that of typhoid fever; that relapses are as common in the latter as they are rare in the former; that well-marked crises occur frequently in typhus, but never in typhoid fever; that the symptoms connected with the abdomen and that the cutaneous eruption are very dissimilar in the two diseases; that there is no resemblance between the anatomical lesions; and that the treatment which may be best adapted to one disease may be most unsuited to the other. Dr. Stewart had studied typhus fever in Glasgow, and typhoid fever both in Glasgow and Paris, before the publication of his very interesting and instructive paper; and many of his conclusions are founded upon his own careful observations of the two diseases. I cannot help remarking that it is somewhat singular that, amongst the many observers whom he quotes in support of the views which it is the object of his paper to establish and to illustrate, he should have wholly overlooked the researches of our countryman, Dr. Gerhard, who, by his history of the epidemic typhus of Phila- delphia, in 1836, had done more than any other observer towards determining the very questions which constitute the subject of Dr. Stewart's essay. It is proper that I should notice here, very briefly, some re- marks upon this subject, appended to an elaborate prize essay, on the sources and mode of propagation of the continued fevers of Great Britain and Ireland by Dr. William Davidson, of Glasgow. Dr. Davidson institutes a loose general comparison of the symptoms of the two fevers, and pronounces them nearly or quite identical. He gets over the difference in regard to diarrhoea, by attributing its frequency in the typhoid fever of Paris to the neglect of the French to use purgatives, and to the consequent irritation of the intestinal mucous surface, by the retained feces. The seeming difference in relation to the comparative frequency of meteorism in the two diseases, he explains by supposing that the French apply this term to much slighter distensions of the abdomen than would 284 TYPHUS FEVER. justify the English in its use. He quotes Dr. Lombard to show that the symptoms of the two fevers are the same. Dr. Lombard's opinions upon this subject may be very sound; but we have already seen that his observations, so far as the symptoms of the diseases are concerned, were too few and too hurried to be of any value whatever. Dr. Davidson admits that the intestinal lesion is very rare on his side of the channel, and almost invariable on the other; but this circumstance he seems to suppose may be accounted for by differences of climate, diet, habits, &c. So far-as Dr. Gerhard's researches are concerned, in relation particularly to the lesions, he begs the question entirely, by implying that the disease which he describes could hardly have been British typhus, since fifty con- secutive inspections- of that disease could not be made without finding one decided instance of alterations in the intestinal follicles. He also misunderstands Dr. Gerhard, in representing him as resting his diagnosis of typhus almost exclusively on the absence of the lesion, and as admitting the almost perfect identity of the symptoms of the two diseases, neither of which does Dr. Gerhard do. In conclusion, he admits that " the strength of his argument11 in favor of the identity of the two fevers lies in the fact that it has been admitted that cases of typhoid fever have occurred with no intestinal lesion. After the full exposition which has been given of this particular point, and the extreme infrequency which has been shown of the occurrence itself, it is obvious enough that the argument deduced from it is characterized by anything rather than strength. In an inquiry into the sources and mode of action of the poison of fever by Dr. Alfred Hudson, physician to the Navan Fever Hospital, republished in this country in connection with the above- mentioned Essay in Dr. Dunglison's Medical Library, the author takes the opposite view of this subject. He recognizes the essential dissimilarity of typhus and typhoid fevers; and gives the valuable results of his own personal observations in the following words: "In the Navan Fever Hospital there have been, for the last seven years, almost always two distinct forms of fever present; one or the other occasionally preponderating, so as at times nearly to exclude the other. Thus, for the first three years, the prominent features were pain, tenderness and meteorism of the abdomen, diarrhoea, and not unfrequently these symptoms combined with catarrh; several cases of perforation of the ileum occurred towards the close of this period; petechiae were not frequent, and were late in their appear- DIAGNOSIS. — HISTORICAL. 285 ance, and we had few instances of communication by contagion. During the three following years a highly contagious fever prevailed, and the symptoms and treatment were completely different; deli- rium, subsultus, dysphagia, being the ordinary symptoms, and diar- rhoea being rarely met with; nearly every case presented the measly efflorescence, and instances of contagion were as numerous as they had been rare previously. During the present summer, the prevail- ing type has been the abdominal fever of the first period, and in- stances of typhus- are infrequent, certainly not a fourth of the whole, and sent exclusively from a district in which the epidemic of last year still lingers. At a meeting of the Dublin Pathological Society, January 31, 1846, Dr. Greene stated that, whenever he met with the phenomena so accurately described by Louis, as belonging to typhoid fever, he invariably concluded that follicular disease of the intestine was present.1 Many of the French writers upon typhoid fever, of the present period, seem to incline to the opinion that the camp and jail fever of former observers, and the typhus of the British authors, are identical with that of their own country. In 1837, the Royal Academy of Medicine crowned with one of its prizes a memoir by M. Gaultier de Claubry, upon the differences and analogies between typhoid and typhus fevers, the conclusion of which memoir is in these words: " There are no means of distinguishing typhus from typhoid fever, in relation either to the lesions or the symptoms of the two diseases." The same writer, as late as October, 1839, says that the identity of the two diseases is henceforth put beyond doubt. It is proper to add that, at the same time, the Academy bestowed a second prize upon another memoir upon the same subject, in which the opposite doctrine was advocated. In regard to the memoir of Gaultier de Claubry, it is important to state that his object is to demonstrate the identity of the typhoid fever of Paris, and the jail, army, and camp fevers of the continent of Europe. He formally puts aside the British typhus. He insists, as though it was one of the strongest points in his argument, upon the constant presence, in the continental jail and camp fever, of the lesion of Peyer's glands. This question has since been very fully discussed by the Royal Academy. I only wish it to be clearly understood that the question is quite different from the one now before us. 1 Dublin Hospital Gazette, March, 1846. 286 TYPHUS FEVER. In the Archives GSntrales de Medecine for January and February, 1842, there is an interesting history of a supposed epidemic typhus fever, which prevailed at Rheims, between the first of October, 1839, and April, 1840, by M. H. Landouzy; in the course of which the author considers, at some length, this question of the differences and resemblances between typhus and typhoid fevers. The epi- demic was confined to the inmates of a certain quarter of the prison of Rheims, and to those whose occupations brought them into close connection with the patients after they were removed from the prison to the hospital, where they were all immediately and succes- sively taken on the appearance of the fever. The entire number of cases was one hundred and thirty-eight, one hundred and three of which were amongst the inmates of the prison; the remaining thirty-five consisting of physicians, medical students, nurses, and others connected with the hospital where the patients were treated. There are some circumstances which render the history of this particular epidemic one of great value. I will mention only one, and that is, that all the cases came under the observation of the medical attendants immediately on the commencement of the disease. This is rarely the case in hospital practice; and, in the present instance, it afforded a good opportunity for the study of the earliest phenomena of the disease. I shall give a brief abstract of its his- tory. Amongst the first and most prominent symptoms of the epidemic was stupor. It frequently showed itself as early as the second or third day, and continued until it was lost in coma or delirium. M. Landouzy does not mean by this stupor any degree of mere som- nolence, or coma. He thinks that it differs from either of these states. The expression of the countenance is that of half-demented and stupid astonishment. That is the stupor attonitus of Foes. In half the cases it was strongly marked, in the other half it was slight in degree. M: Landouzy thinks that it comes on earlier and is more striking than the same symptom in typhoid fever. True somnolence and coma appeared in a certain number of cases later in the disease, often about the tenth day. Profound coma, so that the patient could not be roused, existed in only twelve cases. Delirium was very common, usually making its appearance between the third and the eighth day. It was generally low and muttering in its character, and in fatal cases it continued until death. Headache was uniformly present at the commencement of the disease. It was for the most part dull and heavy, and felt especially over the DIAGNOSIS. — HISTORICAL. 287 eyes. It continued for an uncertain period of time, gradually dis- appearing or losing itself in coma or delirium. Subsultus tendinum was common and strongly marked in grave cases. Redness of the eyes, tinnitus aurium, and deafness, were present in a certain pro- portion of cases, but differed in no obvious particulars from the same symptoms in typhoid fever. There was great loss of muscular strength from the beginning of the disease. In every case except the first, which was not carefully examined, there was an abundant cutaneous eruption, consisting of small spots or ecchymoses, as M. Landouzy calls them, of a red, violet, or black color, not elevated above the skin, and not disappearing on pressure. They were always found on the chest, often also on the abdomen, and in some cases they extended to the arms and legs. They com- monly showed themselves about the fourth or fifth day, and gradu- ally faded away between the tenth and the eighteenth. They were abundant and confluent in proportion to the gravity of the disease. The bodies of the sick exhaled a strong, offensive odor, resembling that of mice. In regard to the absence of appetite, to thirst, the state of the lips, tongue, and mouth, nothing special was observed differing from what occurs in typhoid fever. Nausea was present at the com- mencement of the disease in all the cases. Meteorism and abdomi- nal pains were uniformly absent. There was diarrhoea at the beginning of the disease in only four cases. In all the others, there was no apparent disturbance in the functions of the intestinal canal. The bowels were more inclined to constipation than to looseness. A distinct, well-marked, sibilant rhonchus was present in all the cases. There was nothing remarkable in the frequency of the pulse. It was full and large, and, at the commencement of the disease, resisting. There was nothing unusual in the appearance of the blood. Epistaxis occurred in only eight cases. The tem- perature of the surface was uniformly elevated; the heat was dry and burning. In no instance was there gangrene of any part of the body. The contagious character of the epidemic was very manifest, as has already been intimated. Three physicians, six medical students, twelve nurses, and other attendants on the sick, after they had been transferred from the prison to the hospital, amounting in all to thirty-five, contracted the fever. Amongst these there were nine deaths, or one in four, nearly; while amongst the one hundred and three prisoners there were only eight deaths, or one in thirteen, 288 TYPHUS FEVER. nearly. None of the nurses who had had typhus fever in 1814 were attacked with the disease, but two medical students and one physician who had had typhoid fever, the former six months and the latter twenty years previously, suffered very severely. Of one hundred and four patients in whom the age was accu- rately ascertained, sixty were from fifteen to thirty years old, thirty-six were from thirty to fifty, and eight were from fifty to seventy. The quarter of the prison in which the disease commenced, and to which it was almost exclusively confined, was originally intended to accommodate from eighty to one hundred inmates; it had usually contained from one hundred to one hundred and twenty; at the time when the epidemic appeared, its population amounted to one hundred and eighty. Many, indeed most, of the foregoing circumstances in the his- tory of this local epidemic, correspond to the phenomena which we have found to occur in typhus fever. But, according to M. Lan- douzy, in the six autopsies which were made, the intestinal lesions characteristic of typhoid fever were present. The elliptical plates were either thickened and elevated, or they were the seats of ulcera- tions, and the mesenteric glands corresponding to them were enlarged. The spleen was not increased in size in any of the cases; in four it seemed somewhat softened. In this epidemic, if entire reliance is to be placed upon the observa- tion of its historian, there seems to have been a union in the same cases of many of the elements which are generally found confined either to one or the other forms of continued fever. The symp- toms of contagious typhus were found in connection with the folli- cular lesion of typhoid fever. Is it possible that, even admitting the two diseases to be essentially dissimilar, under certain circum- stances the causes of both may be so commingled, as to give rise to a mixed disease in which there is a combination of the elements of both? Let it be remembered that this, as well as all analogous questions, is to be determined, not by a priori reasoning, however plausible and ingenious, but by simple, careful, rigorous observa- tion. M. Landouzy, in the case before us, in the spirit of a true and sound philosophy, says, that we must await the results of ulterior observation before we shall be able to settle, definitively, this great question in regard to the identity of these several forms of fever. " In effect," he adds, " if in all future epidemics of the typhus of camps, of jails, of hospitals, &c, we find, as in that of DIAGNOSIS. — HISTORICAL. 289 Rheims, complete absence of disease of the spleen, and great dif- ferences between the symptoms and those of typhoid fever, we must confine ourselves to- the conclusion that typhus and typhoid fever are analogous and not identical diseases. If, on the contrary, we find that in one epidemic diarrhoea is absent, in another the petechial eruption, in another the rose spots, and so on, we must conclude that these differences depend only upon variations in the action of the epidemic cause, and that the disease is, in its nature and essence, identical with typhoid fever." M. Landouzy's con- clusion, in regard to the epidemic which constitutes the subject of his memoir, is, that the resemblances between it and typhoid fever are so numerous as to induce him to look upon the two diseases as analogous: but that the differences between them are also too nu- merous to allow him to regard them as identical. I shall conclude this historical survey of facts and opinions, bear- ing upon the question of diagnosis before us, by a short reference to an article contained in the July and October numbers of the British and Foreign Medical Review for 1841. This article contains a pretty full exposition of the subject under consideration, and abating some mere smartnesses in dts criticisms of Christison, Ger- hard, Lombard, and Staberoh, it is written in a good spirit, as well as with fairness and ability. Its noble tribute to Louis has already been noticed. The writer of the paper, after an examination of all the accessible and valid evidence in the case, comes to the conclusion that the contagious typhus of Great Britain and the typhoid fever of France are different varieties, only, and not distinct species of disease. I have already gone over nearly all the ground occupied by this writer; I shall have occasion, therefore, to notice only two or three of his statements and opinions. The most important of these, in its connection with the diagnosis of the two diseases, is this; in his tabular comparison of typhoid fever and typhus, he sets down, so far as the abdominal lesion is concerned, as typhus, all the cases of fever occurring in Britain; thus settling beforehand the very ques- tion at issue, in relation, at least, to one of its elements. The writer admits that the two forms of fever may generally be distinguished during life, but alleges that there are cases in which such distinc- tion cannot be established. The number and authenticity of these latter, are, certainly, thus far, very limited; and if a difference of symptomatology, sufficiently marked to be generally and readily recog- nized, corresponding constantly with a most important difference in the state of certain organs, found in fatal cases, is not adejuate to constitute 19 290 TYPHUS FEVER. separate diseases, it is not easy to see in what radical nosological distinc- tions are to be found. In order to account for the great differences in the appearances of the eruptions in the two diseases, the reviewer suggests the hypothesis, certainly improbable and gratuitous enough, that the lesions of the skin and of the intestine may be supplementary of each other; a most facile method, assuredly, of disposing of a difficulty. Such is the history, as full and fair as I have been able to make it, of the recent investigations in regard to the relations between typhoid and typhus fevers. Excepting those of M. Landouzy, it seems to me that they all go to show that the two diseases are radically and essentially dissimilar. I have no wish, whatever, to make out a case in this matter. I would avoid, scrupulously, any- thing like special pleading. The truth, as Louis's motto from Rousseau says, is in the things, in the facts and their relations, not in my mind, which attempts to judge and to interpret them. I am anxious only that this truth, be it what it may, should be ascer- tained. That this has been done, absolutely and definitively, I do not pretend. That typhoid and typhus fevers are, clearly and un- equivocally, fundamentally distinct diseases, may not have been positively demonstrated. I admit, that the paper of M. Landouzy throws some doubt upon the question. But, as has been remarked before, whether the two diseases be or be not specifically and nosologically unlike each other, it is equally important that the wide differences which confessedly do exist between them should be pointed out, and their real relations established. This I have endeavored, so far as the pre- sent state of our knowledge could enable me, faithfully and truly to do. In regard to the identity of the former camp and jail fevers of the European continent, either with typhoid fever or with typhus, it is not possible to come to a positive conclusion. Louis thinks that they were typhoid, others think that they were typhus. It is probable, as I have already said, that both forms of fever may have prevailed. At any rate, the descriptions given of them are gene- rally so imperfect, that it is wholly impossible now to decide this question with any degree of certainty. It is quite as well, perhaps, not to attempt its solution at all. A friendly critic, in an American medical journal, expresses some surprise at the opinions contained in the above paragraph. He thinks there can be no doubt that the continental camp and jail fevers were true typhus, differing essentially from typhoid fever. Since the publication of my first edition, I have read carefully the DIAGNOSIS. — HISTORICAL. 291 prize memoir of Gaultier de Claubry, upon this question, and I heard a part of the very full and animated discussions, of which it has recently been the subject in the Royal Academy of Medicine, at Paris. These investigations have fully confirmed me in the soundness of the foregoing conclusions. It is impossible to read the detailed and elaborate work of M. Gaultier de Claubry, without being convinced that many of the epidemics prevailing in the armies and prisons throughout various portions of the Continent, from 1804 to 1814, corresponded in all respects to typhoid fever, while in other instances the disease was true Irish typhus. In my Essay on the Philosophy of Medical Science, I have en- deavored to ascertain and to point out the true principles of nosolo- gical diagnosis; I have attempted to lay down the rules by which w« ought to be governed in deciding upon the individuality of any given disease. I do not propose, here, to enter again upon the discussion of this subject; I wish merely to say that the elements which typhoid and typhus fever possess in common are neither more numerous nor more striking than those which are possessed in common by many other diseases admitted to be essentially dis- similar from each other. Would not smallpox be constantly con- founded with typhus, if neither of these diseases was marked by any distinctive cutaneous eruption ? In a note to the chapter in my essay, just referred to, I have said: "Let me here add that this question of the essential likeness or unlikeness of these two diseases —typhus and typhoid fever—one of the most important and inter- esting questions of specific diagnosis that has ever occupied the attention of physicians—if submitted to the test of the principles which I have laid down, and fairly tried by them—cannot fail, I think, to be settled in favor of the doctrine of their fundamental dissimilarity. The two diseases will be found to approach each other very closely in the possession of those morbid processes and phenomena—I mean, general fever of the typhoidal type, certain changes in the composition and quality of the blood, and certain nervous symptoms—which are common to many diseases, and, for this reason, of but small value as diagnostic or distinctive characters; while they are separated clearly and broadly from each other, by the presence in one, and the absence from the other, of very strongly marked and constant anatomical lesions, and of groups of symptoms equally striking, constant and characteristic. Any principles of diagnosis, or any rules of reasoning, that make true typhus fever and typhoid fever essentially one specific disease, will make small- pox, and oriental plague, also, nothing but varieties or modifications 292 TYPHUS FEVER. of the same single disease. This result will be found to be abso- lutely unavoidable."1 It is now five years since the publication of the first edition of my work on fever.2 This question of the true relationship between typhus and typhoid fever still remains a matter of controversy-. It has been extensively discussed, both in England and France, and the opinion of the profession is still divided. I have watched this discussion closely and dispassionately, and I have seen nothing to induce me in any degree to modify the judgment which I had formed and expressed; unless, indeed, it be in withdrawing alto- gether the slight doubt or qualification with which it was accom- panied. The more I have studied the subject, and the more I have reflected upon it, the more thoroughly have I been convinced that the objections to thev opposite doctrine are conclusive and insuper- able, and I cannot doubt that such will be the final verdict of science in the issue before us. l' In connection with this subject, I have the pleasure of publishing the following interesting letter from Dr. William Power, of Balti- more, dated September 4, 1847. "The questions you ask have interested me very deeply; and this summer for the first time I have had ample opportunity to fix definitely my own opinions. What I write you now resumes the opinions also of Drs. Chew and T. Buckler, who saw the disease throughout its whole visitation in this city; nor do I know of one gentleman who had any opportu- nity of studying it here who differs from us. "We have had for the last fourteen months an epidemic of ty- phoid fever in Baltimore. The wards of the almshouse and infir- mary have constantly contained a large number of cases of this dis- ease, presenting nothing remarkable, save that the cases had, as a general rule, more of the adynamic type than in former years, and required and bore more stimulation. Early in May, two vessels arrived bringing Irish emigrants; one from Liverpool, the other from the South of Ireland. Other vessels succeeded these; so that upwards of two hundred cases were treated at the infirmary, and upwards of eighty at the almshouse. These cases were typhus, so exactly corresponding with Gerhard's description of the Philadel- phia epidemic of 1836, that I am constrained to say, I know of no 1 Essay, etc., pp. 140-141. 2 [The apparent anachronism here, and also that on page 296, result from the manner in which Dr. Bartlett preferred to post up this account from four years to live years in successive editions.] DIAGNOSIS.—HISTORICAL. 293 better portraiture of any disease than that which he has given us of typhus fever. I made or assisted at twenty-six post-mortem ex- aminations ; in not one did I see any trace of the peculiar lesion. In nine of those who died, having loose bowels during life, we found either the lesions of dysentery or of diffused muco-enteritis; no mesenteric alteration in any case. The parenchymatous organs and mesenteric vessels were congested with a dark fluid blood; and the condition of the spleen, bronchial mucous membrane, lungs, and brain resembled what we find in congestive remittent or ty- phoid cases. The stomach was uniformly more altered, and pre- sented deeper traces of inflammation than in typhoid fever. We had fourteen autopsies of typhoid fever during the same period, and it thrice occurred that we had the bodies opened side by side for the sake of comparison made at the time. " The mode of access, facies, march, eruption, symptoms, treat- ment, and convalescence are all different between the two diseases. We had both forms of fever at once under observation; German emigrants and domestic patients with typhoid, and Irish and English with typhus. Nay, more than this, four of the seamen of the Rio Grande, a vessel which brought seventy cases of typhus, had true typhoid fever, and several of the steerage passengers had the same disease. There was no mistake in the diagnosis in any case where the issue was fatal, as proved by the autopsy; and in the successful cases, the difference of eruption, diarrhoea, meteor- ism ; the peculiar nervous symptoms; the greater emaciation ; bed sores, which were so rare in the worst cases of typhus, that I saw but two, made the diagnosis simple to every clever student. The effect of a full stimulant treatment made the difference still more obvious. In short, we have here in Baltimore, no doubt, but the fullest conviction of the non-identity of the two diseases. " Furthermore, there is the undoubted contagiousness of typhus. Two of the Sisters of Charity at the infirmary—one of whom died —and three out of five resident students took the disease. Four of the hospital assistants, and several of the inmates of the alms- house were attacked; many cases occurred also in the city, where direct intercourse could always be traced and proved. " Here is another interesting order of facts. A German had typhoid fever, and was eighty days in bed under Dr. Buckler; he recovered, and was acting as hospital assistant; in tending the sick emigrants, he was seized with typhus. Two years ago Dr. Berry- man had at the almshouse a severe attack of typhoid fever. He was 294 TYPHUS FEVER. appointed resident physician at the new quarantine hospital, where all these cases are now sent. He took the fever and died last week ;—the most promising young man I have ever known, and whose loss has filled us all with grief. Again, one of the emigrants who came near dying in May last, with typhus, is at this very moment at the point of death, with typhoid fever. " There is as much difference in my mind between the two dis- eases, as there is between measles and scarlatina. Huxham has beautifully drawn the distinction between the slow nervous and malignant fevers; excepting the new lights we have in pathology, we can add but little to what he has said. Corrigan, in Dublin, sees the difference between what he calls enteric and typhus fevers. Dr. Wood, in his late work, appears to me to have handled this subject better than any of our systematic writers. I perfectly agree with him in his conclusions. It appears to me that we are better placed than either the French or English to study this question without prejudice, and more likely to arrive at the truth." [Dr. Flint, referring to this letter of Dr. Power's, says that the connection of observations of this kind with the question of the identity of typhus and typhoid fever, must be sufficiently apparent, but adds that the facts are too few to authorize the induction of a general law. Dr. Bartlett would have admitted this cheerfully. It will probably be a long time before facts bearing on this point will be accumulated in sufficient numbers to enable us to determine whether either of these fevers has the power to protect from the invasion of the other; or rather, not whether such protection be absolute and complete, but whether, for example, the typhoid fever will defend the system against an attack of typhus, to the same extent as the typhus itself previously undergone. These pages are full of evidence that the typhus fever may occur a second time in the same individual. The experience of New York physicians during the late epidemic is ample on this point. In repeated instances it occurred a second time in young physicians constantly attending on the sick; and, in two instances known to the editor, it occurred three times in the same person. That typhus does not recur in the great majority of cases is perhaps universally admitted, that it does recur in a small minority of cases is equally susceptible of proof; and that it should occur after typhoid fever in a similar minority will not affect the question here raised. It has been stated already that of thirty-six young physicians attached to Bellevue. Hospital during the heaviest of the late visitation of DIAGNOSIS. — HISTORICAL. 295 typhus, thirty-one had the fever there, or at some other hospital before coming there; and that of the five who escaped, three had had typhoid fever in the country a year or more before entering the hospital. The editor assisted in the treatment of at least one- half of twenty-seven who were attacked in the hospital; it was his habit always to inquire whether the patient had had any form of continued fever previously; and in all but one case the answer was that they had not. The exceptional case was in a young gentleman from Philadelphia, who had, a few months before entering the hospital, the miasmatic remittent fever, contracted in a well-known malarious district of his own state. It is pertinent to add that, from November, 1847, to the spring of 1848, the average number of typhus patients in the hospital was about five hundred, and that the care of these fell equally on four attending physicians. Two of these gentlemen had had typhoid fever years before; the other two had not had any form of continued fever. The two latter con- tracted the typhus, and the two former escaped. The exposure in these cases was, as far as is known, equal; and the only circumstance that it is at all important to add, is that the two who contracted the fever were younger than the two who escaped by a mean average of about ten years, though it is believed that the eldest of the four had scarcely passed forty years of age. These facts de- serve to stand side by side with those communicated by the talented and lamented Power, since together they show the im- portance of extended observation and cautious reasoning, while we seek to deduce the laws of diseased action.] I have placed in the following tabular summary, as a matter of convenient reference, the leading points of distinction between typhus and typhoid fever, side by side. Typhoid Fever. 1. Mode of Access.—More generally gradual, insidious, and creeping, than in typhus. 2. Heat of Skin. 3. Mind.—Delirium and other cere- bral symptoms coming on, and increas- ing gradually, after the first week, more generally than in typhus. 4. Boivels.—Diarrhoea, with thin liquid discharges, very common. Gurgling on Typhus Fever. 1. More frequently sudden and for- mal than in typhoid fever. 2. More frequently burning and pun- gent, during the early stages, than in typhoid fever. Fuliginous flush of face more common than in typhoid fever. 3. Cerebral symptoms, especially dul- ness and stupor, more strongly marked at the onset of the disease than in ty- phoid fever. 4. Spontaneous diarrhoea rare. Dis- charges from bowels not liquid. No 296 TYPHUS FEVER. Typhoid Fever. pressure over region of csecum. Me- teoric distension or rigidity of abdomen. Griping pains common. 5. Emaciation.—More common and greater than in typhus. 6. Epistaxis.—More common than in typhus. 7. Hemorrhagefrom the Bowels.—Quite common. 8. Cutaneous Eruptions. — Bright, scanty, rose-colored eruption ; slightly elevated above surrounding skin; rea- dily disappearing on pressure ; mostly confined to skin of chest and abdomen. 9. Eschars.—More common than in typhus. 10. Lesions.—Peyer's glands always altered ; generally ulcerated. Mesente- ric glands reddened, enlarged, and soft- ened. Spleen more frequently enlarged and softened than in typhus. Ulcera- tion of the pharynx and oesophagus more common than in typhus. Large intes- tines more frequently distended with gas than in typhus. 11. Causes.—Confined to no geogra- phical localities. Prevailing constantly and extensively amongst scattered, cleanly, well fed, and well sheltered rural populations. Occasionally and moderately contagious. More frequent- ly sporadic than typhus. More gene- rally limited to the early and middle period of life than typhus. 12. Duration.—Average duration somewhat greater than typhus. Pro- longed to the fortieth or fiftieth day much more frequently. 13. Effects of Remedies.—Bearing de- pletion better than typhus. Typhus Fever. gurgling on pressure over region of csecum. Meteoric distension very rare, Griping pains rare. 5. 7. Very rare. Does it ever occur ? 8. In many cases, especially grave ones, more abundant petechial eruption; not disappearing on pressure ;—in other cases, no eruption. 9. 10. Peyer's glands, and mesenteric glands healthy. Blood more generally dark and grumous. Dark engorgement of vessels and sinuses of brain more Cian- stant than in typhoid fever. 11. Limited to certain geographical localities. Generally confined to crowd- ed, filthy, and poorly ventilated habita- tions. Under such circumstances emi- nently contagious. Occurring much more frequently after the thirty-fifth year of life than typhoid fever. 12. Terminating fatally, or in recover^ within the first ten days much more fre- quently than typhoid fever. 13. Requiring more active stimulation than typhoid fever. Another period of between four and five years1 has elapsed since the publication, in my second edition, of the foregoing summary. I have preferred to let it stand as it was then written, making such additions to it here as the materials accumulated during this period have furnished. I do not know that this question of the true relation between 1 [At the date of the third ed.] DIAGNOSIS.—HISTORICAL. 297 the two great forms of continued fever is any nearer to a positive and final solution than it was five years ago. Medical opinion is still divided, and somewhat singularly so, in regard to it. In the city of New York, where both forms of the disease—but more especially the typhus—have been extensively and carefully studied for several years by sound pathologists, and accomplished and thoroughly reliable observers, the opinion is nearly, if not quite unanimousfthat they axe forms or varieties merely of a single disease. This is the opinion of my colleagues, Dr. Smith and Dr. Clark. I regret that the observations upon which this opinion rests have not been recorded in such form and manner as to render them any further available in the settlement of this question. In Boston, Philadelphia, and Baltimore, the general opinion of the profession is the other way. As to the state of medical opinion in Great Britain, I hardly feel myself authorized to speak; I do not know that it is widely different from what it was five years ago. Still, it is clear enough, I think, that this opinion is undergoing a change; at least, it is true, I suppose, that recent investigations have created doubts as to the soundness of the commonly received doctrine which had not existed before. The question of the identity or the non-identy of typhoid and typhus fever is more generally regarded than it was, as still an open question—to be settled by extensive, various, care- ful, accurate observation. I shall close this discussion with the words of an English physi- cian, Dr. Jenner. This question has never been so carefully, laboriously, minutely, and philosophically investigated before as it has been by Dr. Jenner. My opinion of the value of these investiga- tions has already been sufficiently attested; I only wish to add, that apart from this value consisting in their results, and the new light they have shed upon an obscure and difficult subject, they constitute one of the finest examples in medical history of a true and sound philosophy, and show their author to be a worthy inheritor of the illustrious name he bears. It will be borne in mind that the following summary and analysis apply to forty-three fatal cases of typhus, and twenty-three fatal cases of typhoid fever. "1. Age.—Typhoid fever was limited, in the cases here considered, to persons under forty years of age; nearly one-third of the forty- three cases of typhus were more than fifty years of age. " 2. Mode of Attack.—As a general rule, the attack of typhoid fever commenced more insidiously than that of typhus fever. This 298 TYPHUS FEVER. observation, like all others in this paper, applies, of course, only to fatal cases. "3. Duration.—The average duration of the fatal cases of typhoid fever was twenty-two days. Of the fatal cases of typhus fever fourteen days. Half the cases of typhoid fever survived the twentieth day of disease. Not a single case of typhus fever survived the twentieth day of disease. " 4. Eruption.—The difference in the appearance of the eruption in the two diseases was as great as it well could be, considering that both were of a reddish hue. "5. Miliary Vesicles, or Sudamina.—These vesicles were present in an equal proportion of the cases of both diseases under forty years of age. But in no case of typhus fever, more than forty years of age, wrere they detected. " Subsequent experience leads me to believe that miliary vesicles are rarely seen on individuals more than forty years of age; and very rarely, indeed, if ever, on patients more than fifty years old. I have during the last year, i. e., since my attention was directed to this point, seen these bodies on no one of the many patients more than fifty years of age laboring under various diseases that have come under my observation. " 6. Expression, Manner, Hue of Face, &c.—As the rule in the cases of typhoid fever here analyzed, the expression was much less indica- tive of prostration, and more anxious than in the cases of typhus fever. In the former disease the complexion was tolerably clear, and the flush, when present, was of brightish pink color, limited to one or both cheeks, and often distinctly circumscribed. In typhus fever, on the contrary, the complexion was thick and muddy, the flush of the face uniform and of a dusky red color. " 7. Headache was a constant symptom in all the cases of typhoid and typhus fever; but it disappeared by about the tenth or twelfth day in the latter, and not till the termination of the second or middle of the third week in the former. " 8. Delirium commenced in three only of ten cases of typhoid fever before the fourteenth day; while it begun in fourteen out of fifteen cases of typhus fever before the fourteenth day. As a rule, the delirium was decidedly more active in typhoid than in typhus fever. " 9. Somnolence.—In eight out of nine cases of typhoid fever, som- nolence commenced after the fourteenth day of disease. In seven- teen out of eighteen cases of typhus, before the termination of the second week. DIAGNOSIS. — HISTORICAL. 299 " 10. Coma vigil.—One-fifth of the cases of typhus fever experienced coma vigil; not a single case of typhoid fever experienced that condition. " Spasmodic movements were nearly equally frequent in the two diseases. "11. Retention of urine, and involuntary discharge of urine and stools, occurred with equal frequency in the two diseases, but at a much earlier date in typhus than in typhoid fever. "12. Loss of Muscular Power.—Little more than a fourth of the patients attacked with typhoid fever kept their bed entirely before the seventh day of disease. All the patients affected with typhus, whose cases here considered, took altogether to their beds before the seventh day of disease. The prostration was rarely so extreme in the cases of typhoid fever as in those of typhus. Extreme prostra- tion, when it did occur in typhoid fever, was not observed till from the fourteenth to the thirtieth day, while in a large majority of the cases of typhus fever it was marked between the ninth and twelfth days of disease. " 13. Epistaxis was present in five of fifteen cases of typhoid fever —in not one of twenty-three cases of typhus fever. Hearing was equally and similarly affected in the two diseases. "14. Eyes.—The conjunctivae were very much more constantly and intensely injected in the cases of typhus than in those of typhoid fever; the pupils were absolutely larger than natural in a majority of the cases of the latter disease, while they were abnor- mally contracted in a large majority of the cases of the former affection. " 15. Tongue.—Although individual cases of the two diseases may have closely resembled each other in the appearance of the tongue, yet, taking the whole of either group of cases, this organ presented a singularly different aspect in the one from what it did in the other. It was much more frequently moist throughout the disease in typhoid than in typhus fever. When dry it was often red, glazed, and fissured, in the former; rarely so in the latter. Again, in typhoid fever, when the tongue was brown, its hue was much less deep—it was of a yellowish, instead of a blackish, brown. The small dry tongue, with red tip and edges, smooth, pale brownish- yellow fur, fissured—the surface seen between the fissures being deep red—may be considered differentially as a diagnostic sign of typhoid fever. One only of twenty patients affected with typhoid 300 TYPHUS FEVER. fever, but eight of forty patients laboring under typhus fever, were unable to protrude the tongue when bidden.1 " 16. Intestinal hemorrhage occurred in one-third of the patients affected with typhoid fever—in none of those suffering from typhus fever. The other abdominal symptoms and signs need no recapitu- lation. "17. Pulse.—The frequency of the pulse fluctuated much more from day to day in the cases of typhoid than in those of typhus fever. " 18. Cough and Physical Chest Signs.—Sonorous rale was very much more frequently present in the cases of typhoid than in those of typhus fever—/. e., it was present in eleven out of twelve cases of the former, and in seven only of twenty-one cases of the latter. Dulness of the most depending part of the chest, from intense congestion of the lung, was observed in nine cases of typhus fever —in no case of typhoid fever. " 19. Erysipelas occurred in seven of the twenty-thuee—{. e., in nearly a third of the cases of typhoid; in two only of the forty- three cases of typhus fever—i. e., in less than one-twentieth of them. " 20. Cadaveric rigidity ceased much more quickly in the subjects dead from typhus fever than from typhoid fever. " 21. Discoloration of the walls of the abdomen, and of the skin cover- ing the larger veins, was much more frequently present in those dead from typhus than typhoid fever. " 22. Emaciation had made greater progress in the typhoid than in the typhus subjects. " 23. Spots.—The spots observed during the progress of the cases of typhus fever continued after death; no trace of the spots visible during life could be detected after death from typhoid fever. " 24. Head.—After typhoid fever, the pia mater and arachnoid separated from the convolutions with abnormal facility in one only of nine cases examined with reference to this point. The vessels of the pia mater were abnormally filled with blood in one-third of the cases, but intensely congested in one of fifteen cases ; the cere- bral substance was congested in one-seventh of the cases. After typhus fever, the pia mater and arachnoid separated with abnormal facility in nine of eleven cases, of which notes on the poiut were made. The vessels of the pia mater were congested in nearly half, 1 This clearly indicates the difference in the amount of prostration in the two diseases. DIAGNOSIS. — HISTORICAL. 301 and intensely congested in one-fifth of the whole of the cases, while the cerebral substance itself was abnormally congested in half. " Hemorrhage into the cavity of the arachnoid, which was not found in a single case of typhoid fever, had occurred before death in one- eighth of the cases of typhus fever. The amount of serosity found within the cranial cavity was decidedly greater after typhus than typhoid fever. " 25. Pharynx.—After typhoid fever, this organ was found ulcer- ated in one-third of the cases. After typhus fever, ulceration of the pharynx was not detected in a single case. "26. Larynx.—Ulceration of the larynx was found in one of fifteen subjects dead from typhoid fever—in one of twenty-six from typhus fever. " 27. (Esophagus.—After typhoid fever, ulcerated in one of fifteen cases in which it was examined. After typhus fever, the oesophagus was free from ulceration in all the twenty-four cases in which it was examined. The epithelium separated from the oesophagus spontaneously at an earlier period after death from the latter than the former disease. " 28. Stomach.—In none of the fifteen cases examined after death from typhoid fever was the mucous membrane of the stomach softened throughout its whole extent; in no case did softening of the cardiac extremity approach perforation. In four of thirty-seven cases of typhus fever, the whole mucous membrane of the stomach was softened; and in four others there was such extreme softening of the whole of the coats of the great cul-de-sac that they were per- forated by the slightest violence. " 29. Small Intestine and Mesenteric Glands.—The presence or absence of lesion of these organs was the ground on which the cases of typhoid and typhus fever here analyzed were divided from each other; consequently, they were invariably diseased in the one and normal in the other. "30. Large Intestines.—After death from typhoid fever, the mucous membrane of the large intestines was found ulcerated in rather more than a third of twenty cases. In no instance after death from typhus fever. " Peritoneum.—As peritonitis was in typhoid fever secondary to and dependent on the entero-mesenteric disease, it may here be excluded from consideration. " 31. Spleen.—This organ was enlarged in all the cases of typhoid fever—softened in one-third of the cases only. Before the age of 302 TYPHUS FEVER. fifty, it was as large after typhus as typhoid fever; after that age, it was decidedly smaller in the former than in the latter affection. After the age of fifty, it was as soft in typhus as in typhoid fever; before that age, it was less frequently softened. "32. Gall-Bladder.—There was ulceration of the lining membrane of the gall-bladder in one of fourteen cases of typhoid fever; in none of thirty-one cases of typhus fever. In the latter disease the bile was much thicker, and of a darker green color, than in the former.1 " 33. Liver, Pancreas, Kidneys.—These organs were more flabby in the cases of typhus than in those of typhoid fever. " Urinary Bladder.—This viscus was ulcerated in one of the cases of typhoid fever—in none of the cases of typhus fever. "34. Pericardium.—This cavity contained a small amount of yel- lowish -transparent serosity, in all the cases of typhoid fever ex- amined. The contained serosity was red, from transudation of a solution of haematosin, in five of thirty-one cases of typhus fever. " 35. Heart.—The muscular tissue of this organ was much more frequently and decidedly flabby, and its lining membrane was much more frequently and deeply stained of a dark red color, in the cases of typhus fever than in those of typhoid fever. "36. Lungs.—Granular and non-granular lobular consolidation were very frequent in the subjects dead from typhoid fever—rare in those dead from typhus fever. The reverse was the fact with reference to consolidation from congestion of the most depending part of the lungs. " 37. Pleura.—Recent lymph or turbid serosity was found in six of fifteen cases of typhoid fever—i. e., between half and one-third, or in the proportion of forty per cent. The same lesions, but much less in amount, were found in two only of thirty-six cases of typhus fever—i. e., one-sixteenth, or in the proportion of 5.5 per cent. " The particulars here briefly recapitulated, and still more those fully detailed in the foregoing papers, appear to me to prove indis- putably that the symptoms, causes, duration, anatomico-pathologi- cal lesions, and the tendency to cadaveric changes, are different in typhoid fever to what they are in typhus fever. " To account for the differences in symptoms which exist in con- 1 The condition of the bile, as found after death in these two diseases, is worthy of more careful investigation. The difference in appearance is, in a large majority of cases, well marked. DIAGNOSIS. — HISTORICAL. 303 tinued fever, with and without entero-mesenteric disease, the two following assertions have been put forward: 1. That typhoid fever is merely typhus fever complicated with lesion of a particular organ ; and therefore it is to be expected that certain symptoms referable to, and dependent on, that lesion will be present, and so far modify the symptoms of the disease. " If the symptoms and signs referable to the intestinal disease as a cause—li. e., the condition of the tongue, the diarrhoea, increased resonance, and fulness of the abdomen, gurgling in the iliac fossa, pain and tenderness in the same region, or even the daily fluctua- tions in frequency of the pulse—were the only symptoms by which typhoid fever was separated from typhus fever, although the idea might cross the mind that they were two diseases, no sufficient ground for their separation would be present, unless the specific cause of the one was proved to be different from that of the other. But putting aside the symptoms strictly referable to the abdominal lesion, the general symptoms of the two diseases, in the cases here analyzed, differed widely; such differences having no apparent con- nection with the local affection, but being probably like it, depend- ent on some common cause acting on the whole system simultane- ously. Thus the remarkable differences in the kind, not simple amount, of the rash in the two diseases, and the tendency to local inflammation, to erysipelas, and to ulceration, observed in the cases of typhoid fever here analyzed, cannot, with any show of reason, be considered to have been dependent on the diseases of Peyer's patches—i. e., in the same way as the abdominal signs undoubtedly were; and it is to be carefully borne in mind that the external, the hygienic conditions of either group of cases, were precisely the same in all respects. They occupied the same wards, partook of the same diet, slept in the same beds, under the same amount of clothing, and had the same physician to attend them, and the same nurses to wait on them. " Moreover, of the symptoms common to the two, the headache continued longer, and the delirium and somnolence came on, as we have seen, much later, in typhoid than in typhus fever; and the delirium, too, possessed a more active character. These differences, also, cannot be explained by the presence of intestinal disease in the former, and its absence in the latter affection. " The short comparative duration of the cases of typhus fever, here considered, is another remarkable point of difference, totally inexplicable by the hypothesis, that typhoid fever is typhus fever 304 TYPHUS FEVER. with intestinal ulceration. Had the cases eventually recovered, it might have been said, that the intestinal lesion prolonged the dis- ease in the cases of typhoid fever; but that all the fatal cases of fever, with a local lesion of so severe a nature as that recorded to have been present in the cases of typhoid fever, should have had a much longer course than all those other fatal cases of fever in which no organic change of structure could be detected after death, appears to me inexplicable, on the supposition that the former is simply the latter disease, with this serious lesion superadded. Let me repeat, by this hypothesis we are asked to imagine that death is retarded in fever by extensive ulceration of the small intestines, and enlargement, softening, and even suppuration of the mesenteric glands. Surely it behoves the supporters of such a statement to bring forward cogent proofs of the identity of the specific cause of the two affections ere they ask us to admit its truth. " The same mode of reasoning appears to me equally conclusive, when we consider the comparatively early period of the disease at which the patients, suffering from typhus fever, lost the.ability to make muscular exertion. For, to suppose that the presence of ab- dominal complication in, fever invariably prevented the extremely early supervention of debility, is, a priori, still more absurd than to suppose such lesions to have retarded death. How, again, are we to explain, if we regard typhoid as typhus with abdominal com- plication, the differences observed in the ages of the patients, and in their general manner; the muddy hue of the skin, and uniform flush of the face, the injected conjunctivae, and contracted pupils in typhus fever; and the comparatively clear complexion, the pink flush limited to the cheeks, the pale conjunctivae and the large pupils, in typhoid fever ? " In what way, also, are we to account for the differences observed in the physical breath-signs, on the supposition that the one is merely the other, with abdominal complication? Death itself, moreover, adds new proof to the non-identity of the general affec- tion in the two diseases. The comparatively rapid loss of muscular rigidity, the discoloration of the surface, the more flabby condition of the heart, liver, and kidneys, the extreme softening of the stomach, and the early separation of the epithelium, after typhus fever, are all cadaveric changes, by which death makes us cogniz- ant of a condition of the system at large, which condition must have existed anterior to the cessation of life from that disease; and DIAGNOSIS. — HISTORICAL. 305 which condition could not have been present in the cases of typhoid fever, or death would have made it manifest. "I need not here more than advert to the differences observed in the lesions which death simply enabled us to lay bare. The almost constantly congested brain and membranes in typhus fever; the frequent presence of the signs of pre-existing serous inflamma- tion in typhoid fever; the difference in the nature of the pulmo- nary lesions in the two—are inexplicable on the supposition that the one disease is the same as the other, excepting so far as con- cerns the abdominal affection. Thus tried by facts—i. e., by re- corded symptoms and lesions—the assertion that typhoid fever is merely typhus fever with abdominal complication, is completely refuted. " 2. But another mode of explaining the differences which exist between the two diseases has been given—i. e., that the differences observed depend on variations in the epidemic constitution. These cases afford a complete answer to this assertion. For the majority of the cases here analyzed of both diseases were observed during the same epidemic constitution. I may remark, that during three years' attentive watching of nearly all the cases admitted into the London Fever Hospital, in which time there have been epidemics of relapsing fever, typhus fever, and cholera—and consequently, according to those whose opinions I am here examining, as many changes in epidemic constitution—I have seen no alteration in the general or particular symptoms of either typhus or typhoid fevers, or the lesions observed after death from either—i. e., from Novem- ber, 1846, to November, 1849. The cases of typhoid fever—which disease is rarely absent for a fortnight from the wards of the hospi- tal—preserved their symptoms unchanged, and presented the same lesions, whatever the epidemic constitution that prevailed; the same is true of typhus fever. Cases of the latter disease are also rarely absent from the wards of the same institution. It is there common to see patients occupying beds side by side, and presenting respect- ively the well-marked characters of either disease. But to return to the. particular cases here analyzed. Allowing to epidemic con- stitution all the power of modifying disease claimed for it by certain writers, it must be granted that, whatever influence this epidemic constitution exercised over the group of cases without intestinal lesion, it ought to have exercised over the group of cases with intestinal lesion, because the cases of the two groups were scattered 20 306 TYPHUS FEVER. indiscriminately over the space of two years only. If, I repeat, the two affections were really the same disease, then the same epi- demic constitution ought to have impressed on both the same general features, implanted in both the same local lesions, and given to both the same tendency to cadaveric change, and this, allowing for all the modifying influence which the accidental presence of the abdominal lesion in the one and its absence from the other group might have occasioned. The analysis of every symptom and every lesion shows that the two affections were not thus assimilated by the prevalence of any particular epidemic constitution. But if this epidemic constitution, by any stretch of the imagination, could be supposed to change from week to week, to cause the case attacked to-day to have typhus fever, the individual who takes the disease to-morrow to have typhoid fever, still, it could not account for the fact—as well established as any fact in medicine—that typhoid fever rarely, if ever, affects persons more than fifty years of age; while age exerts little influence in determining the occurrence of typhus fever. " Thus, then, the assertion that typhoid fever is merely typhus fever modified by the prevailing epidemic constitution, is as irre- concilable with facts, as that the former disease is simply the latter with abdominal complication. "To conclude. At the commencement of this analysis, I pro- posed to examine whether typhoid fever and typhus fever differed from each other in the same way as smallpox and scarlet fever differed from each other; and for the purpose of comparison, I laid down certain grounds, as those on which we founded our belief in the non-identity of the two last-named diseases. Those grounds were:— "1. In the vast majority of cases, the general symptoms differ; i. e., of smallpox and scarlet fever. (This holds equally true with respect to the general symptoms of typhoid and typhus fever.) " 2. The eruptions, the diagnostic characters, if present, are never identical; i. e., in smallpox and scarlet fever. (The particulars detailed in the foregoing papers, prove that this is as true of the eruptions of typhoid and typhus fever, as of those of smallpox and scarlet fever.) "3. The anatomical character of smallpox is never seen in scarlet fever. (Just in the same way the anatomical character of typhoid fever; i. e., lesions of Peyer's patches and the mesenteric glands, is never seen in typhus fever.) DIAGNOSIS.—HISTORICAL. 307 "4. Both, i. e., smallpox and scarlet fever, being contagious diseases, the one by no combination of individual peculiarities, atmospheric variations, epidemic constitutions, or hygienic condi- tions, can give rise to the other. (I have here not attempted to determine how far this holds true with respect to typhoid and typhus fever; but I have considered it in a paper read before the Medico-Chirurgical Society of London, December, 1849, the contents of which I may anticipate so far as to state, that to my mind the origin of the two diseases from distinct specific causes is as clearly proved as that scarlet fever and smallpox arise from distinct specific causes.) " 5. The epidemic constitution favorable to the origin, spread, or peculiarity in form or severity of either, i. e., smallpox and scarlet fever, has no influence over the other, excepting that which it exerts over disease in general. (The facts detailed in these papers, prove that this holds as true of typhoid and typhus fevers, as of smallpox and scarlet fever.) "If, then, the above are the grounds—and, after mature delibera- tion, I am able to assign no others, for the separation of smallpox from scarlet fever, I think it is indisputably proved, that typhoid fever and typhus fever are equally distinct diseases; not mere varieties of each other, but specifically distinct; specific distinction being shown in typhoid and typhus fevers, as in smallpox and scarlet fever, by the difference of their symptoms, course, duration, lesions, and cause.111 In further proof of the non-identity of typhoid and typhus fever, Dr. Jenner has published some very striking facts in relation to their local origin. Between May, 1847, and November, 1849, there were sixty-eight instances, in which from two to five persons with typhoid or typhus fever were received into the London Fever Hos- pital from the same locality—generally from the same house or room. With one or two exceptions, there was no instance in which cases of the two diseases came from the same locality—the same house or room. In this connection it is impossible not to be struck with the great fact—so extraordinary, and so utterly inexplicable, on the hypothe- sis that typhoid and typhus fever are only forms or varieties of a single disease, depending upon and originating from the same spe- cific cause—that, for the long period of the last thirty or forty years, in ' Jenner on the Identity or the Non-Identity of Typhoid and Typhus Fevers. 308 TYPHUS FEVER. the city of Paris and throughout New England, where this subject has been most carefully studied, only one of these forms of disease should have prevailed, to the entire and absolute exclusion of the other. I may remark here, that it is very important for us to bear in mind that great difficulties of diagnosis, in • individual cases, are in no way incompatible with the existence of essentially and widely dif- ferent diseases. Morbid affections, very unlike each other, and in most cases easily distinguishable, may, under certain circumstances, have many things in common; and their symptoms may be so mixed up with each other as to render, in the imperfect state of our know- ledge, a positive diagnosis very difficult or impossible; and this without throwing any doubt upon the general question of the radi- cal dissimilarity between the diseases themselves. [Now again, in 1856, for the fourth time, it becomes necessary to say that " the true relationship between typhus and typhoid fever still remains a matter of controversy." The four years which have elapsed, since the issue of the last edition, have added two or three names of wreight and authority to each side of the ques- tion. First in the order of time among these is Dr. Austin Flint, of Buffalo, N. Y., who published in 1852, soon after the last edition of this work appeared, his Clinical Reports on Continued Fever, in which he analyzes seventy-three cases of typhoid fever, and sixty-five of typhus, and gives some account of twenty-six cases which he calls " cases of doubtful type." He is inclined to the opinion that typhus and typhoid fevers are distinct diseases. Yet he thinks that the argument is not yet conclusive, and leaves the impression on the mind of his reader that the lines of distinction here drawn are more marked than in the cases which fell under his observa- tion. Dr. Samuel Wilks has published a report of all the cases of fever which occurred in Guy's Hospital, London, during the latter half of the year 1853, and the whole of the year 1854—in all, two hun- dred and forty nine; of which seventy-three were febricula, or ephemeral fever; fifty-five, typhus; one hundred and sixteen, typhoid fever; and five, fever and cholera. " Dr. Wilks' observa- tions," says the B. and F. Med.-Chir. Rev., "bear out, in a most unequivocal manner, Dr. Jenner's1 distinctions of continued fever 1 [However well Dr. Jenner may have written on this subject, it will be remem- bered that the idea of the distinction did not originate with him.] DIAGNOSIS.—HISTORICAL. 309 into the " typhus and typhoid forms." Those papers have appeared in Guy's Hospital Reports for 1855, and the preceding volume. Dr. Thomas B. Peacock, of St. Thomas' Hospital, has just pub- lished his conviction, that the two forms of fever are distinct diseases. His papers will be referred to in the chapter on Biblio- graphy. On the other hand, Dr. Geo. H. Barlow, also physician to Guy's Hospital, in his Manual of the Practice of Medicine, which has recently appeared, rejects the distinction which Dr. Jenner has labored to support. He says: " The frequency with which one form of the disease is found to occur side by side with the other in many epidemics, though it may not have done so in all, and the almost imperceptible differences by which they appear to be distinguished in some instances, seem at present to preclude the belief that they are specifically different." (P. 626.) Dr. Stokes, of Dublin, in his Lectures, published in 1854 {Med. Times and Gazette), uses the following very decided language: " Here is one of the most important and interesting facts connected with the whole subject, that the same exciting agency, at least as far as we can see it, is capable of producing different kinds of fever in different persons." " Here is another of the great facts which show the impropriety of attempting to draw lines of distinction between what are termed typhus fevers, and typhoid fevers." (March No. 1854, p. 230.) Elsewhere in the same lectures he refers to " the distinctive lesion" of typhoid fever in the following terms: " Al- though it is true, that on comparing our typhus with the French typhoid fever, this difference becomes apparent, that the existence of follicular disease of the intestine is almost the rule, and its absence the exception, in the latter affection; and in the Irish typhus this condition of the intestine is rare; yet you must bear in mind that in Ireland, and in our own time, we have had a great epidemic of what was certainly typhus fever, in which the condi- tion of the intestines accurately represented that which is found to prevail on the continent. * * * In the epidemic of the years 1826- 7 and 8, disease of the mucous glands of the intestine was so fre- quent, that its existence might be held to be the rule and its ab- sence the exception; and it is also true that intestinal ulcerations have been repeatedly observed in the maculated typhus of Ireland, their amount and frequency varying with the epidemic influence." (July 22, 1854.) Prof. Magnus Huss, of Stockholm, Sweden, has given, in his 310 TYPHUS FEVER. book entitled Statistics and Treatment of Typhus and Typhoid Fever, the only history of the fevers of Sweden that the American student is likely to become familiar with. Prof. Huss is understood " to stand at the head of the profession in Northern Europe." He has, as he states, from choice, devoted himself for twenty years to the study of these forms of fevers. His book bears the marks of great labor. He has studied three thou- sand one hundred and eighty-six cases—all that entered the Sera- phim Hospital in twelve years succeeding 1840, though he has made complete analyses of only two hundred and fifty of this num- ber. The researches of this author have led him to the opinion that the typhus and the typhoid fevers (the typhus petechialis and typhus abdominalis, as they are sometimes called), " as they appear in the countries of the North (of Europe), cannot be considered as two separate affections, but it is necessary to look upon them as modifications of form, in one and the same kind of disease." The reasons which have led him to this conclusion he gives somewhat at length. Though here it will not be necessary to follow him, as the book has now appeared in an English dress ; yet it is but fair to the reader to translate a few passages, in obedience to the pre- cept, exaudi alteram partem. He says that for the full understand- ing of the subject it is necessary " to study the historical develop- ment of affections having the character of typhus ; the connection of their changes, in an epidemic form, from the typhus attended with buboes of the Middle Ages, through the petechial typhus of a later period, to the abdominal typhus of the present time." He says that "it is a common thing at least in the north, to witness epidemics which from their beginning to the period of their greatest severity present all the characters peculiar to typhus, but which toward their termination become marked by all the peculiarities of the typhoid fever; while in the progress of the epidemic, various transitional forms become manifest, little by little." He admits that it is very easy to separate the extreme links of the chain, which bind typhus and typhoid fever together, but in taking a general and comprehensive view of the whole group, there are transitional forms which cannot be referred to either one of the varieties. The following facts seem to have had some influence on his opinion. He says: "I have had occasion to study a circumscribed epidemic. It occurred in a barrack of the military police. Of two hundred and fifty men, sixty-four fell sick in the course of six weeks. Notwithstanding these persons led the same kind of life, DIAGNOSIS. — HISTORICAL. 311 were subjected to the same etiological influences, and were all be- tween twenty and forty years of age, it occurred that the fever assumed the form of petechial typhus in a part; of abdominal typhus in a part; and in still another portion it appeared under forms which hold the middle ground between the two." He adds, " I have seen in the house of a joiner, seventeen cases of the disease in the course of fifteen days; of this number ten had the symptoms of typhus, and seven those of typhoid fever; yet the lodging and other conditions were the same for all, except age and sex." The following case Dr. Huss regards as important. " A man died with symptoms of typhus fever, so far as could be learned. A brother came with his wife to live in the lodgings of the deceased, and used his clothes without ventilating or washing them. These two, both fell sick in a short time, and were removed to the hospital, where both died. The husband had a violent delirium with abundant petechial eruption, and at the autopsy it was found that there was no lesion of the intestinal glands. The wife presented milder cere- bral symptoms, and an eruption which was almost nothing; at the opening of the body the patches of Peyer were found to be swollen and ulcerated, and the glands of the mesentery were also swollen."1 Dr. Huss attaches value to a statement of Dr. Fr. Lang, which is in substance, that a traveller arriving in a small island on the coast of Sweden, already ill of petechial typhus, died on the ninth day. It is claimed that seven persons took the disease, directly or indi- rectly, from this traveller; and that of these seven, six had typhoid, and one only typhus fever. Neither disease had occurred on the island for several years before. The value of all such statements must depend on the recognized honesty and competency of the narrator. Dr. Lang's opinion might weigh little with those who know nothing of his character and standing. Indorsed by Dr. Huss, it takes rank with the Profes- sor's own observations. It is urged in a very able review of Dr. Huss's work,2 that all these statements lack the details which are necessary to carry conviction. This is a just criticism, if they were written for the purpose of forming a part of an argument; a pur- pose which probably the author would disclaim. They are more opinions on facts, than the facts themselves, and when put into the 1 [An instance of a similar kind, when the chance of double contagion was to all appearance wholly excluded, was narrated to the editor by the late Dr. Swett, of New York. The autopsies were made by himself, and the cases treated by him.] 2 [Am. Journ. of Med. Sci., July, 1856.] 312 TYPHUS FEVER. argument, their influence will depend, in a considerable degree, on the estimation in which Dr. Huss is held for experience, judgment, and honesty. It is but fair, however, to say that they appear to have been presented with no higher aim than to show the considera- tions that influenced his own mind, when he determined to treat his immense array of cases as one disease—a determination which the profession will not cease to regret; for whatever view may be taken of the main question at issue, there are recognized differences in the symptoms and in the therapeutical requirements of the two types, which every physician desires to understand. As Dr. Bart- lett has well said: " In a practical point of view, the necessity of an accurate diagnosis is not removed by the conclusion, that as a ques- tion of scientific nosology, these two forms of fever are essentially and fundamentally alike." (P. 272.)] 313 CHAPTER IX. THEORY. It is unnecessary to make any general remarks upon this subject after what has been said in relation to the theory of typhoid fever. A rational interpretation of the phenomena of typhus, of their con- nections and dependences, is, if possible, more difficult than in the case of the latter disease. In typhus, there is no constant and uni- form lesion of the solids, to which the symptoms can be referred. We certainly have here, if nowhere else in the nosologies, a general disease; arl essential fever. In regard to its theory, and especially to the primary and fundamental disturbance which, in its turn, gives rise to the subsequent and connected morbid phenomena, the sum of which constitutes the disease, British medical philosophers are mostly divided into two classes; the solidists and the humoralists. More strictly, we might call them the neuropathists and the hemo- pathists. The first maintain that the impression of the morbid poison is primarily made upon the nervous system; the latter maintain that this impression is made upon the blood. I do not propose to enter into any history of the reasons urged by the partisans of these respective theories in support of their opinions, or in any way to discuss their merits. I may be allowed to say that an undue degree of importance seems to me to be attached to them by their authors and advocates. They are at best only explanations or interpretations, more or less probable, more or less ingenious, more or less plausible, of the phenomena of fever, and of the various relations of these phenomena. Sydenham's or Huxham's, or Cul- len's, may be as good as any of them. They are probably all of them more or less erroneous, they may be wholly so.1 Let us re- 1 There seems to have been in the British medical mind an irresistible tendency to theorize in medicine, and to substitute for the careful observation of facts, and their rigorous analysis, the doubtful conclusions of speculative reasoning. This tendency is clearly enough giving way to a better spirit, and there can be no hazard in predicting that the next quarter of a century will witness a complete revolution / 314 TYPHUS FEVER. member, besides, and a consolatory reflection this is, in the midst of these multiform and conflicting theories, that they constitute an element in medical science of very subordinate, perhaps question- able value. The true science of fever is in its appreciable pheno- mena and their ascertainable relations, not in any explanation of the nature of these phenomena and these relations. in the temper and philosophy of British medical science. No one can doubt this, who is familiar with the recent labors of British medical men ; and especially with the tone and spirit of some of their leading reviews. I may refer, without the imputation of invidiousness, for an illustration of what I mean, to an unpretending but most admirable article in the British and Foreign Medical Review for July, 1841, on the numerical method of investigation; and to more than one other paper, in the same Review, containing full and frank acknowledgments of the immense obli- gations which our science owes to the labors and the example of Louis, to whom it is no extravagant praise to say, that the spirit of Dryden's couplet, so far as medi- cine is concerned, is as applicable as it was to the great expounder of true philo- sophy :— The world to Bacon does not only owe Its present knowledge, but its future too. S 315 Chapter x. TREATMENT. I shall not enter so fully into the therapeutics of typhus as I have already done in relation to that of typhoid fever. It is unnecessary to do so, for two reasons; in the first place, typhus is not a disease of very common occurrence amongst us; and, in the second place, although there is not by any means entire uniformity of opinion amongst the best and most extensive observers in regard to the most appropriate treatment of this disease in all its details, and under all circumstances; still, there is a good degree of agreement in regard to some of the leading points in its manage- ment. I shall say what seems to be necessary to the practical understanding of this subject; treating, in so many sections, of individual remedies or classes of remedies, and arranging them somewhat, at least, in the order of importance which has generally been attached to them. Sec. I.—Bleeding. General bloodletting has been pretty fre- quently resorted to by British practitioners, in the management of typhus; although there seems to have been at all times some practitioners more than doubtful about the propriety of this remedy. One very striking fact, however, is observable in connection with this subject; and that is, the extreme caution with which bleeding is, almost without exception, recommended and practised. Sangra- doism was never popular in the treatment of typhus. Amongst the older practitioners, Sydenham, Pringle, and Grant were bleed- ers ; but they were moderate bleeders, as most of their successors have been. During the early part of the present century, this operation seems to have been not often resorted to ; and the credit of having very much aided in restoring it to public confidence has been given to Dr. Thomas Mills, of Dublin. Dr. Mills published his Essay on the Utility of Bloodletting in Fever, in 1813. But even 316 TYPHUS FEVER. Dr. Mills, the restorer and champion of the practice, as he seems to have been regarded, was what would now be considered a very small bleeder. His most common practice was to abstract from four to six ounces, and in many cases this was not even repeated. Sir Gilbert Blane, who saw a great deal of the disease on ship- board, says of bloodletting that it is a remedy very ill adapted to this sort of fever, particularly in a hot climate.1 Sir John Pringle says : " The pulse is little affected by bleeding once, if a moderate quantity of blood be taken away; but if the evacuation is large, and especially if repeated to answer a false indi- cation of inflammation, the pulse increasing in frequency, is apt to sink in force, and often irrecoverably, whilst the patient becomes delirious."2 "Many recovered without bleeding," he adds, "but few who lost much blood." Dr. Edward Percival recommends bleeding, where there is pneu- monic complication, to the extent of from eight to fourteen ounces; and says that sometimes, though rarely, it may be repeated once or twice. He cautions his readers against large bleedings, and says that patients will sink under them. Dr. O'Brien bled early, to the extent of from six to eight ounces, and repeated the process, if necessary, once or twice. Dr. Grattan, and this only when the lungs were affected, adopted the same cautious practice. In one hundred and sixteen patients whom he bled at the Cork Street Hospital, in 1818, the average quantity of blood taken from each was only five and a half ounces. Dr. John Cheyne, of Dublin, had the reputation of being a free bleeder; but he also was cautious. He says that he has known the operation to destroy life ; and that there are many cases of the disease in which, during all their stages, it is wholly inadmissible. His average quantity at a bleeding was only ten ounces, and he rarely exceeded twelve. When more than this amount was to be taken, he considered it his duty to be pre- sent, and to superintend the operation. Dr. Armstrong recom- mends one or two moderate bleedings early in the fever, when it is complicated with local inflammation. Dr. Southwood Smith is one of the most liberal bleeders amongst recent British writers on typhus. But his practice is founded on an assumption doubly gratuitous; first, that inflammation is in all cases the morbid con- dition which is to be removed; and secondly, that it is the only morbid condition in typhus fever over which we have any control. 1 Obs. on Dis. of Seamen, p. 363. 2 Obs. on Dis. of Army, p. 257. TREATMENT.—BLEEDING. 317 The phraseology of his directions for bleeding is, as it always is, clear, distinct, and emphatic; but the ideas contained in his eloquent words are not so manifest and intelligible as might be wished. He insists upon the necessity of bleeding till local pain is not diminished only, but removed ; till inflammation is not merely mitigated, but subdued. The mere mitigation of inflammatory action by bleeding, he even thinks is more hurtful than beneficial. Dr. Smith seems to have changed his notions about the utility of bleeding. He in- formed the author, in the summer of 1846, that, at the London Fever Hospital, bleeding had been performed only four times during the then past year, and twice by mistake. Dr. William Henderson's admirable account of the typhus fever of Edinburgh, in 1838 and 1839, has already been frequently referred to. His analysis of the results of his treatment is especially valuable. Of ninety-six females admitted into the Infirmary during a given period of time, thirty- six were bled from the arm, and the average quantity taken from each patient was twenty ounces. The circumstances which were looked upon as indicating the propriety of bloodletting were—that the fever should not have been in an advanced stage, the individual not of a delicate or previously enfeebled constitution, the pulse at least firm, whether small or full, and either particular local suffer- ing or general pains, restlessness, and flushing. In three instances, some of the most important of these indications were wanting; and two of the three were fatal. The average duration of the cases that were bled and recovered, up to the commencement of convalescence, was eleven days and two-thirds, and the mortality was one in eighteen. Fifty-two other female patients, also admitted succes- sively during a given period, who were not bled, gave a mortality of one in ten ; and the average duration of these cases, excluding those of a milder character, in which no wine was given, was fifteen days and a half.1 In the Philadelphia typhus of 1836, bloodletting was rarely practised, and did not appear to be well borne. The immediate effects of bleeding seem to be much more obvious and decided in typhus than they are in typhoid fever. Thus, of one hundred and forty-nine patients, in whom this means was resorted to by Dr. Cheyne, in 1816, ninety-four experienced imme- diate relief. In nearly all the cases treated at Edinburgh, by Dr. Henderson, in 1838 and 1839, the operation of bloodletting was followed by a speedy relief, or removal of the local pains, and fre- quently by a mitigation in the severity of other symptoms. 1 Edin. Med. and Surg. Journal, Oct., 1839. 318 TYPHUS FEVER. The conclusions to which we come, then, in regard to this import- ant practical matter are these: first, that general bloodletting to a moderate extent, repeated once or twice, if the indications call for it in the early period of the disease, especially in cases where the previous health of the patient had been sound, where the pulse is somewhat hard, and where there is severe local pain, constitutes a remedy of great and unquestionable value; that it mitigates the severity, shortens the duration, and lessens the mortality of the dis- ease ; secondly, that this remedy is always to be used with great caution; that there is an unknown element in the pathology of typhus fever, which renders this caution always necessary, and which, under many circumstances- and in many cases, renders the remedy wholly inadmissible. Arnongst the contraindicating cir- cumstances may be mentioned the advanced stage of the disease; previous debility or ill health of the patient; a constitution impaired by excesses, and particularly by that of dram-drinking; the absence of the special indications for bloodletting which have already been enumerated; and, finally, the predominance of the congestive or typhoid state, characterized by the extreme prostration of strength, feebleness of the pulse, and torpor of the surface which mark the disease more or less strongly during certain seasons. It ought to be added here, that some of the Irish and Scotch practitioners do not resort to the use of bloodletting at all in the treatment of typhus. Amongst these may be mentioned Dr. Mateer, and Dr. Little, both of Belfast. They seem to consider the disease as essentially one of debility. Dr. Graves, also, thinks that the proportion of cases in which general bloodletting can be practised with advantage and safety is small. Local bloodletting may be resorted to with very uniform benefit. There is great unanimity of opinion, in regard to the safety and the usefulness of this remedy. Scarified or dry cups, applied to the nucha or along the spine between the shoulders, have been found of great efficacy in removing or diminishing the suffusion of the eyes, the injection of the face, the headache, the delirium, and other symptoms. They constituted in nearly all the cases a part of the treatment pursued by Dr. Gerhard, at Philadelphia, in 1836. Speaking generally of dry cups, he says: "Applied in considerable numbers, and left upon the nape of the neck and between the shoul- ders, for twenty minutes or half an hour, they always seemed to me a more powerful remedy in nervous functional derangement not attended with inflammation than scarified cups. I have used TREATMENT.—PURGATIVES.—AFFUSIONS. 319 them largely in the treatment of the apoplectic symptoms of malig- nant intermittent with the best effects, and resort to them with con- fidence as one of our most powerful means of controlling disordered nervous action." Sec. II.—Purgatives. The use of purgatives in typhus fever by British physicians has been almost universal. At one of the Dub- lin Fever Hospitals, under the care of Dr. Cheyne, it was formerly one of the standing directions for the nurse to administer immedi- ately to a newly-received patient, two pills composed of one grain each of calomel, scaramony, and aloes; the pills to be followed in three or four hours with a purgative mixture. Nearly all the Irish writers reckon purgatives second only in importance to bloodletting, and much more generally applicable than this remedy. Some of them rely almost wholly upon them, and upon the ordinary hygie- nic measures, applicable to most febrile diseases. They recommend that mild purgatives, especially during the early periods of the dis- ease, should be so administered and continued as to procure two or three discharges from the bowels daily. A small quantity of calo- mel usually enters into the composition of the purgative, although the action of the mercury upon the mouth is not generally con- sidered desirable. From an examination of the opinions of the best modern observers, it is quite clear, I think, that active and drastic purging is to be avoided. Sec. 111.—Affusions and Ablutions. The agreement of opinion and practice in regard to the external use of water at diffent tem- peratures, according to circumstances, is hardly less general than it is in relation to the necessity of purgatives. Dr. Percival used the cold affusion, especially in the treatment of children; pouring several gallons of cold water from a bucket, over the head and body. On account of the inconvenience of this mode, and for other reasons, perhaps, the process of ablution or sponging,has generally been preferred. When the skin is uniformly hot and dry, the water may be applied in this manner quite cold; but if the temperature is not much elevated, or if there is slight or partial perspiration, it is safer and better that it should be tepid. Dr. Gerhard says that, by frequent sponging, he found that he could regulate the heat of the surface with great ease, and in some degree also could moderate the cerebral symptoms. Dr. Graves, of Dublin, has found that the 320 TYPHUS FEVER. pain in the head, and other symptoms of over-excitement in the brain, are often more speedily and effectually relieved by applying fomentations of hot water than they are by the common cold appli- cations. This is in accordance with the extensive experience of my friend and late colleague, Dr. Dudley, of Lexington, Ky., in the similar treatment of many local affections of a painful or inflamma- tory nature: Sec. IV.—Stimulants and Tonics. The almost uniform experi- ence of British observers has sanctioned the use of stimulants in the treatment of this disease; and, amongst the individual articles of this character, a very general preference has been given to wine. Some of them urge its administration earlier in the fever than others, and in more liberal quantities; but none of them, so far as I know, dispense with it altogether. Dr. Stokes, of Dublin, said, in 1839: " I feel certain, humiliating though the confession may be, that the fear of stimulants in fever with which I was imbued was the means of my losing many patients, whose lives would have been saved, had I trusted less to the doctrine of inflammation, and more to the lessons of experience, given to us by men who observed and wrote before the times of Bichat and Hunter."1 When the cutaneous cir- culation is languid and the skin not hot, when the pulse is soft and feeble, and there are great exhaustion and debility, at whatever stage of the disease, there can be no doubt as to the necessity of the stimulating and supporting treatment. During some epidemics, when the adynamico-congestive element in the pathology of typhus is marked and predominant, this condition of the system will often be present at the commencement of the fever, and will require the early use of stimulants and tonics. More commonly, however, this state of things attends the later period of the disease; and then it must be met by the same remedies, with an activity and assiduity commen- surate with the urgency of its symptoms. Dr. Gerhard, in his account of the Philadelphia epidemic of 1836, says: "It is difficult to conceive the extreme prostration in which our patients were left after a severe attack of fever. The skin is usually cool, and the pulse weak and fluttering, but there are still muttering delirium and great feeble- ness. Under these circumstances, wine, combined with quinine, and a nutritious diet, produced an effect which was almost magical." Dr. Stokes thinks that, in addition to the ordinary indications for 1 Dub. Journ. of Med. Sci., March, 1839. TREATMENT.—STIMULANTS AND TONICS. 321 the use of wine in typhus, may be placed want of energy in the action of the heart, as shown by its diminished impulse, and the feebleness or extinction of the first sound. He says that the exist- ence of these phenomena, at an early period of the disease, has sometimes led him " to anticipate the bad symptoms, and to com- mence in good time the use of the great remedy;" and that, " in others, notwithstanding the existence of severe visceral irritations, the use of stimulants has been adopted with the best success from the same indication."1 It does not appear to be necessary that wine should be given in very large quantities. The daily amount used by Dr. Gerhard varied from four to sixteen ounces; in most cases from six to eight. The only other articles belonging to this class of remedies, of which it is necessary to speak particularly, are the preparations of cinchona. Dr. Gerhard, in the latter stages of the disease, during the Philadelphia epidemic, and under the same circumstances that indicated the necessity for wine, employed the sulphate of quinine given in solution to the extent of about twelve grains in the twenty- four hours. Speaking of tonics generally, he observes: "They not only exercised a gradual and permanent influence upon the appetite and strength of the patient, but they produced an immediate impres- sion. The improvement was sometimes so rapid, that it was very obvious from one day to the next."2 Amongst the means for restoring, temporarily, at least, the exhausted and flagging energies of the system, may be included the external application of dry heat, and the use of sinapisms. Dr. Gerhard says of these latter: " They were of great and undoubted advantage in the stage of prostration, which occurs at the decline of the fever, and certainly contributed to save the lives of several of our patients." He also found them useful in diminishing the stupor and prostration during the disease, as well as in reanimating the strength of patients who were brought to the hospital, exhausted from neglect, and a fatiguing ride from a distant part of the town. But if the fever was high, and the heat of the skin considerable, sinapisms were vastly less effectual than when the skin was cool and the patient seemed sinking from mere ex- haustion. ' Dub. Journ. of Med. Sci., March, 1839. 2 [Dr. Dundas claims that quinine is a specific in the typhus as well as in the typhoid type of continued fever; and the conclusions of Dr. Peacock (see pagfe 1G8J relate to both.] 21 322 TYPHUS FEVER. Sec. V.—Miscellaneous Remedies. It would be an irksome and not very useful task to enumerate all the articles which have by one observer and another been recommended under certain circum- stances and for the purpose of answering peculiar indications. I will briefly mention some few of these, the efficacy of which has been best established. Diaphoretics seem to be of considerable service, in allaying the intensity of febrile excitement. Dr. Little, of Belfast, classes them amongst his most useful remedies. The most powerful of these has already been spoken of; I mean the cool and tepid ablution of the body. Amongst the most unexceptionable perhaps of those to be used internally, are the effervescing draughts, and the liquid acetate of ammonia. When bronchitic or pneumonic complications have not been removed by the remedies already spoken of, resort may be had to vesication, and to the guarded use, internally, of ipecacuanha and antimonials. In some cases, where the bronchial secretion was very abundant, Dr. Henderson found great benefit from the ad- ministration, several times a day, of from half a grain to two grains of the acetate of lead, combined with a small quantity of Dover's powder, and one or two grains of squill. Dr. Graves, of Dublin, has made use of antimony in the treatment of typhus, under peculiar circumstances, the credit of which novelty he claims as entirely his own.1 In the latter'stages of the disease, when there are in addition to other symptoms, great prostration of strength, and extreme nervous restlessness and sleeplessness,'he gives tartar emetic, in solution with camphor mixture and combined with laudanum. Six grains of the antimony are given in the course of the twenty- four hours. This combination, under these circumstances, he thinks • possesses an almost magical power in allaying the nervous restless- ness, and in procuring sleep.2 1 Graves's Clinical Lectures, p. 130, et seq. 2 Sir Gilbert Blane says : " The head being particularly affected in this sort of fever, the patient is extremely restless and delirious, especially at night; and there is a medicine which has a most pleasing effect in procuring both rest and perspira- tion. This is a combination of an opiate with an antimonial medicine, which was administered in the evening with great success."— Obs. on Dis. of Seamen, p. 367. The same excellent observer and philosophical physician remarks again: " In this advanced stage of the fever, in which the most common symptoms are weak- ness, restlessness, tremors, and low delirium, no medicine was found so much to be trusted to as opium, which here acts as a cordial, as well as an anodyne and antispasmodic."—Ibid., p. 380. TREATMENT. — MISCELLANEOUS REMEDIES. 323 In regard to the utility of emetics, there is some difference of opinion. They have been mostly used under two circumstances; first, at the very commencement of the fever; and secondly, when a relapse or an aggravation of the symptoms has been threatened at or near the beginning of convalescence, occasioned by some indiscretion of diet. Dr. Gerhard thinks that they were useful at Philadelphia, in 1836, in diminishing the violence of the fever. Dr. Graves speaks very highly of their efficacy, and very confidently also of their power, if administered within the first twenty-four hours from the time of seizure, of wholly arresting the disease. Camphor and opium are amongst the articles which have been extensively used for the purpose, principally, of allaying nervous agitation and restlessness, and inducing quiet and sleep. As a general rule, they seem to be most effectual in accomplishing these purposes, when the general febrile excitement is not very great, and when there are no indications of irritation, or congestion of the brain. I shall conclude these directions for the treatment of typhus, with Dr. Gerhard's remarks upon these two substances. " Camphor," he says, " was certainly amongst the most useful and powerful of our remedies. We used it largely in the severe cases, especially those in which the ataxic nervous symptoms were very marked; and we had no reason to repent its employment. In general, there was a marked diminution of some of the most prominent and harassing symptoms. We gave the camphor in emulsion in doses of five grains every two hours, and in enema in doses of a scruple. The immediate effect was the lessening of the subsultus and tremors, for which it was chiefly administered,, and sometimes the diminution of delirium. In some cases, we possessed a complete control over the subsultus, which was immediately checked by an injection containing a scruple of camphor. It would cease for some hours, but afterwards return nearly with its former severity. Still, it was a useful palliative, and, like most remedies of its class, acted as a useful balance-wheel in preserving the harmony of the system until the disease had passed through its natural course. The camphor frequently acted powerfully as an anodyne, when sleep had been interrupted by the previous dis- turbance of the nervous system." Huxham is high in his praise of camphor. "Its anodyne demul- cent quality," he says, " makes it vastly serviceable in quieting the Erethism, and bringing on composure of spirits and easy sleep when opiates fail, nay, augment the tumult and hurry." 324 TYPHUS FEVER. " Opium and its preparations," continues Dr. Gerhard, " were used by us in a considerable number of cases. Dr. Pennock was the most pleased with their effects. When the insomnia had been tormenting and incessant, and the patient was exhausted by agita- tion and nervous restlessness, a small dose of morphia would gene- rally calm the agitation and procure sleep. This advantage was so great that we were induced to give opiates in cases which were opposed to our ordinary notions of the proper condition of the system for their employment. We observed no inconvenience from them, and found the morphia occasionally of so much benefit, that we should class it amongst the decidedly useful remedies. It is not a remedy which should be used in large doses, as patients with typhus are certainly more readily affected by its narcotic properties than they are in any other disease. An eighth or a sixth of a grain was the usual dose, and was enough to procure sleep. Opiates are obviously improper when there is much dulness of intellect, attended with great suffusion of the eyes and counte- nance." Another positive contraindication to the use of opium, first pointed out and insisted upon by Dr. Graves, of Dublin, is to be found, according to this writer, in a contracted state of the pupil. When this is present, he thinks opium is always injurious. Reasoning from the effects of belladonna in occasioning dilatation of the pupil, Dr. Graves was led to suppose that, given in cases of typhus attended with contraction of the pupil, it might remove the unknown condition of the brain upon which the contraction depends; and he says that he has used it repeatedly, under these circumstances, with very satisfactory results.1 The diet, when the fever begins to decline, should be somewhat more nutritious and supporting than under the same circumstances in typhoid fever. The contagious character of the disease should be borne in mind, and every means taken to prevent a concentra- tion of its peculiar poison. It seems hardly necessary to insist upon the paramount importance of cleanliness, free ventilation, quiet, and good nursing. There is no disease in which all these are more essential to the welfare and safety of the patient than they are in this. The question of the positive efficacy of active medical treatment in diminishing the duration of fever, and in interrupting its course, was examined in a most fair and philosophical spirit, in a very 1 Dub. Journ. of Med. Sci., July, 1838. TREATMENT. —MISCELLANEOUS REMEDIES. 325 accurate manner, by William Brown, M. D., of Edinburgh, in a paper which may well be cited as a model for similar investigations, contained in vol. vii. of the "Annals of Medicine,11 for the year 1802, edited by Drs. Duncan, Sen. and Jun. Dr. Brown shows very clearly and conclusively that the powers of medical treatment in arresting the disease, or in shortening its duration, are, to say the least, very doubtful or very small. Hildenbrand says : " In this disease, our treatment can only be of benefit in an indirect manner, that is, in concert with the salu- tary efforts of the vital powers. No method yet known, whether rational or empirical, can cure the contagious typhus, either in a direct or an indirect manner, nor even abridge its ordinary and natural course, which is about fourteen days."1 [Dr. Stokes has expressed the same opinion, but more strongly. His words should be the ever-present monitor of those who have to do with this disease. " The treatment of fever," he says, " is reduced to a formula. We cannot cure fever. No man ever cured fever. It will often cure itself. If you keep the patient alive till the fourteenth, the eighteenth, or the twenty-first day, he will recover. We prevent his dying of exhaustion, by food, by the use of stimulants, by tonics. We save him from the effects of the secondary local complications by meeting them as early as they can be discovered. Thus, we seek to preserve the patient at the least expense to his constitution up to the time when, by natural laws, the disease will spontaneously subside."2 At Bellevue, during the eight years of typhus fever, the treat- ment varied considerably. General bleeding was not resorted to i emetics were sparingly used; active cathartics were not tried; laxatives were used from first to last, but only pro re nata, not by formula. In the early periods of the epidemic, a mild mercurial course was tried by some of the physicians; others relied on ipecac, one grain every two hours, and the acetate of ammonia; covering the whole body with oil or simple cerate, was practised to some extent. But as early as the third year, most of the physicians fell into a very simple plan of treatment, and the fever wards were those to which the least medicine was sent. It is believed to be literally true, that hundreds of mild cases were treated without a single prescription for the apothecary. Sponging with cold or tepid water when the skin was hot; the 1 Gross's Hildenbrand, p. 94. 2 [Lectures in Med. Times and Gaz., 1854.] 326 TYPHUS FEVER. free use of cold water as a drink; a good daily allowance of beef- tea ; and, more than all, a free circulation of fresh air, even in the cold weather of winter, constituted the whole of their treatment. But in cases of greater severity, while these means were always used, brandy was ordinarily depended on as a stimulant. When the pulse became frequent, and had lost much of its force, this stimulant was almost always given, and especially if the tongue was dry. It was urged, together with the beef-tea, just in pro- portion to the evidences of general depression of the vital powers. Instances occurred in which forty-eight ounces of brandy were given daily for several days in succession, with the most satisfactory results. The stimulant was not withheld in consequence of any complication. In more than one instance it was continued through the whole of a supervening pneumonia. It was not considered improper to give it, while leeches or cups were required for local complications. Camphor and carbonate of ammonia were used, or camphor alone, in the latter stages of severe cases. The bronchial symptoms, though almost always present, did not usually require treatment; if they did, the local means were stimulating frictions, dry cups, and the oil silk jacket next the skin, covered with flan- nel. Pneumonia was treated in the same way. The head symp- toms, when threatening, were treated with dry or wet cups, or leeches to the back of the neck or temples, moderate cold to the head, and blisters to the back of the neck. Camphor was found valuable in quieting the nervous restlessness and the occasional hiccough. Dover's powder, and sometimes small doses of sulphate of morphia, appeared to be useful at night in overcoming wakeful- ness and delirium. Among these curative agents, none was more valued by most of the physicians than fresh air. Even in winter, and in the coldest of the winter, the windows of the fever wards were to be kept open, at least a few inches, while coal and blankets were furnished to meet fully the wants of the patients. The gene- ral mortality from the beginning of the epidemic till the disease dis- appeared was not probably materially less than in similar epidemics elsewhere ; yet one of the physicians had the satisfaction of seeing seventy-two of his patients, received from the first of October, 1851, to the first of February, 1852, recover, without a single death. This was after the greatest force of the epidemic had passed. From these details, it will be seen that the great principle of Dr. Stokes was wrought out and fully put in practice some years before it was formally published by its author.] 327 CHAPTER XI. DEFINITION. This disease, in the present state of our knowledge respecting it, may be defined in the following terms: Typhus Fever is an acute affection, occurring at all ages of life; attacking, at least in cities, somewhat more frequently persons who are recent than those who are old or permanent residents; often transmitted directly from one individual to another; very much more common in the British islands than anywhere else, although prevailing at times in other countries, generally in the form of circumscribed epidemics; often connected with the crowding of many persons into small, dark, and poorly-ventilated apartments, amidst filth and destitution; frequently sudden, but sometimes gradual in its access; attended at its commencement with chills, usually slight and in many instances repeated; then with morbid heat of the skin, in many cases very intense and pungent; with increased quickness, with softness and feebleness of the pulse; with accele- rated respiration; in many cases with the physical signs of bron- chitis and pulmonary congestion; with pain in the head, back, and limbs; dulness or perversion of the powers of the mind; drowsi- ness or stupor; dizziness, deafness, and ringing or buzzing in the ears; morbid sensibility of the skin and muscles on pressure; extreme prostration of muscular strength; spasmodic twitchings of certain muscles; dull and stupid expression of the countenance; fuliginous flush of the face; suffusion of the eyes; with loss of appetite and with thirst; sometimes with a slightly altered tongue, but in grave cases, with a dry, red, brown, or black and fissured state of this organ; sordes upon the teeth and gums; occasional nausea and vomiting; frequently with a constipated or sluggish state of the bowels; the skin of the body and extremities being generally the seat of an abundant eruption, coming out in most cases between the fourth and seventh day of the disease, and declining at uncertain periods during the second and third week, 328 TYPHUS FEVER. consisting of small spots, generally somewhat obscurely defined, and irregularly shaped, not uufrequently grouped and confluent, of a dusky, dingy red color, not elevated above the surrounding surface, and disappearing only imperfectly or not at all on pres- sure ; the body of the patient in grave cases giving out a pungent, offensive, and ammoniacal odor; which symptoms differ very widely in their duration, in their march, in their severity, and in their combinations, in different cases; several of them being frequently wanting, but enough of them being generally present to charac- terize the disease; the most constant of which are the loss of strength, the stupor, the suffusion of the eyes, the fuliginous skin, and the dusky cutaneous eruption; which symptoms may either gradually diminish in severity, and finally disappear between the seventh and thirtieth days of the disease, or may increase in severity and terminate in death between the third and twentieth days from their access; the liability to a fatal termination being much less early than late in life: the bodies of patients exhibiting, on examination after death,, no constant pathological changes of any of the organs; but in a considerable though varying pro- portion of cases, engorgement of the vessels of the brain with moderate sub-arachnoid serous effusion ; engorgement of the pos- terior portion of the lungs; redness of the mucous membrane of the bronchia ; softening or mamellonation of the mucous membrane of the stomach; the blood being generally of a dark color, often fluid or grumous; the coagula, when formed, soft and non-fibrinous; and the body in many cases running rapidly into decomposition; —which disease, thus characterized and defined, constitutes a peculiar individual affection, differing essentially from all others, although related by many analogies to typhoid fever. 329 CHAPTER XII. BIBLIOGRAPHY. For reasons which must be sufficiently obvious, the literature of typhus fever is mostly British. I shall enumerate only those origi- nal treatises which have fallen in my way, and which I have used, more or less freely, in making up the preceding history. Observations on the Diseases of the Army. By Sir John Pringle. Dr. Rush's edition. Philadelphia, 1810. Pringle was attached to the British army, in the Low Countries, from 1742 to 1745, and also in 1747 and 1748. His experience as an army physician was mostly confined to this period of his life. The only portion of the observations of which it is proper to speak particularly here, is that relating to the jail, or hospital fever. This is short, occupying, together with a reply to De Haen, only sixty pages, but worth its weight in gold. His general description of the disease, in six pages, is capital. His clear and unequivocal recognition of the specific and essential difference between the two great forms of continued fever, typhus and typhoid—called by him jail or hospital fever, and miliary fever—has already been referred to. Medicina Naulica: an Essay on the Diseases of Seamen, etc. By Thomas Trotter, M. D., etc. London, 1803. This is a somewhat famous book—rambling, desultory, and egotistical; flaming with patriotism, as it ought to be, since its materials were "gleaned amidst the laurels of the British navy, and protected by its ban- ners ; sprinkled with his personal difficulties with his subordinates and superiors, and sneers at Dr. J. Carmichael Smyth's nitrous fumigation, which he calls " a mock-heroic placebo" for destroying bad smells—but withal rather an agreeable and racy book, whose leaves one can at least turn over with some pleasure and a little profit. Dr. Trotter saw much of true typhus as it originates and prevails on shipboard. The origin of typhus on board crowded ships seems very analogous to its frequent occurrence in Irish cabins. 330 TYPHUS FEVER. A Treatise on the Nature, Cause, and Treatment of Contagious Typhus. From the German of J. Vol. de Hildenbrand. By S. D. Gross, M. D. New York, 1829. Hildenbrand had extensive oppor- tunities for the study of typhus fever, during the latter part of the last, and the early part of the present century, in the German armies connected with the wars of that period. His work is an elaborate and systematic monograph on that disease. Its great fault is that it is over systematic; there is no disease in the noso- logy so fixed, and constant, and uniform in its phenomena—in its symptoms, changes, march, and duration—as his simple regular typhus. " On the fourth day," he says, " there is generally a slight degree of hemorrhage from the nose; critical exacerbations take place exactly at the end of the third, and at the commencement of the seventh day; and subsequently at the end of the tenth and at the beginning of the fourteenth day," and so on. He divides the disease into eight periods. The fever which fell under his obser- vation was probably mostly typhus, mingled, however, I think, more or less, with typhoid. This celebrated work is certainly not with- out its interest, but it has less positive value than I had been led to expect before reading it. In allusion to the different and oppos- ing methods of treatment which have been advocated and employed in typhus, he quotes the adage—Pessima medendi methodo non omnes trucidantur. An Essay on the Utility of Bloodletting in Fever, etc. By Thomas Mills, M. D. Dublin, 1816. The object of this work is indicated by its title. Dr. Mills not only makes no distinction between the different forms of fever—continued, periodical, and so on—but he even confounds with fever various local inflammations. This radical defect in regard to diagnosis, renders the book entirely worthless. Observations on the Prevention and Treatment of the Epidemic Fever at present prevailing, etc. By Henry Clutterbuck, M. D. London, 1819. This book is made up, in a good degree, by an application of the author's theoretical views of the pathology of fever to the treatment of this disease. His work, containing a statement of these views, was published as early as 1807. He regards fever as an inflamma- tion of the brain, and so far as there is any merit in having started the doctrine of the heal inflammatory origin of fevers, it belongs more to Clutterbuck than to Broussais. There is a good deal of reasoning and criticism in the book ; but it is always courteous and good-tempered. The most frequent form of fever in London, BIBLIOGRAPHY. 331 during the prevalence of the epidemic, was that corresponding to the slow nervous fever of Huxham. He doubts whether the pre- valence of fever is as directly dependent upon insufficient food and crowded and close dwellings as is commonly supposed. Dr. Clut- terbuck evidently feels that he has done a signal service to medi- cine by founding the practice of bloodletting, in fever, upon what is called a rational indication or a,principle! thus freeing it from the reproach and disgrace of being merely an empirical remedy! Alas, for the blindness and fatuity of this miserable and false phi- losophy! Strongly as he relies upon bloodletting, he is constantly insisting upon the necessity of great caution and discrimination in its use. This seems to have been forced upon him by his experi- ence, in spite of the pleadings of his theory. The book is vitiated throughout by the hypothetical assumption in regard to the nature of fever, and it adds little or nothing to our knowledge of the dis- ease. An Account of the Rise, Progress, and Decline of the Fever lately epidemical in Ireland, etc. By F. Barker and J. Cheyne. 2 vols. London and Dublin, 1821. This work is a systematic and docu- mentary history of the great Irish epidemic of 1817, 1818, and 1819. It is one of the most substantial and valuable general his- tories of disease that has ever been written: a proud and worthy monument of Irish science, humanit}', and skill. It consists, in great part, of communications relating to the epidemic, made by the leading medical men of all parts of the country. No one can read these papers without being forcibly struck with the high quali- ties of the Irish medical mind : its sagacity, its clear common sense, its accurate observation, and, compared with that of its sister island, its freedom from the corrupting influences of systems and hypo- theses. An Historic Sketch of the Causes, Progress, Extent, and Mortality, of the Contagious Fever Epidemic in Ireland during the years 1817,1818, and 1819. By William Harty, M. B. Dublin, 1820. The objects of this work are sufficiently stated in its title. It is in every way a worthy companion to the history, by Dr. Barker and Dr. Cheyne. It is written with elegance, earnestness, and ability; and it consti- tutes another of the many evidences of the signal excellence of the Irish medical mind.. Dr. Harty does not profess to detail the symp- toms and treatment of typhus; but he enters very fully into a con- sideration of its causes. His views upon this subject are marked by the soundest judgment and good-sense. He insists, with entire 332 TYPHUS FEVER. conclusiveness, upon the action of many concurrent causes, in its production ; and he opposes, with equal success, the doctrines of systematists and exclusives. Contagion, war, famine, want of em- ployment, personal and local uncleanliness, unventilated andcrowded dwellings, are the chief amongst these concurrent causes—acting, in some instances singly, but more generally together. A Succinct Account of the Contagious Fever of this Country, etc. By Thomas Bateman, M. D., F. L.S., etc. London, 1818. This is another of the many valuable essays growing out of the great epidemic of 1817, 1818, and 1819. Dr. Bateman was a good observer, in the British sense of that term, and a sound practitioner. The value of his book is greatly impaired by the absence of all distinction between the typhoid and typhus forms of continued fever—both of which, but principally the former, it is very evident, were present at the period of which he writes. He is over positive in his con- clusion, that epidemic fevers always depend upon scanty and poor food. He insists strongly upon the essential identity of all forms of continued fever. He speaks particularly of the connection between troublesome diarrhoea and protracted cases of the disease—clearly enough cases of typhoid fever. In three autopsies, he found ulcera- tion of the small intestines; and asks if they might not have been produced after death by putrefaction, or by the action of the acrid contents of the bowels! He insists strongly on the advantages of the cooling and antiphlogistic treatment, and dislikes antimony and opium. The last chapter is upon the subject of contagion. Its principal objects are to show that the fever is less contagious than had been generally supposed; that the poison extends only a short distance from the sick ; that dilution with fresh air renders it harm- less ; and that muriatic acid fumigation acts to the same end. A Sketch of the History and Cure of Contagious Fever. By Robert Jackson, M. D. London, 1819. This work on typhus is by the famous author of the treatise on the fevers of the West Indies. It is mostly made up of short and very loose accounts of typhus fever as it occurred during the latter part of the last, and the early part of the present century, in various portions of the British army and navy. It is of small value. Practical Observations on the Treatment, Pathology, and Prevention of Typhus Fever. By Edward Percival. Bath, 1819. This little monograph was written by Dr. Percival after his removal from Dublin to Bath. His description of typhus is pretty full and pretty good. Some of his conclusions are loose and hasty; those, for in- BIBLIOGRAPHY. 333 stance in regard to the connection of certain forms and modifications of fever with season and weather. He says he is an advocate for the humoral rather than the nervous pathology of fever. The book is vitiated throughout by a spurious a priori philosophy, Dr. Per- cival concludes with that stereotyped motto of medical books— " Opinionum commenta delet dies, naturas judicia confirmat." A History of the Epidemic Fever vjhich prevailed in Bristol during the years 1817, 1818, and 1819, etc. By J. C. Prichard, M. D. London, 1820. This is another of the many local histories which were written by British practitioners of the last great epidemic. The author's description of the fever is sketchy and imperfect. He considers it entirely settled that typhus often originates spon- taneously, from unknown causes, and also that it is frequently communicated, directly, by contagion. He takes strong ground for the old doctrine of a pestilential constitution of the atmosphere, favoring the prevalence of certain diseases during certain periods of time. "For explaining such phenomena," he says, "it is not sufficient to trace an infected ship to a particular spot, or to smell out a bog on a piece of marshy ground near some particular town." Dr. Prichard's style is excellent, clear, strong, correct, and always to the point. De VIdentite du Typhus et de la Fievre Typhoide. Par C. E. S. Gaultier de Claubry. Paris, 1844. 1 vol. pp. 496. The Identity of Typhus and of Typhoid Fever. By C. E. S. Gaultier de Claubry. The French Royal Academy of Medicine proposed, in 1835, as the subject of one of its annual prizes, to be awarded in 1837, "The Analogies and the Differences between Typhus and Typhoid Fever11 Instead of the prize thus offered, two prizes of encouragement were given by the Academy, the first to the work above named, in which the identity of the typhoid fever of modern French writers and the typhus of camps and jails is maintained, and the second to M. Mon- tault, for an essay advocating the opposite doctrine. Both essays were ordered to be published in the Memoirs of the Academy. This work of M. de Claubry is the second edition of his prize memoir, enlarged and completed. My own opinion in regard to this matter was very briefly but explicitly expressed in the first edition of my work. I do not see any occasion to change it. M. de Claubry has collected from vari- ous sources, histories, more or less complete, of fevers prevailing in camps, barracks, and prisons, in different localities on the conti- 334 TYPHUS FEVER. nent of Europe, mostly between the years 1804 and 1815. In many instances, these fevers correspond very exactly to typhoid fever; in others, they correspond to typhus. M. de Claubry insists upon the general presence, in these fevers of the continent, called typhus, of diarrhoea, and tympanitic abdomen, and in the existence also of intestinal ulceration. It is very important to remember, that, in this discussion, he expressly sets aside the question of the exist- ence of a separate disease—the British typhus—characterized by the general absence of diarrhoea and of intestinal lesions. Louis is often quoted as authority for the doctrine of the identity between the camp and jail fevers of the continent, and typhoid fever, and rightly enough; but he has repeatedly and explicitly declared his belief that the British typhus, occurring with nearly the same fre- quency, at different periods of life, rarely attended with any promi- nent abdominal symptoms, and not characterized by any intestinal lesion, is fundamentally and essentially unlike the typhoid fever of his own researches. Natural History, Pathology, and Treatment of the Epidemic Fever, at present prevailing in Edinburgh and other towns. By John Rose Cormack, M. D. London, 1843. There prevailed at Edinburgh, in the course of the year 1843, a form of fever, differing, in many respects, from the common typhus of the country, and resembling, in some respects, the yellow fever of hot climates—particularly in the presence of yellowness of the skin, and, in some cases, of black vomit, and hemorrhages. The whole character of the epidemic seems to me to be so questionable and anomalous as to render it difficult for us to assign it its true position. Certainly, it was not the genuine yellow fever, and many of the features of true typhus were wanting. This I suppose was the new Relapsing Fever of British writers. The article on Fever, in the Library of Practical Medicine, is by Dr. Christison, of Edinburgh. He patriotically adheres to the old Cullenian division of fever into Synocha, Synochus, and Typhus. Dr. Christison makes the common mistake of attributing to Louis the opinion that the lesion of the intestine in typhoid fever is the pathological cause of the disease. The article has little or no value for Americans, for the simple reasons, that typhus fever, without lesion of the intestines, is a form of disease rarely met with in this country, except amongst emigrants recently arrived from Europe; and that no clear and well defined difference is recognized between this and the form of continued fever generally prevalent here. BIBLIOGRAPHY. 335 The Article in the Cyclopedia of Practical Medicine is by Dr. Tweedie. He recognizes no essential difference between typhoid fever, and typhus. The paper in the Cyclopedia, on Epidemic Gas- tric Fever, by John Cheyne, is to us much more interesting and valuable. The disease described under this name is very clearly true typhoid fever. The more or less systematic treatises of Dr. Armstrong, South- wood Smith, and Tweedie, have already been sufficiently referred to. Many of the most valuable publications upon typhus fever are to be found in the British Hospital Reports, in the Transactions of Medical Societies, and in the pages of Medical Journals. The Transactions of the American Medical Association. Vol. 1.1848. Report of the Committee on Practical Medicine. The author of this well written report is my friend and colleague, in the, New York College of Physicians and Surgeons, Dr. Smith. More than half of it is devoted to an elaborate and methodical examination of the question of the identity or the non-identity of typhus and typhoid fever. Dr. Smith argues with earnestness and ability the New York doctrine. "Report on the Epidemic Fever in Ireland,11 during the years 1847 and 1848. Dublin Quarterly Journal. Vol. VII. and VIII. This elaborate report occupies nearly three hundred pages of the Dublin Journal. Its general plan and purpose are very similar to those of the great work of Barker and Cheyne. The histories of the epidemic contained in it are so general in their terms and cha- racter as to be of little service to me in this work. It contains abundant evidence, I think, that the epidemic of 1847-8 was made up of several forms of fever. In relation to this matter, I make, the following extract from the report of Dr. Seaton Reid, of Bel- fast:— " I have stated above that the epidemic here was constituted by the prevalence of several diseases, and I now add that in the fever portion of these we had prevailing several separate and distinct species of fever. Twelve years' connection with fever hospitals has convinced me that a very serious error has been committed by almost all the most recent writers of monographs on fever, by their denying the existence, both in this country and in England, of more than one species of that disease. This error exists in the works of Drs. Southwood Smith, M'Cormac, Ormerod, and others, and will be found pervading almost all the communications in Barker and Cheyne's report of the epidemic of 1816-1818. 336 TYPHUS FEVER. " The consequence of this error has been, that we do not possess that amount of precise information regarding the history, the symp- toms, the pathology, and the relative mortality of our several spe- cies of fever, as their frequent prevalence in this country would lead one to expect. In this respect the American physicians are in advance of us, for Drs. Bartlett, Jackson, and others, have not only recognized and described the several species of fever peculiar to America, but have also pointed out the difference existing between ' our maculated typhus, carried into their cities by our emigrants, and their own typhoid fever—the species of fever so minutely described by Louis in Paris, and which has been so often con- founded with our maculated typhus."1 [The works of Dr. Flint and Dr. Huss, embracing both typhus and typhoid fever, have been referred to in the Bibliography of Typhoid Fever. Besides these, no separate volume, treating of either of these diseases has appeared since the publication of the third edition of this work, so far as the editor is informed. The medical periodicals, however, have produced a considerable num- ber of papers, in which attempts are made to draw the line of dis- tinction between these two diseases, or to detail the circumstances that have marked one or other of them, as seen by particular observers. Three only of these articles will be mentioned; others have been quoted on particular points in the preceding pages. Clinical Lectures on Fever. By Wm. Stokes, M.D., &c. Medical Times and Gazette, London. These lectures, thirteen in number, appeared in the above named journal, mostly during the year 1854. The author has not attempted to give a systematic description of fever, but his aim appears to be mainly to enforce two doctrines, the unity of fever, and the supporting treatment of it. The kernel of these lec- tures, so far as relates to the first point, has been already extracted for these pages. The second may be dismissed with a single addi- tional quotation. " In a disease which is under the control of the mysterious law of periodicity, every hour of compelled life is a clear gain." The name of Dr. Stokes is too well known in this country to require further remark here. Report of all the Cases of Fever which occurred in Guy's Hospital during the year 1854, with Remarks, having especial Reference to the Typhus and Typhoid Distinctions. By Samuel Wilks, M. D. G»fs Hospital Reports, Third Series, Vol. I. London, 1855. This paper 1 Dub. Med. Journ., vol. viii. BIBLIOGRAPHY. 337 and one published in the preceding volume, give together a view of two hundred and forty-nine cases of fever; fifty-five of which are reported as typhus, and one hundred and sixteen as typhoid. The author draws broad and clear the line of separation between the two. Nothing, perhaps, illustrates more strikingly the difficulty of reconciling opinions on this subject than the fact that Dr. Wilks and Dr. Barlow, both attached to the same hospital, deriving their opinions from the same class of cases, perhaps from the very same cases, in many instances, should stand committed before the public, one for the unity, and the other for the duality of continued fever. Lectures on the Varieties of Continued Fever and their Discrimina- tion ; Delivered at St. Thomas's Hospital, by Thomas B. Peacock, M. D., Assistant Physician, &c. Med. Times and Gaz., July, 1856, and onward. These lectures recognize and describe four varieties of fever, the typhus, the typhoid, the relapsing, and febricula or ephe- meral fever. For the most part, so far as they have yet appeared, the author's researches lack systematic completeness, and numerical details. On certain phenomena of fever they are full and instruc- tive. Some of his statements and opinions regarding typhus and relapsing fevers have been transferred to this volume. The num- ber of cases from which he has drawn his conclusions is one hun- dred and six. Thirty-five of these he considered typhus, and seventy-one typhoid fever.] 22 PAET THIED THE HISTORY, DIAGNOSIS, AND TREATMENT OF PEEIODICAL FEVER. INTERMITTENT; BILIOUS REMITTENT; CONGESTIVE. PART III. PERIODICAL FEVER. INTERMITTENT; BILIOUS REMITTENT; CONGESTIVE. CHAPTER I. PRELIMINARY MATTERS. ARTICLE I. INTRODUCTORY. Before commencing the formal description of the disease which is to constitute the subject of this Third Part of my book, it is necessary to say a few words about the names which I have placed at its head. The disease which I am here to describe exhibits itself » under several forms, so considerably different from each other as to have received different appellations. Still, the disease under all its forms, in all its varieties and modifications, is a single, individual disease; as clearly so as typhoid or typhus fever is. It becomes necessary, then, that this disease should have its distinctive appella- tion—a name by which it may be designated and known. I have accordingly adopted the term—not a new one—Periodical Fever, as more descriptive and appropriate than any other, and entirely unex- ceptionable. Periodical Fever, is the integral, individual, nosological disease; Intermittent Fever; Bilious Remittent Fever; and Pernicious Intermittent or Congestive Fever, are the three principal forms or vari- eties, in which the disease shows itself. I have felt a little embarrassment in deciding upon the best and most suitable method of procedure, in describing the disease thus designated and divided. The three'leading varieties have many elements in common; they are branches springing from the same 342 PERIODICAL FEVER. root; but notwithstanding this, they differ in some respects so widely from each other that they have often been regarded as specifically distinct and separate diseases, and in order to get any clear and adequate conception of them they must be separately and individually described. If this description is extended, in detail, to their entire natural history, it will lead us into a great deal of tedious and unnecessary repetition; and it would be very difficult to convey to the reader anything like a complete and satisfactory idea of them, by attempting to carry along together the description of the several varieties—endeavoring to put into the same portrait various and differing expressions. Amidst these difficulties, the best course seems to me to be this—to give, in the first place, a full and detailed description of one of the forms of periodical fever, comprising in this description all the phenomena and relations that are common to all the forms; and then to point out only the peculiarities and characteristics of the remaining varieties. Which of the three principal forms of periodical fever we choose for this more elaborate and formal description, is not altogether a matter of indifference; and it would probably strike one, at first sight, that this choice would naturally fall upon intermittent fever, as the simplest and least complicated of these forms—as the type-variety, in some degree, of the disease—and, for this reason, better adapted than the others to exhibit its characteristic features and its true nature. I am satisfied, however, that this view is not the correct one; and that our purpose will be much more successfully accomplished by giving a full description, in the first place, of the bilious remittent variety; filling up and completing the picture, subsequently, by introducing the lights and the shades that mark the other forms. The principal reason for making choice of this variety, for this purpose, consists in the fact that it embraces a larger number of the phenomena and relations which enter into the composition of the entire disease than either of the other varieties. The sources of my materials for the history of periodical fever will be indicated as I go along. I may mention here, however, that the most valuable of these materials are derived from French and American observers. The British Islands are not, to any great extent, the seat of periodical fever; and although some British writers have left us excellent general descriptions of the disease, as it shows itself in the southern and tropical colonies of the British empire, these descriptions are less elaborate and complete than those of some of the more recent French and American physicians. The PRELIMINARY MATTERS. 343 earlier classic authorities upon this subject were the great Italian writers—Torti, Baglivi, Lancisi, and Ramazzini. But their descrip- tions are generally inaccessible here, and they are of course but little known; it should be said further, that they are quite deficient in pathological details. I do not know that the modern Italians have done anything in this department in any way worthy their illustrious predecessors. Italian medicine, like Italian art, Italian science, Italian poetry, and Italian character, has fallen from its high estate, and partakes in the general lethargy that broods over that beautiful land. ARTICLE II. NAMES OF THE DISEASE. There are not many diseases with so few synonyms as this va- riety of periodical fever, if we except those names that have been given to it on account of its geographical relations. Thus, in com- mon with the other grave forms of periodical fever, it has been called Walcheren fever, Hungarian fever, African fever, and so on; in India, it is frequently called jungle or hill fever. It should be added that it has frequently been confounded, especially by British writers, with the yellow fever, and designated by some of the many names which have been applied to the latter disease. Its most common names are these—Remittent Fever; Bilious Fever; and Bilious Remittent Fever. 344 CHAPTERII. SYMPTOMS. ARTICLE I. MODE OF ACCESS. The onset of remittent fever is almost always abrupt, formal, and well marked. This onset, according to many observers, is not usu- ally preceded by any precursory symptoms; according to others it is, if not generally, at least in many instances, ushered in by such symptoms. Dr. William Currie says that the fever makes its at- tack after the existence for a day or two, and sometimes much longer, of a disagreeable sense of languor and debility.1 Dr. Boling, in his excellent paper on the remittent fever of Southern Alabama, says that, although the attack sometimes takes place without any premonitory symptoms whatever, it is most frequently preceded for a day or two by slight headache, want of appetite, bitter taste in the mouth in the morning, pains in the joints, and a general feel- ing of discomfort and uneasiness.2 Dr. Dunlavy, in a paper on the bilious fever as it prevailed in the town of Hamilton and in its vicinity, in Ohio, during the summer and autumn of 1824, remarks that, in some cases, patients complained of pain in the head, sick- ness of the stomach, occasional vomiting, and bitter taste, for several days previous to the occurrence of a chill. If examined at this time, their tongues were found more or less furred, with some frequency of the pulse. During the prevalence of the disease, he met with many persons having a furred tongue, who were not aware of any indisposition; and he adds that this symptom fore- boded an attack of fever, which very certainly sooner or later oc- curred, unless prevented by a timely use of evacuant medicines.3 ' Obs. on Causes and Cure of Remitting Fevers, p. 45. 2 Am. Journ. of Med. Sci., April, 1846. 3 West. Med. and Phys. Journ., vol. i. p. 142. SYMPTOMS. — CHILLS. 345 Senac says: " The access of the chilly fit is usually preceded by various phenomena. These are a general lassitude and heaviness, a sense of anxiety, a yawning and stretching, a paleness, and some- times a disposition to sleep.'" [Dr. Henry A. Ford, in his " Obser- vations on the Fevers of the Western Coast of Africa," adds sleep- lessness, copious and pale urine, peevishness, and an indefinite apprehension of coming danger, to the symptoms of this premoni- tory stage. He says: "The most intense weariness I ever experi- enced has come on in this stage of the fever."2 He thinks that the African periodic fever has generally its " preparatory stage."] ARTICLE II. FEBRILE SYMPTOMS. Sec. I.— Chills. The formal commencement of the disease is nearly always marked by a distinct rigor or chill. This varies in severity and duration in different cases: sometimes it is slight and transient, at others it is extremely severe, and prolonged for two or three hours. Senac says: "The chilly fit puts on a variety of forms; sometimes, for instance, beginning at the feet, at other times about the scapulae, and again in the back, it runs through the whole body, in a manner resembling small streams of water poured irregu- larly in every direction."3 According to Dr. Doling, the initiatory chill is generally slight; sometimes it is well-marked ague, while at others it consists merely in a sensation of coldness, felt especially when the patient turns in bed, or in any way disturbs his covering." In some cases, there is only a single chill; in others, the chill is repeated, usually with diminishing severity, once, twice, three times or more in the course of the disease. Dr. Boling says: " Where the attack is purely remittent from the beginning, a second well- marked ague hardly ever occurs; though in all cases whether the first exacerbation was ushered in by an ague, or merely by slight rigors, a recurrence of the latter in a very slight degree frequently precedes the second and third, and occasionally, even the fourth and fifth exacerbations. Where the fever is of the double tertian type, the first and third, perhaps the fifth, exacerbation may be ushered in by tolerably distinct agues, while the second and fourth may be 1 Caldwell's Senac, p. 24. z [Observations, &c, 1856, p. 5.] 8 Caldwell's Senac, p. 24. 4 Am. Journ. Med. Sci., April, 1846. 346 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. preceded by but the very slightest sensation of coldness, if any."1 : Jr. Stewardson says: " The recurrence of the chill was subject to great diversity: either there were none after the first, or they recurred at intervals, most commonly of twenty-four or forty-eight hours, for the first few days, and then disappeared altogether, or again reappeared towards the conclusion, or during convalescence ; or, finally, showed themselves at various intervals throughout the whole course of the disease.2 Dr. William Currie says: " After the second paroxysm, and sometimes after the first, the fever is seldom preceded by a cold stage."3 [Dr. Ford states that " in a large number of cases there is no chill at the invasion, but head- ache, nausea, pain in the back, &c.,4 in the African fever.] Sec. II.—Remissions, or Type. This disease is so uniformly and so strongly marked by a repetition or recurrence of certain symp- toms and states of the system, more or less regularly periodical, that one of its qualifying terms has been derived from this circum- stance. At certain periods of the day, there is an augmentation in the intensity of all or nearly all the symptoms of the disease some- times preceded and at other times not preceded by the chill. This increase of the severity of the symptoms constitutes what is called the paroxysm of the fever, or its exacerbation. Following this period, and between it and the next, there is a general diminution in the activity of the morbid processes and their manifestations, constituting what is called the period of remission. When these paroxysms and remissions occur, each once in twenty-four hours, the type of the fever is said to be quotidian; when they occur once in forty-eight hours, the type is called tertian; when once in seventy- two hours, it is called quartan, and so on. The most common type is the quotidian, or more strictly, perhaps, what has been called the double tertian. In this form, there are a paroxysm and a remission during each twenty-four hours; but the paroxysm of one day differs in severity or in some circumstances from that of the preceding and of the following day, and agrees with that of the third day. The paroxysms of the alternate days correspond to each other. Besides these, the most common, there are occasionally other varieties of type. Sometimes, for instance, in the tertian form, there are three paroxysms and three remissions, instead of one or two during each 1 Am. Journ. Med. Sci., April, 1846. 2 Ibid., April, 1842. 3 Currie on Rem. Fevers, p. 46. * [Observations, &c, p. 8.] SYMPTOMS. — TYPE. 347 period. This is the semi-tertian of some writers; it is the triple tertian of Cleghorn. The other varieties it is hardly necessary to enumerate. The term true has been applied to those forms of the disease in which the duration of the paroxysm does not exceed twelve hours; when this is considerably protracted the fever is called spurious ; and subintrant, when the paroxysms nearly run into each other. It is alleged by most observers, that the commencement of the paroxysm occurs much more frequently at certain periods of the day than at others. Dr. William Currie, for instance, says the first attack of the fever is usually between eight and eleven o'clock in the forenoon.1 Dr. Cleghorn, in his admirable little treatise on the Diseases of Minorca, makes the following remarks upon this point in the history of remittent fevers: "Some double tertians begin in this manner; on the evening of Monday, for example, a slight fit comes on, and goes off early next morning; but on Tues- day, towards the middle of the day, a more severe paroxysm begins, and continues till night. Then there is an interval to Wednesday evening, when a slight fit commences a new period of the fever, which proceeds in the same manner as the first. In most double tertians, the patient has a fit every day of the disease; the severe one commonly appearing at noon on the odd days, the slight one towards evening, on the even days."2 Dr. James C. Finley, in a paper on the Autumnal Fever of Georgia, says, that " the type is uniformly double tertian, the paroxysms recurring with the greatest regularity; one paroxysm commencing in the morning, and manifesting a dis- position to terminate in the evening of the same day; the other com- mencing on the afternoon of the following day, and continuing through the greater part of the night." [This form of double ter- tian Dr. Ford sometimes observed in Africa as the remittent broke into the intermittent form.3] Dr. Finley says, further, that " there is a very marked difference in the character of these two paroxysms- that which commences in the morning being always more violent and dangerous than that which comes on in the afternoon of the next day."4 Dr. Boling thinks that the period of attack will depend very much upon the time of the patient's exposure to the exciting cause, but he says distinctly that, in fevers of the double tertian type, the exacerbations will, in a large majority of cases, be found 1 Currie on Rem. Fever, p. 45. 2 Cleghorn on Dis. of Minorca, p. 90. 3 [Observations, &c, p. 13.] * West. Journ. Med. and Phys. Sci., vol. iii. p. 175. 348 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. to occur alternately in the fore and after part of the day.1 It has often been alleged that the usual period of access varied with the different types of the disease, occurring early in the morning in the quotidian type, between ten o'clock and noon in the tertian, and between three and five o'clock in the afternoon in the quartan. In relation to this subject, M. Maillot has published the following curious and interesting table. I omit his distribution of the cases according to the month in which they occurred. It will be noticed that, in the two principal types, two-thirds of the cases have their access between midnight and noon ; that the maximum hour is ten o'clock A.M., and the minimum period from nine P.M. to midnight. M. Maillot did not find that the period of access was in any appre- ciable degree influenced by the season, or the temperature of the weather. Table showing the Hours of Access in Periodical Fever. QUOTIDIAN TYPE. From Midnight to Noon. Hour, 1234567 8 No. of cases, 12 15 17 18 31 51 82 118 From Noon to Midnight. 1234567 8 70 113 63 58 54 47 19 22 9 163 10 239 10 21 11 137 11 10 12 Total. 206 1089 12 Total. 8 493 Hour, No. of cases, 1 12 TERTIAN TYPE. From Midnight to Noon. 2 3 4 5 6 7 8 5 12 30 22 38 68 63 From Noon to Midnight. 1234567 8 33 39 23 27 11 11 9 10 9 86 10 87 9 10 11 72 11 4 12 Total. 55 550 12 Total. 3 180 QUARTAN TYPE. From Midnight to Noon. Hour, 1234567 8 9 10 No. of cases, 2 " " 1 2 " " " « » From Noon to Midnight, 12 3 4 5 6 7 8 9 10 "341211 « « « 11 3 12 Total. 5 13 11 12 Total. 1 " 13 No distinction is made in the above table between the different forms of periodical fever, and the double tertian is not recognized as a distinct type.2 1 Amer. Journ. Med. Sci., April, 1846. 2 Traite des Fievres Intermittentes. Par F. C. Maillot, p. 414. SYMPTOMS.—SKIN. 349 In regard to the relative frequency of the leading types, I find the following positive and valuable statement in the excellent work of Maillot. His remarks apply, without discrimination, to the three great forms of periodical fever, intermittent, remittent, and congestive. At Bona, in Africa, of two thousand three hundred and thirty-eight cases, fifteen hundred and eighty two were quotidian, seven hundred and thirty were tertian, and twenty- six were quartan in their type; at Algiers, of seven hundred and seventy-six cases, five hundred and ninety-nine were quotidian, one hundred and seventy-one tertian, and six quartan. In France, according to M. Nepple, of three hundred and eighty-six cases, one hundred and ninety-eight were quotidian, one hundred and fifteen tertian, and fifty-nine, quartan. Thus, of tliree thousand five hundred and eighty-six cases, two thousand three hundred and seventy-nine were quotidian, eleven hundred and sixteen were tertian, and ninety-one were quartan in their type. M. Maillot makes no distinction between the simple quotidian and the double tertiau type.1 It would seem that there is sometimes a tendency to a weekly revolution in the phenomena of this disease. Dr. Forry says: " That intermittent fever has a tendency to a septenary revolution, is a fact that was frequently verified in Florida, under the writer's observation; and that too in a manner so unequivocal, that it attracted the notice of the common soldier. At these septenary periods, either after the seventh, fourteenth, or twenty-first parox- ysm, the disease has a disposition to terminate spontaneously."2 [Dr. Ford makes the same remarks of the fever in Africa.3] Sec. III.—State of Surface. The condition of the skin, like most of the other symptomatic phenomena of bilous fever, varies very much with the several stages and periods of the disease. Cleghorn says, that the cold fit is generally followed by an intense heat over the whole body, which raises the mercury in the ther- mometer to the 103d or the 104th degree.4 According to Dr. Stewardson, the heat of the skin, during the exacerbations, though often great, is not often pungent.5 Dr. Boling seems to have studied thi3 matter more thoroughly and minutely than any other observer, and I accordingly avail myself of his full description. 1 Traite des Fievres Interimttentes. Par F. C. Maillot, p. 9. 2 Amer. Journ. Med. Sci., Oct., 1841. s [Observations, &c, p. 23.] « Dis. of Minorca, p. 94. 5 Amer. Journ. Med. Sci., April, 1842. 350 PERIODICAL FEVER.—BILIOUS REMITTENT FORM. "In the forming stage of the first exacerbation, the extremities generally feel cool or cold to another person, though this is not always the case, even when the complaints of suffering from cold are loudest on the part of the patient. The temperature of the chest and abdomen, even at this time, will generally be found somewhat above the healthy standard, and that of the head con- siderably so. Soon, however, the general temperature increases, and the whole surface becomes hot, and a vivid flush makes its appearance, not only on the face, but occasionally over the whole body, in patients at all plethoric, or of a sanguine temperament. This continues for a longer or shorter period, dependent in a great measure on the type the fever is about to assume; for it will be shorter in the paroxysm of a quotidian than of a tertian, when the heat and redness of the surface decline, and a perspiration appears, in the form at first of the slightest moisture between the under jaw and neck, gradually becoming general and free. In the succeeding paroxysms, the heat of the body is still about the same; but if the case be at all protracted, there is after a certain period a tendency to coolness in the extremities, even during the height of the exacerbations; but unlike the coolness attending the early rigors, the patient is unaware of it, and is much distressed with a sensation of burning heat. This coolness of the extremities gradu- ally increases with each succeeding exacerbation, after it has once appeared, and in cases far advanced towards a fatal termination frequently extends nearly to the shoulders and groins, the surface of the abdomen and chest being most intensely hot at the same time. The perspiration attending the remissions becomes less and less in each, and in the advanced stages of an aggravated case is replaced by a clammy exudation from the cold extremities, while the body is dry and parched. The vivid flush of the surface is much less apparent with each succeeding exacerbation, and in its place a very slight shade of a purple or livid tint makes its appear- ance—more obvious in the face than elsewhere. Frequently, how- ever, the skin becomes yellow: the shade, scarcely perceptible at first, gradually deepening over the whole body, but not com- mencing and proceeding from any particular point, as is said to be the case by Lempriere, Bancroft, Mosely, and others, in the yellow fever. It is, however, for a very obvious reason, most frequently first noticed in the conjunctiva. Petechiae and vibices are never seen, though sudamina are occasionally observed in protracted cases. They generally appear only about the neck and breast, SYMPTOMS.—HEART AND PULSE. 351 and are much more common with children than with adults."1 It should be mentioned that Dr. Boling's remarks have reference especially to the severer forms of the disease. Sec. IV.—Heart and Pulse. The pulse is more or less accelerated during the febrile paroxysms, rising frequently to 120 or 130 in the minute, and falling nearly to its natural standard in the inter- vals. Of eleven cases treated by Dr. Gerhard, at the Pennsylvania Hospital, in 1834, and all terminating in recovery, the pulse was over 100 in only two. It is very rarely that it has the hard, tense feel of the open inflammatory pulse. Sometimes it is moderately hard and strong, or jerky; but, more commonly, it is rather soft and feeble. Towards the close of fatal cases, the pulse usually becomes excessively rapid, " becoming smaller and thready, and at length imperceptible."2 Dr. Boling remarks, that the action of the heart is laboring and strong, its sounds louder than natural, and its impulse more forcible. ARTICLE III. THORACIC SYMPTOMS. Very few writers upon remittent fever make any formal mention of symptoms connected with the respiratory organs; and it seems quite certain that thoracic complications are rare and accidental. Bronchitis, sometimes with mucous rattle, but oftener without it, occurred in twelve of Dr. Swett's thirty-four cases; and he thinks that pneumonia was the immediate cause of death in two instances. Dr. Stewardson speaks of the general infrequency of this class of symptoms; and Dr. Boling merely mentions the moderate accelera- tion of the breathing usually accompanying febrile excitement. ARTICLE IV. CEREBRO-SPINAL, OR NERVOUS SYMPTOMS. Sec. I.—Headache; Pains in the Back and Limbs. Pain in the head, back, and limbs, is one of the most constant, and in many 1 Amer. Journ. Med. Sci., April, 1846. 2 Dr. Swett, in his account of thirty-four cases treated at the New York Hospital, in 1844, says that, during the paroxysm, the pulse usually ranged from 106 to 112, falling in the intervals to 96 or 100. 352 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. cases one of the most distressing accompaniments of this disease. Cleghorn says he has sometimes known this pain so intolerable, and accompanied with such inexpressible anxiety, that persons of the soundest judgment and morality have been tempted to destroy them- selves to get rid of it.1 Dr. Stewardson found headache present in all but one of sixteen cases, terminating in recovery. It generally commenced on the first day of the fever, was most severe during the exacerbations, and commonly declined after the middle period of the disease, at least during those hours of the day when the pa- tients were visited.2 Dr. Boling gives the following account of this symptom as it shows itself in severe cases : " As the febrile excite- ment is developed in the first exacerbation, pain in the head becomes violent and distressing, and is of a throbbing character. It is gene- rally in the forehead, just above the frontal sinuses, but is also occa- sionally felt in the occipital region. During the earlier remissions it either abates or entirely subsides, but, later, is very distressing during the remissions. At this period, too, it loses its throbbing, pulsating character, and is fixed and steady."3 Sec. II.—Mind. Decided delirium is not a common symptom, at least in mild cases, and in those of moderate severity. There was slight delirium in only one case of eleven, terminating in recovery, at the Pennsylvania Hospital, in 1834. Of fifteen cases, also termi- nating favorably, in the same institution, observed by Dr. Steward- son, delirium was noticed in only two. In one it was slight; in the other violent, and in both confined to the exacerbations. Of Dr. Swett's thirty-four cases, at the New York Hospital, there was do* lirium in five. Dr. Boling's account of this symptom, as of many of the others, is more particular and minute. It is important to remember that he is speaking only of grave cases, although always of the simple and not the malignant or congestive form of the dis- ease. " Where the febrile excitement runs high," he says, " slight temporary delirium occurs, even during the first exacerbation. It is most frequently associated with a drowsy stupor, during the par- tial waking from which it is manifested, and passes away as soon as the patient is sufficiently roused to bestow his attention. This de- lirium, like the dry tongue in the first exacerbation, may be present in cases of but moderate severity, and under the use of a gentle 1 Dis. of Minorca, p. 132. 2 Amer. Journ. Med. Sci., April, 1842. 3 Ibid., April, 1846. SYMPTOMS. — SENSES, AND PHYSIOGNOMY. 353 cathartic, a small bleeding, or the spontaneous evacuation of the stomach, disappear, not to return again in the succeeding exacerba- tions, although the violence of the disease may not be subdued; and, indeed, in cases in which the symptoms generally are on the increase as regards severity, it may remain absent during several exacerba- tions, and then again appear, or may not return again at all, should the patient recover; or, should he die, but in the last exacerbation. With the exception of this temporary delirium just spoken of, a patient is apt to pass through several exacerbations without any intellectual aberration. It generally occurs earlier in sanguine, plethoric subjects, and in such is less indicative of danger. Once fairly established, with the exceptions above noted, like all the other phenomena of the disease, while the other symptoms are on the increase, this one is also progressive, and becomes worse and worse with every exacerbation. During the remissions, at least the earlier ones, the delirium disappears, and even in the later ones generally abates considerably in violence, though but shortly before a fatal termination. An amendment once commenced, in a case where the delirium disappears during the remission, this symptom scarcely ever returns, however slow the progress of the cure; but where the delirium remains during the remission, it may continue even after a decided amendment has taken place, abating more or less every day till its complete disappearance, which always takes place during the hour of remission. The delirium is scarcely ever so violent, except in a few malignant cases that run through their course very rapidly, as to require any restraint of the patient. In a very few protracted cases only does it assume that character called low and muttering, and is seldom if ever attended with picking the bedclothes, or subsultus tendinum, though, occasionally, the hands are extended in sleep, as if reaching for some imaginary subject of a troubled dream."1 Somnolence, dulness, or stupon, is an occasional but not very constant or striking symptom. Sec. III.—Senses, and Physiognomy. Dizziness and ringing in the ears are present in a certain number of cases, but they are far from being common. Deafness is hardly ever noticed. Dr. Boling says: " The expression of the eye has nothing peculiar in it in the earlier exacerbations. Where the febrile excitement runs high, it is, perhaps, bright and sparkling, the conjunctiva retaining its 1 Amer. Journ. Med. Sci., April, 1846. 23 354 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. pearly whiteness, and this sometimes continues to the last par- oxysm; the patient's countenance wearing now an expression of indescribable anxiety. At other times it is suffused, and of a reddish muddy tinge; its motions are slow and languid; and, in such instances, the countenance wears rather an expression of dull indifference." Sec. IV.—Muscular Strength. Prostration of muscular strength, and a sense of debility, are early and almost invariable attendants of remittent fever. But, according to Dr. Boling, this extreme degree of feebleness is sometimes more apparent than real. He says: " The sensation of debility is extreme, and is frequently as much complained of in the first or second exacerbations as later in the disease, when the actual debility is much greater. At a time when a patient will make complaints of the greatest debility, let it become necessary for him to get up, or assist himself in any way, and he will do so without any call for aid ; or if he does demand it, will show himself at the same time capable of considerable muscular exertion. It is only in very protracted cases—and few such occur in this part of .the country—that the patient requires much assist- ance in performing any necessary movements, provided he is suffi- ciently sensible to be aware of what is necessary."2 Twitching of the tendons, and hiccough, are present in a small proportion of cases. ARTICLE V. DIGESTIVE AND ABDOMINAL SYMPTOMS. Sec. I.—Tongue and Mouth. The tongue is generally more or less thickly covered with a yellowish, or dirty white fur—the color being probably occasioned in many cases by the fluids ejected from the stomach. The edges of the tongue are often somewhat redder than natural. During the early periods of the disease the tongue usually retains its moisture; but in grave cases, especially, and after the third or fourth paroxysm, it frequently becomes parched and dry, dark brown, or nearly black on the dorsum, more intensely red on its edges, and sharpened at its point. Dr. Swett found the tongue usually coated, first with a thin white, and at length with a more thick and dirty coat, but remaining moist to the end of the 1 Amer. Journ. Med. Sci., April, 1846. 2 Ibid., April, 1846. SYMPTOMS.—APPETITE AND THIRST. 355 disease, in at least two-thirds of the cases; it was noted as becom- ing dry in only twelve of thirty-four cases.1 These and other morbid states of the organ are much more strongly marked during the paroxysms than in the intervals, at which time the tongue often returns nearly to its natural condition. In eleven of Dr. Steward- son's cases which recovered, where this point was noticed, the tongue began to clean on or before the twelfth day in eight, and from the thirteenth to the twentieth in the remaining three. There is more or less dryness of the mouth during the febrile paroxysms. " Late in the disease," says Dr. Boling, " when the ease is of so aggravated a character that a few shades further put it beyond hope, the whole interior of the mouth becomes as it were almost completely dry, and the mucus, inspissated, dry, and black, is collected on the lips and between the teeth. The patient, during the first two or three paroxysms, frequently complains of a bitter taste in the mouth; but after this, with the exception of the im- pression made by matters vomited up, and the taste left by medi- cine, nothing peculiar in this respect is observed, till the commence- ment of convalescence, when a disagreeable bitter taste is again complained of for a few days."2 Dr. Stewardson says sordes about the teeth either did not exist or were so slight as not to be noticed. Sec. II.—Appetite and Thirst. The testimony of observers is very uniform in regard to the entire absence of appetite for food. Dr. Boling says: "From the commencement of the attack, during nearly the whole period of the disease, the disgust for food is almost insurmountable. It is only during one or two of the earlier and more complete remissions that a patient can be induced to swallow any kind of nourishment, and that only at the solicitation of friends, and not from any desire of his own. Towards the close of a case that is taking a favorable turn, and before the establish- ment of complete convalescence, he will swallow a few spoonfuls of light broth, or something of that character ; and even then not to gratify any desire of his appetite, but from a persuasion that nourishment is necessary for him in his weak state. When con- valescence is completely established, the appetite is generally craving, and the strength is rapidly restored. In the case of negroes, the disgust for food is a much less prominent symptom.3 1 Am. Journ. Med. Sci., Jan., 1835. 2 Ibid., April, 1846. 3 This peculiarity in the case of negroes was noticed by Dr. Gerhard in the epidemic typhus of Philadelphia, in 1836, and has already been spoken of in this work. 356 PERIODICAL FEVER.—BILIOUS REMITTENT FORM. The thirst, the desire being.for cold drinks, is most excessive from the very first paroxysm, and this is almost the only symptom of the disease which does not increase with the repeating exacerba- tions, so long as the disease may be considered unchecked. Bu although the thirst in the first exacerbation is, as a general rule, so great as to leave no room for it to increase, it is not so with the remissions. During the first remission the thirst abates somewhat, but this abatement is less and less with each one that succeeds, and after a while, even during the period of remission, the thirst is most excessive, and large draughts will be rapidly and in quick succes- sion swallowed, although with the confirmed assurance that in a few minutes they must be returned. Pure cold water is the drink most generally preferred, and if any addition is at all desired, it is always something sour, such as vinegar, tartaric acid, or lemon- juice.1 Dr. Baldwin, in his account of the bilious remittent fever which prevailed in Burke County, Georgia, in 1831, says that a bitter taste in the mouth, and an intolerable thirst were universally present.2 Bailly says: " One must be sick at Rome, in order to know the happiness of drinking cold water."3 Sec. III.—Nausea and Vomiting. These symptoms are amongst the most constant phenomena of the disease. Vomiting very often accompanies the first rigor; and in most cases is more or less fre- quently repeated, especially in the paroxysms, during the whole course of the disease. The fluids ejected from the stomach are usually of a greenish or yellowish tinge, varying in shade and intensity in different cases. Dr. Boling says that, in grave cases, and in the advanced periods of the disease, although the efforts to vomit become more incessant, the matter vomited diminishes in quantity, so that frequently, in hours of straining and retching, nothing is thrown up but the drinks which had recently been swallowed. Sec. IV.—Epigastrium and Abdomen. Another symptom belong- ing to this strongly marked group, and almost invariably present, is pain or tenderness of the epigastrium, increased by pressure. There is also some degree of fulness, or a sense of fulness, weight, tension, and oppression, extending across the hypochondria, espe- cially on the left side, in the region of the spleen. This feeling is 1 Amer. Journ. Med. Sci., 1846. 3 Traite des Fievres Intermittentes, p. 137. 2 Ibid., Feb., 1832. SYMPTOMS.—BOWELS. 357 often quite distressing, and adds much to the discomfort of the patient. The epigastric uneasiness and oppression are often relieved, temporarily, at least, according to Dr. Boling, by the act of vomiting. True tympanitic distension of the abdomen is of rare occurrence.1 Enlargement of the spleen is rendered manifest by the increased and extended dulness on percussion over the region of this organ. Sec. V.—Bowels. The bowels are, to say the least, generally free from any considerable degree of irritation, so far as this is indicated by pain or diarrhoea. Of Dr. Gerhard's cases at the Pennsylvania Hospital, there was diarrhoea in only one in seven. Dr. Stewardson, in his account of seventeen cases, which were treated at the same institution, in 1838, all terminating in recovery, says : " The bowels were generally costive, the purgative medicines which were given both before and after admission rarely occasion- ing hypercatharsis. In a few instances, spontaneous purging was present near the commencement of the disease, and continued for a few days; but subsequently the bowels were either regular or costive, unless when operated on by medicine."2 Dr. Swett remarks that diarrhoea was absent in almost every case, that all his patients required purgatives at some period of the disease, and that they usually acted freely without leaving any symptoms of irritation behind them. Dr. Boling thinks that this disposition to sluggish- ness in the bowrels has been over-stated, and that, although spon- taneous purging may be rare, there is still a strong tendency to 1 Dr. Boling has an observation somewhat opposed to the statement which I have considered myself justified in making in relation to this symptom. "Some- times," he says, " in cases of a very violent character, this tympanitic distension supervenes early in the disease under the action of a few small doses of purgative medicine, and accompanies almost always a spontaneous diarrhoea, which, in a few cases, makes its appearance early." In the absence of any distinct and conclusive information upon this point, one can hardly avoid the suspicion that the cases thus marked by tympanites, and spontaneous diarrhoea were cases of typhoid fever. A previous remark by Dr. Boling justifies, I think, the suspicion which I have ventured to suggest. Towards the close of protracted cases, he says, there is some- times an obscure sensation of pain between the umbilicus and the right iliac fossa. At any rate, be this as it may, the general absence of this symptom is expressly admitted by Dr. Boling, as well as by other observers. Dr. Gerhard found it in only two of eleven cases at the Pennsylvania Hospital. Dr. Stewardson says, in the history of his cases, that flatulent distension, except in a slight degree, was not noticed in a single instance ; and Dr. Swett says that tympanites, even in the cases where prostration was most marked, seldom or never existed. 2 Am. Journ. Med. Sci., April, 1842. 358 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. diarrhoea—a tendency rendering great caution necessary in the use of cathartics, especially after the first or second exacerbation. It is very probable that the irritability of the bowels may be greater during certain periods, and in certain localities than in others; and it is very important, furthermore, to remember that Dr. Boling expressly excludes from his description the entire class of mild or moderate cases. The character of the discharges from the bowels seems to vary very considerably in different seasons, and in different localities; and not unfrequently, also, during the different periods or stages of the disease. The more general, and to a certain extent character- istic appearance of the stools, is that which has been denominated bilious. These stools vary in color, from different shades of yellow and green, to olive, brown, and almost black. Sometimes this bilious quality of the discharges is entirely wanting. In the fever of 1831, in Dallas County, Alabama, Dr. Heustis found, early in the season, the discharges from the bowels mostly of a light clay- colored complexion, with very little of the black, green, or bilious discoloration so generally present. In a few cases that occurred after the commencement of cool weather, the stools were highly colored, of a dark green, olive, and almost black; becoming in the progress of the complaint of a lighter hue, between an olive and a brown, and of a gelatinous, sleek, and oily appearance, but not peculiarly offensive.1 Dr. Swett says : " In many the secretion of bile, as marked by the stools, was much increased in quantity or altered in its color, so as to constitute one of the most striking symptoms of the disease. This was observed in fifteen or about one-half the cases; while it was also noticed in many, even of the worst cases, especially among those which were admitted early in the season, that no apparent deviation from the healthy standard took place112 Lumbrici frequently accompany the discharges, especially amongst negroes and children.3 Sec. VI.— Urine. Observers are not agreed amongst themselves in regard to the state of the urine. Cleghorn says: "The urine, whether made in the time of the paroxysm or interval, is always clear, frothy, and of a deep red color, without any separation."4 Senac lays greater stress on the appearance of the urine, as charac- 1 Amer. Journ. Med. Sci., Feb., 1832. 3 Boling on Rem. Fever. 2 Ibid., Jan., 1835. 4 Dis. of Minorca, p. 133. SYMPTOMS.—URINE. 359 teristic of periodical fever. " Masked intermittents," he says, "may be no less certainly detected, as was formerly observed, by the color of the urine. In that disease the urine is very often lateri- tious during the remission, which is a sign almost infallible that the disease belongs to this family."1 According to Dr. William Currie, the urine during the cold stage is pale, copious, and crude; but as soon as the hot stage is established, and during its height, it becomes high-colored ; while in the remission it is thick and cloudy, and sometimes deposits a brick-colored or brownish mucous sedi- ment.2 Dr. Stewardson says : " The urine, where noted, was mostly clear, sometimes straw-colored, at others highly colored, reddish, or of a more or less deep yellow, approaching to orange."3 Dr. Swett found the urine generally natural in appearance, and without sediment throughout the disease.4 Dr. Boling, on the other hand, says: " The secretion of urine is scant and highly colored and muddy, during the exacerbation, from the coloring matter floating suspended in it; and sometimes late in the disease is of a deep red- dish brown, possessing apparently a degree of consistency greater than natural, and is passed with pain. In the remissions it is more copious and transparent, but throws down a muddy flocculent deposit sometimes; at others a red, pulverulent matter."5 [Dr. Ford, studying the African type of periodic fever, attaches prognostic importance to the appearance of the urine. In the period of reac- tion, he says : "The urine is always changed, it becomes scanty in most cases. The color in ordinary mild cases is brown, in the malignant cases red or black. There is no more constant symptom of violent disease than these changes in the urine."6] 1 Caldwell's Senac, p. 122. 3 Amer. Journ. Med. Sci., April, 1842. 6 Ibid., April, 1846. 2 Currie on Bil. Fev., p. 46. 4 Ibid., Jan., 1845. 6 [Observations, &c, p. 9.] 360 CHAPTER III. ANATOMICAL LESIONS. ARTICLE I. LESIONS OF THE THORACIC ORGANS. Sec. I.—Lungs. The substance of the lungs, and the mucous lining of the air-tubes, are the seat of no constant or important lesion. Congestion of the former, especially in their posterior portions, and more or less redness of the latter, are found in a certain proportion of instances. Two of Dr. Swett's cases were complicated with pneumonia. Bailly mentions the lungs in only a part of his cases, and in nearly every instance where he does so, calls them healthy. Maillot found the lungs as free from disease as after death from any acute affection. Sec. II.—Heart; Blood. The muscular tissue of the heart is frequently softened and flabby. Dr. Stewardson found this organ flabby in three of the six cases in which it was particularly examined, and combined with this flabbiness there was diminished consistence at least in two cases. In nine of Anderson and Frick's twelve cases, the heart was examined, and in all of them its muscular tissue was found to be more or less softened. Maillot found the heart in six cases pale and softened, once of a yellowish color and flabby, once flabby with dilatation of the left ventricle, and in four cases with hypertrophy of the walls of the left ventricle.1 In another place, Maillot calls the paleness and flabbiness of the heart, mentioned above, " truly remarkable112 Dr. Swett does not seem to have noticed particularly this alteration. In the three cases of Dr. Stewardson, where the heart was softened, its inner membrane was of a reddish brown, deep red, or violet color; in Anderson and 1 Traite des Fievres Intermittentes, p. 286. 2 Ibid., p. 291. LESIONS.—BRAIN. 361 Frick's cases, this membrane is generally described as pale. In regard to the nature of the foregoing lesions, I can only repeat what has already been said upon the same subject in connection with typhoid and typhus fever. The state of the blood in remittent fever has not yet been made the subject of sufficiently extensive or accurate study to justify us in saying anything very positive about it. Dr. Swett does not notice the blood at all, except to say that in one case, examined in the heart, it was fluid. Bailly takes no special notice of it. Dr. Stewardson examined the blood contained in the cavities of the heart in five cases': in one, there were black coagula, mixed with red serum ; in the others, fibrinous, coagula, soft in two, semi-trans- parent and greenish in another, and generally small. No large, firm, fibrinous coagulum was found in a single instance.1 The state of the blood in the heart is mentioned in only one of Anderson and Frick's cases; in this there were large fibrinous concretions. ARTICLE II. LESIONS OF THE CEREBRO-SPINAL APPARATUS. Sec. I.—Brain, and its Envelops. I do not think that the condi- tion of the brain and its membranes, after death from remittent fever, has yet been satisfactorily determined. It was examined by Dr. Stewardson in five cases. "The sub-arachnoid effusion was either entirely wanting or moderate, except in one case where there was a considerable quantity of reddish serum. In the same case, the ventricles contained an ounce of bloody serum, whilst in two of the others they were empty, in a third nearly so, and in the fourth contained scarcely a drachm of fluid. In one, the walls of the ventricles were of a yellow color. The pia mater was deeply injected in one case, in which also there appeared to be a slight effusion of blood into the cells in a small circumscribed space; its veins much distended posteriorly in another. The cortical sub- stance was of a deep shade in two cases, and in none is it mentioned as being paler than natural, or presenting other alteration. In two cases, the medullary substance was natural; in a third, it felt pasty without giving the sensation of softness ; whilst in a fourth it was soft and pasty, being at the same time dry and of milk, white color, 1 Amer. Journ. Med. Sci., April, 1841. 362 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. with few bloody points. In a fifth its color was a dirty white, mixed with a faint reddish brown—its consistence natural, with the ex- ception of a slight central softening."1 Dr. Swett describes the substance of the brain as natural in four of his five cases; in the other, the central portion of the left side was somewhat softened. In two cases, there was slight sub-arachnoid effusion. Neither Dr. Stewardson nor Dr. Swett seem disposed to regard these cerebral lesions as in any degree important, or peculiar to this disease; they look upon them as wholly accidental, or at least such as occur with the same frequency and to the same extent in other acute febrile affections. This conclusion may prove to be sound ; but I do not think that we are justified in adopting it without more extensive researches. In ten of the twelve cases reported by Anderson and Frick, the brain and its membrane were examined, and in all of them there was more or less alteration. In eight, the substance of the brain was more or less injected; in two, it was natural. In two cases, the pia mater was healthy; in the others, it was injected, or its meshes infiltrated with serum, or both; in one case, there were three ounces of serum between the arachnoid and dura, mater.2 In their connection with this subject, I have examined and analyzed with some care the cases reported by Bailly. They occurred at Rome, during the summer of 1822. It is important to remark that they all belonged to the variety of pernicious intermittents, as they are called; in other words, they were cases of congestive fever, as were also many of those the lesions of which have already been described. Most of them were of the comatose form; four only belonging to the strongly marked cold or algid variety. In twenty- five or twenty-six cases, the prominent cerebral symptoms during the paroxysms were stupor or coma—the latter often profound —in many, spasmodic contractions of the muscles of one or both arms; and in some few, delirium. The cerebral symptoms were also present in the algid cases, but less constantly and less strongly marked. In seventeen of the thirty-one cases in which the brain was examined, there was extensive or general inflammatory injection of the arachnoid membrane. In many instances this injection is described as intense, universal, and fine, extending to the minutest capillaries, and resembling a beautiful anatomical preparation. In some cases it was rather more strongly marked on one side than on the other. In two cases the meshes of the membrane contained ' Amer. Journ Mod. Sci., April, 1841. 2 Ibid., April, 1846. LESIONS. — BRAIN. 363 coagulated blood; and in two or three there was an effusion of fibrin. In the remaining fourteen cases the membrane is described as moderately or slightly injected; in only three or four was it natural. Another alteration consisted in a dark reddish-brown color of the cortical substance of the brain. This was present and strongly marked in ten of thirty-one cases, all of which were of the comatose form.1 In one case, of the algid variety, the cortical substance was paler than natural. In nine cases, sections of the brain were immediately covered with numerous bloody points from the orifices of the.cut vessels; in a certain number, also, there was more or less venous engorgement of the superficial vessels, and a moderate accumulation of serum; but all these changes are fre- quently found in other diseases, and, as has already been said, can hardly be regarded as peculiar or important. The following important additions to the pathology of the nerv- ous centres in periodical fever, mostly of the pernicious form, are derived from the excellent and accurate work of Maillot. He 1 This alteration would seem to have been more frequent than is indicated by this proportion of cases in which it occurred. It is probable that Bailly mentioned it in his descriptions, only when it was strongly marked. It may be a matter of interest to my readers to see his remarks upon it. He says : " The brown color of the cortical substance was so generally present in those who perished with coma- tose fever, and in whom the coma returned with each successive paroxysm, during a great part of the summer, that I came at last so far to habituate myself to this shade as to consider it almost natural. Although I had formerly been especially occupied in France with the anatomy of the brain, and had thus familiarized myself with a type of the natural color of the cortical substance, as must always happen with those who labor constantly upon any similar subject; still, the habit of seeing none but the brains of these comatose patients, had at last substituted a new type for the old one. I therefore seized every occasion that presented itself.of comparing these brains with those of individuals who had died with other diseases ; and then the enormous difference between the two classes became manifest. For pathological anatomy demands not only extensive observations, but continual comparisons between healthy and diseased organs. Show the brain of a person who has died with comatose congestive fever to a physician but little in the habit of examining brains, and very certainly he will consider himself authorized to deny the alteration, which is quite evident to one who is familiar with the natural appearance of this organ. During the epidemic constitution of the year 1822, at Rome, there were fatal cases of phthisis, aneurism, dropsy, and so on, in which the brain was not implicated. Now, the cortical substance of the brain in these cases, when placed by the side of that of the fever patients, as I have noted in many instances, appeared white. In many instances, the morbid condition of organs is so slight or obscure that its existence may be questionable; but this of which I am now speaking I have found so many times, and so constantly, and it has been so marked and evident, that not one physician in a thousand would have hesitated in admitting it."— Traitc An at. Path, des FiUvres Inter. Par. E M. Bailly, de Blois, p. 181. 364 PERIODICAL FEVER.—BILIOUS REMITTENT FORM. examined the brain and its membranes in twenty-seven cases. In five cases, he found general opacity of the arachnoid; in three cases circumscribed opacity; in one case of icteric algid fever, the arach- noid had a yellowish tinge; and in one case, where a quotidian fever had passed into a typhoid condition, the cavity of the arach- noid contained a sero-purulent collection. In eleven cases, the pia mater was injected more or less vividly, the arachnoid remain- ing natural; in six other cases, both membranes were the seat of a vermilion injection; in most cases, the vessels which run along the surface of the brain were strongly congested; many times the injection of the cerebral envelops was sufficiently fine to form patches, more or less extensive, of a vivid and brilliant red. In twenty-two cases, the cerebrum was more or less strongly injected, in most instances with a firmness and density that appeared to M. Maillot much greater than natural. Generally, the substance of the brain exhibited a red color, very thickly dotted with bloody points; in some cases of comatose and delirious fever, the cerebral mass was so strongly congested that when compressed after having been divided, the blood flowed copiously from the cut surfaces. In eight cases, the gray substance had a very dark color, in five of them approaching a blackish tinge; in six cases, the choroid plexus was of a deep red color; in ten cases, the ventricles contained bloody serum. In one comatose case, the brain was strongly injected, but soft; in one icteric algid case, it was slightly injected, of natural consistence, and of a yellow color; in three other cases, it was slightly injected, but without change of color or consistence. The cerebellum exhibited changes analogous to those of the brain, but less frequently. In fourteen cases, the spinal pia mater was the seat of a vermilion injection; in five cases, the pia mater and arachnoid were both injected; in one case of algid fever, both had a yellowish color; in one case, their condition is not mentioned. In four cases, the substance of the spinal marrow was generally injected and firmer than natural; in one case, it was less firm than natural; in one case, the injection was very slight; in three cases, its consistence was natural, without any injection; in two cases, the injection was general, but it was much more strongly marked at the cervical and lumbar regions than elsewhere; in one case, it had a yellowish tinge, without any other alteration ; in four cases, there was gene- ral injection, with red softening of the dorsal portion; in three cases, there was white softening of the dorsal portion; in one case, LESIONS. — LIVER. 365 there was white softening of the cervical portion; and finally, in one case, the injection of the gray substance, generally more consi- derable than that of the white, was very strongly marked in the cervical region, and carried to the red softening in the dorsal. In all these cases, death took place in the acute period of the disease. Maillot says, in another place, that these lesions are found in all the varieties of pernicious fever, but that in the algid form he has found the cerebral congestion less strongly marked than in the -comatose and delirious, while the spinal changes have been more so than in these.1 In four cases reported by Mr. Nepple, the lesions of the brain described by Bailly and Maillot were not observed. In two cases reported by M. Raymond Faure, they were present.2 The fine injection of the membranes, the dark color of the corti- cal substance, and the general vascularity of the brain, would seem to constitute sufficient evidence of the previous existence, at least, of a high degree of irritation, approaching, and in some instances perhaps passing into actual inflammation. The same remarks may be made in regard to the spinal marrow and its envelops. ARTICLE III. LESIONS OF THE ABDOMINAL ORGANS. Sec I.—Liver. I commence this article with a full account of the condition of the liver, because there is good reason for believing that the lesions of this organ constitute the anatomical characteristic of the disease. For this discovery, and for the special attention which has recently been directed to the state of the liver in period- ical fever, we are indebted to Dr. Thomas Stewardson, of Savannah, Ga. Dr. Stewardson, before leaving Paris, in 1834, had been made acquainted with the observations of Louis on the state of the liver in all the fatal cases of yellow fever examined during the epidemic in Gibraltar of 1828: and on his return, soon after, to America, he naturally felt a strong interest in ascertaining whether the same lesion was to be found in remittent fever, a disease regarded by many physicians as a mere variety of yellow fever. Opportunities for determining this interesting and important point of pathology soon presented themselves, and were zealously and faithfully made 1 Traite, etc., p. 334. 2 Traite des Fievres Intermittents, p. 283, et seq. 366 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. use of. Cases of periodical fever, in its several forms and degrees, are annually received into the Philadelphia hospitals, coming mostly from certain localities in Pennsylvania, and from the southern ports of the Atlantic, and occurring amongst sailors. During the years 1838, 1839, and 1840, there were seven cases of the disease, which terminated fatally, and in which autopsies were carefully made. The first examination was made on the 9th of September, 1838, seventeen hours after the death of the patient. The form of dis- ease was that most nearly approaching yellow fever. The liver was of natural size, flabby, and of a bronze color, becoming livid in the small lobe; internally, it was of a uniform light bronze color. The acini were distinguishable by a slight elevation, but there was no difference of color in the two substances. The history of the condition of the liver is thus summed up by Dr. Stewardson: " The liver was enlarged in three cases, and in one of them to a great degree; in the others, it was of natural or moderate size. The consistence of the organ appears to have been generally dimi- nished, being flabby or softened, or both, in four cases; a little soft in a fifth; and moderately firm, but still readily penetrated by the finger, in a sixth; in a seventh, the consistence is not men- tioned. The color was nearly the same in every case, but very different from natural. In most of the cases; the liver is described as being of the color of bronze, or a mixture of bronze and olive; in one as a dull lead color externally, internally bronzed with a reddish shade; in another as between a brown and an olive, the latter pre- dominating ; and finally as a pale, slightly greenish lead color, with a tinge of brown in one instance. The most correct idea of the color before us would, perhaps be conveyed by stating its predominant character, the same in every case, to be a mixture of gray and olive, the natural reddish brown being entirely extinct, or only faintly to be traced. This alteration existed uniformly, or nearly so, throughout the whole extent of the organ, except in a single instance, where a part of the left lobe was of the natural reddish- brown hue. As the alteration of color pervaded both substances, the two were frequently blended together, and the aspect of the cut surface remarkably uniform. In one case, however, there was a marked distinction of color, the olive being predominant in the parenchyma, the brown in the acini. Of the four cases in which these characters are mentioned, the cut surface is described as smooth in three; of a shagreened appearance, and rough in the left lobe, in the fourth. This last character was evidently depend- LESIONS. — LIVER. 367 ent upon hypertrophy of the lighter colored substance, which existed also in another instance, both cases, however, being exam- ples of a very protracted form of the disease."1 In concluding the summary thus given, Dr. Stewardson very naturally suggests, at least the strong probability, that this alter- ation of the liver may be found to constitute the essential anatomi- cal characteristic of marsh fever, as the lesion of Peyer's glands, and the lymphatic ganglia, constitutes that of typhoid fever. He very properly, however, admits that the number of cases is not sufficiently large to determine this point conclusively ; and he refers its definitive settlement to future and more extended observations. In this connection, he states that, in the only case of marsh fever examined during the year 1840, at the Blockley Hospital, by Dr. Gerhard, the liver presented the appearances which have just been described. The investigations which have been made and published, since the appearance of Dr. Stewardson's paper, are the following. In January, 1844, Dr. Wm. T. Howard communicated to Dr. Steward- son the history of a case which was observed in the Baltimore Almshouse, during the preceding season. " The liver was smooth externally, and of a uniform slaty, bronze color, marked with white striae through it. When cut into, it presented the same uniform slaty, olive, or bronze color, with the red and yellow substances confounded together, so as not to be distinguished. It was moist when cut into, its vessels not much gorged with blood, and it was easily penetrated by the finger. No one portion was more changed than another."2 Dr. Swett's cases, observed in the New York Hospital have already been referred to. Five of them were fatal; and in all, the peculiar change in the color of the liver, described by Dr. Stew- ardson, was present. Externally, this organ had a slaty and bronze tint, and an olive tint internally. Its volume was natural; in four cases it was slightly or moderately softened; in some cases the granular structure was less distinct than in a natural state, while in others it was not altered; in one case each granule was surrounded by a ring of vascular injection. There was no unusual accumula- tion of blood.3 1 Stewardson on Rem. Fever. Am. Journ. Med. Sci., April, 1841. 2 Am. Journ. Med. Sci., Jan., 1845. 3 Swett on Path. Rem. Fev. Amer. Journ. Med. Sci., Jan., 1845. 368 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. Dr. Alfred Stille* has published, in the American Journal of the Medical Sciences, for April, 1846, brief histories of twelve fatal cases of remittent fever, which occurred during the summer and autumn of 1844, in the Baltimore Almshouse Infirmary, and which were reported by Dr. W. F. Anderson, and Dr. Charles Frick. Setting aside two of the cases, on account of some doubtful or qualifying circumstances in their history, the condition of the liver in the other ten is thus summed up by Dr. Stille". "The size of the liver was noted in nine cases, in all of which it was unnaturally large. Its consistence was very much diminished in ten cases, in eight of which the right lobe was the principal seat of the altera- tion ; in one the left lobe was chiefly affected, and in the remaining one the whole organ was softened. In all the color of the liver was either bronzed, or like that of slate ; the surface of a section was polished or shining; and in every instance but one the different colors of its component parts could not be distinguished."1 Dr. Stille remarks, in the number of the Journal which contains these histories, that the same condition of the liver has been found in numerous dissections made at the several public institutions of Baltimore, during the fever season of 1845. The result of Dr. Boling's observations can hardly be regarded, in the present state of our information upon this subject, as of any great value; at any rate, these results are not sufficiently authentic and conclusive to throw any reasonable doubt upon the conclu- sions of Dr. Stewardson, Dr. Swett, and others. He says that, not having found the changes in the liver which he had looked for, he was led to believe that lesions of this organ were less frequent than of almost any other. On the appearance of Dr. Stewardson's paper his attention was again directed to the liver, but he has been able, he says, in but a very few instances to find any alteration, the organ in a large proportion of cases, so far as he was capable of judging, being entirely healthy. Where it was otherwise, he found the con- cave surface of the liver of a bluish slate color. Dr. Boling does not give any detailed histories of his autopsies; he speaks of him- self as not accustomed to frequent post-mortem examinations; and, as I have already intimated, it will be considered, in the actual state of our knowledge, as a perfectly fair judgment, that these cases shall, provisionally, at least, be set aside, and not be allowed to have any effect on the settlement of the question before us. Maillot 1 Swett on Path. Rem. Fev. Amer. Journ. Med. Sci., April, 1846. LESIONS. — LIVER. 369 describes the liver in nine cases as congested; in three cases as easily torn; in one case as friable; in three cases as yellowish, pale, and somewhat softened; once as greenish yellow; once as chocolate colored; and in five cases as natural. In five other cases its condition is not mentioned.1 It would be hardly worth the time and room necessary for this purpose, to go into any detailed account of the pathological re- searches of older writers upon this family of diseases. The Italian authors—Baglivi, Lancisi, Torti, Ramazzini, etc.—the great classics in this department of medicine—are not at our hand; and if they were, they would be of little service, as they are said to give but meagre and unsatisfactory details in regard to the state of the organs after death. George Cleghorn, in his admirable little treatise on the diseases of Minorca, written more than a hundred years ago, says that he had examined the bodies of near a hundred persons who had perished with tertian fevers, and had constantly found "one or other of the adipose parts in the lower belly—the caul, mesentery, colon, etc.—of a dark black complexion, or totally corrupted." Bailly, in his elaborate and interesting history of the pernicious intermittents of Rome, reports a large number of autopsies; but in many of them the liver is not mentioned; in others it is said to have been gorged with blood; and in others it is called natural. It need hardly be said, that the overlooking by these writers, and under such circumstances, of a lesion like that under consideration, is no proof that it did not exist.2 There seems to be no uniformity in the character of the bile contained in the gall-bladder. Dr. Stewardson found it generally abundant and very fluid; while in nearly all the cases reported by Dr. Swett, Dr. Anderson, and Dr. Frick, it was dark, thick, and viscid, like molasses. Bailly rarely mentions the appearance of the bile. As to the nature of the lesion of the liver just described, it is impossible, in the present state of science, to say much, without running into the merest speculation. We have no right to consider it inflammatory. It may be the result of repeated congestions; but it is more philosophical, for the present, to say simply, that it seems to be sui generis—to consist iu an alterationof a special and pecu- 1 Traite des Fievres Intermittentes, p. 285. 2 Prost is said to have exhibited the, extensive intestinal lesions of typhoid fever in bodies which had been examined by Pinel and Corvisart, and the alterations wholly overlooked. 24 370 PERIODICAL FEVER.—BILIOUS REMITTENT FORM. liar character, the nature and mechanism of which are quite un- known to us. It is probably connected in some way with the poison of periodical fever—alike unknown to us—and it may be the result of the action of this poison upon the system, or of the morbid processes to which the poison gives rise. [The cause of the peculiar color in the bronze or olive liver of remittent fever, has occupied the attention of the Editor. His views are published in the first volume of Dr. La Roche's great work on Yellow Fever, as a note or appendix. It is there stated that the hue is produced by an infinite number of colored, microscopical particles of irregular shape and size, totally different from anything that enters into the constitution of the healthy liver; that these colored particles are scattered irregularly through the hepatic tissue, are seen to occupy the secreting cells of the organ, and even the nuclei of these cells; that they vary in hue from red or orange to an opaque, jet black, though much the greater number are of a semi-transparent, dark brown color; and that, in shape, the red and dark brown particles are, some beautifully crystallized, some in globular dots and grains; while the black, often in globular grains, are also seen in friable, semi-crystalline scales, some of them almost large enough to be seen by the naked eye. The nature of this coloring matter, it is stated, must be sought among the chemical transformations of the hematin, or coloring principle of the blood. The belief is expressed, that in the remittent fever, as in many other diseased states, the hematin is readily yielded by the blood, and passing into the liver substance, there meets with some unknown agent, which changes its chemical constitution, and converts it into the forms and colors here described. To explain why the liver is the seat of this particular change, reasons are offered for the con- viction that this organ is the seat of hyperaemia, falling short of inflammation, or, as Dr. Bartlett has expressed it, " of repeated congestions," in the course of remittent fever, in a degree not shared by any other organ, except, perhaps, the spleen, and for a short time, in particular cases, by the brain. The name hematdidin is proposed for all the various forms and colors of this pigment material, because Virchow has given that name to the crystalline element among them, and because the others seem to be only varieties in form of the same substance. Lebert, (see Anatomie Pathologique, still in course of publication), describes all these forms, except the opaque, black matter, under the phrase, les elements hematiques, amorphes, granuleux, globuleux, et crystallins, LESIONS.—SPLEEN. 371 aborigine hemorrhagique. In his view, these forms have a common origin ; yet, in the liver of remittent fever, it is plain that they are not d:origine hemorrhagique in any proper sense, but, in all proba- bility, the coloring matter of the blood escapes in this case as it does in other instances cited in the " note." Hematoidin is probably the best name that can be applied to the whole group, provisionally, till the nature of the material can be more thoroughly investigated. It is stated in the "note," that this coloring matter is not dissolved by water or alcohol. This statement, it has been since found, is not strictly true; for specimens colored by it lose slowly something of their peculiar hue, by being kept in alcohol and water, especially if the color depends on the crystalline and red varieties. Two or three statements regarding the general history of the bronze liver may, perhaps, be thought worthy of a place here. In about seven fatal cases of remittent fever, the liver was found of the peculiar color described by Dr. Stewardson, and, in each of these, the microscopical examination gave the results quoted above. In two instances the bronze liver was found, a year and more after the patient had suffered from remittent fever, and, in the interval, these persons had enjoyed good health, showing that this pigment matter does not materially interfere with the functional offices of the liver after the fever has subsided, and that the absorption and removal of it is a slow process. In one instance, a liver was found enlarged, and of a bronze color throughout, apparently in conse- quence of a complete obstruction of the common duct, and the same coloring matter was found in it as in the remittent fever liver. It need only be added, that a suspicion that this coloring matter is the result of some transformation of the bile, is excluded by the fact that all the forms of it, except the black, are abundant in the old clots of cerebral apoplexy, in the corpora lutea and blood spots of the ovaries, and in many other places where bile can exercise no direct agency, and that the black element is abundant in the lungs.] Sec. II.—Spleen. The spleen is almost always enlarged, softened, and of a very dark or bluish black color. This lesion is so constant, and has been so long familiar to all observers of this class of dis- eases, that it is hardly necessary to multiply cases or to' quote authorities. In some instances, the volume of the organ is enor- mously increased. In one of Drs. Anderson and Frick's cases it weighed three pounds, in one of Dr. Swett's cases it was nine inches long and four thick. Bailly mentions instances of its weighing 372 PERIODICAL FEVER.—BILIOUS REMITTENT FORM. eight or nine pounds. It is often so much softened as to consist merely of a sort of half-fluid putrilage—a dark, pulpy mass, appa- rently destitute of organization. Dr. Bailly reports several cases in which these changes in the state of the organ resulted in a rupture of its enveloping membrane, and the consequent escape of its soft- ened contents into the peritoneal cavity. Maillot saw but one in- stance of rupture of the spleen, in Africa. He suggests that its greater frequency in Italy may depend upon the less active means adopted there to prevent local congestions. Dr. Boling thinks that these alterations of the spleen are rather the consequence of what he calls the latent action of malaria than the immediate and direct result of the disease. He says he has never found any evidences of enlargement during life, nor any morbid appearance in the organ after death, in a first attack of remittent fever, in a person who had not previously resided some considerable time in a malarious region. He believes the alterations to take place gradually from the effects of the febrile poison upon the system, and that they are merely in- creased by the febrile attack itself.1 This condition of the spleen is probably the result of violent and repeated congestions. Sec. III.—Stomach. The condition of the stomach has not been ascertained with a sufficient degree of accuracy, and in a sufficiently large number of instances, to settle definitely the part which its lesions play in the pathology of remittent fever. Its mucous mem- brane presents, in a large majority of cases, marks more or less ex- tensive and striking of inflammation. It is generally reddened and vascular; sometimes over certain portions only, and at others throughout the whole extent of its surface. This redness is some- times continuous and uniform, sometimes in patches; in some cases arborescent, and in others pointed or dotted. The consistence of the membrane is also sometimes diminished; and in many cases it is mamellonated. In five of six cases reported by Dr. Stewardson, marks of inflammation were present; there was mamellonation, in 1 This opinion of Dr. Boling induces me to record here, in a note, a pathological fact that may have some bearing upon the subject. During the winter of 1844, a patient died, in the Baltimore Almshouse, with simple pneumonia. He came from the Mine Banks, a locality celebrated for the number and severity of its marsh fevers. He had resided there during the sickly season, but was not known to have had the fever. In addition to the lesion of the lungs, his liver presented the alte- rations already described as belonging to remittent fever. I suggested at the time the possibility, at least, that the change in the liver might have been the result of the gradual and long-continued action upon the system of the febrile poison. LESIONS.—STOMACH. 373 three; thickening, in two; thinning throughout, in one; in the great cul-de-sac, in another; softening in two, and in several there were changes of color. In one or two instances the lesions were very slight.1 The membrane was injected in seven of nine cases reported by Anderson and Frick—in three of them intensely. In five cases it was softened near the cardiac extremity, and in four near the pylorus; where also it was for the most part grayish, thickened, and mamellonated.2 Dr. Swett found nearly similar alterations; but he is disposed to regard them as less important than they are con- sidered to be by Dr. Stewardson. " Most of the changes," he says, "that I have observed in the mucous membrane of the stomach, have appeared to me of a chronic nature, and probably long antecedent to, and entirely independent of, the acute disease. I refer particularly to the thickened and mamellonated condition of the organ. The in- jection of the mucous membrane, although present in all the cases to a certain extent, did not appear to me beyond what is commonly noticed in other acute diseases, and might in some cases, at least, be referred distinctly to simple post-mortem venous congestion."3 Of thirty-one cases of malignant intermittent, or congestive fever, oc- curring at Rome, and reported by Bailly, the stomach is described as presenting marks of inflammation, more or less extensive and intense, in twenty-six; in some cases the mucous membrane was thickened; in some mamellonated, and, in many, thickly covered with a layer of viscid, tenacious mucus, adhering pretty firmly to the membrane itself.4 The stomach is not unfrequently contracted upon itself, its inner membrane thrown into prominent folds, and its cavity containing a moderate quantity of fluid of a yellowish, brownish, or greenish color. Maillot examined the mucous membrane of the stomach carefully in twenty-eight cases, most of them belonging to the pernicious form of the disease. In only one was the membrane entirely healthy. In five cases he found gray, slate-colored softening, with- out any red injection; in one case gray, slate-colored softening, with pointed redness; in eleven cases gray, dirty softening, with red injection; in one case gray, dirty softening, without redness; in four cases reddish softening; in two cases reddish-brown softening, in one case blackish softening, without injection; in one case where death was occasioned by rupture of the spleen, very slight recent ' Amer. Journ. Med. Sci., April, 1841. 2 Ibid., April, 1846. s Ibid., Jan., 1845. * Bailly on Inter. Fevers. 374 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. injection, with a gray tint; and in one case of typhoid affection, the red injection, with softening, common in acute gastro-enteritis. I have already spoken of Dr. Swett's opinion in regard to the cha- racter of these gastric lesions. Maillot has arrived at a similar con- clusion. He thinks it quite clear that, in most cases, the alterations, especially the softening with gray, brown, and slate coloration, extending to large portions of the membrane, are the result, not of recent acute inflammation, but of chronic irritation, preceding the attack of the febrile disease. The difference between the result of his observation and that of Bailly's he believes to be more apparent than real. Sec IV.—Intestines. Although our knowledge of the lesions of remittent fever is far enough from being full and complete; and although there are some apparent differences in the results of recent observation in regard to the condition of the mucous membrane of the alimentary canal, we are justified, I think, in saying that there is no satisfactory evidence that this membrane is the seat of any constant, important, or characteristic alteration. Dr. Stewardson has called the attention of the profession to a condition which he supposes may be peculiar to this disease;—I mean, an enlargement of the mucous follicles of the duodenum, or the glands of Brunner, as they are called. He found these glands remarkably distinct in all the six cases, where the duodenum was particularly examined.1 In all the twelve cases reported by Anderson and Frick, Brunner's glands were also unusually developed, and in three of them to a remarkable degree.2 Dr. Swett, on the other hand, did not find, in his five cases, any change in the state of these glands which he could look upon as morbid.3 The elliptical plates of the small intestines, commonly called Peyer's glands, are, so far as the most authentic and trustworthy observation enables us to determine, uniformly free from any well- marked morbid alteration. This, at any rate, is the conclusion which I myself, in the present state of our knowledge, and after a careful examination and estimate of all the evidence within my reach, feel compelled to adopt. But as the question of the condition of these glands is one of so much pathological interest and importance; as it has a direct bearing upon the relations of bilious remittent to 1 Amer. Journ. Med. Sci., April, 1841. 2 Ibid., April, 1846. 3 Ibid., Jan., 1845. LESIONS. — INTESTINES. 375 other forms of fever, and as it may fairly enough be regarded as not finally and definitively determined, I will state briefly, but com- pletely, the results of recent observation upon this matter. Dr. Gerhard examined particularly and carefully the state of Peyer's glands, in two cases of remittent fever, as long ago as 1834; and he found them in both entirely free from the slightest alteration. In the seven fatal cases which constitute the material and basis of Dr. Stewardson's paper on the lesions of this disease, the glands of Peyer were uniformly healthy. They are described in some cases as distinct and well defined in their outline, honeycombed on the surface, or dotted with depressed points, and these latter sometimes of a dark color; but uniformly free from thickening, softening, ulceration, or any other obvious and unequivocal alteration.1 In Dr. Swett's cases, "the glands of Peyer were very distinct from their pale white color, contrasting strongly with the dirty hue of the surrounding mucous membrane, but neither thickened, softened, nor injected."2 In two of the twelve cases reported by Anderson and Frick, the elliptical plates were either not examined, or are not mentioned; in the remaining ten they were generally pretty dis- tinctly visible, but free from any decided disease.3 These results may seem to be in contradiction to certain other observations on the same subject. In the New York Journal of Medicine and Surgery for 1839, Dr. Richardson, resident physician of the New York Hospital, has published the pathological histories of six cases of what was regarded by him as remittent fever, in all of which Peyer's glands are alleged to have been diseased. In three they are said to have been enlarged, but not ulcerated; in one there were numerous small ulcers on one of the plates; and in two there were more or less extensive and unequivocal ulcerations, the ulceration in one of these having extended through all the coats of the intestine. My attention was called to these cases by a medical friend very soon after their publication, on account of the contradiction which they appeared to furnish to one of the most generally received and well established opinions in regard to the intestinal lesions of typhoid and of remittent fever. I studied them with great interest, and with great care, and was immediately and thoroughly convinced that the deductions which had been made from them were wholly gratuitous and unfounded. It was 1 Amer. Journ. Med. Sci.. April, 1841. 2 Ibid., Jan., 1845. s Ibid., April, 1846. 376 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. quite clear that in the two cases in which extensive and unequivocal ulceration was present, either the diagnosis was manifestly wrong, or there was no sufficient ground for regarding them as cases of remittent fever; while in all the others, in which the diagnosis was most probably correct, there was no sufficient evidence of any morbid condition of the elliptical plates. This whole matter has since been placed in its true light, and the importance of these cases reduced to its proper position, by Dr. Swett, in the American Journal of the Medical Sciences for January, 1845. If these cases do not furnish any additional evidence of the wide difference between typhoid and remittent fever, so far as the condition of Peyer's glands is concerned, they do not at least furnish any evi- dence of a contrary character. They have one value, however; and that consists in the lesson they teaeh us—a lesson that can hardly be too frequently or too emphatically repeated, of the great danger, in all questions requiring careful observation and rigorous analysis, of trusting in any, the slightest degree, to incomplete, inadequate, or equivocal facts. Such facts, under such circum- stances, so far as the interests of true science are concerned, are worse than none, inasmuch as ignorance is better than positive error; and as it is safer and more profitable to stand still in the dark than it is to follow a false light in the wrong direction. Dr. Boling reports two cases in which he found ulceration of the elliptical plates. The history of the cases is not given; but in one of them, we are told that the fever was of about forty days' duration; in the other, the case terminated on the ninth day, and was attended by diarrhoea. I have already had occasion to express the opinion that some of the cases alluded to by Dr. Boling, in his description of the symptoms of bilious fever, were cases of typhoid fever; this I believe also to have been true of the two cases just spoken of. At any rate, the most that we can do with them is to set them aside, or to place them in the category with those of Dr. Richardson.1 As to the mucous membrane generally, both of the small and large intestines, there is no evidence that it is more than occasion- ally and accidentally altered. Bailly describes it, in most of his cases, as more or less extensively inflamed ; and the same thing is 1 Since writing the above, I have had a correspondence with Dr. Boling in regard to the most striking of these two cases. His letter to me contains nothing to induce me to change the opinion already expressed in regard to the true character of these cases. LESIONS. — GENERAL REMARKS. 377 true of some other observers. It is quite clear, however, that, in many of Bailly's cases, the presence of a few patches of increased redness or vascularity was the only proof of the previous existence of inflammation. According to the researches of all the more recent and accurate observers, the changes found in the general intestinal mucous membrane, after death from periodical fever, are only those customary and accidental lesions, found with the same frequency after death from many other acute febrile affections. I am not aware that there is anything peculiar in the contents of the ali- mentary canal. The mesenteric glands are generally without alter- ation ; the same thing is true of the kidneys and the bladder.. Maillot found in fifteen cases, the mucous membrane of the small intestines softened, with a gray, brown, or slate tint, with or with- out recent injection; in one case softened with bright redness; in twelve cases the elliptical plates with the honeycomb development, in three of which the surface of the plates resembled the newly- shaven chin; in eleven cases, some development of the isolated fol- licles ; once only ulcerations; in four or five other cases slight changes; and in four cases no lesions whatever.1 ARTICLE IV. GENERAL REMARKS. Sec. I.—Relation of Lesions to Symptoms. It is sufficiently demonstrated by the foregoing details, that periodical fever does not often destroy life without leaving behind it very decided and somewhat extensive anatomical lesions. As I have done in regard to the fevers already treated of, I propose here to say a few words about the connection between the symptoms of the disease on the one hand, and these lesions on the other. This connection, so far at least as the more constant and important pathological alterations are concerned, would seem to be pretty uniform and direct. We can hardly hesitate, I think, for instance, in referring the nausea, vomiting, and epigastric distress, so nearly always present, to the disorders of the mucous membrane of the stomach, resulting in the changes that are found after death. So, the moderate fulness across the upper part of the abdomen, with the tension, the feeling of weight and oppression, in each hypochondrium, and especially in 1 Traite des Fievres Intermittentes, p. 284. 378 PERIODICAL FEVER.—BILIOUS REMITTENT FORM. the left, are evidently connected with and dependent upon the con- gestion of the liver and spleen, resulting in the alterations which these organs constantly exhibit. In the same way, it is impossible to doubt that the coma and delirium are intimately and directly connected with the striking lesions usually found in the brain and its membranes; and if the relationship here sometimes fails—if it is not absolutely invariable—this is only what happens occasion- ally, even with the best established and most constant of these relations, in other diseases. M. Maillot thinks that the algid symp- toms—the failing circulation, and the icy coldness—are especially and immediately connected with the lesions found in the spinal marrow and its membranes.1 I do not see any reason to suppose that the lesions of periodical fever follow any fixed or uniform order of succession in their de- velopment. The congestions and irritations of the several organs and tissues, which bear the chief burden of the disease, are in many cases evidently simultaneous in their origin—occurring together; in others the weight of the disease, to use the favorite phraseology of the older writers, falls principally upon one organ—the brain, for instance ; in still others, upon some other organ—the stomach, the liver, or the spleen;—and all this without anything that is con- stant or regular. Sec. II.—Importance—Relative and Absolute. The relative and absolute importance of the appreciable lesions in periodical fever— the part which they severally play in the production of the aggre- gate phenomena of the disease, and the share which each of them contributes towards the fatal issue, in fatal cases, are matters which can be only approximatively and in some degree conjectur- ally determined. We can hardly doubt that a sudden and over- whelming congestion of the cerebro-spinal axis will be attended by greater danger than a corresponding congestion of the liver and spleen; but to attempt to go much beyond a few obvious and manifest conclusions, similar to this, and nicely to gauge and mea- sure the agencies of each pathological alteration, would be but an idle and profitless labor. 1 Traite des Fievres Intennittentes, p. 329. 379 CHAPTER IV. CAUSES. Sec. I.—Locality. There is probably no form of endemic disease the geographical boundaries of which are so extensive as those of periodical fever. With certain limited exceptions, it may be said to encircle the earth in a broad belt, parallel with the equator, its northern and southern boundaries quite irregular in their disposition —now approaching to the line of the tropics, and now receding from it. The portions of this immense territory which are entirely exempt from periodical fever increase with the distance from the equator, while within the tropics, and along the range of several degrees beyond them, these portions are confined mostly to certain geologi- cal formations, and to elevated situations. The particular regions most extensively and constantly the seat of this disease in its more malignant forms are low-lying and wet lands, situated in hot cli- mates, and covered with a rank and spontaneous vegetation—the flat, wooded sea-coasts, the interior swamps and marshes, and the rich alluvions of the deltas and courses of the great rivers. It is hardly worth while to make a detailed enumeration of all these individual localities. I shall confine myself to a few statements in reference to the distribution of malarious fevers throughout the different portions of the United States, for which I am mostly indebted to the researches of the late Dr. Forry. These statements are founded upon data furnished by official records in the Medical Department of the United States, and in the Adjutant-General's office. They extend over a period of ten years; and they exhibit the actual and relative prevalence of periodical fever amongst the soldiers in the several military stations of the country. In these several classes of stations, the ratio of cases annually of intermittent fever, in each one thousand of mean strength, was as follows: On the coast of New England, 36; on the northern chain of lakes, 193 ; in posts north of latitude 39°, and remote from the ocean and inland seas, 151; on the sea-coast, 380 PERIODICAL FEVER.—BILIOUS REMITTENT FORM. from Delaware Bay to Savannah, 370 ; in the southwestern sta- tions, including Jefferson Barracks, Forts Gibson, Smith, Coffee, Towson, and Jessup, 747 ; on the Lower Mississippi, 385 ; and in the peninsula of East Florida, 520. These averages, derived from sufficiently large numbers, and running through a period of ten years, with one or two explanations and qualifications, may be safely taken as a true exponent of the relative prevalence of this form of fever in these several regions of country. The apparent ratio in the New England division, low as it is, is still vastly too high, since all or nearly all these cases originated in some of the other divisions. It may be remarked here incidentally that Nova Scotia and New Brunswick, in the British dominions, are entirely free from intermittent fever, while in Upper Canada the disease prevails very extensively, although there is no difference in the climate or soil of these regions to account for the circumstance. The ratio of remittent fever, according to Dr. Forry, throughout the same regions, is as follows: On the coast of New England, 26; on the northern chain of lakes, 33; in posts north of latitude 39°, and remote from the ocean and inland seas, 24; on the sea-coast from Delaware Bay to Savannah, 181; in the southwestern sta- tions, 180; on the Lower Mississippi, 196; in East Florida, 102. The diagnosis in the present case is less to be relied upon than in that of intermittent fever; it is probable that most of the cases reported in the New England division were continued in their type, and not periodical. The only considerable portion of the vast and various territory now occupied by the United States which is quite exempt from malarious fever is to be found in its extreme northeastern corner, constituted by the five New England States, and a large part of the State of New York. From nearly the whole of this region periodical fever has almost entirely disappeared. That it was suffi- ciently common here for a long period after the settlement of the country has been clearly shown by the very careful and thorough inquiries of Dr. O. W. Holmes, contained in his prize essay upon this subject. There are still a few small localities, mostly along the valley of the Housatonic, in Massachusetts, where a solitary case of domestic origin may be still occasionally met with; but with these exceptions, the disease is never seen in any of the New England States. [The last few years seem to have produced some changes in this respect, in a limited district of New England. The intermittent fever has been very rare in all parts of the Housatonic CAUSES. — LOCALITY. 381 valley, but has made its appearance in several of the towns of Connecticut bordering on the sound, between Bridgeport and the New York line.] Throughout the remaining portions of the coun- try the disease prevails with great irregularity of extent and severity. Large portions of some of the States, those particularly which are most thoroughly cultivated, and the higher granitic regions, with the dry, pine country of the South, are to a great extent free from the disease; and this freedom- is gradually extend- ing its area with the progress of cultivation.1 As a general rule, the simple intermittent form of the disease predominates throughout the cooler and more temperate regions; in the warmer climates, and during the latter part of the hot sea- son, the bilious remittent variety becomes more common, inter- spersed with occasional cases of the pernicious or congestive variety, the latter becoming more frequent in the more southern regions, and especially along the low, rich river bottoms and swampy lagunes. Dr. Lewis, of Mobile, says the low lands in the State of Alabama, lying along the creeks, known as the slough prairie, the swamps, and reed marshes, have proved to be more certain and prolific sources of disease than any other formations, the low alluvions of the river bottoms not excepted. Some of these localities, as the reed marshes in Green County, though very fertile, have been abandoned. There are said to be farms near the junction of the Bigby and Alabama rivers upon which no white man can permanently reside.2 There are many other regions where the disease is not less com- mon and malignant. Lind says Hungary has been properly called the grave of Germany. A very striking instance of the power and intensity of the febrile poison on the western coast of Africa will be found in the chapter on bibliography. Dr. Nicolle, in a report made in 1821, says: "About one in twelve, or very nearly nine per cent, of the better class of society, died last year in Sierra Leone ; and it appears, from official documents in tfie office of the secretary of government here, that such has been the average annual mortality from the census of Europeans in this colony. On the 31st of December, 1818, there were one" hundred and 1 At the beginning of the present century, of one hundred men employed at the Onondaga salt works, in New York, ninety-eight were attacked with bilious remit- tent fever. Many of the cases were fatal.—Edward Miller's Works, p. 97. 2 Lewis's Med. Hist, of Alabama, p. 16. 382 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. twenty-eight, of whom eighteen sailed before the rainy season for England, two of whom died; and of the remaining number—one hundred and ten—eight perished."1 Mr. Tidlie says: " The excep- tions are very few where Europeans have passed twelve months in the country from England without an attack of the fever. In the year 1819, there were at Cape Coast Castle eight new-comers from England, all of whom were seized with the fever, and three died; and out of forty, the total strength of Europeans in the service of the late African company, five died. In 1820 and 1821, there were eleven new-comers, all of whom were attacked, and four of whom died."2 Another of the most celebrated malarious regions of the old world is to be found in the middle and southern portions of Italy; and hardly in Africa itself, along the delta of the Niger, is the malarious poison more concentrated and malignant than it is here. Many a traveller has lost his life by a night ride over the Pontine Marshes. Bailly estimates that one-tenth of the population of Rome are annually attacked by disease, and that two-thirds of these suffer from periodical fever. Some of our best and earliest histories of the disease were from Italian pens, those of Torti, Lancisi, Ramazzini, &c. In 1818, there were consumed at the hospital of the Holy Spirit, at Rome, between the months of June and October inclusive, three thousand and two hundred pounds of cinchona.3 Sec. II.—Season; Temperature; Weather. There can be no doubt, as I have already said, that, other things being equal, periodical fever increases in frequency and gravity with an increase in the heat of the climate or locality. The simpler and milder form of the pure intermittent type is most common in the more northerly and cooler regions, and in the cooler seasons of the year, while the remittent and congestive forms are mostly confined to the hotter regions and seasons. M. Maillot shows conclusively, by extensive and accurate tables, that the frequency and intensity of visceral irritations and congestions increase in a constant and direct ratio with the elevation of the atmospheric temperature. He says, further, that the dry and hot season in Africa is marked by irri- tations of the brain and of the upper portion of the alimentary 1 Boyle's Dis. West. Africa, p. 149. 2 Ibid., p. 152. 3 Traite, etc., par Bailly. p. 139. CAUSES.— SEASON.—TEMPERATURE.—WEATHER.—AGE. 383 canal, while the wet season brings with it bronchitic and dysenteric complications.1 Throughout the United States, the great season for all the forms of periodical fever may be said to extend from the middle of sum- mer to the close of autumn, varying, of course, somewhat in differ- ent years and in different places. Dr. Wilcocks treated, during the season of 1846, in Philadelphia, one hundred and seventy-one cases of remittent and intermittent fever: In July, ten cases; in August, eleven; in September, ninety-nine; and in October, fifty-one.2 On the western coast of Africa, the largest number of cases occur near the commencement and the termination of the rainy season, March and September.3 At Rome, the disease prevails most extensively during the months of August, September, and October.4 In regard to the influence of the prevailing character of the season, there is a general impression that hot and wet weather promotes the prevalence of marsh fevers, while cool and dry weather prevents it. This impression is probably, in some degree, well founded, although the connection between the obvious quali- ties of the season and disease are far enough from being fixed and uniform. Some observers, indeed, deny this connection altogether. Dr. Cooke, of Opelousas, in a paper on congestive fever, says: " We have seen our country enjoying one year extreme good health, notwithstanding the long continuance of the most intense heat, superabundance of rain, and easterly winds; another year, under similar circumstances, it has been ravaged by disease; other years, when anticipating good health, in consequence of a moderate temperature, a uniform season, and moderate rains, without pre- vailing east winds, we have also had to sustain the most extensive visitation of disease. No one in this section of the country, resting on experience or observation, can designate any infallible circum- stance as productive or promotive of sickness'."5 Sec. III.—Age. The influence of age upon the occurrence of malarious fever does not seem to have been very particularly studied. It certainly may occur at all ages. It is more common during adult life than it is earlier; and this may, in part at least, depend upon the greater degree of exposure. Cleghorn says 1 Traite des Fievres Intermittentes. Par F. C. Maillot, p. 20. 2 Amer. Journ. Med. Sci., Jan., 1847. 3 Boyle's Dis. West. Africa. 4 Bailly, p. 134. 6 N. 0. Med. Journ., vol. ii. p. 180. 384 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. malignant tertians are most common amongst adults, and those of an advanced age.1 Dr. Charles Parry, in his paper on congestive fever, says: " This disease is confined chiefly to adults of both sexes ; children are rarely affected. I never saw a case in an indi- vidual under twenty years of age."2 Dr. Wharton, of Mississippi, says of congestive fever: " Children under ten years of age are comparatively free from its ravages; and persons from twenty to thirty are most subject to it."3 Dr. Lewis, of Mobile, on the other hand, thinks that the liability to congestive fever is alike at all ages, and that its greater frequency amongst male adults is entirely owing to the greater and more frequent exposure of this class to the malarious poison.4 [There is a sort of masked intermittent occurring in children who live in a miasmatic district, that many physicians are familiar with, but regarding which little has been written. Every second day the child becomes ill with symptoms that are but imperfectly de- fined. There is no chill, but the little patient is ill at ease—"is sick," he says: and little more can be learned from him. The pulse is frequent; the appetite gone for the time; the tongue somewhat furred; the countenance often pale, though sometimes flushed; sometimes there is pain in the head and back. These " bad feel- ings" wear off after some hours without marked sweating, and the next day the patient is pretty well. This state of things continu- ing, the child becomes cachectic, but treated by quinine is usually promptly and easily overcome, at least when treated, as the editor has seen it, away from the region of its origin. It seems to be a variety of what has been called in some districts "the dumb ague."] Sec. IV.—Sex. There are more cases of periodical fever, in all its forms, amongst males than amongst females; but the difference in the degree of exposure of the two sexes to the causes of the dis- ease are sufficient to account for this result. Sec. V.—Race. The negroes of malarious regions are less sub- ject to their fevers than the whites. Dr. Lewis, in his paper on the yellow fever of Mobile, makes the following remarks, in connection with this subject: "I will now travel so far out of my course as to give a few of the facts which 1 Rush's Cleghorn, p. 106. 2 Amer. Journ. Med. Sci., July, 1843. 3 Ibid., April, 1844. * Med. Hist, of Ala., p. 26. CAUSES. — RACE.—EXPOSURE. — EXCESSES, ETC. 385 have been gathered concerning the liability of the negro race to other diseases indigenous to Alabama. I practised two summers in the interior of the State; during the autumnal months, conges- tive fever prevailed so generally in my neighborhood as to amount to an epidemic; there were in my professional circle two blacks to one white, yet I did not see a single case of congestive fever in a negro, nor did I hear that any died of the disease in that section of country. I have made inquiries of several medical gentlemen who have been practising for many years in the country; their experi- ence does not materially differ from mine. The fact is, that the remarkable exemption from yellow fever, which this race enjoys, extends, in a great measure, to all the malarious fevers of hot climates; they may all have intermittent and light bilious fevers, as well as the milder, grade of yellow fever, but it is only under extraordinary circumstances that these diseases affect them so seri- ously as to cause death."1 The same writer, in his Medical History of Alabama, speaking of congestive fever, says: "Of twenty-five correspondents, residing in different sections of the State, two-thirds aver that, with the limited exposure to which the whites are sub- jected, negroes would not have the disease." A very striking in- stance of the exemption of the negro race from these forms of dis- ease is found in the history of the late disastrous expedition of the British government up the Niger, notice of which will be found in the chapter on bibliography. Sec. VI.—Exposure; Excesses, &c. There is no room whatever to doubt the agency of the ordinary exciting causes of diseases in bringing on an attack of marsh fever. The poison of the disease very frequently lies dormant in the system until it is suddenly kindled into activity by the action of some one of these causes. The most active and important amongst them are—exposure of the body to cold, after it has been heated; exposure to intense heat; fatigue; and all excessive indulgences. Sir Gilbert Blane says: "If I were required to fix on a circum- stance the most pernicious of all others to Europeans, particularly those newly arrived in the West Indies, I would say that it is exercise in the sun. The practice most hurtful next to this is in- temperance in drinking, and to one or both of these the sickness and mortality amongst new-comers may be ascribed."2 1 N. 0. Med. Journ., vol. i. p. 416. 2 Obs. Dis of Seamen, p. 226. 25 386 PERIODICAL FEVER. It is important, however, to add, that where the poison of the disease is very active and concentrated, it overbears all resisting influences, and does not require the co-operation of any of these occasional causes. Hillary, in his account of the diseases of Minorca, says: "Surprising as it may appear, it is nevertheless true, that the peasants, who are remarkable for temperance and regularity; and the soldiers, who, without meat and clothes, fre- quently lie abroad drunk, exposed to all weathers, have diseases almost similar, both as to their violence and duration. Hence it is evident how far the power of the air is superior to that of the other non-naturals in producing disorders of the animal economy."1 Sec. VII.—Malaria. The essential, efficient, producing cause of periodical fever—the poison whose action upon the system gives rise to the disease—is a substance or agent which has received the names of malaria and marsh miasm. The nature and composition of this poison are wholly unknown to us. Like most other analo- gous agents—like the contagious principles of smallpox and typhus, and like the epidemic poisons of scarlatina and cholera—they are too subtle to be recognized by any of our senses; they are too fugitive to be caught by any of our contrivances. Neither the strongest lenses of the microscope, nor the nicest analyses of chemistry, have succeeded in discovering the faintest traces even of the composition and character of these invisible, mysterious, and stupendous agencies. As always happens in such cases, and under similar circumstances, in the absence of positive knowledge, we have been abundantly supplied with conjecture and speculation; what observation has failed to discover, hypothesis has endeavored and professed to supply. It is quite unnecessary even to enume- rate the different substances to which malaria has been referred. Amongst them are all the chemical products and compounds possible in wet and marshy localities; moisture alone; the pro- ducts of animal and vegetable decomposition; and invisible, living organisms. In regard to the alleged agency of animal and vegetable decom- position in the production of the poison of periodical fever, I have but little to say, and this for the simple but sufficient reason that we have no positive knowledge upon the subject. Unquestionably, there is a very active decomposition, both of vegetable and of 1 Rush's Hillary, p. 42. CAUSES. —MALARIA. 387 animal substances, usually going on in malarious localities; it is possible enough that this decomposition may produce the poison, but there is no positive evidence yet that it does so, and there are some reasons for doubting it altogether. One of these reasons is to be found in the common and notorious fact that this same decomposition is constantly going on without giving rise to period- ical fever.1 The hypothesis of the animalcular or cryptogamic origin of this and of some other endemic and epidemic diseases is an old one, which has been recently revived, and advocated with great ingenuity and ability. It is only a hypothesis; but it may be safely said of it, I think, that it may be made to correspond to the ascertained phenomena in connection with the etiology of these diseases better than most other hypotheses, and that it is less embarrassed by objections which cannot be met, and by difficulties which cannot be overcome. Inscrutable, however, as the intimate nature of this substance or agent may be, there are some few of its laws and relations which are very well ascertained. One of these consists in its connection with low and wet, or marshy localities. This connection is not invariable and exclusive, that is, there are marshy localities which are not malarious, and there are malarious localities which are not marshy; but there is no doubt whatever that it generally exists. The terms marsh miasm and marsh fever have originated from this circumstance. Again, it is quite certain that the malarious poison may be transported by the atmosphere to a considerable distance from the place of its origin. M. Rigaud de ITsle says : " About the end of 1810, I was at Civita Vecchia, in Italy. Passing through St. John's Place, which is a pretty regular square, I was shown one whole side where the inhabitants had been much afflicted with diseases occasioned by bad air, while those on the opposite side had almost escaped. What could be the cause of such an extra- ordinary difference between houses so near to one another? Dr. Nucy, an intelligent physician, pointed out to us that the former 1 Bailly says that in 1822 Rome was visited by immense numbers of larg3 grasshoppers, so that the streets and fields were covered with them, living and dead, but that the fevers of the country were much less'extensively prevalent than during the previous year. He says also that the Ghetto in Rome—the Jews' quarter—is excessively filthy, the narrow streets covered with decaying animal and vegetable matters, but that it suffers much less from endemic fever than the more open, cleanly, and aristocratic neighborhood of the Vatican.—Traite" des Fievres, etc. Par E. M. Bailly, p. 125. 388 PERIODICAL FEVER. faced the south, so as to receive directly the southeast winds, which arrive, saturated with miasmata, from the marshes on the coast."1 A similar circumstance was observed in Philadelphia in 1846. Dr. Wilcocks noticed that the occupants of houses exposed freely to the southerly winds suffered much more generally than those living on the same street, but more or less sheltered from these winds.2 Sir Gilbert Blane, in speaking of bilious remittent fever, says: " I have known a hundred yards in a road make a difference in the health of a ship at anchor, by her being under the lee of marshes in one situation, and not in another. It is difficult to ascertain how far the influence of vapors from woods and marshes extends; but there is reason to think that it is to a very small distance. When the ships watered at Rock Fort, they found that if they anchored close to the shore, so as Co smell the land air, the health of the men was affected; but upon removing two cables' length, no inconvenience was perceived."3 The effect of a wall of dense foliage in arresting the progress and preventing the diffusion of malaria has often been noticed. A striking instance is given by Dr. Wooten, of Alabama. I quote from Dr. Lewis's Medical History of Alabama. "Mr. P. E. had negro quarters situated on the first prairie elevation above the low grounds of a small creek, the fourth of a mile from the houses. This belt of low ground frequently overflowed, causing water to remain in holes over its entire breadth, on the subsidence of the stream; but it was well shaded by a dense foliage, the plantation lying on the prairie in the rear of the cabins. In the winters of 1842 and 1843, the trees between the houses and creek were cleared away; and up to that time, some eight or ten years, the negroes living in this quarter had enjoyed uninterrupted health, a case of fever scarcely ever occurring. During the summer of 1843, the first after the forest had been cleared away, fever prevailed amongst the negroes with great violence, continuing until frost. The negro quarters were afterwards removed to the opposite side of the creek, about the same distance from it, but with an intervening growth of timber, and no fever has occurred on the place since."4 The latent period of the poison is quite indefinite; it is some- times short, and sometimes long. Disease may follow its reception 1 Johnson on Trop. Climates, pp. 11 and 123. 2 Am. Journ. Med. Sci., Jan., 1847. 3 Dis. of Seamen, p. 221. < Med. Hist., etc , p. 17. CAUSES.—MALARIA. 389 into the system in the course of a day or two, or not until after the lapse of several months. Illustrations of this law are often fur- nished on a large scale by armies. John Hunter gives an instance which occurred in Jamaica. A fine healthy regiment, stationed in a malarious locality, suffered severely from fever; they were re- moved to a healthy region, and first attacks continued to occur for four months after the removal. Dr. Bancroft says many officers and soldiers, after their return from the expedition to Zealand, had primary attacks of intermittents, from six to nine months after their arrival in England.1 Macculloch doubts the entire authen- ticity and conclusiveness of these reported instances of the action of malaria, at so long a period of time after exposure.2 The duration of the exposure to the poison, necessary for the production of the disease, is very short. The susceptibility of the system to the influence of malaria is lessened by long-continued exposure, but it is not destroyed. Malaria itself is destroyed, and its further evolution arrested by a temperature as low as the freezing point. [For the fullest exposition of laws which govern the production and spread of intermittent and remittent miasm, that has yet ap- peared in this country, the reader is referred to a volume on Pneu- monia and marsh fevers, lately published, from the pen of Dr. La Roche, of Philadelphia.3 To extract from it as freely as its merits would justify, would extend this section unduly, and too much increase the size of this book.] 1 Bancroft's Essay, p. 241. 2 Macculloch on Marsh Fever, p. 24. 3 [Pneumonia: its supposed connection with Autumnal Fevers ; including an In- quiry into the Existence and Morbid Agency of Malaria. Phila., 1854.] 390 CHAP T ER V. VARIETIES AND FORMS. ARTICLE I. BILIOUS REMITTENT FORM. I have already spoken of the subdivision of periodical fever into its three principal forms; and it is in this chapter that I find a suitable place for stating the grounds of this subdivision, and for indicating the principal features of these three leading varieties. Bilious remittent fever has now been pretty fully described; and it is sufficient to say, here, that the principal point of dissemblance between it and the pure intermittent form, consists in the continu- ance, in the former, of a considerable degree of febrile excitement, or of morbid action, during the intervals between the paroxysms or exacerbations of the disease. The several elements of a parox- ysm—the chill, the febrile reaction, and the perspiration—are also more distinctly marked in the intermittent than they are in the remittent variety; and they are repeated from clay to day, or from period to period, with greater regularity and uniformity. The remittent form is generally more inclined to run a determinate course, and then to cease, or to pass into the intermittent form than the latter. The fundamental pathological difference between the two varieties consists, probably, in the existence in remittent fever of more fixed and permanent local irritations than are to be found in intermittent fever. Bilious remittent fever itself can hardly be said to exhibit any very uniform or well-marked varieties. Still, is is important to state that the fever of one season and one locality frequently differs pretty widely from the fever of another season or another locality; and similar differences may exist between the dis- ease during one portion or another of the same season. In this respect, periodical fever only partakes of the mutability to which almost all diseases—and especially such as are at all endemic or VARIETIES AND FORMS. 391 epidemic in their character—are subject. During certain seasons, and throughout certain regions, it is not only more or less violent and dangerous than it is at other times and in other places, but it assumes certain peculiarities, more or less striking; at one time there is a predominance of one set of symptoms—at another, of another set. Cleghorn says: "In July, when these fevers first break out, their type is commonly simple and regular; their paroxysms are of short duration; and after three, four, or five periods, they vanish of their own accord. As the season advances, the tertians become more dangerous and difficult, often terminating in malig- nant forms, especially if much rain without wind fall during the dog-days. About the time of the equinox they assume a sur- prising variety of forms, and very often counterfeit continual fevers, having long redoubled paroxysms. But as the winter draws near, their type becomes more simple, and though they prove tedious and obstinate in cold weather, yet they are more regular and less dangerous than in the summer."1 Dr. Stewardson says: " In some seasons, the remissions are very well marked, and the disease very manageable; whilst in others it is more prolonged, the remissions more obscure, and the symptoms of the typhoid state more developed."2 ARTICLE II. CONGESTIVE FEVER. Sec. I.—Names. There has been a good deal of confusion from the somewhat indefinite signification which has been attached to the term congestive fever, and from the loose manner in which it has been applied. The qualifying prefix, congestive—is generic in its character; like the term typhoid, it is expressive of a pathological state or condition which may exist in different diseases. In this way most writers speak of congestive varieties or cases of cholera, of scarlatina, of yellow fever, and so on. They mean simply those forms of these diseases in which this pathological element, thus designated, predominates. The essential nature of the pathological condition itself is obscure. It is probably complex; and it may be more or less modified by its connection with individual diseases. In its simplest form, we generally understand by it an undue accu- ' Rush's Cleghorn, p. 107. 2 Amer. Journ. Med. Sci., April, 1842. 392 PERIODICAL FEVER. mula^ion of blood in the vessels—usually the larger ones, and especially the veins—of an organ or part. But in its connection with the grave forms of disease, of which I have just spoken, there seems to enter into its composition some unknown but profound modification of the great function of innervation. This function is the seat of a sudden and violent perversion; and at the same moment, there is a like sudden and violent rush of the blood to- wards some one or more of the organs; or a draining off of the serum, as happens in epidemic cholera. This congestive state gene- rally occurs during the early period of the diseases with which it is associated. The term congestive fever is now generally made use of, in the Western and Southern States, to designate the pernicious or malig- nant form of malarious fever. I can see no objection whatever to this use and application of the term; it is only important that its meaning should be determinately settled, and its application gene- rally agreed upon. I would never attempt to introduce a new name for a common disease, so long as an old and familiar one could be found, not positively and seriously objectionable. Sec. II.—Type and Mode of Attack. Congestive fever may belong either to the intermittent or to the remittent variety; but to the former more frequently than to the latter. It may also assume any of the types of periodical fever; but the quotidian and tertian are the most common. Sometimes the disease is fully developed, and clearly marked at the outset—the congestive seal is set upon it during its first paroxysm. At other times, and this seems to be more common, the first paroxysm does not differ very essentially from an ordinary attack of simple intermittent. Dr. Charles Parry, who has written a short and fragmentary, but most excellent paper upon the disease as it occurs in Indiana, says: "In the majority of cases, the symp- toms of the first paroxysm are such as occur in an ordinary inter- mittent attack. One main peculiarity is an expression of intense apprehension, or terror, without experiencing it. Perhaps the face is paler, or more livid, than in common cases. * * The first paroxysm attracts so little attention that, after it is over, the patient meeting a physician, or friend, says that he feels as if he was about to be sick, not that he has been sick. The second paroxysm is always severe, not so much in the violence of the rigors, as in the VARIETIES AND FORMS. 393 extreme coldness, and in the approaching death-like hue of the face and extremities."1 Sec. III.— Varieties; Comatose. Congestive fever occurs under several well-marked and pretty distinct varieties, depending, pro- bably, upon the predominance of certain elements in its complex pathology. Torti divided the disease into seven varieties, to wit: 1. Choleric, or dysenteric; 2. Subcruenta, or atrabiliaris ; 3. Car- diac; 4. Diaphoretic; 5. Syncopalis; 6. Algid; 7. Lethargic. Alibert makes no less than twenty varieties, elevating to this dis- tinction every case marked by any peculiarity, accidental and unimportant as it may happen to be. The most common and im- portant forms are the comatose, the delirious, the algid, and the gastric or gastro-enteric. . It is necessary, in order to get a distinct and adequate idea of the disease, to give separate descriptions of these principal varieties. To aid me in doing this, I shall transfer to my pages a series of graphic delineations from the capital work of Maillot. "The name of the comatose variety," he says, "indicates its essential character. The coma varies from simple stupor to the most profound carus. The pulse is full, large, without hardness, ordinarily a little accelerated, sometimes slower than natural. The patient lies upon his back, the limbs as it were paralyzed; when the coma is not carried to its highest degree, if the skin is pinched, he utters a feeble and plaintive cry; there is often trismus; still, liquids can generally be swallowed, although with considerable difficulty; sometimes, however, they are rejected, either by a sudden and convulsive movement, or by a tranquil and prolonged expulsion. In some rare cases, instead of the usual resolution of the limbs, there are epileptiform movements, frothing at the mouth, and grinding of the teeth, truly frightful From their noise and rapidity. It is during the second paroxysm that the coma shows itself, in most cases nothing having occurred in the first indicative of its coming. If anything may foreshadow its appearance, it is a certain slowness of speech during the preceding apyrexia. But this indication is often fallacious, and its absence is no guarantee / that the following paroxysm will not be comatose. Sometimes a case is comatose from the beginning; at others it suddenly becomes so after a certain number of paroxysms, which had not affected the 1 Amer. Journ. Med. Sci., July, 1843. 394 PERIODICAL FEVER. — CONGESTIVE FORM. brain more than is usual in simple intermittents. Sometimes the coma reaches its highest degree suddenly, as by a single bound; at other times, and this is more common, the eye may follow the pro- gress of its development. In the latter case, the physiognomy of the patient assumes that expression of stupor characteristic of coma- tose affections, and so striking in these; his replies are slow and unfinished ; the eyelids grow heavy and close. In certain cases, the coma is preceded by delirium. " After a period which it is impossible to determine beforehand, and which varies with a multitude of circumstances, if death is not occasioned by the violent cerebral congestion, a general sweat breaks out upon the surface, the patient executes some automatic move- ments, the eyelids are elevated, the eyes remain fixed and widely open, he remains a long time unconscious of what passes about him, and it is now, especially, that his look has that air of astonishment, which I have never seen so strongly marked in any other affec- tion. He recovers by degrees the use of his senses ; sight, hearing, and speech return successively. Finally, all the functions resume their natural play, and in many cases after the paroxysm, especially if bloodletting has been practised, there does not remain even head- ache. " This variety is perhaps the most common. Most of the cases reported by Bailly at Rome belonged to it, and I have met with it more frequently than with any other form in Corsica, and Africa. It may be accompanied by visceral congestions or irritations in the chest or abdomen, but these complications are accidental." Sec. IV.—Delirious Variety. " When, during the second stage of a paroxysm, the headache becomes very severe, there is reason to apprehend the occurrence of delirium, especially if, during the preceding intermissions, this symptom has not entirely disappeared. The pulse is hard and accelerated; the skin hotter and drier than in the comatose form; the eyes are brilliant, the conjunctiva in- jected, and the face red and animated; the patient cries, sings, and endeavors to escape; the carotids and temporal arteries beat vio- lently. This state of excitement commonly continues for several hours; and then it is not unusual to see coma succeed to the deli- rium, so that, so far as the symptoms are concerned, the paroxysm may exhibit in the course of a few minutes the principal phenomena of the two stages of acute meningitis. Death frequently occurs suddenly, without the supervention of coma; life is destroyed by a VARIETIES AND FORMS. 395 single shock. When a favorable crisis occurs, the skin becomes soft and sweaty, the pulse loses its hardness, and the delirium gradu- ally ceases. There is some remaining headache, more frequently than in the comatose form. This variety is also very common. Nervous and irritable persons, subject to depressing passions, are strongly predisposed to it; it is often seen also in stout and robust men of a strongly marked sanguine temperament. I have never seen in the same paroxysm coma precede delirium." Sec. V.—Algid Variety. "Algid fever is not generally, as has been said, a mere prolongation of the cold stage of a paroxysm. I have rarely seen it commence in this manner. There is between these two conditions a striking contrast even. In the first stage of a simple paroxysm, the sensation of cold is out of all proportion to the actual diminution of the temperature of the surface, while in algid fever the cold is not felt by the patient, even when the skin is icy. It is commonly during the period of reaction that the cha- racteristic symptoms begin to show themselves; often they super- vene suddenly in the midst of a reaction which appeared to be open and frank. The pulse becomes slow, flags, and disappears; the ex- tremities, the face, and the trunk become successively and rapidly cold ; the abdomen alone preserves a slight degree of warmth, the n skin feels as cold as marble; the tongue, whatever may have been its appearance at the commencement, becomes flat, white, moist, and cold; there is no thirst; and if the patient is induced to drink, the liquid is frequently returned as if by regurgitation; the lips are colorless, the breath cold, and the voice broken; the action of the heart is slow, feeble, and struggling, appreciable only by ausculta- tion ; the mind is unimpaired, and the patient may seem to enjoy even this state of repose, especially when it has succeeded to a vio- lent fever; his physiognomy is without mobility, the most absolute impassivity is stamped upon his countenance; its expression is dead. It is only when vomitings and choleric discharges are added to this algid condition, that the eyes become sunken and glassy, and are surrounded by a blue circle; and it is only when the respiration is carried on through the open mouth that the tongue becomes dry and dark colored. The march of this variety is very insidious; there is no one, perhaps, whose vigilance has not been deceived by it. If one is not familiar with this state of things, the kind of calm which follows the febrile excitement may easily be mistaken for a great amelioration, attributable, perhaps, to sanguineous depletions, 396 PERIODICAL FEVER. — CONGESTIVE FORM. and the mistake is revealed only by the sudden and unlooked for death of the patient.'" Bailly notices particularly the tranquil expression of the counte- nance in these cases. " I have already' mentioned," he says, " that, in algid fevers, the patients pass from life to death without our being able to foresee this event; we can hardly believe them to be sick even, either during the intermissions or the paroxysms, espe- cially in the early period of the latter." In the reflections which follow the report of his thirty-seventh case, he says: "In this instance especially, the color of the face was natural; its expression was that of repose, of tranquillity; only the muscles were a little tightened upon the bones of the face, but not like those of a phthisical patient, or of a person dying from acute gastritis; it was rather the look of a man in full health who rests after excessive fatigue. Indeed, if this man had not been pointed out to me as one attacked with algid fever, I should not have paused to notice him, near as he was to the termination of his existence; and when the paroxysm came on, his countenance, without becoming any more alarming in its expression, approached that of a person just sinking into sleep. Nothing could be more striking than the contrast between this immobile face and the pain which he alleged to exist in the abdomen. It seemed as if the torpor in which he was plunged had destroyed all the sympathies which usually exist between our organs, and as if the suffering abdomen had no power to act upon the physiognomy with which it was no longer in rela- tion."2 Whenever to a reaction, more or less decided, there suddenly succeeds feebleness of the pulse, with paleness of the tongue, and colorless lips, there should be no hesitation in regard to the case —it is one of algid fever. Temporizing here is death. When the termination is to be favorable, the pulse becomes more distinct; the skin resumes its natural heat; and there follows sometimes, though rarely, an irritation of the brain, or digestive organs, requiring sanguineous depletion. The coldness dissipated, the patient enters at once into full convalescence, as he does after a comatose or delirious paroxysm. I have never seen the pheno- mena constituting algid fever proceeding by distinct paroxysms; they have hardly presented any appreciable remissions; once established, they march steadily towards death, unless they are 1 Maillot. 2 Traite des Fievres Intermittentes. Par E. M. Bailly, p. 235. VARIETIES AND FORMS. 397 arrested.1 The pulse, Dr. Charles Parry says, even from the beginning of the second paroxysm, is rapid, small, and thready; sometimes hard and wiry, and sometimes irregular and intermit- ting. The skin is of a livid hue, and of a marble coldness; and it is covered from head to foot with a cold, clammy, sticky sweat; in some instances, this perspiration is confined to the face and neck. The hands are shrivelled like a washerwoman's, and the patient begs for cold drinks, and to be fanned.2 According to Maillot, the three preceding varieties constitute the immense majority of cases of pernicious intermittents. Sec. VI.— Gastro-enteric Variety. This form of congestive fever seems to be pretty common in our Western and Southern States. Dr. Charles Parry, in his description of it, says: " The vomiting and purging are almost incessant; the discharges are often mixed with blood, but not with bile. They have the appearance of water, in which a large portion of recently-killed beef has been washed. Sometimes, however, the proportion of blood is much greater, at times amounting almost to clear blood; and from three to five or even twelve ounces at a discharge, with intervals of from ten to forty minutes. The discharges have but little odor, and there is but little abdominal pain or tenderness; though the patient com- plains of a sense of weight and burning heat in the stomach. * * The thirst is most intense. The constant cry is for cold drinks, cold ice water; and a very common exclamation is: '0, that I could lie in the river!'—' If I could only have a stream of cold water running through me!' "3 I add the following, from Dr. Parry's general description. " The respiration," he says, " is often very peculiar. It consists of a deep- drawn double inspiration, or double sigh, with one expiration. This double breathing is seen in perhaps more than two-thirds of the cases; it is a fatal symptom. It is seen very early in the secoud paroxysm, generally at the beginning, and continues to its close, either in the agony of death, or to the febrile reaction. " Restlessness is very great, the patient constantly tossing about from one side of the bed to the other, throwing about his arms and legs; frequently endeavoring to get out of bed, and walking across the room, if permitted, only an hour or two before death. I have ' Traite des Fievres Intermittentes. Par F. G. Maillot, pp. 28-36. 2 Amer. Journ. Med. Sci., July, 1843. 3 Ibid., July, 1843. 398 PERIODICAL FEVER. — INTERMITTENT FORM. seen persons get out of bed, walk across the room, and stand in the doorway, hours after it was impossible to detect any pulse at the wrist, though the carotids could be felt plainly. Such is the intense desire of patients to get cold air, that they frequently ex- press themselves determined to have it, at all hazards; and, indeed it frequently happens, even when nearly all the symptoms just enumerated are present, that the patient does not think there is much the matter with him, and wonders why he is kept in bed, and not suffered to go out. " The usual length of the fatal paroxysm is from three to six hours, though it is longer in some cases;—the moribund symptoms increasing, the pulse becoming more and more frequent, feeble, irregular, thready, and fluttering; the respiration prolonged and sighing; the skin cold and shrivelled, and covered with large drops of clammy perspiration."1 It is proper to mention that the preceding varieties may be more or less mixed up with each other, sometimes one of them preponderating, and sometimes another. It is hardly necessary to take any separate notice of the minor varieties—the cardiac, the icteric, the syncopalic, and so on. ARTICLE III. INTERMITTENT FEVER. The principal points of difference between the simple intermittent and the bilious remittent forms of periodical fever, have already been indicated. It only remains for me here to give a short general description of the former variety of the disease. The paroxysm of a regular and simple intermittent commences with the rigor, or chill. This is usually severe and strongly marked. The patient has an intense feeling of coldness; his teeth chatter, and his whole body shivers with cold. The skin is pale and shrivelled, with a dark bluish or purplish tinge on the tip of the nose, the lips, and the extremities, and it is cold to the touch; the features are pinched and shrunken; the expression of the face is languid, listless, and uneasy; there are frequent gaping and yawning; a general feeling of weariness and fatigue, pains in the head, back, and limbs; sighing respiration, oppression of the prae- ' Amer. Journ. Med. Sci., July, 1843. VARIETIES AND FORMS. 399 cordia; a small and frequent pulse; and the mind is feeble and depressed. Such are the ordinary and more obvious phenomena constituting the cold fit. The urine is generally abundant and limpid. After a period of time, varying from fifteen or twenty minutes to three or four hours, the average length being an hour or so, the first stage passes gradually into the second. The sensation of cold- ness yields to a feeling of morbid heat; the skin is full and injected, and is hot to the touch; the face loses its languid expression, and becomes animated and flushed; the precordial oppression is some- times removed or diminished, but not always; there are less lan- guor and depression; the local pains, instead of diminishing, are increased in severity; the pulse becomes full and strong; there is increased thirst; and the urine is now scanty and high colored. This second or hot stage continues from one to fifteen or eigh- teen hours, and then gives way to the third, or sweating stage, which completes the paroxysm. As the surface becomes moist, the febrile perturbation subsides;—the pulse is slower and softer; the expression of the face tranquil ; the local pains and the other uneasy sensations disappear; the urine deposits a reddish sediment, and there is a general and delightful feeling of relief and of restora- tion to health. The period between the termination of this and the commence- ment of the next paroxysm constitutes the intermission. In many cases, where the disease is quite simple, and where there are pro- bably no considerable local irritations or congestions, this apyrexial period seems to be one of entire freedom from disease. The strength, the appetite, and the cheerfulness of the patient are re- stored ; all his functions, animal and organic, seem to have resumed their healthy activity. In other instances, however, there are still remaining, throughout the entire period of intermission, evidences more or less obvious and serious, of a disordered state of the sys- tem. The entire duration of the paroxysm, as well as that of its several stages, varies very greatly in different cases. It ranges from a few hours to eighteen or twenty. 400 CHAPTER VI. DURATION AND MARCH. Sec I.—Duration. The average duration of the common form of remittent fever seems to be about two weeks, perhaps a very little longer. Of eleven cases treated in the Pennsylvania Hospital, by Dr. Gerhard, the mean duration was fourteen days and a half; of fifty-four cases treated in the same institution, and reported by Dr. Stewardson, the mean duration was about fifteen days. The duration of the other varieties is so various and indefinite, and so much influenced by circumstances, that it is not easy to es- tablish any positive averages. Congestive fever terminates speedily, in most cases, either in recovery or death. Dr. Charles Parry says: " The general duration of this disease is from six to nine days, in recovering so as to walk about; in fatal cases, from two to three days, death usually occurring in the second or third paroxysm, hardly ever in the first."1 The duration of the simple intermittent form is altogether indefi- nite. It may consist of only one or two paroxysms; or it may be continued, with more or less regularity, for several weeks, and even for several months. Sec II.—March. The types of periodical fever have been already sufficiently treated of in the chapter on the symptoms of the disease. The march of the fever differs considerably in the different forms of the disease. The progress of remittent fever is generally pretty regular—the disease gradually increasing in severity until it reaches its height or acme, and then passing into convalescence. Cleghorn seems to have studied this subject with great care, and he makes the following observations in regard to it: " As the fever advances to its height, the coldness and shivering which usher in the parox- ysms become less, or entirely imperceptible; in which case a cholera 1 Amer. Journ. Med. Sci., July, 1843. DURATION AND MARCH. 401 morbus, or acute pains in the back or limbs, supply their place. In the mean time, the paroxysms themselves become longer, and bring on more formidable symptoms, such as headaches, raving, sopors, apoplectic fits, bleeding at the nose, cough, difficulty of breathing, palpitation of the heart, irregularity of the pulse, sick- ness and anxiety, pain about the upper orifice of the stomach, and so on. Besides, it often happens, during the second, third, fourth, or fifth period, that the tertian becomes double, though at first it was simple; or if it was double from the beginning, the weaker fit continues without any intermission, till the stronger comes on, and both being blended together, the disease puts on the appearance of a semi-tertian having one very long fit, with a short interval every forty-eight hours. It must likewise be observed that, in the pro- gress of the fever, the regular order of the periods is frequently disturbed by the paroxysms changing their hour of invasion, and attacking unawares, without any previous cold. After this manner, these proteiform distempers continue to vary their shape in every period, and to produce longer, more severe, or more frequent parox- ysms till they arrive at their height; about which time the fits and intervals are often so confused that they are scarcely to be distin- guished ; nevertheless, if death be not speedily the consequence of this confusion, they commonly again put on a more simple or regular form, and, after one or more slight paroxysms, go away of their own accord. Those fevers which come to their height in the third period, terminate in the fourth or fifth period; those which come to their height in the fourth period, terminate in the fifth or sixth ; and those which come to their height in the fifth period, terminate in the sixth or seventh. When the most vehement paroxysms happen on the odd days, the crises will be on the odd days: when they happen on the even days, the great changes of the distemper will likewise be on the even days. If the fever increases to the seventh period, it probably will not cease before the ninth; but it rarely happens that remitting tertians run out to so great a length. Yet I have seen every year a few of the continual kind, which began with great mildness, and, increasing by slow degrees, broke out violently in the third or fourth week, and soon after ended in intermittents; though some of them have continued without any considerable intervals for six or seven weeks. But it is much more common to meet with tertians, which set out furiously, with severe subintrant double paroxysms; so that for some days they have little or no interval. On the third or fifth day a profuse sweat commonly 26 402 PERIODICAL FEVER. brings on an intermission; and afterwards the disease assumes the type of a double intermitting tertian, or of a semi-tertian. Such fevers I have frequently observed to terminate spontaneously on the seventh, ninth, and eleventh days ; and, for the most part, they are less to be feared than those which begin deceitfully in the shape of a slight double or simple tertian. For, however mild and in- significant these intermittents may at first seem to be, we are never to trust appearances till they have performed three or four revolu- tions."1 The progress of the malignant form of the disease is more irregu- lar and uncertain. Senac thus speaks of the sudden and great changes so striking in this last variety: "It may be thought singular in these diseases that sometimes, from so slight a beginning, the danger should become so urgent and threatening in the course of a few days. But it is a problem no less difficult to solve, how a cause which so disorders the brain, and so oppresses the lungs can, of its own accord, give the system a temporary respite, or cease for a time to act. Thus, after the third or fourth day, the action of this cause is suspended, and for a day or more the patients seem free from disease., Other maladies do not pursue such a course; in them the affected parts recover only by degrees; and after they have recovered, or appear to have recovered in the space of a day or two, the life of the patient is seldom brought into danger again by a sudden return of the disease; at least this is not generally the case, as it is in malig- nant intermittents. * * * Hence it appears that these terrible symptoms may arise from some wandering stimulus, which flies off and returns, or acts and lies dormant, alternately; and that they are sometimes more alarming in appearance than dangerous in reality."2 Bailly says: " This sudden transition from a state of imminent danger to apparent safety is especially characteristic of comatose intermittents. In the other varieties of pernicious fever, there is not so striking a difference between the different stages of a paroxysm. * * * A finger compresses the brain—the patient sleeps; if the pressure is light, everything returns promptly to its natural condition; if the pressure is strong, it kills on the spot."3 Sec III.—Critical Days. It is the proper place here to say a word or two about the existence of what have been called critical 1 Rush's Cleghorn, p. 95, et seq. 2 Caldwell's Senac, p. 118. 3 Traite, etc., p. 171. RELAPSES. — SEQUELS. 403 days—days upon which, more than upon others, the disease has a tendency to terminate either in recovery or death. There is no doubt, whatever, that the old doctrine upon this subject is the true one, and the disputes which have arisen about it have originated in the circumstance that physicians have endeavored to apply it to the family of continued fevers, a class of diseases in regard to which it utterly fails. It follows almost necessarily that a disease, marked as periodical fever frequently is, by a regular tertian revolution, should be liable to particular changes, either for better or for worse, on particular days; and this is the whole substance of the doctrine of critical days. Sec. IV.—Relapses. Periodical fever, more than any other form of acute disease, is liable to return, and to repeat itself, again and again, in the same subject. When the malarious poison has been once received into the system, the action of slight occa- sional causes will often continue, for a long time, to bring back the disease. Dr. Charles Parry says of congestive fever: "Once having had an attack does not exclude the possibility of having another the same season, although a second attack is rare. I had one patient who had two attacks one season; and I had one patient who had an attack in three successive summers."1 Sec. V.—Sequelce. Periodical fever, especially if it has been often repeated, or long continued, very frequently leaves behind it serious and profound alterations of some of the organs, or more or less grave disturbances of their functions. The principal of these I shall here enumerate. The first to be mentioned consist of various chronic alterations of the liver and spleen, especially the latter. These organs become enlarged or indurated, or both; and their inti- mate structure, in many instances, variously changed. From the time of Hippocrates to the present day, the frequency of these chronic organic alterations has attracted the notice of all observers. When they become inveterate and extensive, from long exposure to the malarious poison, and from repeated attacks of fever, they generally entail upon the patient gradually increasing debility, dropsical accumulations, a broken-down constitution, and finally death. In many instances, however, it is surprising to what an 1 Am. Journ. of Med. Sci., July, 1843. 404 PERIODICAL FEVER. extent, and for how long a period, the system will bear up against these inroads. "I have often seen these subjects," says Bailly, "arriving at the hospital in Rome, with the abdomen hard as a stone, the spleen occupying the whole anterior part of the cavity. A few intermittent paroxysms constituting the only disease which brought them to the hospital, they were treated like the other patients; the paroxysms were arrested by quinine, and at the end of two or three weeks, they departed to resume their occupations, cured of the fever, but with the abdomen as hard as ever." Maillot says that he has often noticed, amongst the shepherds of Corsica, stout and robust men, engaged in rough out-door occupations, with the abdomen enormously distended in consequence of these alterations.1 The notion has been extensively prevalent, that these visceral obstructions are the result, not of the disease itself, but of the bark and its preparations, which are given for its cure. It is hardly necessary for me to say that there is no foundation whatever for this opinion. The dropsical effusions, and especially the ascites, which so fre- quently accompany the latter stages of these cases, are, for the most part, the result of the changes in the state of the liver and spleen, and of the watery condition of the blood. In hot climates and seasons, long-continued cases of periodical fever are pretty frequently followed by chronic dysentery and diarrhoea. Maillot says that these consecutive affections are almost constantly without fever; there is little or no pain in the bowels; the discharges are serous, mucous, or sanguinolent, and generally abundant and frequent, but sometimes scanty. There is rapid emaciation; the skin is of an earthy hue, dry and furfuraceous. Of thirty cases, occurring in the French military hospital in Algiers, fourteen terminated fatally.2 • Dr. Finley, in a paper on the autumnal fever of Georgia, says: "A severe attack of the disease always leaves the system very much deranged. All the secretions are impaired; the skin is dry and harsh; the biliary secretion alternately vitiated and defective; the bowels constipated."3 Another pretty common consequence of this disease consists in different disturbances and perversions of the nervous system. 1 Traite des Fievres Intermittentes, p. 246. 2 Ibid., p. 244. 3 West. Med. and Phys. Journ., vol iii. p. 179. SEQUELAE. 405 Amongst these are—neuralgic pains; headache; muscular weak- ness; partial and incomplete paralysis, usually of the lower limbs; and impaired activity, or derangement, of the mind. Senac says, in speaking of the headache: "Patients sometimes declare that the head feels as if it were cleft asunder in the middle." Dr. Mosely says: " Imbecility of mind, as well as of body, is a common conse- quence of long and obstinate disorders in hot climates; and I have fre- quently observed that the mind has been greatly impaired after irre- gular and harassing intermittents; and sometimes a temporary insan- ity has ensued. This must have been also observed by others; but as far as I know, no person except Sydenham, who was the first that noticed it, has mentioned it as occurring in practice. He says he has often found, when the patients had been extremely debilitated by long continuance of the disease, the doubling of the fits, and re- peated evacuations, that they have been seized with a madness, when they began to recover, which went off proportionally as they gathered strength; but that, sometimes, from injudicious evacua- tions only, it has degenerated into a miserable kind of folly for life."1 Maillot mentions amongst the effects of the disease noticed amongst the French soldiers in Africa, extreme debility during convalescence, especially in the hot season; and trembling of the muscles, like slight chorea, or like the paralysis of the insane. He thinks that neither the type of the fever, nor the intensity of the local irritations, has much influence in the production of these effects.2 Macculloch enumerates a great variety of nervous dis- turbances and perversions, the result of repeated attacks of marsh fever. Another common consequence of long continued periodical fever, or of the chronic lesions to which it gives rise, is an anemic condi- tion of the system. The blood loses its healthy proportion of glo- bules; the gums, lips, and tongue lose their fresh color; and the skin is sallow and pale. [The anemic condition, with a dingy paleness of the skin, and great muscular weakness, was remarkable in the cases of periodic fever, brought to New York from the Isthmus, during the building of the Panama railroad. A few paroxysms of intermittent fever were often sufficient to produce extreme cachexia, and it seems as if the miasm of that region had the force to penetrate far deeper into sources of life, than that pro- duced in more temperate latitudes.] 1 Mosely on Trop. Dis., p. 189. 2 Maillot on Inter., p. 250. 406 CHAPTER VII. MORTALITY AND PROGNOSIS. The danger attending periodical fever depends very much upon the form which the disease assumes. The purely intermittent and benign variety is never fatal, without some accidental complication. It often entails upon its subjects chronic visceral alterations, which impair the vigor of the system, and which often shorten life, but it is never directly and immediately fatal. The ordinary remittent form is more grave in its character, but still in a very large propor- tion of instances, it terminates favorably. Of sixty-three cases of periodical fever admitted to the Pennsylvania Hospital, in 1838, 1839, and 1840, six terminated fatally; but three of these belonged to the congestive form, and were received only a short time before death; and in one other case the disease had been greatly aggra- vated by improper treatment.1 Dr. Wilcocks treated one hundred and seventy-one cases of remittent and intermittent fever, in Phila- delphia, in 1846, and they all recovered. He does not state the proportion of cases of the two forms. At the hospital of Montluel, of thirteen hundred and fifty-two cases, treated between June, 1822, and December, 1826, one hun- dred and thirteen terminated fatally. At the military hospital of Bona, in Africa, in twenty-two thousand three hundred and thirty admissions between April, 1832, and March, 1835, there were two thousand five hundred and thirteen deaths, nearly one in nine.2 Other things being equal, and as a general rule, the gravity and fatality of periodical fever increase as we approach the tropics. "Thus," say MM. Fournier and Begin, "if we examine the endemic diseases of the principal malarious countries, we shall see in Hol- land, intermittent fevers attacking great numbers of subjects, but generally following a slow march, and giving the physician suffi- 1 Am. Journ. of Med. Sci., April, 1842. 2 Traite, etc. Par F. C. Maillot, p. 276. MORTALITY AND PROGNOSIS. 407 cient time to combat them. In Hungary, these fevers are more fre- quently remittent, and complicated with dysentery. The fevers of Italy, in the neighborhood of the Pontine Marshes, have short in- termissions, and are frequently complicated with ataxic pheno- mena."1 In regard to congestive fever, Maillot makes the following inter- esting observations and statements. " I do not know," he says, " how the opinion has established itself that pernicious intermittents are readily curable, and that art is almost certain to triumph over them. But, ever since Lautter said that in these diseases the phy- sician is the arbiter of life and death, writers have spoken very lightly of the prognosis of these terrible affections; they have pro- claimed their treatment as the triumph of medicine. Certainly, it is a beautiful thing to snatch from an imminent death, to rescue almost from the tomb, a man stricken with a pernicious paroxysm; the danger was so urgent that one has hardly indulged a hope of his patient's recovery, when he is already cured; but deceived by the eclat of similar successes, we have been carried away by our enthusiasm, and have refused to believe in the possibility of re- verses, for it has been almost alleged that we had reached mathe- matical certainty in the treatment of these diseases. But to this enthusiasm, in which we ourselves for a long time participated—to these sanguine anticipations which we should still rejoice to indulge, let us oppose the rigorous impartiality of positive statistical results. In eight hundred and eight-six cases of pernicious fever, observed in 1818 and 1819, at the hospitals of the Holy Spirit, and Saint John in Lateran, at Rome, there were five hundred and forty-five recoveries, and three hundred and forty-one deaths—one death in two and a quarter. In five hundred and eighty-one cases of peri- odical fever, observed by M. Nepple, fourteen belonged to the per- nicious form; six of these terminated fatally. Antonini and Monard, in thirty-nine comatose or apoplectic cases, had nine deaths; in eighty-six encephalitic cases, they had only eight deaths—unquestionably the most favorable result on record, if they include in this category only cases of the delirious variety. The following is the result of my own experience. I have notes of one hundred and eighty-six cases, belonging to the comatose delirious, and algid varieties, occurring between the first of June, 1834, and the first of March, 1835, thirty-eight of which, about 1 Diet, des Sci. Med., art. Marais. 408 PERIODICAL FEVER. one-fifth, terminated fatally. Seventy-seven comatose cases fur- nished fourteen deaths, one in five and a half; sixty-one delirious cases furnished twelve deaths, one in five; and forty-eight algid cases furnished twelve deaths, one in four. The mortality varied with the type in the following manner. Sixty cases of the quotidian type furnished fifteen deaths, one in four; thirty of thes» were of the comatose form, and gave six deaths, one in five ; twenty-one were of the delirious form, and gave five deaths, one in four; and nine were of the algid form, and gave two deaths, one in four and a half. Twenty-seven cases of the tertian type furnished six deaths, one in six, nearly; nine of these were of the comatose form, and gave two deaths, one in four and a half; fourteen were of the de- lirious form, and gave three deaths, one in five, nearly; four were of the algid form, and gave one death, one in four. Ninety-nine cases of the remittent and pseudo-continued type, furnished nineteen deaths, one in five, nearly; thirty-eight of these were of the coma- tose form, and gave six deaths, one in six, nearly; twenty-six were of the delirious form, and gave four deaths, one in six, nearly; thirty-five were of the algid form, and gave nine deaths, one in four. "Such is the mean rate of mortality that has attended pernicious fevers at Bona. In localities where the malarious poison is less powerful, it is probable that more favorable results may be looked for; but otherwise, I have reason to believe, from the researches which I have made, that proportions much more encouraging than those just indicated have never been obtained, unless it may have been accidentally. " If now we endeavor to ascertain the modes in which death takes place in periodical fever, we shall find that in the acute forms, the patient is either carried off suddenly, during a paroxysm, or that the paroxysms are prolonged and run into each other, the visceral congestions becoming fixed and being followed by inflam- mation, and complicated frequently with a typhoid condition. When death does not happen in either of the foregoing modes; when relapses have followed each other in rapid succession; especi- ally when the disease has been neglected, and the irritations feebly combated, there then supervene chronic affections of the digestive tube, engorgements of the abdominal viscera, intractable diarrhoeas, dropsical effusions, etc. "Amongst three thousand seven hundred and sixty-five patients received into the military hospitals of Bona, in the space of fourteen months, there were one hundred and thirty-five deaths, occurring in MORTALITY AND PROGNOSIS. 409 the following modes. Fifteen hundred and eighty-two cases of the quotidian type furnished forty deaths, one in forty, nearly; of these patients, eight died in a delirious paroxysm; eight, in a comatose paroxysm; three, in an algid paroxysm ; one, with jaundice; five, in a typhoid condition; thirteen, with chronic diarrhoea or dysen- tery ; one, with acute dysentery ; and one, anemic. Seven hundred and thirty cases of the tertian type furnished twelve deaths, one in sixty-one, nearly; of these patients, three died in a delirious parox- ysm ; two, in a comatose paroxysm; one in an algid paroxysm; three, with chronic diarrhoea or dysentery; and one each with chronic bronchitis, chronic pneumonia, and marasmus. The quartan type furnished no death. One double tertian had a fatal issue, after six weeks' duration. Seventy-nine cases of the remittent type furnished two deaths, one in a delirious and one in a comatose paroxysm. Thirteen hundred and thirty-two cases of a continued or pseudo-continued type furnished eighty deaths, one in sixteen and a half, nearly; of these patients, five died in a delirious parox- ysm; seven, in a comatose paroxysm; ten, in an algid paroxysm; thirty-one, with chronic diarrhoea or dysentery; three, with acute dysentery; three, with typhoid affections; three, with chronic pneumonia; six, with acute follicular colitis; two, with chronic bronchitis: two, with chronic affections of the heart; and one each, with acute gastro-colitis, encephalitis, encephalic irritation followed by paralysis, apoplexy, acute bronchitis, acute carditis, and maras- mus. " To sum up these details, death took place during the paroxysm, in fifty-one cases; in a typhoid condition, in eight cases; from dis- eases such as occur in non-malarious regions, in fifteen cases; from chronic affections, in sixty-one cases, forty-seven of which were chronic diarrhoeas or dysenteries."1 In another place Maillot says: "The prognosis in pernicious fever is always very grave. The principal varieties—the delirious, the comatose, and the algid—give nearly the same mortality. When, notwithstanding large sanguineous depletions, the coma continues profound, and the pulse remains strong and full, although the patient may be bathed in sweat, we have reason to fear a fatal issue. Death may be equally apprehended, if the persistence of the coma is accompanied by a rapid, feeble, small and vibrating pulse. There are comatose cases where the trismus is so strong 1 Traite des Fievres Intermittentes. Par F. G. Maillot, p. 277, et seq. 410 PERIODICAL FEVER. that the patient is unable to swallow; or, where on the other hand, the rectum will not retain any injection : the prognosis is here very unfavorable; there are no means of administering the sulphate of quinine but by the skin. The delirious variety isolates itself less frequently than the comatose in the nervous system ; it is more frequently associated with symptoms of acute abdominal inflam- mation ; if with this there is vomiting, so that the febrifuges are rejected, the danger is very great. When the delirium persists, and the pulse at the same time becomes small and feeble, and the skin is covered with a cold, clammy sweat, death is imminent. In the algid variety, the prognosis varies with the intensity of the morbid phenomena. If the pulse entirely disappears, the danger is extreme. The suspension of the circulation, if it is continued for some time, is certainly followed by death. If the pulse can be still felt, although only at considerable intervals, whatever may be the degree of coldness, we may indulge hope. When algid fever is accompanied by choleric vomiting and purging; when the face and extremities are blue, the breath cold, and the voice broken and sepulchral, death is almost inevitable. Vomiting without effort, as if by regurgitation, in the course of algid fever, with a moist, white, cold, and flat tongue, is always of fatal augury; it has ap- peared to me to be connected with extensive and chronic softening of the mucous membrane of the stomach."1 Maillot thinks that in cases of fatal pernicious fever, there existed some chronic lesion before the access of the disease. Dr. Charles Parry, in his paper on the con- gestive fever of Central Indiana, says: " Without treatment, or with the usual treatment of bilious fever, which is little better than none in this disease, probably three-fourths of the cases terminated fatally. But with a special treatment, not more than one in eight."2 " In the mean time," says Cleghorn, " it is to be remembered that, as in all acute diseases, so, particularly in these fraudulent, deceitful fevers, the presages either of death or recovery are not always certain and infallible, it frequently happening that those who have laid in the paroxysm for hours together, with few or no signs of life, have at length recovered, as it were, from the jaws of death, and asked for some uncommon sort of food, to the great surprise oteverbody about them ; on the other hand, the fit antici- pating sometimes brings on death before the time it was indicated."3 1 Traite des Fievres Intermittentes. Par. F. G. Maillot, p. 343. 2 Am. Journ. Med. Sci., July, 1843. 3 Rush's Cleghorn, p. 103. MORTALITY AND PROGNOSIS. 411 " Can we determine in advance," says Maillot, " whether a simple intermittent will or will not become pernicious in its character ? I think not. Frequently, we cannot do this even at the commence- ment of a pernicious paroxysm. Without doubt, we have reason to apprehend the approach of this perilous form of the disease whenever any of the visceral irritations are intense—whenever the symptoms of gastro-enteritis or encephalitis are strongly marked; but this rule has many exceptions, and I have often seen the most pernicious paroxysm succeed, without any premonition, to those of the simplest character."1 The prognosis is thus summed up by Cleghorn : " If the parox- ysms are not attended with acute pains in the viscera, and do not last above twelve hours; if they decline with plentiful warm sweats, and leave the intervals tolerably free; if the patient bears the distemper well, and begins to have an appetite for victuals; if small pustules break out in the inside of the mouth, or scabs about the lips; if the urine has recovered its natural complexion, or is cloudy and turbid, or lets fall a white or a pale red sediment—I say if all these signs concur about the third or fourth period, we may safely prognosticate a speedy recovery. On the other hand, it announces danger when, about this time of the disease, the paroxysms are long and protracted, or are accompanied with an obstinate delirium, an intense coma, great anxiety, and pain in the loins, or about the upper orifice of the stomach ; when the patient has an utter aversion to food, and even in the intervals is so feeble, and attended with such a swimming in the head, that he can scarcely walk about; when the hypochondria and epigastric region are swelled, hard, and painful to the touch; when numerous blotches, like the stinging of nettles, frequently break out on the skin; when the urine continues thin, clear, high-colored, or covered with an ash-colored membrane, like a cobweb; and lastly, it announces danger when larger evacuations come on than the strength can well bear, such as vQmiting, purging, bleeding of the nose, colliquative sweats, or the like. For fevers with these appearances sometimes are immediately changed into mortal dysenteries; sometimes they become continual tertians, and run out to a great length; but for the most part, they preserve the form of remitting or intermitting fevers, and daily growing stronger, prove very dangerous about the sixth or seventh period. 1 Traite des Fievres Intermittentes, p. 338. 412 PERIODICAL FEVER. " Those fevers are most to be dreaded, whose violence is greatest on the even days; and if the paroxysm stops on the third, fifth, or seventh day, but continues on the fourth, sixth, or eighth day, we must be upon our guard, lest a sudden storm should succeed this treacherous intermission.1 * * Nor is there only a possibility, in many cases, of foretelling the day, but likewise the hour, on which the patient will expire; for that stage of the paroxysm which he usually got over with the most difficulty will most probably in the end prove fatal. I have seen some expire in what may be called the first stage of the paroxysm; the skin being chilled and wet with cold sweats, their pulse small and irregular, and their senses entire to the very last. But the greatest numbers are hurried off in the height of the hot fit, stupefied, senseless, the breathing short and laborious, and the skin covered with a burning fiery sweat."2 Maillot observes, that in the delirious variety of pernicious in- termittents, there is frequently a strong apprehension of approach- ing death, and that this feeling is always a fatal augury.3 Dr. Charles Parry observes, that the plethoric, young, and robust, are most apt to die; and that the age, in a majority of fatal cases, is from twenty-five to thirty-five. The return of the paroxysm, in all the forms of periodical fever, at an earlier and earlier period of the day, is a favorable indication; its appearance at a later and later period is unfavorable. 1 Rush's Cleghorn, p. 98. 3 Traite des Fievres Intermittentes, p. 58. 2 Ibid., p. 103. 413 CHAPTER VIII. DIAGNOSIS. The diagnosis of well-marked and uncomplicated cases of nearly all diseases is a matter, in the actual state of medical science, not often attended with any considerable difficulty. This is true of periodical fever. Under such circumstances, its several forms can be distinguished from each other, and from all other diseases, with great facility and certainty. The mark which is set upon these diseases by their family seal of periodicity separates them broadly and widely from nearly all other affections. It sometimes happens, however, that this seal becomes so blurred and indistinct, or is so nearly obliterated, as to lose much of its value as a diagnostic and distinctive indication, and we are obliged to resort to other and collateral sources for the true character of the disease. This happens most frequently under the following circumstances. In the warmer malarious regions, and during the prevalence of the graver forms of periodical fever, the bilious remittent variety, especially, frequently loses to a great extent its periodical or remit- tent character, and assumes more or less entirely a continued form. This modification usually takes place during the latter period of prolonged cases, and under these circumstances the resemblance between the disease and continued fever becomes very close; and this resemblance is frequently increased by the presence of typhoid phenomena—great debility, feeble pulse, dry and brown tongue, tympanitic abdomen, diarrhoea, and so on. It would be foolish to deny the difficulty,. under such circumstances, of always distin- guishing between this modification of remittent fever, and con- tinued fever of the typhoid character. The resemblance here is so striking, that the opinion has extensively prevailed in this country, and still continues to prevail, that bilious remittent fever is not un- frequently changed in its progress into continued typhoid fever. The mistake here is that very common one of confounding the typhoid state or condition present in many diseases, with specific typhoid 414 PERIODICAL FEVER. fever. But, notwithstanding this resemblance, and the difficulty which I have admitted, a careful study of the previous history of these cases, and of all the circumstances attending them, will generally enable us to come to a pretty positive conclusion, and to establish a pretty certain diagnosis. We shall almost always find that during the first week or two of the disease, its remittent character was so decided as to remove all uncertainty as to its true nature. We shall find, further, in most cases, certain differences between the actual condition of the patient and the phenomena of typhoid fever. The rose-colored eruption will be wanting; the low, muttering, and continuous delirium, with twitching of the tendons, and picking at imaginary objects, so common in grave cases of continued fever, will at least very rarely be as prominent and striking; and the periodical tendency, masked and crippled as it is by the complication of local congestions and inflammations, will still, if closely watched for, frequently manifest its presence, by various slight and irregular but sudden changes, such as are not often met with in continued fever. Dr. Stewardson says, that when the disease is prolonged, the remissions obscure, and the typhoid state present, the distinction between bilious remittent and typhoid fever may be rendered some- what difficult; but that generally errors of diagnosis might be avoided by greater attention, and a more intimate acquaintance with the essential characters of the two diseases.1 During the paroxysm of the unmixed comatose or delirious form of congestive fever, the condition of the patient may be almost the same as in some local diseases of the brain. The history and the collateral circumstances of the case will generally be sufficient to remove all doubts as to its true nature. " If, as it frequently happens in the hospitals," says Maillot, " we had no previous knowledge of a patient, whom we find with coma or delirium, we might suppose the case to be one of acute menin- gitis, and resort at once to bloodletting, which, indeed, would be proper in either case. But the influence of the treatment upon the march of the symptoms would soon dissipate all doubt as to the nature of the affection. If it is a pernicious intermittent, and death does not take place during the paroxysm, the coma or the delirium will disappear in a few hours, the skin will cover itself with an abundant sweat, the pulse will become apyretic, and there will 1 Am. Journ. Med. Sci., April, 1842. DIAGNOSIS. 415 remain little or nothing of the condition, which, a few minutes before, so seriously endangered life. If, especially, all this hap- pens in a malarious region, or during the prevalence of inter- mittent fevers, it is impossible to mistake a pernicious paroxysm for any other disease. For it is not in this manner that acute con- tinued affections proceed. Look at a meningitis. As it is by degrees that it arrives at its highest point of intensity; as it is only after having continued for several days that the headache gives place to delirium or coma, so also it is only by degrees that the symptoms subside. Never, as in a pernicious paroxysm, does the delirium of acute meningitis yield in the course of a few minutes; never is the coma dissipated with a rapidity that partakes of the marvellous. The abrupt cessation of very dangerous symptoms; — the calm which succeeds to them; their almost instantaneous reap- pearance ;—such are the phenomena proper to periodical fever, and which we may in vain seek to find in continued affections."1 I have said nothing about the distinctions between the several forms or varieties of periodical fever itself. After the full descrip- tion that has been given of these varieties, it is hardly necessary to do this. I will merely observe that all these forms and varieties may run into each other; they are mutually convertible; and not fundamentally and specifically distinct forms of disease. 1 Traite des Fievres Intermittents, p. 339. 416 CHAPTER IX. THEORY. An adequate and complete theory, even of the very simplest form of disease, is beyond the reach of our science; and the diffi- culties in the way of establishing such a theory increase with the increasing complexity and obscurity of the disease to which we wish to apply it. Still, as I have already intimated, I have no dis- position to abjure entirely all attempts to explain and interpret the phenomena of disease; I do not wish, because we cannot render our theories perfect, to reject them altogether. Science here, as everywhere else, is in the appreciable phenomena with which we deal, and in their ascertainable relations; but there is no objection to our endeavoring to interpret these phenomena, and these relations, provided only that we do so with a clear comprehension of the nature and scope of the task we have undertaken. Bearing in mind that these interpretations are, in their very nature, more or less hypothetical and conjectural; that they are entirely subordinate to the facts with which they are concerned; that they may be false as well as true; that they are never to be treated like the facts and their relations which they attempt to explain, as essential and con- stituent elements of science; and that our absolute loyalty to the latter is never to be impaired by any claims or pretensions of the former;—bearing these things always in mind, we may not only engage with safety in these explanations—provided that we do so with becoming modesty and caution—but they may even help us somewhat in systematizing and arranging our knowledge. It can hardly be regarded as hypothetical to say that there is a double element in the pathology of periodical fever. This double element consists of a perversion of the function of innervation, and of local congestions in certain organs and tissues. Maillot and some others, refer the former of these elements to irritation of the cerebro- spinal axis. They think that this view is justified by the phe- nomena during life, and by the alterations found in the brain and THEORY. 417 spinal marrow, and in their membranes, after death. Maillot looks upon this affection of the cerebro-spinal axis, not as a pure ordinary inflammation, but as a nervous irritation—an active neurosis—with a sudden raptus of blood to the organs. However this may be, it is quite certain that one of the essential elements in the pathology of periodical fever consists in some modification of the nervous system; and it is nearer the truth, probably, in the present state of our knowledge, to say that this modification is peculiar in its character and obscure in its nature, instead of attempting to refer it to any of the ordinary and common morbid conditions of this system. It is possible that this lesion of innervation may constitute alone the pathology of periodical fever; the disease, in its purest and simplest form, may be without any other pathological condition; the local congestions in the liver, spleen, stomach, and so on, may be altogether wanting. This, however, it seems to me, is not the most probable and rational conclusion to be derived from the phe- nomena of the disease. There is no doubt of the general tendency to these local congestions; there is no doubt of their existence in all grave and severe cases ; they are always found on examination after death. Under these circumstances, although in mild and simple cases of pure intermittent fever, there may be no positive evidence of the existence of these congestions, and although I admit the possibility that they may not be present, still, as I have already said, taking into consideration all the circumstances, it seems to me more philosophical and more rational to conclude that they constitute an invariable and essential element in the pathology of this disease, than it is to regard them as accidental complications. The relations of the lesion of innervation, and of the local con- gestions, to each other, and the relative and absolute importance of all these—the parts which they respectively play in the integral disease which they constitute—must be more or less matters of opinion merely. The nervous disturbance constitutes, probably, the first visible and tangible link in the chain of morbid actions; it is, probably, the point of departure in the series of morbid pro- cesses making up the disease; it seems reasonable to suppose that it takes precedence of the local congestions, and that the latter are under the control of the former. All this, however, let it be admitted, may be otherwise; or, it may be that both elements— the nervous lesion and the local congestions—instead of being dependent one upon the other, are alike occasioned by the action on 27 418 PERIODICAL FEVER. the s}rstem of the malarious poison—their common and independent cause. In regard to the relative and absolute importance of the several morbid elements, I cannot say anything that is not altogether con- jectural. The danger to life would seem to depend, generally, upon the intensity of the visceral congestions and irritations; but our knowledge of the nature of the nervous disturbance, and of the part which it plays, is so incomplete and so qualified, that it is neither very philosophical nor very safe to indulge to any great extent in these and similar speculations. It is safe, perhaps, to say that the element of periodicity is probably connected directly with the lesion of innervation, and not with the local congestions.1 Some of my readers, especially the younger ones, may be not a little disappointed that I do not engage in the attempt so often undertaken, to lift the veil which hides from us the efficient causes; the mechanism, and the essential nature of this mysterious and complex phenomenon of periodicity. For their gratification, and I trust for their benefit, I shall make two or three remarks upon this subject, which, unlike the subject itself, will at least be sufficiently intelligible. First, then, all the interpretations and explanations which have been given of this phenomenon, are entirely and abso- lutely hypothetical; they are the coinage of the brain—the fruits of the imagination and the fancy. Not only so, but, in most cases, they are as obviously and glaringly absurd, preposterous, and false, as they are hypothetical. They have not even the merit of possi- bility, to say nothing of probability, plausibility, or ingenuity. No- where, perhaps, in the boundless region of medical speculation, has the rage for hypothesis been wilder and crazier than here. Secondly, the essential nature of this phenomenon is probably inscrutable. We may analyze it; we may resolve it into its elements; we may ascertain the relations of these elements to each other, and to their modifiers—we may do all this, and still be as far as ever from its 1 Hippocrates attributed tertians and quotidians to a superabundance of bile in the first passages, and quotidians to atrabile. Galen referred quotidians to an alteration of the pituita; tertians to that of the bile ; and quartans to putrescence. of the atrabile. The anatomists said that quartans were the result of an obstruc- tion occasioned by the minutest atoms ; tertians by those a little larger ; and quo- tidians by the largest. Rayer refers periodical fever to a cerebro-spinal neurosis ; Guerin de Mamers does the same. Brachet, of Lyons, says it consists in a modifi- cation of the ganglionic system. Bouillaud calls it an active neurosis. M. Roche refers it to a contamination of the blood by the malarious poison.—Maillot, p. 316, et seq. THEORY. 419 ultimate cause, its essential condition, its intimate and absolute nature. Who understands, or can comprehend even, the nature of sleep f And what reason is there to believe or to hope, that the thick darkness which has ever wrapped and which still wraps this intermittent physio- logical phenomenon, so full of mystery and wonder, will ever be dis- pelled?1 1 Darwin attributed the phenomenon of intermittence to the nutritive movement of composition and decomposition, and the periodical recurrence of waking and sleep. Reil taught that it was connected with the analogous phenomena of the physical universe. Willis referred it to the periodical development of a ferment- able matter in the blood ; De La Boe to the introduction into the blood of an acid, pancreatic juice ; Borelli to an irritation of the nerves of the brain, and of the fibres of the heart, occasioned by an acidity or an acrimony developed in the nervous fluid. Werlhof referred it to the periodical movement of the earth, while Mead and others attributed it to lunar influence, to the alternate action of day and night, the direction of the winds, &c. Giannini said intermittence was occasioned by the excessive diminution of sensibility during the sweating stage. Guerin de Mamers attributed it to an extraordinary development of nervous influence, its concentration upon a given point, its subsequent exhaustion, its renewal, and so on. M. Roche finds a sufficient explanation of this phenomenon in the intermit- tent character of its causes, and in certain other collateral influences.—Traite" des Fievres Intermittentes, p. 270. Bailly, notwithstanding his general good sense, labors through many idle pages to show that morbid intermittence is occasioned by the diurnal change in the position of the human body, from the upright to the recumbent, and vice versa. Maillot concludes this enumeration with the following quotation from Monfalcon: " To know that we know nothing is a great deal; we are then much nearer the truth than when we mistake, for this latter, erroneous hypothesis." 420 CHAPTER X. TREATMENT. To combat the visceral lesions; to oppose the return of the paroxysms ; to pre- vent the occurrence of relapses;—such is the triple base upon whioh rests the treatment of periodical fever.—Maillot. ARTICLE I. BILIOUS REMITTENT FEVER. Sec I.—Preliminary. The treatment of the common form of bilious remittent fever is pretty well settled; and although the varieties in the character of the disease, in different seasons and localities, render necessary certain modifications in the treatment, the essential principles of this remain the same. Sec II.—Bloodletting. General bleeding is not commonly resorted to in the treatment of this disease. There can be no doubt, how- ever, that in robust and plethoric habits, and where there exists no contraindication, either in the circumstances of the individual case, or in the prevailing character and constitution of the disease, early and moderate general bleeding is of much utility. Early in the disease, under these circumstances, where the headache is violent, the skin dry and hot, and the pulse full and bounding, the symp- toms will be moderated by this remedy; but in the absence of these or analogous special indications, it would seem to be safer to abstain from general bleeding. Lind cautions against bleeding in hot cli- mates. He says great harm has been done by English practitioners, who follow the example of Sydenham. Sir Gilbert Blane recom- mends bleeding in athletic habits, with high excitement, violent pains, or delirium: but he adds these words: "Although the cases requiring bloodletting are more frequent in this sort of fever than in typhus, yet great caution and nice discernment are necessary with regard to it, in all cases, in a hot climate. Bloodletting, un- TREATMENT. 421 seasonably and injudiciously employed, either endangers life, or has a very remarkable effect in protracting recovery, by the insur- mountable weakness it induces."1 Topical bleeding, by cups or leeches, is of very great service, and of very general application. There are, probabty, but few cases in which it may not be beneficially applied. This means is especially valuable for the removal or diminution of the epigastric pain, tenderness, and distress. In ordinary practice, cups will usually be made use of; and they should be applied across the epigastrium and the hypochondria, and repeated according to the urgency of the symptoms and the strength of the patient until their object is accomplished. The best time for their application is during the febrile exacerbation, when the skin is warm and dry; and the earlier in the disease the better. "As regards the stage of the disorder," Dr. Stewardson says, "I should say that it was not worthy of much consideration in determining upon the propriety of local depletion in cases of an ordinary remittent, where considera- ble epigastric or hypochondriac tenderness coincided with more or less acceleration of pulse, and heat of skin. For although here, as in the more severe disease of hot climates, early depletion, i. e., from the first to the fourth day, is highly desirable, in order to shorten its course and diminish the force of the local determina- tions, yet the same danger does not exist as in the latter, in refer- ence to depletion at a much later period; unless, of course, where the symptoms of prostration clearly forbid it. I would not hesitate, then, to abstract a few ounces of blood under the circumstances mentioned, even at a late period of the disorder, since it is certainly a point of paramount importance, in the treatment of remittent, to prevent, as far as practicable, the production of those chronic altera- tions of the spleen and liver, which, when once firmly rooted, so generally prove fatal after lengthened suffering."2 Strong determination of blood to the head, indicated by head- ache, heat, throbbing, and in some instances delirium, requires the application of scarified cups to the temples and back of the neck. Sec III.—Purgatives. The use of purgatives in the treatment of bilious remittent fever is almost universal. In the United States they are nearly always given at the commencement of the disease, and repeated occasionally, during its subsequent course. Different 1 Diseases of Seamen, p. 389. 2 Am. Journ. Med. Sci., April, 1842. 422 PERIODICAL FEVER.—BILIOUS REMITTENT FORM. combinations of cathartic substances are adopted by different prac- titioners ; but nearly all of them make use of some mercurial pre- parations—either calomel, or blue pill. One of these substances is preferred on account of the peculiar action which they are believed to exert upon the liver; and for their efficacy in restoring and correcting arrested or depraved secretions. Whatever may be the precise mode of action of the mercury, experience seems to have demonstrated its usefulness as a purgative in this form of disease. From five to ten grains of calomel may be combined with ten or fifteen grains of jalap, or with fifteen or twenty grains of rhubarb, to constitute a single purgative dose; this may be repeated, if necessary, or it may be followed by an ounce of castor oil. Instead of the calomel, ten or fifteen grains of blue pill may be made use of. Excessive purgation should be avoided. This evil, owing to the disastrous influences of a false and preposterous pathological theory, has been pretty extensively prevalent throughout many portions of our Southern and Western States. Happily for science and humanity, like the bastard philosophy whose legitimate offspring it was, it has nearly run its race, and had its day, and is fast dis- appearing from the practice of our art. It is quite enough, as a general rule, that two or three consistent stools should be procured during each twenty-four hours, for the active period of the disease, and one or two, later. If there is intestinal irritation, still greater caution is necessary; and the milder laxatives should always be preferred. Sec IV.— Cinchona. The periodical element in the pathology of this disease is to be met and neutralized by the great anti- periodic remedy—cinchona and its preparations. There is no sub- stitute for these. They are universally relied upon for this purpose. In all countries, and at all periods, since the discovery of the pro- perties of this incomparable and invaluable substance, amidst all the conflicting dogmas of different medical doctrines, Peruvian bark has never failed to sustain its reputation, and to answer the expecta- tions that have rested upon it. Amidst the manifold uncertainties of medical science, and the perpetual contingencies of medical art; amidst the disheartening scientific infidelity which has lately been taking possession of the medical mind, shaking to*its deep founda- tions the firm old faith in the potency of drugs, and threatening to overturn and demolish it altogether—it is gratifying and consola- tory to feel and to know, that here at least we stand upon solid TREATMENT. 423 ground, that here we may hold—that there is at least one great and important therapeutical relationship definitively and positively ascertained and established, defying alike the open assaults of quackery from without, and the treacherous machinations of indo- lent scepticism from within. The sulphate of quinine is altogether the best of the preparations of the bark, and it is now almost universally and exclusively used. There is a good deal of difference in the mode and circumstances of its administration, by different practitioners—a difference that is probably rendered necessary by modifications in the character of the disease itself. As a general rule, in the treatment of the com- mon form of bilious remittent fever, practitioners desire to diminish the intensity of the local congestions and irritations, by depletion and purgatives; to lessen the general febrile excitement, and thus to develop the periodical element in the disease, by rendering the remissions more distinct, before resorting to the use of the quinine. Two or three grains an hour are then usually given during the period of remission. Some physicians prefer very much larger doses—fifteen or twenty grains, for instance—given at once, and repeated, if necessary. Other observers attach less importance to the preparation of the system, by bloodletting, cathartics, &c, for the quinine, and resort immediately, and without much regard to the stage of the disease, to its use. There seems to be good ground for believing, as I have just intimated, that these differences may have arisen from differences in the character of the disease. It appears probable, for instance, that in the more northern and tem- perate latitudes, it is more necessary to prepare the way for the use of quinine, by the preliminary remedies before mentioned, than it is in the more southern and warmer latitudes. In these lati- tudes, the disease may sometimes assume a graver character than it wears in the former, verging towards its congestive co-gener, and requiring somewhat the same treatment that is necessary in the latter. Sec. V.—Diaphoretics; Refrigerants, &c. Remedies of this class are generally made use of, especially during the height of the febrile paroxysm. Small doses of ipecac, nitrate of potash, and spirit of mindererus, are amongst the articles most frequently selected—the choice depending upon the circumstances of the case, or the opinions of the practitioner. Cold drinks, acidulated or not, 424 periodical fever.—congestive form. effervescing draughts, and so on, according to the taste of the * patient, should be freely administered. ARTICLE II. congestive fever. Although the general indications in the management of the con- gestive variety of periodical fever may be nearly the same as in that of the bilious remittent form, very important modifications are necessary in the details of the treatment and in the application of remedies. In no other disease, of so grave a character, does so much depend upon the prompt, efficient, and judicious interference of art; under no other circumstances, of ordinary acute disease, is the life of the patient placed so absolutely in the hands of his phy- sician. A blow struck at the right time, in the right place, and in the right direction, will very often save the life that would other- wise have been lost. And the action of the physician in the treat- ment of this terrible form of disease is crowded into the briefest space of time; the issues of life and death hang upon a single hour; the morbid processes must be immediately arrested, or modified, or they will inflict irreparable and fatal injury upon the organs in which they are situated. In laying down rules for the treatment of congestive fever, I shall rely mostly upon the observation and experience of the phy- sicians of our Southern and Western States. They have long been extensively familiar with the disease in all its phases, and in its gravest form; they have studied carefully and attentively its thera- peutical relationships; they have been, for the most part, sufficiently free from the influence of preconceived opinions and doctrinal theo: ries, to look steadily at Nature and to follow its teachings, and I regard their authority upon this subject as high at least as any in the world. There are, as might naturally enough be expected, some differences amongst them; but, so far as the most important and fundamental principles of treatment are concerned, they are very well agreed. I shall first speak of the means that are usually resorted to during the cold fit—a condition which appertains to all the varieties of the disease—in what is commonly called the congestive chill—in order to bring about reaction. External heat and stimulants, and internal stimuli, are generally relied upon for this purpose. Hot TREATMENT. 425 bricks, or bottles of hot water, are applied to the legs; and the surface of the body is extensively covered with sinapisms. Small quantities of brandy, or wine whey, porter, or some similar article, are frequently repeated internally. At the same time, the sheet-anchor is to be at once thrown out—the great remedy is to be immediately and boldly resorted to. The sulphate of quinine, usually in com- bination with some other articles, according to the circumstances and condition of the patient, is to be freely given. From ten to twenty grains of the sulphate should be administered, either alone or in combination with half a grain, or a grain, of one of the salts of morphia, with a few grains of calomel, or blue pill, according to the indications. Dr. Charles Parry, during the chill, applies hot bricks to the feet, and sinapisms over the belly and legs. Every half hour, he gives a pill composed of one-fifth of a grain of sulphate of morphia, one grain of camphor, two grains of blue pill, and sometimes half a grain of capsicum. If there is much blood in the discharges from the bowels, and these are frequent, he gives every half hour one-fifth of a grain of sulphate of morphia, three grains of sugar of lead, and two grains of calomel. He prefers ice, internally, to stimuli. If there is much purging, he makes use of opium; and to diminish the local congestions, he applies cups and ice. To prevent the return of the paroxysm, his great remedy is, of course, quinine. Dr. Wharton, of Grand Gulf, Mississippi, applies blisters to the thighs, and sinapisms over the belly. He administers at the same time, every hour or two, from four to seven grains of quinine, com- bined with capsicum and camphor. Brandy, he says, is often use- ful in promoting reaction. As soon as this is established, free doses of spirits of turpentine and castor oil are given, and repeated till they produce copious tarry discharges. Dr. Thomas Barbour, of Pulaski, Tennessee, has published in the American Journal of the Medical Sciences, an interesting paper on the congestive fever of what is called the Tennessee Valley, in North Alabama. His treatment of the disease differs so much, in some respects, from that which is usually adopted, that I think it proper to give an outline of it. The principal peculiarities in the method adopted by Dr. Barbour consist of his means of procuring reaction during the cold stage of the disease; these means are bleeding and the cold affusion. In ordinary cases, and where there is no contraindication from age, 426 periodical fever.—congestive form. intemperate habits, or feeble and broken-down constitutions, he bleeds cautiously from the arm, keeping the finger on the pulse, and watching the effect. If the pulse falters, the orifice is to be closed, and diffusible stimuli given ; but if it rises, and becomes fuller and more regular, as it often does, the operation is to be continued till the pulse is well developed. When general bleeding is not proper, free cupping is substituted. A sinapism is applied over the stomach, and small quantities of ice or iced drink are given. If the bowels are torpid, he makes use of moderate doses of calomel, rhubarb, and ipecac.; if the discharges are thin, he suppresses them with moderate doses of calomel, camphor, and opium. He then resorts to the cold affusion, for the application of which he gives the following directions :— " Have a broad plank placed upon two chairs, at a convenient distance apart, and place two vessels of hot water on each side, corresponding with the feet and hands ; then strip the patient, and lay him on his back on the plank, with his extremities in the hot water, having at hand twenty or thirty gallons of spring water, or, what would be better, water made colder by ice or salt; pour the water from a pitcher, in a full and rapid stream, over the chest and abdomen. The second mode which I adopt, particularly in cases where the brain and spinal marrow are the chief seats of congestion, is to place the patient upon a blanket on the floor, on his side, and then to dash the cold water as forcibly as possible over the head, and along the spinal column. Having applied the water, the patient should be quickly wiped and placed in bed, and covered with two or three blankets, and smartly rubbed either with dry mustard, flour, or salt, or with spirits of turpentine. " Under the combined influence of these agencies, reaction, if at all possible, soon ensues; the surface rapidly recovers its natural temperature; the pulse, from being quick and thready, becomes fuller, softer, and more regular; the countenance becomes fuller and more animated; and from insatiable thirst and uncontrollable restlessness the patient often experiences so much relief that it is not uncommon for him to fall into a quiet and refreshing sleep, from which he awakes greatly improved. "The effects of the cold dash are frequently permanent, and complete reaction takes place, followed by rapid convalescence. In many instances, however, the effects of the first affusion sub- side, and the patient relapses into his former condition of coldness, restlessness, and insensibility. In such cases, it is proper to repeat TREATMENT. 427 the affusion until complete and permanent reaction takes place, which may be confidently anticipated in a large majority of even the worst cases, provided it is applied sufficiently early."1 As auxiliaries to the cold affusion, Dr. Barbour generally applies cups along the course of the spine, over the epigastrium, the right hypochondrium, or the bowels, according to the indications, and stimulants to the skin. When there are strong marks of cerebral congestion, he applies a blister to the back of the head or the neck. He gives light, diffusible stimuli, especially porter. When, by the above means, moderate reaction is procured, he gives from three to five grains of blue mass, five grains of rhubarb, and from half a grain to one grain of opium, every six or eight hours, until the secretions become' of natural color and consistence, and from ten to twenty grains of quinine, with from five to ten grains of Dover's powder, every three or four hours. He prefers the morning for the administration of the quinine, and the evening for that of the aperient. If reaction is violent, with signs of local congestion, he again applies cups, and administers calomel, followed by oil, or an infusion of senna with ginger, and repeats either the cold or the tepid affusion. It may sometimes be proper to bleed from the arm ; but under these circumstances, this should be done with extreme caution, as there is danger of excessive prostration. Where the cold stage is protracted for several days, with imperfect reaction, or none, Dr. Barbour thinks but little can be done; but he would rely, under such circumstances, upon the occasional use of the cold bath, large and numerous sinapisms, blisters, hot spirits 1 Relying upon what are commonly called rational indications in the application of therapeutical means, nothing certainly can well be imagined more absurd and irrational, more directly opposed to all a priori considerations than this use of general bloodletting, and the free affusion of iced water, to remove the collapse of a congestive chill. But these rational indications, as they are called, are very frequently, notwithstanding their high pretensions, most untrustworthy and treach- erous guides ; they lead us astray as frequently as in the right path, and whenever they oppose, as they so often do, the lessons of simple experience, they are to be utterly contemned and disregarded. It cannot be too often repeated, nor too emphatically proclaimed, that therapeutics rests on only one true and immovable basis, that of pure observation; her steps can be guided aright by the light alone of experience. So here, as everywhere else, the utility and value of the new method are to be settled solely by its results. Its apparent unreasonableness or impropriety is not to stand in the way of its adoption if clinical observation establishes its utility. The practice is said to have originated with Dr. Thomas Fearn, of Huntsville, Alabama. Trial has been made of it by a considerable number of physicians ; it deserves further and still more careful study, for its absolute value can hardly be regarded as definitely ascertained and determined. 428 periodical fever.—congestive form. of turpentine, calomel often repeated, large doses of quinine, and the free use of brandy or porter. Rice water, barley water, arrow- root, gruel, or chicken water are the best articles of diet during the course of the disease, and also for several days after convales- cence commences. After the strength of the digestive organs has somewhat improved, chicken broth, broiled milk, or milk and mush are appropriate for a few days, after which the patient can return to his usual diet. For drink during convalescence, nothing is so good as old porter.1 Maillot, an extensive and accurate observer, who saw much of periodical fever, in all its forms, in the French military hospitals in Africa, insists very strongly upon the necessity, in all the perni- cious or congestive varieties, of a prompt and bold use of the sul- phate of quinine. He says that his medical education and philoso phy had impressed him with the common notion that quinine could not be safely given in these diseases, so long as there were signs of local irritation or inflammation present, and only during the apy- rexy. His experience amongst the violent congestive fevers of the hot malarious region of Algiers soon convinced him of his mistake; and his use of the great remedy was as free and lavish as that of any of our own practitioners in the Southern and Western States. During the paroxysm, in the comatose and delirious varieties, he recommends general and local bloodletting, and cold applications to the head. Cutaneous revulsives he also regards as important auxili- aries. In the algid variety, he endeavors to promote reaction by the free application of sinapisms, and by large doses of ether, given both by the mouth and the rectum. He recommends that com- presses, saturated with water and ammonia, be placed along the spine, over which is to be pressed a hot iron; and that after their removal the parts shall be covered with sinapisms. He attaches but small value to cathartics. It will have been noticed, in the course of the foregoing details, that some of the most important rules of practice, followed by most of the older physicians, in the management of periodical fever, have been altogether disregarded. I allude particularly to the use of quinine, in very large doses, and at all periods of the disease, and without regard to those conditions of the system that have generally been supposed to contraindicate its use. This mode of administering quinine is now almost universally adopted, in the 1 Amer. Journ.^Med. Sci., July, 1841. TREATMENT. 429 grave forms of congestive fever, by the physicians of the South and West; and both its necessity and its safety have been abund- antly demonstrated. The paroxysms must be arrested, or the patient will die ; the only agent in our possession, by which this can be done, is the bark and its, preparations; and no time is to be lost in their use. There is no evidence that, in this form of fever, they have any tendency to increase the intensity of the local irritations.1 Dr. Thomas Fearn, of Huntsville, Alabama, more than fifteen years ago, gave the sulphate of quinine in doses of twenty grains, repeated three times, at intervals of one hour; and the credit of having originated this mode of practice has been given to him. The late Dr. Perrine, in a letter -to Dr. Dewees, says that he used large doses of the bark, in the treatment of marsh fevers, given during the paroxysms, as early as 1819. As soon as quinine was introduced, he used that, in average doses of ten grains, every two hours, at any period of the disease, without regard to the state of the pulse or skin. He did not find it to interfere with the simultaneous use of antiphlogistics or stimulants.2 Maillot says: " That treatment which in a malarious region attempts to remove local irritations before administering the sul- phate of quinine, which waits to convert a grave into a simple in- termittent before resorting to febrifuges, prepares for itself inevita- ble reverses."3 Lind speaks of the Dutch in Batavia, as early as 1763, adminis- tering bark, without waiting for any remission ; and, in grave cases, Cleghorn did the same in Minorca, more than a hundred years ago. About the modus operandi of the sulphate of quinine, I have but a single word to say. Certainly, there is no propriety in regarding it as a simple tonic, or stimulant. In congestive fever, at least, it does not act as a tonic or stimulant; and no known tonic or stimu- lant can be substituted for it, or supply its place. It is a specific anti-periodic. It is endowed with the peculiar property of arrest- ing or counteracting this pathological process characterized by periodicity; it stands in a special relation to this particular form of 1 Note to third edition.—-The practice of administering quinine early in the vari- ous forms of periodical fever has been becoming more and more general at the West and South within the last few years.—Dr. Drake, Dis. N. A., vol. i. p. 789-793. 2 Transylvania Journal, vol. vi. p. 301. 8 Traite des Fievres, etc., p. 81. 430 PERIODICAL fever. — INTERMITTENT form. disease; and this is the entire sum and substance of our knowledge of the matter—just as easily packed in a nutshell as blown out into an empty balloon. ARTICLE III. INTERMITTENT FEVER. It is hardly necessary to enter at any considerable length into the details of the treatment appropriate to the simple intermittent form of periodical fever. The management of simple chills and fever has been, to a very great extent, taken out of the hands of medical men, and intrusted to those of the patients themselves and their friends. This management consists almost exclusively in the use of the sulphate of quinine, with occasionally, perhaps, a simple or a mercurial purgative. The quinine is usually given during the intermission, and in various doses, from one or two to eight or ten grains. Amongst persons constantly residing in malarious localities, intermittents frequently become obstinate, irregular, and pro- tracted. In these cases, and in the simple forms, when the latter resist the influence of quinine, various substitutes for this sub- stance have been made use of. Amongst these, the most important are arsenic, and some of the bitter vegetables, Cornus Florida, or dogwood, chamomile, thoroughwort, and so on. There is no doubt at all of the anti-periodic property of arsenic; and in those cases to which I have referred, it may sometimes be used with advantage. So, an infusion of one of the vegetables just mentioned will occa- sionally be found more efficacious in arresting the paroxysms than even the bark itself; and when the disease does not yield to its usual remedy, it is well to employ them. In regions where marsh fevers are extensively prevalent, there are many remedies and modes of practice, besides those already mentioned, which acquire a popular celebrity. Most of them pro- duce a pretty sudden and powerful .impression either upon the mind or the body, and in this way they frequently break up the disease. I shall mention particularly only one other remedy, and that is opium. This substance has been a good deal used in the treatment of periodical fever, and there seems to be no doubt of its great value. The following interesting account of its action and effects is by James Lind, who for a long period during the last TREATMENT. 431 century was a careful and extensive observer of periodical fever. His testimony in regard to its advantages is so emphatic and decided that I feel bound to introduce it. The history of his experience is thus related. Having given a dose of opium in an obstinate case of ague, on account of some accidental symptom, to the great relief of the patient, he concluded to try the remedy more extensively. " Having at that time," he says, " twenty-five patients laboring under intermitting fevers, I prescribed an opiate for each of them, to be taken immediately after the hot fit, provided the patient had any inquietude, headache, or similar symptom subsequent to the fever. The consequence was that nineteen in twenty-two received immediate relief; the other three had no occasion to take it. " Encouraged by this success, I next day ordered the opiate to be given during the hot fit. In eleven patients out of twelve to whom it was thus administered, it removed the headache, abated the fever, and produced a profuse sweat, which was soon followed by a perfect intermission. Since that time, I have prescribed an opiate to upwards of three hundred patients laboring under that disease. I observed that when given during the intermission, it had not any effect either in preventing or mitigating the succeed- ing fit; when given in the cold fit, it once or twice seemed to remove it; when given half an hour after the commencement of the hot fit, it generally gave immediate relief. " The effects of opium, given in the hot fit of an intermitting fever, are these: First, it shortens and abates the fit; and this with more certairfty than an ounce of bark is found to remove the dis- ease. Second, it generally gives a sensible relief to the head; takes off the burning heat of the fever, and occasions a profuse sweat. This sweat is attended with an agreeable softness of the skin, in- stead of the disagreeable burning sensation which usually affects patients sweating in the hot fit, and is more copious than in those who are not under the influence of opium. Third, it often pro- duces a soft and refreshing sleep to patients before harassed with fever, from which they awake bathed in sweat, and in a great mea- sure free from complaint. " I have always observed that the effects of opium are more uni- form and constant in intermitting fevers than in most other diseases, and are then more quick and sensible than those of most other medicines. An opiate thus given, soon after the commencement of the hot fit, by abating the violence and lessening the duration of 432 PERIODICAL FEVER.—INTERMITTENT FORM. the fever, preserves the constitution in a great measure uninjured. Since I have used opium in agues, a dropsy or jaundice has seldom attacked any of my patients in these diseases. "In cases where opium did not immediately abate the symptoms of the fever, it never augmented their violence. On the contrary, most patients reaped some benefit from an opiate given in the hot fit; and many of them bore a larger dose of opium at that time than at any other. Even a delirium in the hot fit is not increased by opium, though opium will not remove it. If the patient be delirious in the fit, the administration of the opiate ought to be de>- layed till he recovers his senses; an opiate will then be found to relieve the weakness and faintness which commonly succeed the delirium."1 Dr. Drake says of opium in the treatment of malignant inter- mittents : " Of its great value no physician of experience, in those diseases, can entertain a doubt. If there be no diarrhoea, however, it is not necessary to administer it throughout the intermission, but reserve it for the last dose of the sulphate, before the approaching chill. The quantity in which it is then given, is often entirely too small, and much better fitted to simple intermittents, in which the susceptibilities of the system are lively, than to those in which they are greatly reduced. In such a state of the system, three or four times as much as would be required in an ordinary ague, is not a large dose. I have met with many physicians who had a just appreciation of this state of the system; but with none who carried the practice logically deducible from it, so far as Dr. Merriman and Dr. Henry, of Springfield, Illinois. It has grown into a settled opinion with those gentlemen, that a moderate quantity of the sul- phate, combined with a large quantity of opium, is the very best practice. Hence through the early periods of the intermission, they do little or nothing; but three or four hours before the chill, administer a bolus of four grains of opium and eight grains of sul- phate, which, as they affirm, scarcely ever fails. Dr. Henry has even found that dose of opium, without the other medicine, success- ful. Dr. Jayne pursues the same practice, but generally limits the opium to two grains."2 To prevent the occurrence of relapses, I know of no means of any value, except an occasional use of the bark; a careful regula- tion of the diet and exercise, so as to keep the system in as vigor - > Lind on Hot Climates, Phila. ed., p. 236. 2 Dr. Drake on the Diseases of North America, vol. i. p. 776. TREATMENT. 433 ous a tone as possible; and an avoidance of the night air, and of all the ordinary exciting causes of disease. There is only one means certainly to be depended upon, and this consists in a removal be- yond the influence of the malarious poison. For the removal of the various remote consequences of the dis- ease which have already been enumerated, no very particular rules can be given. The local engorgements of the liver and spleen— especially of the latter—so long as they are simple engorgements, without any fixed change of structure, are to be met by the means already indicated, particularly by quinine, paying attention at the same time to the state of the bowels and secretions. When these engorgements have been so long continued and so often repeated, as to result in chronic structural alterations, only palliative effects can be looked for from remedies. The headache and other cere- bral troubles, which sometimes follow the disease, and which seem to be connected with a kind of nervous erethism, may generally be removed by shaving the head and keeping it cool; by quiet and rest; and a careful regulation of all the organic and animal func- tions. Neuralgic affections are to be treated upon the same general principles. There can be but little doubt, that a free and persever- ing use of cold water, externally and internally, with a plain but substantial diet, and active exercise in the open air, would consti- tute the best possible treatment in many of these cases. The best special remedy for the anemic condition which the disease fre- quently leaves behind it consists in the different preparations of iron. [The cachexia produced in those who had been affected with the fever of the Isthmus, was found to require quinine and iron in tonic doses, often for a period of two months after the febrile paroxysms had wholly ceased, before the patients were regarded as well enough to be discharged. At the Bellevue Hospital, New York, for the last year or two quinoidine or chindidine has been gradually taking the place of quini ne, in the treatment of fever and ague. So far, it is thought to be equally efficacious as an afiti periodic; and is substituted on account of its comparative cheapness. Although it must be given in doses two or three times larger than the quinine, still the substitution sensibly diminishes the expenses of the apothecary's department, in so large a hospital.] 28 434 CHAPTER XI. DEFINITION. There is so wide and various a range in the forms of periodical fever that it is very difficult to frame any definition of it which shall possess the necessary brevity, and at the same time be sufficiently comprehensive to include all the essential features of the disease. I can come no nearer the fulfilment of these conditions than in the following endeavor. Periodical fever is an acute affection, occurring at all periods of life ; much more common in the white than in the negro race; confined to certain geographical localities, and prevailing most extensively, as an annual endemic, in marshy and uncultivated regions, and along low-lying and luxuriant alluvions; mostly con- fined in temperate climates to the latter part of the hot season of the year; immediately excited, in many instances, by the ordinary occasional causes of acute disease, such as exposure and excesses; dependent for its essential cause upon a poison called marsh miasm or malaria, the nature and composition of which are unknown; generally sudden in its access, commencing with a rigor or chill, which is succeeded first by febrile excitement, and then by general perspiration ; these successive phenomena constituting the three stages of what is called the paroxysm of the disease; this paroxysm having a tendency to recur, or to repeat itself, more or less regu- larly, at certain definite periods, and after certain intervals, these intervals constituting the remissions or intermissions of the fever; the paroxysms and intervals being in an immense majority of instances either diurnal or bi-diurnal in their recurrence; the symptomatic phenomena constituting these periodical stages, vary- ing very widely in their intensity and combinations, thus giving rise to numerous fluctuating and diverse forms of disease; the simpler varieties attended with but little immediate danger, and continuing from a few days to an indefinite period of time; the graver and pernicious forms dangerous in their tendency, and DEFINITION. 435 speedily fatal in their results, unless promptly arrested by art; all the varieties, if long continued, or often repeated, finally under- mining the constitution, and occasioning various structural alter- ations, especially of the spleen, attended by dropsical effusions, anemia, general debility, and neuralgic pains; the bodies of patients exhibiting, on examination after death, in most cases, hyperaemic irritation of the cerebro-spinal axis; in nearly all, redness, soften- ing, thickening, thinning, and mamellonation—one or more—of the mucous membrane of the stomach; and in all cases [at least of the remittent type], a bronze or olive color of the liver, enlarge- ment of the spleen, and a diminution in the normal quantity of the fibrin of the blood; which disease, thus characterized and defined, sustains a special therapeutic relation to cinchona and its prepara- tions, and is to a great extent modified and controlled by them. 436 CHAPTER XII. BIBLIOGRAPHY. Observations on the Epidemical Diseases of Minorca, etc. By George Cleghorn, 31. D. Philadelphia, 1812. This admirable little book was written more than a century ago. It is a model of the class to which it belongs, and a fit companion to Hillary's similar book on the diseases of Barbadoes. Dr. Cleghorn's description of the several forms and varieties of malarious fever is very full and complete; and the disease seems to have been as judiciously and efficiently treated a hundred years ago as it is now, excepting in the advantages derived from the possession of quinine. Dr. Cleg- horn used the bark early and freely, and he regrets that he had not always given it with as much freedom as he did during the last seven years of his practice in Minorca. In grave or threatening cases, he urges the importance of the bark, without regard to the state of the system, the presence of offending matters in the bowels, the existence of local inflammation, and so on. A Treatise on the Hidden Nature and the Treatment of Intermitting and Remitting Fevers, etc. By Jean Senac. Translated from the Latin by Charles Caldwell, M. D. Philadelphia, 1805. Senac's book is one of the classics in this department of medicine. He practised in Paris during the reign of Louis XV., when periodical fevers were more common than at present. His treatise is systematic and elaborate ; his description of the mixed, irregular, and masked forms of the disease is particularly full and valuable. He speaks of the bark as a divine discovery. The Treatise has a good deal of useless rationalism ; but its practical portion is excellent, and it is, on the whole, a capital old book. Observations on the Causes and Cure of Remitting or Bilious Fevers. By William Currie, M. D. Philadelphia, 1798. I have already, on other occasions, had the pleasure of commending this excellent lit- tle book. Its style is clear, simple, and unpretending; its descrip- tions are full and accurate; and it is quite free from the false BIBLIOGRAPHY. 437 philosophy which pervades, obscures, and vitiates all the writings of Dr. Currie's great contemporary and fellow citizen, Dr. Rush. The radical differences between bilious remittent and yellow fever are very fully and clearly stated. An Essay on the Diseases of Hot Climates, etc. By James Lind, M. D. Philadelphia, 1811. This somewhat celebrated work con- tains short and cursory notices of many of the localities in hot climates, which are in the hands of the more northern nations, or which are often visited by Europeans; and of the principal dis- eases—especially fevers—to which they are subject. The book is marked by good sense; though its contents are not now of any special value. The Influence of Tropical Climates on European Constitutions, etc. By James Johnson, M. D. This is the celebrated work of the cele- brated editor of the Medico-Chirurgical Review, on the diseases of hot climates. There are few medical books which have been so extensively read in this country; there are few that have been so generally popular; and there are none that have been so over-esti- mated and over-praised. No English work has, directly and indi- rectly, exerted so powerful an influence upon medicine in the Western States as this.1 This influence may be distinctly seen, not only in the popular pathology and practice of these States, but in the prevailing style of writing, and modes of expression, amongst medical men. The style of Dr. Johnson's book is free, fluent, rambling and slashing, with a copious sprinkling of scraps of poetry, native and foreign. His pathology abounds in excitability, venous congestion, stagnation of the blood in the portal circle, balance of the cir- culation, and similar hypothetical fancies. His descriptions of dis- ease are entirely without value. One of the most sensible remarks in the book is this: "The opinion that these grand endemics, yel- low fever, for instance, are only the bilious remittents of all tropi- cal climates, in a more concentrated state or degree, is founded, I fear, on too great a rage for generalizing." Traite des Figures Pernicieuses Intermittentes. Par J. L. Alibert. bih edit. Paris, 1820. This work of Alibert is mostly a compila- tion ; and I have been able to find but very little in it of any value. i The monstrous pathology of Dr. Cooke, and the still more monstrous practice growing out of it, are only elaborate exaggerations and caricatures of the pathology and therapeutics of this work. 438 PERIODICAL FEVER. TraitS Anatomico-Pathologique des Figures Intermittenten, Simple et Pernicieuses, etc. Par E. M. Bailly, de Blois. Paris, 1825, pp. 535. This is a large and substantial treatise upon periodical fever. Its author is a Frenchman, who studied his subject mostly at Rome, in the year 1822, amongst the patients of the great hospital of the Holy Spirit. Altogether the least valuable portion of the book is the first long chapter of one hundred and twenty pages. This is made up of a very elaborate and very tedious statement and deve- lopment of the author's notions about the nature of periodical fever, the cause of periodicity, &c, with theories of waking and sleep, in- flammation, and crises. I will merely say of it, further, that he attributes the phenomenon of intermittence to the diurnal change which takes place in the position of the human body. It would be an idle and a useless task to repeat the reasoning which leads him to this conclusion. It is a great pity that so sensible a writer should attach so much importance to speculations so entirely empty and visionary. The great fault of the book consists in its diffuse ver- bosity, and its constant efforts to explain and interpret the pheno- mena of disease. There is nothing of any special importance in its therapeutics. The author insists earnestly upon the twofold element constituting periodical fever—the nervous disturbance, and the local congestions and inflammations—and his principal means for meeting the double indication, growing out of this pathological doctrine, consist of bloodletting, purgatives, and cinchona. The latter he regards, not as a stimulant or tonic, but as a peculiar anti- periodic, and nervous sedative. Ligatures upon the limbs, he says, will frequently prevent the occurrence of an expected paroxysm. * An Essay on the Remittent and Intermittent Diseases, including generically Marsh Fever and Neuralgia. By John Macculloch, M. D., F. R. S., etc. etc. Dr. Macculloch vaults at once into the saddle of his hobby, by announcing, in the first sentence of his preface, his conviction of the intimate dependence of neuralgia upon intermit- tent fever. The leading idea of the whole work is to be found in the almost boundless extent and variety of action which he attri- butes to malaria, in the production of disease; its leading, philo- sophical error consists in this broad, loose, and sweeping general- ization. Dr. Macculloch's style is involved and clumsy; but he writes from clear and strong conviction, and no one can wade through the episodical but racy prolixity of his heavy pages, without a strong feeling of his logical acuteness, his good sense, and his free- dom from professional cant. His hardest and favorite hits—well BIBLIOGRAPHY. 439 merited and well put in—are at Sangradoism, asceticism, and the then fashionable practice of daily purging with " calomel and salts." There are other and more extensive localities than the British islands which might profit by his warnings. Sketches of the most prevalent Diseases of India. By James An- nesley, Esquire. London, 1829. Mr. Annesley had ample opportu- nities for the study of periodical fever, in its several forms, during his residence in the British East Indies; but he has contributed very little in this work to our knowledge on this subject. There is no description of the fever, and the book is overloaded with gratui- tous and hypothetical fancies, which the writer very sincerely and honestly mistakes for principles ! Traite des Figures, ou Irritations Cerebro-spinales Intermittentes, d^pres des observations recueilles en France, en Corse, et en Afrique. Par F. C. Maillot. Paris, 1836, pp. 420. In an earnest and straightforward introduction of only five pages, M. Maillot awakens the interest and wins the confidence of his readers. He indicates the general character of his work, and makes amongst others these two remarks. In the midst of the numerous works, he says, which have followed each other upon this obscure subject of intermittent fever, there is one idea which is tending to become more and more predominant, namely, that which refers these fevers to a lesion of the nervous system. This, he adds, was the opinion of Boerhaave, of Cullen, of Borelli, of J. P. Frank, of Fodere', of Giannini, of Georget, etc.; and in the present day of Alibert, Rayer, Bricheteau, Brachet, Nepple, and others. The cerebro-spinal axis he looks upon as the point of departure of the series of morbid actions constituting periodical fever; but patholo- gical anatomy has demonstrated, he says, that there is something superadded to the neurosis, and that this is an acute irritation or hyperaemia of the great nervous centres. The treatment, he says, which consisted in removing or attempting to remove the local irritations and congestions, before the administration of cinchona was allowed, failed in hot climates and malarious regions; and it became necessary to fall back upon the method of Fore, that of giving large doses of this remedy during the paroxysm, and while the tongue indicated active gastric excitement. I have made free use of Maillot's excellent and accurate observations in various parts of my book. He has contributed largely to our knowledge of periodical fever, especially as it shows itself in hot climates. Every part of his work abounds in positive and reliable information; and it is gene- 440 PERIODICAL FEVER. rally pervaded by a cautious and sound philosophy. It is interest- ing to witness the exact coincidence between his convictions—the result of extensive experience, forced upon him in opposition to his previous opinions—and those of many observers in our own country, of the safety and necessity of large doses of quinine, in the graver forms of periodical fever, regardless alike of any signs of local irritation or inflammation, and of the particular period of the disease. In one of his reported cases of comatose intermittent, occurring at Bona, in 1835, he gave, in the course of a few hours, eighty grains of sulphate of quinine, by the stomach, and sixty in an injection, all during the paroxysm. On the second day, the patient took forty grains, and twenty-four on the third; the follow- ing day, he was convalescent. Medical History of the Expedition to the Niger, during the years 1841 and 1842, etc. By James Ormiston M1 William, M. D. In the year 1841, an expedition was fitted out by the British government, to the River Niger in Africa—the leading object of which was to promote the abolition of the slave-trade. The expedition consisted of three iron steam-vessels, the Albert, the Wilberforce, and the Soudan; and of one transport for stores. The expedition left Eng- land in May, 1841, and entered the Niger on the 13th of August. When the four vessels entered the new branch of the Niger, the following was their complement of officers and men—many of the Kroomen and liberated African boys having joined the vessels on the coast: Officers, 53; white seamen, 63; marines and sappers, 29; men of color entered in England, 25; Kroomen and liberated Africans, entered on the coast, 110; blacks for model farm, 23; grand total, 303. The expedition went on very successfully, the officers and men all in good health and high spirits, until it had passed the delta of the river, and arrived at the town of Iddah, in the kingdom of Eggana, nearly two hundred and fifty miles from the mouth. This was on the 2d of September, and on the 4th, fever of a most malignant character appeared in all the vessels. It spread with great rapidity; and on the 9th, the first death took place, that of the captain's steward, of the Soudan. On the 11th, there were two deaths; on the 17th, there were sixty-nine sick, and there had been seven deaths. On the 19th, the Soudan, with forty cases of fever on board, started for the mouth of the river; and on the 21st, the Wilberforce followed; leaving the Albert to go on her dreary way alone—convoyed by tornadoes, tempests, savagery, pestilence, and death. By the third of October, the Albert having BIBLIOGRAPHY. 441 reached Egga, some three hundred and fifty miles from the sea, there were only seven persons on board well enough to do duty, and the Albert also abandoned the enterprise, and turned her prow towards the Atlantic. On the 8th, in the night, one of the patients, in delirium, jumped overboard, but was saved; the next morning, the second engineer threw himself into the river, and was drowned. On the 17th, the three steamers arrived at the island of Fernando Po. " On the 16th of December," says Dr. M'William, " Dr. Vogel, the botanist of the expedition, died, and in the evening his body was deposited in the burial ground at Fernando Po, by torchlight. It was pitch dark, and the stars, seen through the dense foliage, were the only objects in nature that relieved the surrounding dismal gloom. At every step, we trod over our former messmates or fel- low-laborers. As near as possible to the grave of Lander, lie thir- teen of the Niger expedition, who, like himself, fell in the cause of Africa." The whole number of deaths from fever, during the ex- pedition, was forty-two; all of which were amongst the whites. The whole number of whites, in the three steam-vessels, up and down the Niger, was one hundred and forty-five; all these were attacked except fifteen. The whole number of blacks was one hundred and fifty-eight; of whom only eleven had the fever, and these in a mild form. Dr. M'William's description of the disease is very incomplete and unsatisfactory. It was evidently remittent, many of the cases being congestive or malignant. There was no case of black vomit; and, indeed, there seems to have been little or no resemblance between it and yellow fever, although Dr. M'William not only makes no distinction between the two diseases, but evidently con- founds them. Dr. M'William was sent in 1846, by the Admiralty Commission- ers to investigate the circumstances attending the prevalence of a malignant disease at Boa Vista, one of the Cape de Verd Islands, in 1845. The disease, which was yellow fever, showed itself first on board the British ship Eclair, during the passage from the coast of Africa. It occurred at Boa Vista, for the first time, nearly a month after the departure of the Eclair. A Practical Medico-Historical Account of the Western Coast of Africa, etc. By James Boyle, London, 1831. Mr. Boyle occupied different positions as a medical officer, in the British stations on the western coast of Africa, between the years 1822 and 1831. His volume of more than four hundred pages constitutes, he says, 442 PERIODICAL FEVER. the first systematic treatise on the diseases of Western Africa. It is very desultory and immethodical in its plan, and is written in an awkward and ungraceful manner. The first seventy pages are occupied with the medical topography of the western coast, from the River Gambia southward to Sierra Leone. Sluggish, muddy rivers, swarming with alligators, hippopotami, and mosquitoes, their low banks covered with a rank growth of bush and man- grove, deluging rains and devastating tornadoes, one-half the year, and the fiery and blinding harmatan the other, and an average temperature during each of the twelve months of at least 80° of Fahrenheit, make up the prominent features of the scene. Mr. Boyle describes two forms of endemic fever, the climatorial bilious remittent, and the local endemic bilious remittent, as he calls them. There is no evidence that there is any essential difference between them. His descriptions of the African fever are very short, sketchy, and imperfect. The strongest impression left upon the mind by the reading of this book is that of the terribly pestiferous and malignant character of this region, so far as the northern races are concerned. Surgeon Tedlie says that although the Gold Coast has a moderate range of temperature, the mercury rarely rising higher than 85°, or falling lower than 76°, it is more unfriendly to the European constitution than any other country on the face of the globe. No European, he says, ever escapes the fever. The first attack is the regular remittent, called the seasoning, after which the person is still subject to remittents and intermittents, more or less irregular in their character. Yellow fever rarely occurs on the coast. It visited Sierra Leone in 1823 and 1829, attacking old residents as violently as more recent comers. The articles on intermittent and remittent fever, in the Library of Practical Medicine, are by Dr. Shapter. They are compilations; and, so far from containing anything new, they are very far from embodying our actual knowledge upon the subjects of which they treat. The articles in the Cyclopaedia of Practical Medicine are by Dr. Joseph Brown. The same remarks may be made of them as of the foregoing. The American Medical Journals contain many original articles upon the several forms of periodical fever, of much value. A Systematic Treatise, Historical, Etiological, and Practical, on the Principal Diseases of the Interior Valley of North America as they BIBLIOGRAPHY. 443 appear in the Caucasian, African, Indian, and Esquimaux varieties of its Population. By Daniel Drake, M. D. Cincinnati, 1850 : pp. 878. This is the first volume of the great work of the learned and veteran physician of the West, Dr. Drake, on the Diseases of the Interior Valley of North America. It has been long promised by its distinguished author, and impatiently waited for by his many friends and pupils, throughout that wide and wonderful region, where his name has been a familiar household word for so long a period of time. These friends and pupils, and the profession gene- rally, will not be disappointed, I think, in this result of Dr. Drake's labors. This first volume contains the fruits of a vast amount of personal observation and research, as carefully and thoroughly made as circumstances allowed. It is an immense magazine and storehouse of important and valuable facts, from which all future historians and observers, working in the same great field, will derive many of their best aids and their richest materials. [Dr. Drake's second volume will be noticed in the Bibliography of Yellow Fever. Pneumonia; its supposed Connection, Pathological and Etiological, with Autumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. By R. La Roche, M. D., &c. Philadel- phia, 1853. The purpose of this book is to show that pneumonia is not a miasmatic disease. It is understood to have been written for certain regions of the West, where that inflammation is regarded as having an origin analogous to that of periodical fever. East of the Alleghanies, and in many regions west of them, the argument is wholly unnecessary, but there is no region in which the book will not be found useful. Pertinent to the argument is a very full examina- tion of the laws which govern the generation and diffusion of miasm, together with many facts connected with the development of the fever itself.] PART FOURTH. THE HISTORY, DIAGNOSIS, AND TREATMENT OF YELLOW FEVER. PART IY. IELLOW FEVER. CHAPTER I. NAMES OF THE DISEASE. Yellow Fever has received a goodly number and variety of appellations; this, its most common name with English, French, and American writers, was very naturally derived from that strik- ing and common phenomenon in its natural history, the yellow discoloration of the skin. One of its earliest names was that of mal de Siam—disease of Siam—first given to it by the Dominican, Father Labat, near the close of the seventeenth century, from the belief that it was derived from that country. Chisholm calls it a Malignant Pestilential Fever; Lempriere calls it Tropical Continued Fever; Burnett calls it Mediterranean Fever ; many call it the Bulam or Boullam Fever; and various other names have been given to it. Amongst the many names which systematic writers have applied to it are the following, to wit: Typhus iclerodes; Elodes icterodes; Febris maligna biliosa Arnericoz ; Causus tropicus endemicus, etc. etc. 448 CHAPTER II. SYMPTOMS. ARTICLE I. MODE AND PERIOD OF ACCESS. Yellow fever is almost always marked by a distinct and formal access, so that the precise period of its commencement can be generally fixed with great precision and certainty. The most constant initiatory symptoms are chills, and pains, often violent, in the head, back, and limbs, the latter not unfrequently being very severely felt in the calves of the legs. Dr. Barrington, in his account of the disease, as it prevailed on board the vessels of the United States Navy, and at Pensacola, in 1828,1829, and 1830, says that, in a few cases, the fever was ushered in by an acute pain felt in some spot, and afterwards becoming general. "In one patient, on board the Grampus, the penis was the seat of this suffering; in another, the attack was announced by a neuralgic affection of the right temple. In several, the knees were alone complained of at first; and in four patients, in the Hornet, a spasmodic affection of the muscles of the leg was the prelude."1 In what proportion of cases this well-marked commencement of the disease is preceded by premonitory symptoms, I am unable to say with any degree of accuracy, the statements of most observers upon this point being made only in general terms. It is quite certain, however, that in many instances the person receives no warning of the approach of the disease; he is stricken down in an instant, no shadow of the coming blow having fallen upon him. Dr. Rush, in his description of the yellow fever of 1793, in Phila- delphia, says: "Many went to bed in good health, and awoke in 1 Amer. Journ. Med. Sci., Aug., 1833. SYMPTOMS.— MODE AND PERIOD OF ACCESS. 449 the night with a chilly fit. Many rose in the morning, after regu- lar and natural sleep, and were seized at their work, or after a walk, with a sudden and unexpected attack of the fever."1 Dr. Barrington says that in a majority of instances the onset was without any previous indisposition. In other cases, this distinct commencement of the disease is pre- ceded for some hours, or for some days, by certain premonitory symptoms. [Dr. J. N. Schoolfield, in the history of the murderous epidemic at Portsmonth, Va., in 1855,2 says that " Usually, for two or three days, an attack was preceded by feelings of languor and weariness, loss of appetite and chilly sensations." Dr. Blair says that at Demerara, " Occasionally the headache may have been experienced several days before the invasion."3] There is nothing constant or invariable in the character of these ; sometimes they consist of moderate febrile excitement, and at others of various disturbances of the nervous and digestive functions. Dr. Rush enumerates nearly twenty of these precursory signs; but they are, none of them, sufficiently uniform in their occurrence, or sufficiently characteristic of the disease, to render it worth while to repeat them. It is alleged by many observers, that the attack of yellow fever occurs much more frequently during the night than during the day. Dr. Rush says: " A great proportion of all who were affected by this fever were attacked in the night."4 Dr. Barrington says, that the time of the onset was generally between sunset and sun- rise.5 Dr. T. A. Cooke, in a paper in the New Orleans Medical and Surgical Journal, on the Epidemic Yellow Fever which prevailed at Opelousas, in the years 1837, 1839, and 1842, says that, in the two former years, the attack came on suddenly, rarely with pre- monitory symptoms, and, in a large majority of cases, between the hours of midnight and daybreak. I do not know that this greater liability to an attack of the disease during the night is formally contradicted by any writers; but there are many who say nothing about it; and it can hardly be regarded as an unreasonable skep- ticism to say that the question must be determined by further, more extensive, and more accurate observation. In his description 1 Rush's Med. Inq., vol. iii. p. 52. 2 [Report of the Portsmouth Relief Association, &c, together with a sketch of the fever, Richmond, 1856.] 3 [Brit, and For. Med.-Chir. Rev., Jan. and April, 1856.] 4 Rush's Med. Inq., vol. iii. p. 51. 6 Amer. Journ. Med. Sci., Aug., 1833. 29 450 YELLOW FEVER. of the epidemic of 1828, at Gibraltar, Louis merely remarks that the disease commenced at different hours of the day, sometimes in the night; and I find, on looking over the only cases, seven in number, reported by him, in which the time, of attack is particu- larly mentioned, that this was during the day in two ; at five P. M., seven P. M., and eight P. M., in one each; in the morning, in one; and in the night, in one. Of five cases, occurring at the Charity Hospital, at New Orleans, in 1843, and reported by Dr. Slade, the attack took place during the day in one; and at five A. M., eight A. M., and eleven A. M., in one each.1 Dr. E. B. Harris has re- ported twenty cases, which occurred at New Orleans, in 1833. The time of attack is particularly stated in sixteen, and in only two of these was the attack in the night.2 ARTICLE II. FEBRILE SYMPTOMS. Sec. I.— Chills. There is probably no disease, unless it is puer- peral peritonitis, the access of which is more invariably attended by a chill or rigor than this. The testimony of observers is so uniform upon this point, that it is quite needless to accumulate authorities. It is present alike in mild, grave, and fatal cases, with one exception, perhaps, which will be mentioned hereafter, in speaking of a very singular and striking form or variety of the disease. The chill is almost always one of the first symptoms; although, in a very few cases, it takes place some hours, or even a day or two, after the formal commencement of the fever. The chill is sometimes severe, but generally moderate, of short duration, and is rarely though it is occasionally repeated. [Chills do not seem to have been noticed so frequently by Dr. Blair in Demerara, during the epidemic of 1851-2-33, as by the observers in tem- perate latitudes. He does not state the number of cases in which they were absent, but he says that the patient could generally state with accuracy when the disease began. "He was probably awakened in the night by a severe pain in his forehead and back, 1 N. 0. Med. and Surg. Journ., vol. i. p. 85. 2 Amer. Journ. Med. Sci., May, 1834. 3 [Brit, and For. Med.-Chir. Rev., Jan. and April, 1856. Report of the first eighteen months of the fourth yellow fever epidemic of British Guiana. By Daniel Blair, M. D., Surgeon General of British Guiana.] SYMPTOMS. — TEMPERATURE OF SURFACE. — SWEATS. 451 with sickness of stomach and vomiting, and a sensation of heat and thirst. Or he may have had a decided chill with frontal headache and a sweaty skin. Or he may have had violent purging and vomiting, with cramps of the gastrocnemii muscles. In almost all cases, however, supra-orbital pain and fever are associated."] Sec. II.—Temperature of the Surface; Sweats. Following the initial chill, there is frequently increased heat of the surface; but this heat is only moderate. The high and burning heat of continued fever, and of some of the eruptive fevers, is almost never present; and in very many cases the skin never rises above its natural tem- perature. The increased heat, in those cases where it is present, rarely continues beyond the second or third day; rapidly giving place, in cases that are running on towards a fatal termination, to coldness of the surface, beginning usually in the extremities, and more striking here than in other parts of the body. According to Louis and Trousseau, coldness of the lower extremities is a very constant attendant upon the black vomit, a symptom that will be particularly described hereafter. In a certain number of cases, there is more or less perspiration; in others, the skin preserves its natural softness and moisture; it is not often morbidly dry. Dr. Lewis, of Mobile, says there is a natural tendency to perspiration. Dr. John Wilson says the state of the surface differs in the two forms of the disease—the inflamma- tory and the congestive. "In the former, the heat of the skin is high, free, and diffused; it impresses the hand instantly and powerfully, being nearly as intense at the extremities as at the centre, sometimes even more so. In the latter, the heat of the surface is frequently less than in health, particularly on the ex- tremities. When it equals or surpasses the healthy standard, as it sometimes does, being highest about the epigastrium, it is of a peculiar kind. The hand is scarcely impressed by it, when applied lightly and hastily to the pit of the stomach, but when kept there with steady pressure, a sensation of deep-seated and accumulated heat is communicated. * * * With this peculiar condition of the surface as to temperature, there is connected a peculiar want of tone in the skin, which it is difficult to render intelligible by description. It is sometimes dry, harsh, and dense; sometimes moist, with a thin, serum-like fluid, or a greasy exudation; sometimes it is smooth, slippery, inelastic, and doughy without moisture; but in whatever manner its functions may be perverted or abolished, its 452 YELLOW FEVER. characteristic condition is want of vitality; when grasped in the hand, and raised from the parts beneath, it feels like the skin of one who had ceased to breathe."1 [Dr. Blair makes the following remark: " High temperature of the body seems to have persisted longer through the stages of the disease in this epidemic than in the last. There is great irregularity in the temperature of the surface. Sometimes the forehead is the hottest part of the body, and occasionally the chest. The uncovered portions of the body in the late stages are easily reduced in temperature; thus while the exposed chest and extremities may feel cold to the touch, the axilla may raise the thermometer to 102° or 103°. The highest tem- perature I observed in the axilla during the course of the disease was 107°."] The color of the skin will be more appropriately noticed in another place. Sec. III.—Pulse. It is not an easy matter, for one who has never felt the pulse of a yellow-fever patient, to form any very distinct and clear idea of its character and peculiarities; so contra- dictory, and sometimes so apparently fanciful, are the descriptions of it by different observers. On one point, however, and that is, its frequency, there is great uniformity in the statements of writers. The pulse never reaches the frequency that is so common in nearly all other febrile and inflammatory affections. Louis and Trousseau, at Gibraltar, even in cases that terminated fatally, never found it higher than a hundred in a minute, and this in only five instances, and for a single day. In cases that recovered, they generally found it only slightly accelerated, and this for a day or two only, at the beginning of the disease, after which it rapidly fell to its natural standard.2 As to its other characters, it is commonly described as natural, or more or less full, tense, and bounding. In eight fatal cases, Louis and Trousseau found it large and vibrating in one; a little stronger than natural in two; almost natural in two, and small and serrated in three. Amongst the patients who recovered, they found the pulse large and rather full on the second or third day of the disease, in half the cases; small and feeble during the first days, in only two cases; and natural in the rest.3 It is generally regular, but sometimes unequal and intermittent towards the close of the 1 Memoirs of West Indian Fever, p. 20. 2 Louis on Yellow Fever, p. 208. 3 Ibid., p. 209. SYMPTOMS. — PULSE. 453 disease. Dr. Rush devotes more than three full pages to a descrip- tion of the pulse, a considerable portion of which description is not particularly clear or intelligible. He mentions several occa- sional peculiarities of the pulse, such as irregularity, intermission, preternatural slowness, and so on. He has a great deal to say about a small, intermitting, tense, corded, and slow pulse, which he thought was peculiar to certain forms of yellow fever; which one of his pupils characterized as an undescribable pulse, and which he called a hobbling or a sulky pulse.1 My personal friend and former pupil, Dr. P. H. Lewis, of Mobile, has published, in the first volume of the New Orleans Medical and Surgical Journal, a valuable and interesting paper on the yellow fever of that city, to which I shall have occasion frequently to refer. Since the publication of my second edition, our profession and our science have sustained a serious loss in the premature death of this active, laborious, and able physician. His observations were mostly made amidst the hurry and confusion inseparably attendant upon epidemic visitations of disease, and they necessarily partake somewhat of the imper- fections unavoidable under such circumstances; but they are marked by carefulness, acuteness, and conscientiousness, and con- stitute a valuable addition to our knowledge of yellow fever. Dr. Lewis says that, during the sort of remission which follows the first febrile reaction, and which he calls, after a medical friend, the stage of calm, the pulse is usually about or below par, and to many would appear natural. "But, so far from being normal," he adds, "there are gentlemen in Mobile, who, blindfolded, can separate it from all others. It comes up to the finger like an air-bubble, and rebounds under the least pressure; again, there is not that strength and lengthened vibrating feeling, which belong to the healthy pulse- Dr. Childress, who has been practising in the South thirty-five years, remarked to me, that it was the most deceptive pulse he had ever 1 Dr. Rush, enlightened by the blaze of that luminous philosophy which sur- rounds all his medical writings, met with no difficulty in understanding and ac- counting for this perverse and unreasonable pulse; he said it was occasioned by a spasmodic affection, accompanied with preternatural dilatation or contraction of the heart! The slow, feeble, and intermittent pulse have been improperly ascribed, says Dr. Rush, to the absence of fever. They are occasioned, he adds, " by the stimulus of the remote cause acting upon the arteries with too much force to admit of their being excited into quick and convulsive motions ;" there being a deficiency of strength in the artery from an excess of force applied to it, as Milton describes a darkness from an excess of light! The illustration from Milton is Dr. Rush's— not mine. 454 YELLOW FEVER. felt; at first appearing natural, but, upon examination, there was none of it.11 This pulse is spoken of by Dr. Lewis, in another place, as full and bubbling, compressible and gaseous, rebounding under the least pressure of the finger. He says, also, that in twenty cases, in which the three stages—the febrile, the stage of calm, and that of collapse—were well defined, he found the mean range of the pulse, for two days, between 90 and 115, for one day about par, and for three and a half days below par; the average range of the pulse during the whole course of the disease being rather below the natural and healthy standard. This compressible character of the pulse is particularly noticed by some of the older writers. Chisholm says: " It is observable that, in several cases, the slightest pressure could produce a cessation of pulse."1 A sufficiently obvious reason for the contradictory descriptions which are to be met with, of the pulse in yellow fever, may be found in its different characters in the dif- ferent forms and stages of the disease. Dr. John Wilson says that, in the inflammatory variety, the pulse is remarkable for its strength, forcibly repelling the finger, and not yielding to ordinary pressure. In the congestive form, he says, it is always weak. "It offers no resistance to the touch: when the finger is applied to an artery, it acts as it would on an inanimate elastic tube half full of fluid; it depresses easily the point on which it bears into contact with the opposite point, the contents receding in either direction. This state of the pulse is so striking and characteristic, that I think it can scarcely be overlooked or misapprehended."2 ARTICLE III. DIGESTIVE AND ABDOMINAL SYMPTOMS. Sec. I.—Tongue and Mouth. The tongue is generally moist, and more or less coated with a light-colored, whitish, or yellowish- white, villous fur. It is sometimes red, and towards the close of life, in fatal cases, sometimes dry, red, and cracked, like the tongue of continued fever. In many instances, it remains nearly natural through the entire course of the disease. Dr. Rush says: " The tongue was in every case moist, and of a white color, in the first and second days of the fever. As the disease advanced, it assumed a red color, and a smooth, shining appearance. It was not quite 1 Chisholm's Essay, vol. i. p. 162. 2 Memoirs of the W. Indian Fever, p. 19. SYMPTOMS. — TONGUE AND MOUTH. 455 dry in this state. Towards the close of the fever, a dry black streak appeared in its middle, which gradually extended to every part of it."1 Dr. Gillkrest says the most characteristic appearance of the tongue is that of the pasty surface, with red edges and apex, and, further, that the red, or, as it has been called by some, crimson border of the tongue, ranks among the most characteristic signs in the first stage of the malady.2 Bally and some others, especially amongst Spanish observers, speak of an abundant spontaneous salivation as a common occurrence. It is rare to find sordes on the teeth. [There seems to be considerable variety in the appearance of the tongue in different epidemics, and perhaps in the different stages of the same epidemic. Dr. Schoolfield says of it in the Portsmouth epidemic: " Its appearance was peculiar, being large, flabby, and milky, with a heavy coating of white fur, and often on its edges exhibiting the indentations of the teeth. From its size and color, it so much resembled an oyster as to cause the term ' oyster-tongue to be applied to it." On the other hand, Dr. Blair holds that " a broad, flat, flaccid, pale tongue, rounded at the tip and indented,'- is the most unlike a yellow fever tongue. He promulgates the doctrine that " capillary irritation" is the essential lesion of the disease, and carefully examines all accessible mucous surfaces for the evidence of local congestion. His inspection of tongue is, therefore, minute. " The general appearance of the tongue," he says, " is uniform redness of the tip, or tip and edges together, and the general shape is inclined to be compressed, or wedge-shaped." The redness is sometimes punctated, especially in the initiatory stage, and often at the commencement of convalescence. The fur is at first smooth and uniform; afterwards, it seems as if it had been curdled, and lies on the surface in innumerable little grayish- white flakes. The term is derived from the resemblance of the fur to milk curdled by acids. In a more advanced stage, he says, the villi forming the fur are no longer " tufty and flaky, but appear like separate pavement-shaped forms on the surface of the tongue.' He adds : " The next step in the tongue symptom is the peeling of the epithelium. This generally begins at the point, and proceeds to the edges and down the raph£, and may continue till the whole surface is denuded, and the papillae obliterated, and the tongue becomes smooth and dryish, and of the color and appearance of 1 Rush's Med. Inq., vol. iii. p. 63. 2 Cyc. Prac. Med., vol. ii. pp. 270, 273. 156 YELLOW FEVER. raw beef. In the late stages, the tongue is liable to be encrusted by the buccal hemorrhage. In general, the raw, denuded tongue in convalescence appears as if brushed over with a thin coat of milk and water, and the epithelium and papillae are speedily restored." At Surinam, during the same epidemic, " the tongue was gene- rally broad, covered with a dark slime; only in a few cases were the edges more than usually red. In general, the tongue was moist and sticky." Dr. Blair quotes this description, at the same time remarking that one hundred and sixty-three of the Surinam cases were treated for " abrasions of the skin about the anus, in conse- quence of severe purging," and suggests that the " capillary irri- tation was displaced," occupying the rectum and colon instead of the stomach and duodenum, " forming the intestinal variety of yel- low fever, a few cases of which," he says, " were seen by us in the present epidemic." He adds elsewhere regarding his own cases, that towards the end of April, 1852, the tongue symptoms were unpronounced; that they were well marked toward the end of May; in September less noticeable; in October again well marked; in December declined again, to reappear in March, 1853. Cdunected with these appearances of the tongue is a coarse reticular vascularity, often to be seen along the roof of the mouth, extending to the uvula, claimed by Dr. Blair as a discovery of his own. He, however, advises, when the other diagnostic marks of yellow fever are satisfactory, that this appearance be not sought for by depressing the tongue, on account of the vomiting which this depression is likely to induce.] Sec. II.—Appetite and Thirst. It is a little singular how gene- rally writers upon yellow fever neglect to give any particular account of the state of the appetite; many of them, indeed, make no mention of it whatever. Even Louis and Trousseau say nothing special about it. Dr. Rush says: " The appetite for food was impaired in this, as in all other fevers; but it returned much sooner than is common after the patient began to recover. Coffee was relished in the remissions of the fever in every stage of the disease. So keen was the appetite for solid, and more especially for animal food, after the solution of the fever, that many suffered from eating aliment that was improper from its quality or quantity. There was a general disrelish for wine, but malt liquors were fre- quently grateful to the taste. Many people retained a relish for SYMPTOMS.— NAUSEA AND VOMITING. 457 tobacco much longer after they were attacked by this fever, and acquired a relish for it much sooner after they began to recover, than is common in any other febrile disease. I met with one case, in which a man, who was so ill as to require two bleedings, con- tinued to chew tobacco through every stage of his fever."1 The remark that has just been made in regard to the general omission by writers on yellow fever of any particular description of the state of the appetite is also applicable to the thirst: by many, this symptom is not mentioned at all, and by most others, it is spoken of only incidentally. It would seem, as a general rule, to be only moderate. Dr. Rush says: " The thirst was moderate or absent in some cases, but it occurred in the greatest number of persons whom I saw in this fever. Sometimes it was very intense. One of my patients, who suffered by an excessive draught of cold water, declared, just before he died, that he could drink up the Delaware. It was always an alarming symptom, when this thirst came on in this extravagant degree in the last stage of the disease. In the beginning of the fever it generally abated, upon the appear- ance of a moist skin. Water was preferred to all other drinks."2 Sir Gilbert Blane says there is no excessive thirst.3 Dr. Deveze, in his description of the Philadelphia epidemic of 1793, says that, during the first stage, the degree of thirst corresponds to the febrile heat; and that in the second stage it is unappeasable.4 Bally says there is rarely any considerable thirst; and he quotes Jackson, Chisholm, and Clark, to the same effect.5 Dr. Lewis, of Mobile, in a letter to me, dated September 26,1847, says: "In genuine yellow fever, the thirst is not urgent. It is true the patient often says he is thirsty; that he wishes he had a cold stream running through him; but when water is handed to him, he drinks very sparingly, saying that it lays on his stomach, or produces pain at the epigas- trium. Others have no desire for cold drinks, but take warm tea without objecting." [Dr. Schoolfield declares that at Portsmouth the thirst was so urgent that the desire for cold drinks could not be satisfied.] Sec. III.—Nausea and Vomiting. Amongst the most constant, and in certain circumstances the most striking and characteristic 1 Rush's Med. Inq., vol. iii. p. 67. 2 Ibid., p. 6«. 3 Observations, &c, p. 404. 4 Traite de la Fievre Jaune, p. 22. 5 Du Typhus d'Amerique. Par Vr. Bally, p. 216. 458 YELLOW FEVER. phenomena of yellow fever, are nausea and vomiting, especially the latter. In a certain proportion of cases, the vomiting occurs in the course of the first day of the disease; in the others, on the subse- quent days, from the first to the fifth. In cases which terminate fatally, the vomiting almost always, after it has commenced, con- tinues to be repeated at longer or shorter intervals till the death of the patient; sometimes, however, the vomiting ceases a day or two before death. In cases which terminate in recovery, the vomiting usually ceases after having been present a few hours only, or from twenty-four to forty-eight hours. The matters vomited consist, at first, usually, of the fluids that have been taken into the stomach; they then become yellowish or greenish, and in patients who re- cover, they do not generally present any other appearances. In cases, however, which are to terminate in death, these vomitings soon give way to the well-known and fatal black vomit. This pecu- liar and striking symptom sometimes commences thirty-six or forty- eight hours before death; but more commonly not till the last day of life.1 Louis and Trousseau's particular description of the ap- pearances of the matter of black vomit, as found in the stomach and intestines, will be given in the chapter on the post-mortem phe- nomena of the disease. It is generally described as resembling coffee-grounds. Dr. Rush made a distinction, however, between this kind of fluid and the true black vomit; I suppose that the for- mer was only the early stage of the latter. Dr. Lewis, of Mobile, gives the following account of the gastric symptoms. " As a general rule, there are far less vomiting and irritability of stomach during the first stage of yellow than that of bilious fever. During the stage of calm, a mucus, containing little flocculent masses, resem- bling bees1 wings, is sometimes vomited. If bile is ejected, it may be set down not only as an exception but a favorable indication. The black vomit which takes place in the collapse stage is of vari- ous consistence and appearance. The little masses which have been likened to bees1 wings, occasionally deepen, so that, by the time the disease arrives at the collapse stage, it assumes the appear- ance of a thick black mass. The vomit is more generally thin and black, with a coffee-ground sediment; this is usually pumped up, suddenly, and without previous warning; the patient complains of its being sour, and so very acrid as to scald the throat. Black vomit, in a few instances, made its appearance on the night of the 1 Louis on Yellow Fever, p. 217. SYMPTOMS.—NAUSEA AND VOMITING. 459 second day after the attack; these were exceptions, the fourth and fifth day being the most usual; many cases terminated fatally in which this symptom was wanting."1 Blood but slightly changed is sometimes vomited. The easy, sudden, pumping character of the act of vomiting, in these cases, mentioned by Dr. Lewis, is spoken of by other observers. Several patients, says Louis, appeared to vomit without effort, the basin being placed on the edge of the bed, and their heads supported on their hands. Dr. Lewis, again, in his account of the treatment of yellow fever, remarks incidentally that there are less nausea and retching than in bilious fever; and that " the stomach is frequently disgorged without any other symp- tom than a slight tremulous curl of the upper lip, and a concious- ness, on the part of the patient, that his stomach is in a rebellious mood."2 Dr. Rush says : " The contents of the stomach were some- times thrown up with a convulsive motion, that propelled them in a stream to a great distance, and in some instance, all over the clothes of the bystanders." [Dr. Blair found a disposition to vomit a prominent symptom and one of the earliest, the ejecta being first the food, or other con- tents of the stomach, not characteristic; after that, mucus and bile, occasionally with a streak or speck of blood. So far the ejections are alkaline. In rare instances the vomiting continues from first to last, but generally the first vomiting over, the stomach remains tolerably quiet till the second, third, or fourth, or even the fifth day, when the second stage sets in. Then the stomach, on any tri- fling provocation, without warning or nausea, may eject a quantity of clear, pale, almost limpid, or slightly opalescent acid fluid. This is the white vomit. It usually indicates the beginning of the stage of acid elimination, and is generally contemporaneous with the first peeling of the tongue. The true white vomit is serum, more or less acid, which remains clear on the application of heat and nitric acid. In some rapid cases in which the urine is albuminous on the first day, there is no intermediate white vomit, or green tinted vomit, but the bilious ejections are followed rather abruptly, by the black vomit. The transition is, however, generally gradual, and the white vomit stained, or unstained, appears, and presents the " snuff-like" specks, and the " suspicious sediment," before it merges into the well-defined black vomit.] 1 N. 0. Med. and Surg. Journ., vol. i. p. 299. 2 Ibid., p. 420. 460 YELLOW FEVER. Sec. IV.—Bowels; Abdomen; Epigastrium. The bowels are generally costive ; at least there is rarely any tendency to diarrhoea. The only striking peculiarity in the character of the discharges consists in their brownish or black color. This symptom, like the black vomit, is found in a large proportion of the fatal cases; it occurs towards the close of the disease, but on an average a little earlier than the black vomit. It depends upon the same cause. It occurs also in cases which terminate in recovery, but in a much smaller proportion.1 [Dr. Blair looks on the alvine evacuations in yellow fever as an important part of its history. Ordinarily, the stools first observed were those produced by the calomel and castor oil early prescribed. They were bilious, and contained nothing worthy of particular description. Occasionally in the early stage, a greater or less quantity of dark matter appeared in the evacuation. This Dr. Blair calls the melanotic stool, and looks upon the substance which colors it as "the first tangible morbid product of the disease, and as highly diagnostic in the first stage. It is black, as after taking the preparations of iron, or blackish brown, or blackish gray," and pultaceous. It differs in quantity and appearance from the scanty black-vomit-stool, though both probably derive their color from the effused and altered blood. After the melanotic stools have ceased, the evacuations assume another appearance which Dr. Blair also regards as characteristic. They are of a dirty gray color, abilious, and liquid, with a sediment. He calls them caddy stools, from their resemblance to a fine dark sandy mud, known by that name. The sediment of these evacuations examined by the microscope was found to contain well-defined crystals of uric acid and the triple phosphates, properly belonging to the urine. As the disease approached a fatal termination, the alvine discharges became scanty and mucous; sometimes grass, or olive, or spinach green; sometimes fawn colored, sometimes primrose, sometimes rusty; sometimes brown, or black, or streaked, the latter being called the black-vomit stools. The alvine evacuations, he says, are alkaline from first to last, except the black-vomit stool, and that is acid. The bilious element in the yellow fever stools is yellow at first, subsequently, "contemporaneously with the stage of acid elimination," it is green. The attack of yellow fever in Demerara appears to have commenced frequently by diarrhoea or cholera. ' Louis on Yellow Fever, p. 229, et seq. SYMPTOMS. — BOWELS.—ABDOMEN. — EPIGASTRIUM. 461 Such cases occurred "not sporadically, but in clusters, as is the mode of appearance, disappearance and reappearance of the several prominent symptoms." A single explanatory remark may interest those who are begin- ning to apply the microscope to pathological investigations. It relates to the altered blood which seems to give color to the caddy and black-vomit stool, described by Dr. Blair. Blood corpuscles are rarely found in the alvine evacuation, however much the dis- charge may seem to owe its color to blood. The blood coloring matter may be there, either diffused, or converted into numerous grains and irregular masses of black opaque matter, and grains of a dark brown color, which the editor believes are the hematine, and hematoidine formed from the hematine; but the cell-walls of the blood corpuscles disappear in the intestinal fluids, except when the blood comes from the lower part of the canal, or takes the form usually denominated hemorrhage. It does not appear that blood corpuscles were found in either of these stools, but in the first there were " numerous little amorphous masses of black opaque matter, which seemed to be its constant ingredient." This is one of the substances referred to in the description of the remittent fever liver, under the denomination of hematoidine. It exists in the black vomit, and in all probability in the black-vomit stool, though no allusion is made to it in Dr. Blair's account of them.] Colicky pains occur in different parts of the abdomen in a certain proportion of cases, and during a limited period of time. They are sometimes occasioned by cathartic medicines; and according to Louis, their commencement often coincides with the appearance of the brown and black stools. The shape and feel of the abdo- men are nearly always natural, through the entire course of the disease. Epigastric tenderness and distress are frequently but not con- stantly present. They occur at all periods of the disease. They are sometimes severe, but more generally moderate.1 Dr. Lewis, of Mobile, and Dr. John Harrison, of New Orleans, both speak of an exquisite tenderness of the epigastrium, occurring chiefly towards the close of fatal cases. Dr. Harrison says : " The slightest attempt to press upon the parts is resisted by the patient with all the expres- sions of intense agony and horror." The same symptom is thus described by Dr. Rush: " The stomach, towards the close of the 1 Louis on Yellow Fever, p. 212, et seq. 462 YELLOW FEVER. disease, was affected with a burning or spasmodic pain of the most distressing nature. It produced, in some cases, great anguish of body and mind. In others, it produced cries and shrieks, which were often heard on the opposite sides of the streets to where the patient lay."1 Bally, and many others, mention the same symp- toms.2 According to Dr. Rush, flatulence of the stomach is a very constant and in many cases a very distressing symptom. Sec. V.— Urine. The urine seems to be, generally, but slightly or not at all changed ; at any rate, its alterations are accidental, and in no way characteristic of the disease. In a certain proportion of i cases, precisely how large, I am unable to say, the renal secretion is wholly suspended. This is more frequent in fatal cases than in others, although it is not entirely confined to them.3 Bally says that, in the third stage of the disease, the urine is very various in its appearance; sometimes yellow, sometimes red or bloody, some- times brown, black, fetid, and so on.4 [No section of the history of yellow fever has received additions, since the last edition of this book, equal in importance to those which should be recorded here. The significant part which albu- minuria plays in the progress of cholera is now well known to the profession. It has fallen to the lot of Dr. Blair to show that albu- minous urine, and the associated uraemia are perhaps equally frequent and equally fatal in this disease. The credit of the discovery appears to belong to Dr. Collings, but Dr. Blair has confirmed, and given practical tone to the important fact. He reports about eighteen hun- dred cases of yellow fever after the discovery of Dr. Collings came to his knowledge, and it is presumed that he speaks of all, when he says that "albumen appeared in the urine in every fatal case of normal duration." All the fatal cases were but little short of five hundred and fifty. He does not state in what proportion of recoveries the albumen was found, but says that" albumen appears on the second or third day generally, but in a few cases it was found as early as the first day of illness; and in a few cases it did not appear till the day of death, and after the black vomit had set in. In several instances the urine was not yet coagulable on the fourth day, when the tongue was completely denuded. Albumen was seldom seen 1 Rush's Med. Inq., vol. iii. p. 66. 2 Du Typhus d'Amerique. Par Vr. Bally, p. 217. 3 Louis on Yellow Fever, p. 235, et seq. * Du Typhus d'Amerique. Par. Vr. Bally, p. 244. SYMPTOMS. — URINE. 463 in the aborted cases. In a few it appeared during convalescence. During the period of the epidemic when the torpidity of the bowels required croton oil occasionally, as an early purge, the urine was later in becoming albuminous. In three cases the albuminosity was intermittent, for one or two days. It sometimes ceased in con- valescence suddenly, always before the yellow suffusion of the skin and eye, or bile in the urine disappeared, except in a single case, in which Bright's disease seemed to be a sequel of yellow fever. Between the eleventh and the twentieth day, it generally disappeared in the graver cases, and its disappearance was the indication for the discharge of the patient from the hospital. The color of the pre- cipitated albumen was never white, as in Bright's disease, but of a primrose or sulphur color, and it is still a question whether this tint is due to bile, since in several specimens the nitric acid failed to bring out the bile colors." Thus it appears that albuminous urine was one of the marked characteristics of yellow fever in its second and third stages, at Demerara in 1852-3. Connected with its occurrence, casts of the urinary tubuli, and broken up and amorphous epithelial matter were very commonly found by the microscope. In its albuminous stage it does not appear that the urine was always scanty, though it seems not to have been often abundant till convalescence. The author, however, remarks, "no matter how desperate the condition otherwise, if there was copious transparent urine, though ever so coagulable, and black as ink with bile, the struggle was hopefully maintained." Dr. Blair regards the urine in yellow fever as diagnostic of the disease. It is always acid, he says, in the first stage, and continues so generally till convalescence, when it becomes alkaline, or till it becomes heavily charged with bile. During the early stage it is normal in color, clearness and quantity. Usually about the third day, the color becomes that of sulphur, or primrose, or straw, or light -gamboge, and is, perhaps, slightly turbid, with a little floating sedimentary matter. The color deepens in the progress of the disease till it becomes yellow or orange; and if the case ends in convalescence, it is abundant in quantity, and may appear en masse black. As the color deepens the sediment becomes more decided, still the quantity is not considerable, and might escape casual observation. The termination by suppression, when it occurs, is commonly abrupt; at times, however, when the event is the same, the urine is expelled of an amber color, and of an oily consistency 404 YELLOW FEVER. and in quantities of a drachm or an ounce, as if with tenesmus of the bladder. Regarding suppression, Dr. Blair says little, but that little is em- phatic. " No sign, not even black vomit, was so dooming as the suppression of urine. Hope was gone—suppression after the abun- dant appearance, or the curdy appearance of albumen, and tube- casts, rendered despair reasonable." He supposes that copious urinary secretion permits the elimination or decomposition of the yellow fever poison. Bloody urine was noticed by Dr. Blair in some of his cases, and he looks upon it as rather a favorable indica- tion. He first remarked it in May, 1852, in a single case. A year after the cases became numerous, in a few assuming the form of active hemorrhage, in a few giving a smoky hue to the fluid, and a thin layer of blood corpuscles as a sediment. In these latter cases there was but a trace of albumen in the urine. In many of the cases of bloody urine there were no tube-casts or epithelium, and the author thinks the kidneys were relieved from congestion by the bleeding, and therefore left in a better state to perform their function. Dr. Blair concludes his history of the urine with the following remark: "It may be safely affirmed, that for a correct knowledge of the progress, diagnosis, and prognosis of yellow fever, the close observation of the condition of the urine is indispensable; and that after the attempt to abort ihe disease has failed, the- prime object of solicitude and of treatment is the function of the kidneys." One additional statement may be best made here. It is well known that when albumen exists in the urine, and especially when this secretion is suppressed or scanty, urea or its elements may remain in the blood, often producing the most grave symptoms. It is also known that Frerichs has found the breath ammoniacal, under such circumstances, and that he supposes it is made so by the conversion of urea into the carbonate of ammonia. Dr. Blair often examined the breath of those whose urine was scanty or suppressed in yellow fever. For this purpose he used slips of moistened test-paper, and a glass rod moistened with muriatic acid, holding them in succession close to the mouth. In some he failed to find the evidence of ammonia in the breath. In several he was more successful, the test paper becoming promptly blue, and the rod giving off the white fumes of the muriate.] SYMPTOMS.—HEADACHE. 465 ARTICLE IV. CEREBRO-SPINAL, OR NERVOUS SYMPTOMS. Sec. I.—Headache, and other Local Pains. Pain in the head is al- most invariably present; and it is nearly always the first, or one of the first signs of the formal access of the disease. It is sometimes slight and at others moderate; but more generally it is acute and violent. [It is often denominated frontal or supra-orbital head- ache.] It is frequently felt through the temples and eyeballs. In a few cases it continues through the whole course of the disease, but in most instances it subsides in the course of two or three days. Pains in the back, loins, and limbs are equally constant and equally severe; occurring usually with the headache, or immediately fol- lowing it, and subsiding in most cases with the latter. In some instances there are violent pains in the calves of the legs. Dr. Rush says: " The back suffered very much in this disease. The stoutest men complained and even groaned under it. The sympathy of friends with the distresses of the sick extended to a small part of their misery, when it did not include their sufferings from pain. One of the dearest friends I ever lost by death declared, in the height of her illness, that no one knew the pains of a yellow fever, but those who felt them."1 Bally speaks particularly of the atro- cious pain in the small of the back, which accompanies the first stage of the disease as the shadow follows the substance.2 Dr. Lewis says that females suffer very little from pain in the head, while it is usually very severe in the back and hips; and that some mothers complain of these pains as worse than those of parturition. In addition to these acute local pains, which are mostly confined to the early period of the disease, the subsequent stages of many cases are marked by an indefinite feeling of extreme restlessness, wretchedness, and distress, often manifesting itself in fits or paroxysms, with longer or shorter intervals of comparative ease. Dr. Lewis, in reporting a fatal case, has the following: " Be- ing asked why he was so restless, he replies that he is not restless, neither does he feel very sick; at the same time, in a slow, metho- dical manner, somewhat peculiar to this disease, he removes the pillow to the other side of the bed, and places his head upon it, 1 Rush's Med. Inq., vol. iii. p. 66. 2 Du Typhus d'Amerique. Par Vr. Bally, p. 225. 30 466 YELLOW FEVER. with the same care and caution as though it were a piece of glass. After a few minutes conversation, the same preparations are being duly made for a change of position."1 This paroxysmal restless- ness attends the second and third stages of the disease, and con- stitutes one of its most constant and striking features. " Jactitation," says Dr. Gillkrest, " is of more frequent occurrence, and more severe in degree, than in any other disease, spasmodic cholera not excepted; the patient tosses his head and limbs about incessantly, unable to procure sleep in any position, or relief from the feeling of distress by which he is Oppressed."2 Dizziness and giddiness are rarely mentioned by writers on yellow fever.3 Sec. II.—State of the Mind. Delirium is rarely present, ex- cepting for a short period, varying from a few hours to a day or two preceding death; it is very rarely wild and violent, and in many cases the mind remains clear quite to the close of life. "In 1 N. 0. Med. and Surg. Journ., vol. i. p. 296. 2 Cyc. Prac. Med., vol. ii. p. 270. 3 [It is not often that we find a physician's account of his own sufferings in yel- low fever. The following case is introduced here because the prominent features are pain and restlessness referred to in this section. Dr. Schoolfield, of Portsmouth, Va., says: "I retired at 11 o'clock at night, after having been actively engaged all day, and up to that hour, without having experienced a sensation of languor or debility ; on the contrary there seemed to be an exhilaration of spirits. Within an hour from that time, I was aroused from a sound sleep, by intense pain in the head and back, but more particularly in the back. Every joint ached, and a feel- ing of tired soreness pervaded the whole body. The skin was preternaturally hot and dry, but the thirst was not very great. There was extreme restlessness and jactitation, and there was no position in which I could lie that afforded the least ease. All the next day these symptoms continued in an aggravated form. The pulse was very quick and somewhat augmented in strength; and before night the thirst had become very troublesome. The strength was reduced in an aston- ishing degree, considering how short a time the fever had existed, and sleep was not to be had. For three days this state of things continued, when a profuse perspiration coming on ; the fever was broken. The condition of languor and apathy, which succeeded, was beyond description. The prostration, mental and physical, was so overwhelming that it required the greatest exertion even to talk. The severest suffering in the stage of excitement was caused by the pain in the back, and the aching and tired sensation in the lower extremities. From observation in the after progress of the epidemic, it appeared that those, who suffered most in the manner just described, more frequently escaped the dangerous cerebral and gastric symptoms, and consequently had a better chance of recovery." (Report of the Portsmouth Relief Association, p. 146.) In this case it will be seen there wai no chill and no vomiting, but pain, aching, and prostration.] SYMPTOMS.—PHYSIOGNOMY. 467 no other grave malady," says Bally, " do the intellectual faculties maintain themselves with such entire integrity as in this; it is a singular phenomenon—that of the presence of mind preserved to the last instant of life."1 Dr. Barrington says there is often an inclination to sing; Dr. Lewis says the delirium consists in joking, singing, or idle chit-chat; and Dr. Harrison speaks of the little tricks of the patients, the kind of perverse pleasure which they manifest in thwarting the designs of their nurses and physicians, and their great delight at the success of their schemes, as characteristic rather of a species of insanity, than febrile delirium. [Dr. Blair has met with similar cases, and thinks he has reason to ascribe them to urasmic intoxica- tion.] The kind of stolid indifference of patients in this disease has often been noticed. The editors of the New Orleans Medical Journal say: " It is remarkable to witness the indifference with which the victims of yellow fever in the Charity Hospital seem to view death. The large congregation of sick and dying seems to render them familiar with his face, and to rob him of more than half his terrors. After entering the hospital, and witnessing the dying struggles of some half dozen or a dozen fellow-sufferers, they meet their fate with composure, and quietly resign a life which, perhaps, to many of them, had presented naught but a varied scene of toil and care."2 Dr. Rush, and Dr. Lewis, of Mobile, speak of occasional cases, not attended with delirium, in which the patients after recovery retain no recollection of what took place during their illness. Coma is an uncommon symptom ; but sometimes grave cases are marked by different degrees of drowsiness and stupor. The sleep is generally disturbed, and the patients often harassed by distress- ing dreams. Sec III.—Physiognomy. The appearance of the face, and the expression of the countenance, have always been particularly noticed by observers of yellow fever. Dr. Rush says: "Upon entering a sick room, where a patient was confined by this fever, the first thing that struck the eye of a physician was the counte- nance. It was as much unlike that which is exhibited in the com- mon bilious fever, as the face of a wild is unlike the face of a mild 1 Du Typhus d'Amerique. Par Vr. Bally, p. 211. 2 N. 0. Med. and Surg. Journ., vol. i. p. 77. 468 YELLOW FEVER. domestic animal. The eyes were sad, watery, and so inflamed, in some cases, as to resemble two balls of fire. Sometimes, they had a most brilliant or ferocious appearance. The face was suffused with blood, or of a dusky color, and the whole countenance was downcast and clouded."1 Mr. Pym says, it is impossible to describe the appearance of the face, but that those wishing to form an idea of it may see what he calls its fac-simile in the countenance of any person with a florid complexion, during the burning of spirit of wine and salt, in a dark room, as is practised in the game of Snap Dragon during the Christmas Gambols.2 Dr. Lewis, of Mobile, says: " The physiognomy of the disease is striking and peculiar. I have not noticed, however, any of that wild, ferocious expression of eye and features which is spoken of by many writers. There is usually an attempt on the part of the patient to appear amiable and indifferent, seldom becoming peevish, or losing temper. The expression of which I am speaking is, in many cases, stamped upon the brow at an early period; and, ' once enthroned,' no effort of the patient can disturb its reign; he may smile and laugh, but he can- not chase it away; there it still sits, mocking the assumed gayety and levity of its victim. Even the cradle is not exempt from its visitations; within the last hour, I have seen a child, but fifteen months old, over whose brow this mysterious fiend has spread its gloomy mantle, giving to the little patient a dejected, cheerless, and earnest look, ill suited to its infant face."3 Dr. John Wilson, in a report of a case of what he calls apoplectic congestive yellow fever, speaks of a peculiar smile seen at times on the patient's face, and then adds, in a note: " It would be difficult to give a just notion of this peculiar smile to a person who has not seen it. Unlike the smile of health and happiness, it is confined to the mouth; the face generally, and the eye in particular, having no share in its expression, but rather counteracting or contradict- ing it, by their fixedness and despondency: neither has it any of the hideousness and distortion of the risus Sardonicus. It is a quiet, transient, smiling movement of the lips alone, melancholy in itself, and by contrast with the general aspect; and rendered more melan- choly, by being associated with apprehensions of a fatal issue; for in my own observation it has always been the forerunner of death."4 1 Rush's Med. Inq., vol. iii. p. 52. 2 Pym upon Bulam Fever, p. 5. 3 N. 0. Med. and Surg. Journ., vol. i. p. 299. * Memoirs of the West Indian Fever, p. 57. SYMPTOMS.—STRENGTH. — MUSCLES.—SENSES. 469 The redness and suffusion of the eyes, so striking in this disease, and noticed by nearly all writers, have been particularly described by Louis. He found them in all cases, the mild as well as the severe; and they were generally present at the commencement of, or early in, the disease. In cases terminating fatally, the redness of the eyes sometimes continues undiminished to the close of life; more generally it becomes less intense, or disappears, before death. In cases terminating in recovery, it disappears with convalescence and the patient's restoration to health. In most instances, the red- ness had a double character—a uniform delicate rose tint, as if put on with a brush, and a more or less marked injection of the vessels of the conjunctiva. "In the cases where the redness had not dis- appeared at the time the yellowness came on, the mixture of yel- low and red in the sclerotic was very remarkable. The eyes were usually more or less glistening, moist and suffused, frequently sen- sible to the light, but rarely what may be called painful."1 Sir Gilbert Blane says: "There is something very peculiar in the countenance of those who are seized with this fever, discernible from the beginning by those who are accustomed to see it. This appearance consists in a yellow or dingy flushing or fulness of the face and neck, particularly about the parotid glands, where the yellow color of the skin is commonly first perceived. There is also in the eye and muscles of the countenance a remarkable expression of dejection and distress."2 Sec. IV.—Strength ; Muscles ; Senses. In a certain proportion of cases, there is more or less loss or prostration of muscular strength. Sometimes, and especially when there is much hemorrhage, this may be extreme; but it is more commonly only moderate, and in many instances it is absent to a very striking degree. Dr. Rush says: " Patients in the close of the disease often rose from their beds, wralked across their rooms, or came down stairs, with as much ease as if they had been in perfect health. I lost a patient in whom this state of morbid strength occurred to such a degree that he stood up before his glass and shaved himself on the day upon which he died."3 These are called walking cases by the physi- cians of our southern cities.4 Although they are exceedingly 1 Louis on Yellow Fever, p. 200. 2 Obs. Dis. Seamen, p. 400. 3 Rush's Med. Inq., vol. iii. p. 64. 4 This term is said to have been first applied to these cases by Professor Cald- well, of Louisville, Kentucky. 470 YELLOW FEVER. grave in their character, almost always terminating fatally, they are not generally marked by the usual symptoms of the disease. There may be no chill, no fever, no local pain; and the tongue, pulse, and skin are nearly natural. These singular latent cases are noticed also by Louis. " It is under this form of the disease," he says, "that patients died without taking to their beds—on foot, as it was expressed by their friends. Thus, Dr. Mathias, who died after an illness of four or five days, experienced no other symptoms but severe pains in the calves of the legs, and a suppression of urine. He had no nausea; he did not vomit. His miud was perfectly clear during the whole course of the disease ; he noticed the continuance of the suppression of urine, dictated three or four letters to a friend, begged him to write rapidly the last, so that he might sign it, then devoted a little time to an affectionate inter- course with this friend, and soon after, unable to speak, he thanked the friend by a sigh, and in a quarter of an hour he was dead."1 "I have known a man," says Dr. John Wilson, " in cases like these, ordered to do his duty because the surgeon could not perceive much the matter with him; he continued to do his duty, after a fashion, for nearly two days, when the eruption of black vomit gave irresist- ible and mortifying evidence that the man was no impostor."2 Spasmodic contractions of the muscles are of rare occurrence, excepting, however, those of the diaphragm, constituting hiccough. This is a frequent and very sure precursor of death. The senses are generally free from any considerable disturbance. Slight intolerance of light is not unfrequently present. The hear- ing is unimpaired, and there is not often any ringing in the ears. ARTICLE V. MISCELLANEOUS SYMPTOMS. Sec I.— Color of the Skin. Yellowness of the surface of the body is almost always present in fatal cases; occasionally, it is wanting' Sometimes it appears early in the disease, but in most instances not till about the middle period, or later. The yellowness is often deeper on the chest than upon other parts of the body ; and it is frequently preceded by a more or less vivid redness and injection of the integuments. It usually shows itself first on the conjunctiva, 1 Louis on Yellow Fever, p. 170. 2 Memoirs of the West Indian Fever, p. 15. SYMPTOMS. — COLOR OF THE SKIN. 471 and round the border of the chin, then extending to the chest, and afterwards over the body. In mild cases, and in those terminating in recovery, this symptom is very frequently absent. Dr. Bancroft says : " The yellowness is sometimes of a dingy or brownish hue, sometimes of a pale lemon, and at others of a full orange color."1 Dr. Gillkrest says the yellowness may be partial or general, and may vary from the light lemon color to deep ochre yellow.2 Dr. John Wilson says the discoloration of the skin differs in the two forms of the disease, the inflammatory and the congestive. " In the former, the skin is yellow, of different shades in different instances. Sometimes it is light, sometimes dark ; sometimes it is of the color of an unripe lime, sometimes of a mellow orange, varying con- stantly, and being scarcely the same, in every respect, in any two cases; still, it is yellow, and would be instantly pronounced so by all observers, though in endeavoring to describe its exact tinge different words would be employed by different persons, sometimes inappropriate ones, and erroneous opinions would thence be formed. * * * In the congestive form, the skin is discolored, but does not become yellow. Its color is not like that of an icteric patient; it may rather be called petechial, as it resembles, though it is not exactly like, the skin of persons in the last stage of what is called putrid fever. From the first, the skin loses its proper lustre. It becomes blanched, or lurid ; and as the disease advances, livid and black patches of various sizes are observed on the breast, back, hips, scrotum, and extremities. They pervade the surface, but are most numerous generally on the trunk. About their margins there is a yellowish or greenish hue, either of them indistinct, and what is called dirty. It is difficult to describe the aspect of the skin accurately and intelligibly ; but by comparing it with a fami- liar object, which it very closely resembles, a pretty correct notion of its peculiarities will be obtained. When yellow leather gloves are worn on horseback in rainy weather, and the glove of the bridle hand is thoroughly wet, the palm part of it exhibits a very just likeness of what I have attempted to delineate,—turbid white and livid or black, intermixed with imperfect margins of yellow and green, or a hue in which yellow and green are blended, and it is difficult to say which predominates. This appearance of the skin in the congestive form, and the yellowness which I have appropriated to the inflammatory, I am persuaded are characteristic ' Bancroft's Essay, p. 34. 2 Cyc. Prac. Med., vol. ii. p. 273. 472 YELLOW FEVER. of each respectively; but I am not, from my experience, justified in saying they are so absolutely, and without any exception." [The yellow color of the skin and conjunctiva, whatever be its hue, is a true jaundice, and arises only after the liver has begun to suffer the material changes which are described in the chapter on Anatomical Lesions, Sec. III., and after the alvine discharges have become abilious, or contain but little bile.] Sec II.—Hemorrhages. Nearly all writers upon yellow fever speak of the frequency of hemorrhages from different parts of the body. Dr. Rush, after mentioning the occasional occurrence of bleeding from the nose, and from the uterus, in the early period of the fever, says: " As the disease advanced "the discharges of blood became more universal. They occurred from the gums, ears, stomach, bowels, and urinary passages. Drops of blood issued from the inner canthus of the left eye of Mr. Josiah Coates. Dr. Woodhouse attended a lady who bled from the holes in her ears, which had been made by ear-rings. Many bled from the orifices which had been made by bleeding, several days after they appeared to have been healed. These last hemorrhages were very trouble- some, and in some cases precipitated death."2 Similar bleedings are spoken of by other writers, from blistered surfaces, from the scrotum, from the uterus, from mosquito-bites, from leech-bites, and so on. They take place more frequently from the gums and tongue than from any other part of the body; and there is good reason for believing that these last are occasioned, in part at least, by the action of mercurials. [Dr. Blair, speaking of the difficulty of examining the urine in females, says: " At that stage when the urine should become a study of great value and interest, the cata- menia were sure to appear, whether due or not, and thus effectually embarrass the examination."] Hemorrhages are more common in the latter stages of grave cases, than under other circumstances; and they seem to be more general in some seasons and places than others. By many pathologists, the matter of black vomit, and of the black stools, is considered to be the result of a true hemorrhage from the gastro-intestinal mucous surface. Sec III.—Chest. The symptoms connected with the lungs are 1 Memoirs of the West Indian Fever, p. 22. 2 Rush's Med. Inq., vol. iii. p. 57. SYMPTOMS. — CHEST. 473 quite unimportant and accidental. There is no cough, and there are no morbid rhonchi [in the great majority of cases, though in a few, both have been noticed accompanying bloody expectoration]. The breathing in the late stages of grave and fatal cases is not un- frequently more or less deep, and sighing. I do not know that the action of the heart has been particularly studied. 474 CHAPTER III. ANATOMICAL LESIONS. ARTICLE I. LESIONS OF THE LUNGS, HEART, AND BLOOD. Sec I.—Lungs. The condition of these organs, so far as I know, has been particularly and carefully studied only by Louis and Trousseau; and in fifteen cases they found them the seat of lesions which seem to have been very rarely met with in any other disease. These lesions consisted of black spots of from two to five lines in diameter, or of masses of the same color more or less impermeable to the air. The spots were found in nine subjects. In a few cases they were of a crimson hue, but generally they were brown or black. They were more or less crowded together, occu- pying a space of variable extent on the surface or in the interior of the lung; in some cases, they were found only in the lower lobe. The density of the tissue which was the seat of them was not manifestly increased, except in two cases; this increase of density was evidently the result of an effusion of blood, more or less intimately combined with the pulmonary tissue. " The black or blackish masses existed in six individuals; their consistence was greater or less; they contained no air; they had not the granulated aspect of hepatized lung; they presented but slight traces of organization, so that merely some cellular fibres irregularly dis- posed could be distinguished in them. Usually, they could be easily broken down; in some cases, also, they yielded by pressure the blood of which they were almost entirely composed, and the pulmonary parenchyma remained apparently of its natural con- sistence. In one case it was impossible to remove the blood by a gradual and moderate pressure, and here the tumor or mass was as large as the fist, had more cohesion than the parts in the second degree of pneumonia, and less than the parts in the state which the LESIONS.—LUNGS. 475 illustrious Laennec has designated as pulmonary apoplexy. The same was true in another subject, in whose lungs were found from twenty-five to thirty tumors of this same character, though of a little different aspect, and somewhat resembling the thyroid gland. Their structure was apparently homogeneous, quite friable, and as in the other cases, there was no line of demarcation between them and the pulmonary tissue." I do not know whether it was this lesion of the lungs that was noticed by Arejula at Cadiz in 1800. He says: " On opening the cavity of the thorax, the lungs appeared speckled with black and gangrenous spots, which were particularly observed in those bodies in which the disease had assumed the most malignant form."1 Mr. M'Colme says: "The lungs were often blackish next the pleura, and interspersed in many places with large livid spots."2 Dr. Deveze seems to have studied the anatomi- cal lesions of yellow fever, during the Philadelphia epidemic of 1793, with more zeal and carefulness than any other physician. He does not state the number of his autopsies, but he reports in detail eight examinations which he made at the Bush Hill Hospital. The lungs, he says, were sometimes found healthy; but more fre- quently they were flabby, covered with black spots, engorged with blood of the same color, and so on. He quotes other observers who had noticed black and gangrenous spots on the surface of the lungs.3 O'Halloran did not notice any special alteration of these organs. Louis and Trousseau found, in several cases, a livid color of the air-passages, more or less vivid, occupying the mucous and sub-mucous cellular tissue. [The statement of Dr. Blair regarding the lungs and their appendages is, "The lungs are often apo- plectic, with the interlobular spaces broken and infiltrated, so as to lose all physical appearance of pulmonary tissue, and to resemble huge blood clots. The pleura costalis participates in the same sanguineous appearance, as the tissues of the throat, from universal hyperaemia and extravasation beneath that membrane. The trachea and bronchi are (often) in the same condition." Dr. T. Hewson Bache had an opportunity of examining the bodies of fourteen persons who died of yellow fever in the Pennsylvania Hospital during the summer of 1853. He records the state of the lungs in thirteen. In seven, the structure he regards as normal; there was general congestion posteriorly in two, congestion in spots, ecchymoses in 1 Reports, etc., by Sir J. Fellowes, p. 68. 2 Hunter's Dis. of Array, p. 161. 8 Traite de la Fievre Jaune. Par Jean Deveze, p. 62. 476 YELLOW FEVER. five; effusion of blood in one, of serum in three. He examined the trachea and bronchial tubes in eight cases, and found them injected in all.1 "No recent writer mentions the " gangrenous spots" referred to in the text, and there is every reason to suppose that dark ecchymotic and apoplectic "spots" have been mistaken for gangrene.] Other lesions of the lungs and pleurae are of very rare occurrence.2 Sec II.—Heart. Louis and Trousseau found the heart soft or flabby, or both soft and flabby, in a considerable proportion of cases. Other changes in this organ, and in the aorta, are accidental merely, and such as are frequently found after death from acute disease. Deveze found the heart flabby, pale, and very soft.3 [The heart was examined by Dr. Bache in twelve cases. The tissue was reported normal in seven; black ecchymoses at the base in one; pale in two; small in one. Professor Riddell,4 of New Orleans, has found that the muscular fibres of the heart undergo molecular degeneration, often miscalled fatty degeneration, in yellow fever. He says, I first observed this remarkable change * * on the 11th of August, 1854. * * I have since had the opportunity of examin- ing nearly thirty yellow fever hearts. In general, the molecular change is either complete or well marked, rarely it is very slight or imperceptible. When the change is complete, all traces of striation have disappeared, and the fibre has become granular. The pericardium was inspected by Dr. Bache in eleven of his fatal cases. Of these it was normal in seven; tinged yellow in one; injected in three; injected in spots in one. It contained an orange brown or yellow fluid in nine; blood with clot in one; and four ounces of a dark greenish brown fluid, resembling black vomit, in one, making effusion of some kind in all. The condition of the aorta was noticed in eight cases. The lining membrane was yellow, of different shades in three; buff in two; and red of different shades in three. The appearance of the pulmonary artery was noted in four. The lining membrane was of a pale yellow color in one; yellowish pink in one; and buff in two.] Sec III.—Blood. The blood found in the cavities of the heart, 1 [Amer. Journ. of Med. Sci., July, 1854.] 2 Louis on Yellow Fever, p. 63, et seq. 9 Rush's Med. Inq., vol. iii. p. 92. 4 [La Roche on Yellow Fever, vol. i. p. 392.] LESIONS.—BLOOD. 477 and in the large vessels, after death, seems to be very generally changed from its natural condition. This change was noticed by the older observers; and it has been more particularly studied in our own time. Dr. Physick and Dr. Cathrall say : " The blood in the heart and veins is fluid, similar in its consistence to the blood of persons who have been hanged, or destroyed by electricity."1 Hillary speaks particularly and repeatedly of the state of the blood. " Even at the beginning of the disease," he says, " it is often of an exceeding florid red color, much rarefied and thin, and without the least appearance of siziness; and the crassamentum, when it has stood till it is cold, will scarce cohere, but fluctuates."2 Louis and Trousseau found the blood generally either liquid only, or liquid and clotted ; the clots being black, or yellow, and fibrinous. Dr. Nott, of Mobile, gives the following interesting account of the blood in the cases examined by him, in 1843 and 1844. " This was found dark and fluid in every case where the bodies were opened. Minute observations were not made, in all the cases, but in about one-half, the blood was collected by thrusting a trocar into the right auricle, and drawing it off into clean quinine bottles. It was so fluid, and was accumulated in such quantity in the auricle and veins connected with it, that, ten or twelve hours after death, it would run freely through the canula, to the amount of a pint or more. When set aside, it coagulated at intervals, varying from fifteen or twenty minutes, to thirty-six hours; the clots were soft, grumous, easily broken down, showing a great deficiency of fibrin, and corresponding with Andral's description of the blood in the other pyrexiae. In one case, it did not coagulate at all, but pre- sented a true state of dissolution."3 Dr. Harrison says it requires a much longer time for the blood to coagulate than in other dis- eases, and that the coagulum is large and soft; he adds, that it rarely presents the buffy coat when drawn from the arm, and that he has never seen it cupped.4 [The researches of Dr. Blair into the conditions of the blood in yellow fever appear to have been more carefully made and to be more trustworthy than any yet reported. They go far to show that this fluid is much less frequently changed in its most important elements than is commonly supposed. Regarding its coagulability, 1 Rush's Med. Inq., vol. iii. p. 92. 2 Rush's Hillary, p. 108. 3 Amer. Journ. Med. Sci., April, 1845. 4 N. 0. Med. and Surg. Journ., vol. ii. p. 140. 478 YELLOW FEVER. Dr. Bache, quoted in the last section, reports the right cavity of the heart " distended with blood (fluid ?) in two cases, and contain- ing a clot in seven." The left cavity was distended with blood in three cases, and contained a clot in six. Dr. Blair says: " Cupping, the use of artificial and natural leeches, arteriotomy, and in a few cases venesection, epistaxis, and other hemorrhages gave ample opportunity during life for examining the physical, chemical, and microscopical properties of the blood. In no instance could we discover any really abnormal condition of color, corpuscles, serum, and crassamentum, during the first stage, except sometimes the presence of bile. In every instance the blood retained its natural alkalinity in the first stage. The changes in the blood were found, therefore, only in the last stages, and in the post-mortem blood. And yet cases terminating fatally after normal black vomit and hemorrhages, are numerous in which no unhealthy appearance of the blood after death could be noticed except as to bile-tinge. The appearance of yellow fibrinous coagula in the heart was frequent after the worst cases, the texture of the blood often remained good." These conclusions are based on the examination of blood procured direct from the vessels. When the blood of certain hemorrhages was examined, the result was very different. That of a case of hematemesis is described as a thin dark fluid, looking like port wine, without fibrin, strongly alkaline, not brightened by nitrate of potash and muriate of ammonia, giving off ammonia freely when heated, and not containing a single perfect corpuscle. Blood passed by stool and free from fecal matter, though "of good crassitude and color to the naked eye, is always found under the microscope with all its corpuscles ruptured." The blood corpuscles were always found during the first stage, and often throughout the disease, and after death, perfectly natural in color, form, apparent quantity, and in their disposition to adhere in rouleaux,—when derived directly from the vessels. Yet the blood was not always healthy in the last stages. In one case "the fibrin was so diminished in quantity as almost to be lost;" in another, "it had in a great measure lost its power of fibrillation ;" and in a third, " both fibrin and cells suffered; the color of the blood was a dirty brown, and it was entirely fluid ; the corpuscles were all altered and misshapen,"—in a fifth, " the corpuscles were misshapen, and had no tendency to form rouleaux." In a sixth, " corpuscles were flat, indistinct, and irregular in shape, with many nuclei (granules) adhering." In a seventh, after death, " the blood wras highly ammoniacal, and was LESIONS.—CEREBRO-SPINAL APPARATUS. 479 totally dissolved. I failed to detect a single normal corpuscle." Again, referring to some specimens of blood taken after death for analysis, " The first important fact observed in performing these experiments was the rapidity with which the blood decomposed. It set rapidly, and within half an hour all the healthy physiological changes occurred, which were to be expected, and soon after decomposition commenced. Frequently no separation at all occurred in the coagulum." In one case, twenty-four hours post-mortem, very soon after the blood was put into the bottle it began to bubble with gas, and actually frothed soon after. In another, twenty-four hours after removal, "the bloodsmelled decidedly urinous;" and in another still, " throughout the analysis, the phosphates caused much trouble and delay." Finally, the agency of the retained urinary elements, especially of urea, as Dr. Blair views it, is expressed in the follow- ing words : " The healthy condition of the blood in yellow fever seems associated with the free action of the kidneys, or copious black vomit, and alkaline exhalations of the breath. The deterio- rated fibrin has an obvious relation to the amount of free ammonia remaining in the circulation. The changes in the shape of the corpuscles were probably due to the density and saline constituents of the serum. The blood of the cadaver in this epidemic was in the vast majority of cases more or less ammoniacal."] ARTICLE II. LESIONS OF THE CEREBRO-SPINAL APPARATUS. There are no alterations of this apparatus, excepting such as are frequently found after death from other acute diseases. These are moderate effusions of serum in the sub arachnoid tissue and into the cavities of the brain; a more or less red, or violet, or lilac color of the cortical substance, and occasional slight injection of the medullary portion of the brain. [Dr. Bache examined the head in four of his fourteen cases. He found the dura mater congested in two; tinged yellow in two; effusion (serous ?) under it in one. The arachnoid was opaque in one. The pia mater was congested in three; thickened and opaque in one. Hemispheres were partially coherent in one. The structure of the brain was normal in all. Effusion (probably serous, Ed.) was found within the ventricles in two. Dr. Blair met instances in which there was " congestion, effu- sion, and extravasation of blood in the brain."] 480 YELLOW FEVER. ARTICLE III. LESIONS OF THE ABDOMINAL ORGANS. Sec I.—Stomach. The mucous membrane of the stomach is more or less altered in a pretty large proportion of cases. Louis and Trousseau found it of natural thickness, consistency, and aspect, with the exception only of slight changes of color in five, of twenty- three cases; in the remainder it presented evident traces of pre- vious inflammation. Its color was quite natural in only three cases; in several it was more or less deeply red, sometimes over its whole surface, and at others only over circumscribed portions; in eight cases, instead of a red color, there was an orange, or a slight rose tint, or a color of onion parings, varying in extent; in two cases there was a ruddy or bistre hue, and in two others the mem- brane was greenish or yellowish. The thickness of the membrane was natural in half the cases; in the other half the thickness was increased; in some universally, and in others partially. Its con- sistence was natural in only two subjects, in all the rest it was more or less diminished. The softening was general but moderate in five; partial and but rarely to a remarkable degree in the others, so that in no region, not even in the great cul-de-sac, was the mem- brane reduced to the consistence of mucus. Well marked and more or less extensive mamellonation was found in two-thirds of the subjects; and it is important to remark that this lesion was always accompanied by thickening, or softening of the membrane, or by both, and by alterations of its color. Dr. Ashbel Smith has published a history of the appearance of the abdominal organs in seven cases of yellow fever, occurring in Galveston, Texas, in 1839. He found the mucous membrane of the stomach of a whitish pearl color, much thickened and softened. In four cases, these lesions were limited to certain portions of the membrane, while the remain- ing portion, in the cardiac extremity, was the seat of a very intense, uniform, red injection, but was neither thickened nor softened.1 Subsequent observations, by other physicians, have led to the same general results, in regard to the condition of the stomach. Dr. Jo- siah C. Nott, of Mobile, in sixteen cases, examined in 1843 and 1844, found the mucous coat of the stomach free from any appre- ciable change in seven; in the remaining nine it was more or less reddened, softened, thickened, and mamellonated.2 1 Amer. Journ. Med. Sci , Feb., 1840. 2 Ibid., April, 1845. LESIONS.—STOMACH. — CONTENTS. 481 The contents of the stomach are thus minutely and particularly described by Louis. In four subjects, the stomach contained only a small quantity of flocculent mucus, or a little grayish, yellowish, or dark-colored liquid; in all the others, eighteen in number, the contents of the stomach were red, more or less inclining to black. This red or black matter varied in quantity, from four to twenty ounces; and its quantity was in proportion to the depth of the red color; the mean quantity where the color was bright red being nine ounces, and fourteen ounces where it was entirely black. The consistence of the red and the black matter was about the same; in some it was quite liquid, in others it was like porridge. It separated on standing into two portions; the upper more liquid than the lower, and of a bistre color; the lower less abundant, and formed as it were of blackish parcels.1 [Dr. Bache found the material of black vomit, varying in color, dark, dark coffee color, dark chocolate, and dark green, in all his fourteen cases.] This matter of black vomit was formerly supposed to be derived princi- pally from the liver, and to consist of vitiated bile, mixed with the fluids of the stomach. Dr. Rush says that he at one time believed this matter to consist of vitiated bile, but that subsequent dissec- tions by Dr. Stewart and Dr. Physick, convinced him that it was derived from the stomach; although I find in the report of the dissections, made by Dr. Physick and Dr. Cathrall, and quoted by Dr. Rush, the black liquor found in the stomach and intestines referred to an altered secretion from the liver. This opinion is now, I think, generally if not universally abandoned; and it seems to me quite clear that the matter of black vomit consists of blood, mixed with the fluid secretions of the stomach, and derived directly from the mucous membrane. Dr. Nott, and Dr. P. H. Lewis, of Mobile, have made some interesting experiments for the purpose of ascer- taining the nature of this substance. Dr. Nott believes it to consist of blood, exhaled in its natural state from the capillaries of the stomach, intestines, and even the bladder, and changed black by the secretions with which it comes in contact; this chemical change being produced by one or more acids. He says that the matter of black vomit is always acid, turning litmus paper red; and he sup- poses that the acrid property of the liquid may depend upon the presence of these acids. Dr. Nott found, further, that the matter of black vomit can be very exactly imitated, by adding to a few ' Louis on Yellow Fever, p. 79, et seq. 31 482 YELLOW FEVER. drachms of blood four or five drops of muriatic acid, and a little gum water, or flaxseed tea, to represent the mucus of the stomach. No one can distinguish, he says, the artificial from the natural black vomit; although he admits that the small coffee-grounds coagula are more difficult to imitate. A very small quantity of blood, he thinks, oozing gradually in a minutely divided form, and mingling slowly with the secretions of the mucous membrane of the stomach and bowels, will make a large quantity of black vomit.1 The opinion that the coloring matter of black vomit consists of blood, is strengthened by the fact that, in some instances, pure blood is found in the stomach. It is probable that, as a general rule, this matter is derived exclusively from the mucous surface of the stomach, and not from that of the intestines; although the observations of Louis lead to the conclusion that it may sometimes be furnished by the latter. It is important that a single additional remark should be made here. We have no right to assume that the appreciable inflammatory lesions of the stomach are the essen- tial cause and condition of the presence of the matter of black vomit; and this for the obvious reason that the latter is not un- frequently found where the former do not exist. All that we can do in the present state of our knowledge is to refer the productions of this substance to some special but unascertained pathological action or condition of the mucous membrane of the stomach, or of the fluids of the body; or, as is more probably true, of both; the inflammatory lesions of the gastric mucous membrane being also one of the results or complications of this same action or condition.2 [The views here expressed regarding the nature of the black vomit are confirmed by the late chemical and microscopical study of that . ' Amer. Journ. Med. Sci., April, 1845. 2 The true character and origin of the matter of black vomit were clearly stated a long time ago. Dr. Bancroft quotes Dr. Henry Warren, who wrote on the yellow fever of Barbadoes, in 1740. Dr. Warren says: " I ought here to observe, that the fatal black stools and vomitings are vulgarly supposed to be only large quan- tities of black hile or choler, which false notion seems to be owing to that fixed unhappy prejudice that the fever is purely bilious. But let any one only dip in a bit of white linen cloth, he will soon be undeceived, and convinced that scarce any- thing but mortified blood is then voided, for the cloth will appear tinged of a deep bloody red, or purple, of which I have made many experiments."—Bancroft's Essay, p. 28. Sir John Pringle, Dr. John Hunter, and Sir Gilbert Blane, amongst others, entertained similar views. Mr. Pym says he is convinced that the matter of black vomit is blood in a dissolved state, poured forth from the small vessels, abraded by the separation or disease of the villous coat, and acted upon by the gastric fluid. LESIONS. — STOMACH. — CONTENTS. 483 fluid. Dr. La Roche has collected these recent observations.1 Prof. R. E. Rogers has furnished Dr. La Roche with an analysis of six specimens. He found in them all albumen; earthy phosphates; and iron; hydrochloric acid in a free state; and sulphuric acid, chlorine, and alkaline bases in a state of combination. All these substances, he remarks, except the hydrochloric acid, are constituents of the blood; and the albumen, the iron, and the sulphuric acid, he thinks, can have no other origin than the " altered blood." Dr. John Davy's " examination of a single specimen confirms the most important of these results. The specific gravity of four specimens examined by Prof. Rogers was, A, 1.010; B, 1.005; C, 1.004; and D, 1.003. One specimen, examined by Prof. Hume, which was remarkably black, had a specific gravity as high as 1.032." Both Dr. Davy and Dr. Blair noticed a considerable amount of muriate of ammonia in black vomit. The latter, finding how scanty the urea was apt to be in the urine during the advanced stages, was disappointed in his search for it in the vomit. The doctrine of Frerichs at length suggested the tests for ammonia, instead of those for urea and uric acid. Both liquor potassae and heat produced this gas in abundance. " The presence of ammonia in black vomit," he says, " is universal, that is, it has always been found when looked for, and may be considered one of its tests; while vomit also contains it in notable quantity." This elimination is regarded as vicarious, and however grave the lesions which produce the vomit, is considered one of the means of relieving the system from the equally grave uraemic poisoning. The microscopical characters of black vomit, Dr. La Roche remarks, have been examined " by Dr. John Davy; Drs. Hayne and Michel, of Charleston; Dr. Riddell, of New Orleans, Dr. A. Clark, of New York; Dr. Hassell, of London; and, at my request, by Dr. Leidy of this, city" (Philadelphia). All but Hassell agree in ascribing the dark hue of the vomited matter to the presence of " altered blood." They find that the coloring substance exists in various forms; granules extremely minute, frequently aggregated in small masses; globules of all appreciable sizes less than the diameter of a blood disk, held by all to be blood corpuscles altered in size and form by the secretions of the stomach; and bodies having the size and shape of blood corpuscles (or only a little altered), some colorless, and some of a yellowish brown hue, the color not remov- 1 [Am. Journ. of Med. Sci., July, 1854, and La Roche on Yellow Fever, vol. i.p. 314.] 484 • YELLOW FEVER. able by water and other fluids which promptly imbibe hematin from the unchanged blood. These substances are all supposed to have been derived directly from the blood. The granules, whether dif- fused or clustered, are considered by the editor and by Prof. Leidy as in part the coloring matter of the blood, discharged from the corpuscles and converted into hematoidine,1 and in part the broken down corpuscles. The brown coloring of the bodies which still retain the shape of blood-corpuscles, and of many which are dwarfed and globular, is believed to be due to the convertion of hematin into hematoidine, within the capsule of the blood-cell, thus, so to speak, dyeing it indelibly. Some of the blood-corpuscles appear to be in a state of disintegration (Clark), or degradation (Leidy), thus be- coming converted into granules of the same dark yellowish brown color as those formed from the hematin. Opaque black scales, having no uniform shape, and susceptible of fracture, were seen in some of the specimens, and were regarded by the editor as having the same origin as the brown material which chiefly gives color to the black vomit. Beside these essential constituents of black vomit, most observers notice epithelial cells both from the lining membrane, and from the crypts of the stomach, in greater or less abundance. These are colorless, and most of them highly granular. Their presence is thought to be important only when they are numerous. Then they probably indicate unusual vascular action in the mucous lining of the stomach. Oil globules, crystallized margarine, and other remains of food also noticed, deserve no men- tion here. The same may probably be said of certain cryptogamous productions, which were discovered in some of the examinations. The variety of forms in the microscopic plants described, their entire absence in many specimens, and their evident production, after the vomit was exposed to the air in others, conspire to show that they are not essential constituents of this discharge. Dr. Blair2 has just published a letter addressed to Dr. John Davy, in which he states that he has detected hepatic cells in the matter vomited in yellow fever.] As to the nature of these lesions of the stomach, it seems to me there can be no reasonable doubt. Where they are well marked, and especially where the membrane is reddened, softened, and 1 [For the nature of this hematoidine, so far as it is known, see the section on the Bronze Liver in Remittent Fever.] 2 [Brit. For. Med.-Chir. Rev., July, 1856.] LESIONS.—STOMACH. — INTESTINES. 485 mamellonated, we are obliged to consider them the result of in- flammation. If we refuse to do this, merely because some of the ordinary phenomena of simple acute gastritis are wanting, there is at once an end to all rational or positive conclusions. At the same time it must be admitted that the inflammation of the gastric mucous surface is a peculiar or specific inflammation ; it is in some way modified by the general disease; it derives from the latter some special and unknown element, which does not exist in other forms of gastritis, whether these latter are primary or secondary. Dr. Ashbel Smith concludes from his observations, that the soft- ened, thickened, and mamellonated condition of the membrane is always preceded by an intense sanguineous engorgement, differing in its nature from inflammation, and resulting in the production of the matter of black vomit, and the lesions of the membrane which it precedes.1 Ulceration is of very rare occurrence. In regard to the volume of the stomach there is nothing constant: sometimes it is con- tracted, sometimes distended, and at others natural. Sec II.—Intestines. The mucous membrane of the small intes- tines is, in a considerable number of cases, quite natural through- out its whole extent; or it is the seat only of slight and unimport- ant alterations. Its thickness and consistence are rarely changed; in a certain proportion of cases there are patches or sections of redness, mostly within a few feet of the caecum. Redness, soften- ing, and thickening of the lining of the larger intestine are more frequent. Louis and Trousseau found universal softening in four- teen of twenty-three cases. The latter lesions are probably the result of inflammation. [Dr. Bache noted the appearance of the intestines in twelve cases. The mucous membrane of both the large and small intestines was variously discolored in most, red, or slate color, or purple, &c. It was marked with ecchymotic spots in the small intestines three times. There was no softening in any case, even in the colon, that he noticed, but in one there was a fibrinous patch at the sigmoid flexure, and in another the plates of Peyer were unusually distinct.] The upper portion of the small intestine usually contains the same kind of reddish, brownish, or blackish matter that is found in the stomach; and the same substance is found also in the large 1 Amer. Journ. Med. Sci., Feb., 1840. 486 YELLOW FEVER. intestine.1 It is thicker and more consistent especially in the large intestine than it is in the stomach. Pure blood has occasionally, though rarely, been found in both the stomach and bowels. The volume of the intestines is not often altered. Louis and Trousseau found the epidermis which lines the oeso- phagus perfect in only five cases; in all the others it was more or less completely destroyed.2 Dr. Nott, of Mobile, thinks it probable that this destruction of the epidermis of the oesophagus depends upon the acid acridness of the matter of black vomit.3 [The con- dition of the oesophagus was noted by Dr. Bache in nine cases. The mucous membrane was injected in four, slate colored in one, spotted red in two, spotted and striped black in two, softened in one, partly divested of epithelium in all, and sphacelated (?) in one.] Sec III.—Liver. Since the publication of the researches of Louis and Trousseau upon the yellow fever of Gibraltar, in 1828, the attention of pathologists has been turned particularly to the condition of the liver in this disease; and the result of subsequent observations in regard to the state of this organ in periodical, or marsh fevers, has imparted to the subject new interest and import- ance. The following, I believe, is a full and fair summary of the present state of our knowledge in relation to this question. Louis and Trousseau, in all the subjects examined by them at Gibraltar, found a very striking and uniform change in the color of the liver. They describe the liver as being sometimes of the color of fresh butter; sometimes of a straw color; sometimes of the color of coffee and milk ; sometimes of a yellowish gum color, or a mustard color, and, finally, sometimes of an orange or pistachio color. "This discoloration," they say, " was not the same throughout the whole extent of the liver: more marked in the left than in the right lobe; it was also more uniform. In cases where the color was uniform in the left lobe, there was in the right lobe a mixture of gum yellow, orange, or red points, larger or smaller; or else we found in the right lobe a rose tint, which did not exist in the left lobe. .The cases in which the color of the liver was formed by the mingling of different colored points were rare; and this disposition was some- what remarkable in one of them, where the liver presented a mix- ture of yellow and green points. This change of color extended 1 Amer. Journ. of Med. Sci., Feb., 1840. 2 Louis on Yellow Fever, p. 100,- et seq. 3 Nott on Path, of Yellow Fever. LESIONS. — LIVER. 487 throughout the whole of the organ, in all but three cases; in these, it was limited to the left lobe, or to the left and a part of the right, the latter preserving its natural color throughout, or in its obtuse edge only." " With the discoloration of the liver, are found a more or less marked paleness, and a diminished quantity of blood, so that wher- ever this appearance of the liver was well marked, the sections of it were dry, and of an arid appearance in the left lobe. This ap- pearance reminded us at first of the greasy transformation of the liver, a transformation always accompanied by a softening, more or less marked. In the cases now under consideration, the cohesion of the liver'was not at all diminished, even where the organ was of a clear coffee and milk color, or of a straw yellow, or of the color of sole leather."1 The cohesion of the liver, and the resistance of its tissue to the knife, or to the hand, on attempting to break it, were increased in five cases, and diminished in five others. The singular change in the color of the liver, thus particularly and specially studied by Louis and Trousseau, is regarded by the former as the characteristic anatomical lesion of yellow fever—the only lesion constantly found after death from this disease. Louies ^ conclusion, so far as his own facts are concerned, and he carries it ' no further, is legitimate; but these facts were not sufficiently nume- rous and various, finally and definitively to determine the question. These facts were gathered in a single locality, and during the same epidemic season; and although analogies drawn from some other forms of fever, and especially from typhoid, might seem to favor the probability, or in some degree to justify the conclusion that this lesion of the liver would prove to be constant and characteristic, still, such analogies are never to be trusted, and the settlement of the question must be referred to further and more extensive observa- tions But before giving the results of these observations, so far as thev have yet been made, it may not be wholly without interest to notice some of the allusions to the condition of the liver made by the older writers upon yellow fever; from which it appears that this change of color had not entirely escaped their notice, although they generally describe the organ as natural or congested, or corrupted, and so on. " Dr. Hume," says Dr. Rush, " in describing the yellow fever of Jamaica, informs us that, in several dead bodies which he opened, he found the liver enlarged and turbid with bile, and ot a 1 Louis on Yellow Fever, p. 117, et seq. 488 YELLOW FEVER. pale yellow color.111 Dr. Chisholm made five autopsies, in the yellow fever of the West Indies, towards the close of the last century, and he describes the liver as being "of a color nearly approaching to buff, or a mixture of yellow and that of ashes.112 Arejula, in his account of the yellow fever of Cadiz, in 1800, says: "In many subjects the liver was enlarged, and its consistence so much altered as to appear as if it had been macerated; and this organ, as well as others, was found tinged of a different