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CLINICAL  REPORTS
CONTINUED   FEYER,
ANALYSES OF ONE HUNDRED AND SIXTY-FOUR CASES;
WITH REMARKS ON
THE MANAGEMENT OF CONTINUED FEVER ;  THE IDENTITY
    OF TYPHUS AND TYPHOID FEVER ;  RELAPSING
            FEVER ; DIAGNOSIS,  ETC.
TO WHICH IS ADDED
               A MEMOIR ON THE

TRANSPORTATION AND DIFFUSION  BY CONTAGION

                       OP

        TYPHOID  FEVER,

    AS EXEMPLIFIED IN THE OCCURRENCE OF THE DISEASE
         AT NORTH BOSTON,  ERIE COUNTY, N. Y.
         AUSTIN  FLINT,  M. D.,
PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE, AND OP CLINICAL MEDICINE, IN THE
     UNIVERSITY OF BUFFALO, AND EDITOR OP THE BUFFALO MEDICAL JOURNAL.

                   ____________      „o, ■
                              <£,  r,TT>"f?. A ' -

             PHILADELPHIA:  ty-f^   ^°

     LINDSAY  &  BLAKISTON.
1855. 
lr
        Kntkred, according to Act of Congress, in the year 1852, by
                       AUSTIN FLINT,
In the Clerk's Office of the District Court of the United States, for the Northern
                      District  of New York.
NOTICE.
The reader is requested to correct the following errors:
  Page 176, fifth line from the bottom of the page, for 22-39, read, 22-29.
    "   307, fourth line from the top of the page, for 61, read 73.
   The author avails himself of this opportunity to call the attention of the reader
to the fact, that the three Clinical Reports which  constitute  the larger portion of
the work, are divided into the same number of Sections, each Section treating of
the same subjects.  By reference to the table of contents, the pages of correspond-
ing Sections in the three Reports may be found;  and it is respectfully suggested
that corresponding Sections in the three Reports be read in succession, instead of
reading the  Reports, as a whole,  in the order in which they are  printed. 
PREFACE.
   In submitting the following work to the  medical public, it is proper that
the reader should be made acquainted with  the circumstances which led to
its preparation, and  with the  manner of its  publication.  At the annual
meeting  of the  New York  State  Medical  Society in  February, 1850,  the
scientific subject which  elicited most discussion was  the  identity or non-
jdentity of the forms of fever now commonly known as Typhus and Typhoid;
and a committee was appointed, on which the author was placed as chairman, to
collect facts relating to Continued Fever, and report at the next annual meeting.
The assignment of this duty led the iiuthor  to examine the cases, occurring
under his  own  oi si-nation, the histories of  which he  had recorded,  and
finding the number  considerable, he coi.cluded to subject them to numerical
analysis; but finding, in  the prosecution of  this task, that  the results would
not well  admit of Lcing  orally  submitted at  the meeting < f the Society,  and
also that t  y would  occupy more space than could be  conveniently ap-
propriated  to them in the annual volume of  transactions, they were published
in successive number.- of the Buffalo Medical Journal, and subsequently  pre.
Rented in that shape as a report to  the Society.   The first one hundred  and
thirty-one pages of the following work are occupied by this Report.  During
the  autumn of lh.O, ainl  the wii ter of 1850-51, another series of cases
passed under observation, at the Bvffalo Hospital of the Sisters of Charity,
the institution at which most of the cases forming  the ba>is of the report
ju*t mentioned had  been observed.   Desirous of ascertaining how the results
of an analysis of this second collec  on of  cases would compare with those
of the first analysis, the  labor required for that object was undertaken in the
sin  in r < t lb51, hi d the results published, as before,  in successive numbers
of the Huffalo Meikai .Journal, under the title of a "Second Clinical  Report
on Continued Fe\er based on an analysis of forty-eight cases.' As a supplement
            * 
iv
PREFACK.
to this, and the preceding Reports, were contributed some  remarks on the
'Symptoms distinctive of Typhoid and Typhus fever; the identity of these
two types; the diagnosis, etc'   A paper on * the management of Continued
fever' was also added.  This second report, with the appendix, extends from
page  131  to  page 304,  covering  one hundred and  seventy-three pages.
Again, during the autumn of 1851, and the winter of 1851-52, another series
of cases more numerous than  before, passed  under observation, during six
months service as attending physician to the institution already mentioned,
and, during the present summer, the author has again yielded to the desire to
study the facts contained  in a new  collection  of cases.   The results of this
last analysis have also been published in  the  Buffalo Medical Journal under
the title of ' Third Clinical Report on Continued Fever  based on an  analysis
of sixty-four cases.'  This report, following the remarks on the management
of Continued fever appended to the Second Report, embraces fifty-four pages
of the following work.  As appendices to the  third  report, the work contains
two papers.  The first of these  is on the  ' morbid  appearances after death,
(exclusive of intestinal lesions,) distinctive of  Typhus,  and  Typhoid fever.'
The  facts contained in  this paper  are borrowed from publications by Dr.
William  Jenner, Prof, of pathological anatomy in University College, Lon-
don.   Dr. Jenner communicated  for the  Edinburgh  Monthly Journal  of
Medical Science, in a series of  a tides commening with the No. for April,
1849, and ending with the No. for April, 1850, an analysis of the symptoms
and  morbid appearances  in sixty-six cases of Continued fever, embracing
the two types,  Typhoid and Typhus, the object being to settle the question
of the identity or non-identity  of the  two types by a comparison of the
phenomena presented during life, and disclosed by the scalpel after death.
The last of these  articles was published about  the  time that the first of the
three  analyses upon which are based the reports  contained in the following
work, was commenced.  The author,  however, was acquainted  with  Dr.
Jenner's  contributions only by an occasional  reference  to them in some of
the Medical Journals of this country, prior to  the  completion of his three
reports.  The  papers  referred to have not been republished in the United
States, and the only opportunity of consulting them which  the  author has
enjoyed, was recently during a short visit at the city of New York.   At that
time  he copied  the section  devoted to a comparison of the  morbid appear-
ances, exclusive of the intestinal lesions, which appear in the  following work
but he  has not yet been able to compare  the results of the analysis  of
symptoms  by Dr. Jenner with  those which appear  in the three reports sub-
mitted in this volume.  It would have been  interesting to have referred  to 
PREFACE.
V
Dr. Jenner's  results during  the  preparation  of these reports had  it been
practicable.   The second paper following the third report, relates to  Relaps-
ing fever,  and presents the results of an  analysis of fifteen  cases, among
those observed during the autumn of  1850 and  the  winter of 1851-52
characterized by the occurrence of relapses, and, as the results of the  analysis
show, by other of  the features which  are said to belong to an affection re-
cently described by Dr. Jenner, and  others, as a distinct form of continued
fever.   The two  papers just mentioned  have also appeared in the Buffalo
Medical Journal, and cover seventeen pages  of the following work.
   Finally, in collecting the  foregoing  reports, etc., for publication in  the
present volume, the author concluded  to  add a memoir  on the 'Transporta-
tion and  diffusion, by contagion, of Typhoid  fever, exemplified in its occur-
rence at North Boston, Erie Co.'   The reasons for inserting the memoir in
this volume will be found in the propriety of  the connection with the prece-
ding  pages so far  as relates to the nature of  the subject, and in the interest
and importance which, in the author's estimation, belong to the facts therein
contained considered in their bearing on the question of contagion.
   So much for the origin and preparation of the work.   The manner of its
publication should now, in  justice to the author, be explained.   During the
publication of the  first report  in the Buffalo Medical Journal, the author  was
desirous of having it issued separately, and an edition of a thousand copies
was  accordingly   struck off,  as  successive  portions  appeared in the Jour-
nal.  A small part of the report remaining  to be prepared, the edition  was
not issued  prior to the following summer, and then deferred  in  order to
include the second report.   Again, it was deferred until  the present  summer
in order to embrace the third report.  The printing of  the volume  has thus
been  going on, intermittingly, during the past three years, being executed only
as  fast  as successive  portions were inserted  in the  Medical Journal.   This
must be an apology, not only for some typographical blemishes which  may
be discovered, but  for defects in the arrangement of  the matter contained in
the work.  Were it proposed to  prepare  a treatise  on Continued fever after
the three reports had been published,  based on the facts therein contained,
the plan adopted  would be much  more convenient for the  reader, and alto-
gether better.  The results  of the different analyses might then be brought
together, and  the  work condensed by excluding some  details which might
with  advantage be dispensed with.
   If  the author might  presume to entertain any expectations of a degree of
interest in the present volume being manifested by the medical public suffi-
cient  to encourage the undertaking, he should venture to look forward to the 
VI
PREFACE.
task of remodeling the work  for a  second edition.  As the work  is  now
arranged, the inconvenience attending the disconnection of parts which relate
to similar subjects, has been  obviated, as far as practicable, by prefixing  a
table of contents, by means of which the reader can readily refer to the same
sections in  the  different  reports; and  it is suggested, as  the best mode of
reading the work, to consult, with the assistance of this table, in connection'
corresponding sections of the three reports.
   In conclusion, the author by no means flatters himself with the belief that
the work will be found, by the majority of  medical readers, attractive.   On
the contrary, he is well aware  that, a large portion being devoted to dry sta-
tistical details, it will generally be regarded in quite a different light.   It
would, however, be affectation  not to avow  an  indulgence of the hope, that,
even as respects these details, it may  be thought by those whose appiobation
he would  be most ambitious to obtain, to contribute somewhat to the study
of the natural history of  the different forms of continued fever, and to the
aggregation of  facts having important bearings on diagnosis, pathology and
therapeutics.
   Buffalo, July, 1852. 
CONTENTS.
First Clinical Report on Continued Fever, based on an Analtsis of Fiftt-two
    Cases,............................................................  1-13S

Second Clinical Report on Continued Fever, based on an Analtsis or Fortt-
    eight Cases,.....................................................  133-233

Third  Clinical Report on Continued Fever, based on an  Analtsis of Sixtt-
    four  Cases,......................................................305-358
CORRESPONDING SECTIONS OF THE THREE  CLINICAL  REPORTS, EACH DEVOTEO
                           TO THE SAME SUBJECTS.
Section First.—Age.  Occupation.   Civil Condition.  Nativity. Habits.  Season.
    Constitution and previous health of the patient  Period of residence in this
    country and this city.  Duration of the disease before coming under obser-
    vation.
         First Clinical Report,.............................................  1$
         Second do.   do................................................ 136
         Third   do.   do................................................ 30f

Section Second.—The access. Its duration and symptoms.  Circumstances sup-
    posed to have been concerned in the production of the disease.
        First Clinical Report,.............................................  2&
        Second do.   do................................................ 141
        Third   do.   do................................................ 309

Section Third.—Symptoms  referable to the general aspect Expression of coun-
    tenance. Decubitus.
         First Clinical Report,.............................................  28
         Second do.    do................................................ 148
         Third   do.    do................................................ 314 
riii
CONTENTS.
Section Fourth.—Symptoms  referable to the  nervous system.  Mind.   Sleep.
    Coma.  Senses and sensibility.  Muscular contractions,  etc.
        First Clinical Report,.............................................  34
        Second do.    do................................................ 150
        Third   do.    do................................................ 314

Section Fifth.—Symptoms referable to the djgestive  system.  Appetite.  Thirst.
    Tongue.   Sordes.   Parotitis.   Nausea aud  vomiting.   Alvine dejections.
    Tympanites.  Tenderness of Abdomen.   Gurgling.
        First Clinical Report,.............................................  60
        Second do.    do................................................ 164
        Third   do.    do............,...................................315

Section Sixth.—Cutaneous Eruptions.
        First Clinical Report,.............................................  87
        Second do.    do................................................ 181
        Third   do.    do................................................ 319

Section Seventh.—Symptoms referable to the respiratory apparatus.  Cough.
    Expectoration.  Pain in chest.  Pneumonitis.  Aberration of respiratory move-
    ment  Epistaxis.  Singultus.
        First Clinical Report,.............................................  91
        Second do.    do................................................ 184
        Third   do,    do................................................ 323

Section Eighth.—Symptoms referable to the circulation.   Pulse.  Capillary con-
    gestion.
        First Clinical Report,.............................................  90
        Second do.    do................................................ 209
        Third   do.    do................................................ 328

Section Ninth.—Symptoms (exclusive of eruptions) referable to the skin.
        First Clinical Report,............................................. 107
        Second do.    do................................................207
        Third   do.    do................................................ 330

Section Tenth.—Symptoms referable to the genito-urinary system.
        First Clinical Report,............................................. 114
        Second do.    do................................................ 215
        Third   do.    do.........................................,......334

Section Eleventh.—Duration  of the disease.  Circumstances attending  Convales-
    cence.  Sequelae.  Mode of dying.   Fatality.
        First Clinical Report............................................. 125
        Second do.    do................................................ 216
        Third   do.    do................................................335 
                                  CONTENTS.                                ix

Section Twelfth.—Examinations after death.
         First Clinical Report.............................................. 127
         Second do.    do................................................230
         Third   do.    do................................................ 339

Section Thirteenth.—Treatment.
         Third  Clinical Report,............................................ 345

Section Fourteenth.—Cases of Doubtful type.
         Third Clinical Report,............................................ 352
                         SUPPLEMENTARY.

Summary of symptoms distinctive of Typhoid and Typhus Fever,..............23T
Identity of Typhus, and Typhoid Fever,.................................... 239
Diagnosis differential of Typhoid, and Typhus Fever,.........................249
Discrimination of Continued Fever from other affections,.......................254
Summary of Characters distinguishing Remittent  from Typhoid Fever,..........255<
Discrimination of Typhus and Typhoid Fever from  Encephalitis,...............258
    do.               do.               do.       Pneumonitis,...............258.
    do.               do.               do.       Enteritis,..................260
The Management of Continued Fever,.......................................261
Morbid appearance after death (exclusive of intestinal lesions) distinctive of Typhus
     and Typhoid Fever,.................................................. 359
On Relapsing Fever,......................................................364
The Transportation, and Diffusion, by Contagion,  of Typhoid Fever, exemplified in
     its occurrence at North Boston, Erie Co., N. Y............................. 375
                                  ERRATA.

  The reader is requested to make the following corrections:—
  Page 86, seventh line from  the top of the page, for the first
the line, read nine; and for the second ten read two.
  Page 129, last line on the page, for 203, read 38. 
 
       CLINICAL   REPORT
                         ON

CONTINUED    FEYER,

                   BASED ON AN
       ANALYSIS OP FIFTY-TWO  CASES.
  Having preserved histories of a considerable number of cases of Conti-
nued Fever, I propose to analyze them, and report the results.
  The first step in the analytical investigation, is to separate and classify
all the important  particulars embraced in the histories of the  cases that
have been collected.  This has been already done.  All the  important
circumstances occurring in the progress of every case (so far as recorded)
have been selected and  distributed in appropriate divisions.   The labor
which even this has required, can  be best appreciated by those who are
practically conversant with such  tasks.  In order  to collocate the facts
in the classes  to  which they belong, it was necessary that the  exami-
nation of the history of each case should be repeated from twenty to thirty
times.  Multiplying the whole number of cases by the number of perusals
of each case, will afford some idea of the tediousness of the process.
  This is but  a  preliminary stage of the analysis.  To develop useful
results, the details thus brought into juxtaposition must be farther investi-
gated.  How shall this be done ? in other words, how are these classified
facts to be interrogated?  Some may possess interest and value in them- 
10                  REPORT ON CONTINUED FEVER.

selves—isolated from the others—but, for the most part, it is by enumera-
tion and comparison that the fruits of the analysis are to be acquired.   It
will be an object to determine,  whenever practicable, the numerical  pro-
portions in which the different traits, symptoms, etc., belonging to the gene-
ral  history of the disease, respectively occur.  That is to say, with regard
to each of these particulars, in  how many of  the  whole number of cases
analyzed is it found to be present.  This result is obtained  by the simple
process of counting.  In this way is ascertained the numerical ratio which
each bears to  the  whole number of  cases, and, by comparison  with ea^h
Other, the mutual relations of all of them in  this respect.   By such enume-
rations, sufficiently often repeated, are  developed the laws of a  disease in
so far as concerns the relative frequency of the production of the various
particulars which  compose its  natural history.  And the  knowledge of
these  laws  has other  advantages  than merely the gratification of a
taste  for statistics.  If certain  events, or  symptoms, be  proved  to be
to be constantly associated  with a disease, and the same events, or  symp-
toms, be proved not  to be present, with any degree of constancy, in  other
diseases, it is a logical  inference, that some very intimate  connection sub-
sists between the events, or symptoms, and  the disease.  This is an impor-
tant result of numerical analysis, notwithstanding we  are not able to pene-
trate farther by this  method of investigation, and explain the nature of the
bonds which bind these events, or symptoms,  to the  disease.  The  know-
ledge of the existence of such connections is certainly important as a point
of departure for other investigations instituted with a hope of penetrating
deeper into the mysteries of pathology.   In like manner, events which are
proved  by enumeration to be not constant, but more or less  frequent in
their occurrence, may be considered  as  proving contingent relations to the
disease in proportion to their frequency, or they may be proved to  be purely
accidental;  and thus may  be determined, not  only what  particulars  intrin-
sically belong  to the disease, but the relative degrees of relationship which
other particulars sustain to it, and  that certain events are to be excluded
as having no  real connection with  the disease  whatever.  This kind of
knowledge, moreover, has  an  important bearing on diagnosis,  for, in  pro-
portion as an event or symptom  is constant,  or more or less frequent, is its
diagnostic value to be estimated, provided, always, that it  does not occur,
or  is  far less  frequent in  its occurrence,  in other  diseases.  Numerical
analysis, therefore, tends to establish the relative importance  of the several
Bymptoms of disease as diagnostic criteria of the presence of that disease. 
REPORT ON CONTINUED  FEVER.
11
To follow out the trains of inquiry to which the  foregoing considerations
lead, would be to engage in discussions respecting the resources and limi-
tations of the  " numerical system," foreign to my present purpose.
   Another  mode of  interrogating the  facts contained in a collection of
recorded cases of disease, is to compare the different cases with  each other
as respects associated  symptoms.   We find, for example, in a  greater or
less number of cases, a certain symptom; now, in the  cases which present
this symptom, do  we always  find certain other symptoms associated,  and
in the cases not presenting the  symptom,  are the associated  symptoms
absent ?   If  analytical examination establishes  any such relations,  they
involve, as a  logical  inference,  some dependent connection between the
symptoms thus associated  in  different  cases,  although  the problem  still
remains to be solved, which of the symptoms are causes, and which effects,
or whether all may not be alike effects of an unobserved, or inappreciable
cause.
   Again, the cases may be divided into several groups,  and comparisons
instituted  between the groups, in order to ascertain what phenomena, or
facts, belong  to one or more  groups,  which do not belong to  the otheia
We may  thus be led to  esta': fish  relations between  the distinctive features
upon which the division into  groups was based, and  other  circumstances
less obvious  to observation,  which the  ana'ysis and comparison reveal.
 Thus, we may  separate fatal  cases from those not fatal,  and if we should
 chance to find in all the fatal  cases certain characters which are  not present
 in those cases which are not fatal, it would be  a fair  presumption, to say
 the least,  that some connection existed between these characters and the
 fatal issue  ; at all events, knowledge of these characters would  have an
 important practical bearing on the prognosis.
    These few rema ks are offered, by way of introduction, simply to suggest
 some of the leading objects to be kept in view in an analytical study of the
 data embraced in the records of  clinical observations, foregoing discussions
 respecting the  nature and scope of the logical principles involved in the
 application of what is known as the numerical system to investigations of
 disease.   The  litter is an highly interesting and important subject, but it
 is altogether too profound and  extensive  to  be treated in an incidental
 connection.  The  value of this  method of investigating medical truth is
 doubtless as much exaggerated by some, as it is underrated by many.  In
 general terms, its advantages may be said to consist, not only in the de-
 velopment of a much greater number of  results, but in  rendering medical
 observation  and experience  vastly more  precise and accurate.  But it is 
12
REPORT  ON CONTINUED FEVER.
 hardly less desirable to  understand its  limitations, than to appreciate its
 advantages; and, in general terms, it furnishes dala  for  delineating with
 completeness and correctness  the  natural  history of  diseases, it  discloses
 relations between the events, or symptoms, of disease, it leads to a know-
 ledge of laws regulating the succession  of  morbid phenomena; but it fails
 to penetrate the  hidden springs upon which the observable characters of
 disease are dependent, it cannot unfold  the links  connecting those pheno-
 mena which are  found to sustain  relations with each other, and it  leaves
 unexplained the laws the existence of which it declares.
   To be satisfied of  the very great utility and importance of recording
 cases, and subjecting them to analytical  examination, it is only necessary to
 compare the general  impressions  which are formed while cases are under
 observation, with the results obtained,  subsequently,  by enumeration and
 comparison.  These results are frequently as unexpected to the analysf, as
 toothers:  they often  conflict directly with the anticipations derived from
 observing and recording the  cases  while in  progress.  This  fact points to
 the great source of error in the medical  experience of  those whose induc-
 tions  are based on facts retained in the memory alone.   It is  exceedingly
 difficult, as  the phenomena of disease pass under observation, for the mind
 to resist becoming committed to generalizations  which  are often immature
 and erroneous; and when the mind is thus committed, it is equally difficult
 to continue observations  fairly and impartially.  Every person  who studies
 the operations of mind  in  others, or  who  candidly  reviews  his own
 intellectual  experience, must be convinced of the truth of this  remark.
 How  common is it to hear assertions made  in the most  positive manner,
 that in all cases of a particular disease, certain things are so and so—asser-
 tions made to sustain some peculiar views of pathology, diagnosis, or thera-
 peutics; when a few observations by one who is unbiassed, or skeptical as
 to the correctness of the  assertions, suffice for their disapproval.   It does
 by no means follow that such rash declarations denote either dishonesty or
 stupidity; but they show that the mind,  without vigilant watching, imposes
 upon  itself.   The prime error is in arriving at conclusions too hastily, with-
 out sufficient data, or  proper  investigation.   So  soon as this false step is
 taken, the mind is constantly seeking  for  evidence to sustain its  position.
 Facts incompatible with such a position are not only overlooked, or excluded
from the memory, but, sometimes, by an  obliquity, and almost perverseness
of judgment, even appear to sustain  the false  views  which are pertina-
ciously cherished.  This, it will be admitted, is a highly colored representa-
tion, but it is not  a fancy sketch; exemplars are not so rare as not to be 
REPORT  ON CONTINUED FEVER.
13
occasionally met  with;  of a lesser degree of the self-deception described,
illustrations are abundant, and there are few so fortunate as to escape alto-
gether the influences, alike imperceptible and  untoward, of erroneous pre-
conceptions,   upon  the  powers  both  of  observation and  ratiocination.
Hence originate the " false facts" with which medicine abounds,  and that
experience which is worse than valueless.  The practice of recording obser-
vations, and submitting  them  to  careful analysis, is  of inestimable value,
not only in the greater  number, and better character of the  results  deve-
loped, but in cultivating a habit of mind which precludes error by with-
holding  judgments, and accepting only as  truth  results  elicited  by ade-
quate, trustworthy investigations.  The whole philosophy of this subject
is admirably embodied in the sentiment of Rousseau, selected by Louis as
the motto for his work on Fever:—" Je sais que la verite est dans les
choses, et non dans mon esprit que les juge, et que moins je mets du mien
dans les jugemenls que fen porte, plus je suis  sur d\ip>procher  de la
verite."
   After the incomparable work of Louis giving the results of his researches
on Continued Fever compared   with other  acute  diseases,  and subse
quent reports by several distinguished observers, it may perhaps appear a
 gratuitous, if not a presumptuous undertaking to  make choice of cases of
this affection, as  a subject  for analytical study.  The elucidation, however,
 which the disease has  already received, renders  it  more  interesting,  and
 scarcely  less important,  to prosecute continued researches.   Were  the
 results to be the same  as those previously obtained, the labor would by no
 means be uselessly  bestowed, since to confirm  truth, is often very  desirable,
 although  a humbler  attainment than  the discovery of  it.   But other
 advantages are  secured by a series of analyses  of cases of  the same affec-
 tion occurring at different  periods and places, and under a variety of cir-
 cumstances.  If the results are not uniform, the variations are to be  attrib-
 uted to the disturbing or  modifying  influences  incident to  time, situation,
 and  other circumstances ; and we  may thus learn what belongs to the
 disease per se, and what is due to extrinsic causes.   It  is at once obvious
 that this kind of knowledge  is  highly desirable.  For a similar  reason it
 were probably better that a number of cases occurring during a succession
 of years should  be subdivided—those occurring within the space of one or
 two successive years being grouped together, and each group analyzed sepa-
 rately.   In view of this consideration, I have deemed it best  to analyze the
 cases I  have already   collected, without  waiting longer  to increase  the
 number. 
14                  REPORT ON CONTINUED  FEVER.
   Of the fifty two cases which have furnished the data for the examination
 upon which  I wi 1 now enter, fourteen occcurred in private  practice, and
 the remainder, thirty-eight, were observed  at the Buffalo Hospital of the
 Sisters of Charity.   I shall consider these as forming two distinct groups.
 The cases from  private practice are recorded less  fully than those at the
 Hospital.  They run through a longer period of time, the first case being
 observed in December, 1845, and the last in  June,  18o0—a  space of five
 years.   The hospital cases were all observed between August, 1848, and
 March 1850—a space of eighteen months.   The circumstances surrounding
 the patients  in private practice, would, of course,  be expected  to differ
 in different cases.  On the other hand,  at  the hospital,  the  patients  were
 similarly situated.   Inasmuch as the hygienic condition incident to hospi-
 tals, as well  as private families, tend to modify, more  or less, the symp-
 toms and progress of a disease, frequently preventing a fair exemplification
 of its natural history, itl should  be premised that the Hospital  of the
 Sisters of Charity presents in a'l respects a most favorable combination of
 circumstances for the relief of the sick.   The  wards, during the time these
 cases occurred,  were  not crowded, and were extremely well ventilated.
 The attendance and nursing could hardly be improved, and was much bet-
 ter suited to  the welfare of patients, than in the private houses even of
 those who can command all the  comforts of life.   The personal attentions
 of family and friends, in severe  illness, are often unskillful and injudicious'
 and money cannot purchase the discreet and  faithful offices of a Sister of
 Charity/
   The records of the  cases in private practice were not made at the  time
 of the daily visits ;  sometimes no record was  made  for several days,  and,
 in a  few instances,  the details were noted from memory as the disease was
 about to terminate.
   The histories of  the cases in the hospital  consists of daily records, (with
 occasional exceptions of a day or two,) made by  myself  at the bedside, at
 he diurnal visit, which was usually in the morning.   I can therefore vouch
 that they are as accurate as I  had the ability to make them.    I must  con-
 fess, however, that  while  arranging the facts for  examination, I had occa-
 sion to regret that the records had not contained some particulars of  which
 frequently no mention is made, either positive'y or negativelv.   In  this
respect the histories are far less complete then I could wish  them  to be-
This,  however, does not affect  the accuracy  of  the analysis  in so far a
the facts are recorded.
  The  phrase Continued Fever  is used, generally, in a genei ic sense,  em- 
REPORT ON  CONTINUED FEVER.
19
bracing two  or more species of febrile disease.   The distinctions between
what have been  termed typhus, and typhoid fevers,  have,  of late years
occasioned much  discussion by medical  writers, and practitioners are not
agreed whether to regard the different types thus distinguished, as really
and essentially distinct forms of fever, or not, some contending  that thej
are different febrile  affections,  others that  they are essentially  identical.
The views which the writer has hitherto entertained on this point are, that
cases of continued fever admit  of being nosologically  discriminated after
this division, but that there do not exist sufficient grounds for regarding the
two forms of disease as radically and essentially distinct ; in other words,
that continued fever is one disease, and that the. divisions which  it  may be
convenient to make,  are based on differences which are nosological, rather
than pathological, the uniformity of  which, even for nosological  purposes,
not being perfectly reliable.   The distinctions between Typhus and Typhoid
fever, and the subject of diagnosis,  will come up more appropriately here-
 after.  The facts contained in the  cases under examination will be studied
with reference to the points just mentioned, and, for  this end, it becomes
necessary to discriminate  beforehand, between  those cases which have
 claims to be considered  as cases of  Typhus, and those which are properly
 cases of  Typhoid fever.  Applying the rules of discrimination as laid down
 by those writers who maintain that the two forms of disease are  essentially
 distinct, and rejecting as indeterminate all cases in which there  exists any
 room for doubt  as to the type,  the result is as follows : of the fourteen
 cases in private practice twelve are distinctly cases of   Typhoid fever ; one
 wss a  case of  Typhus, and one  is doubtful  from absence of sufficient data
 in the record.  Of the thirty-eight hospital cases, eighteen  were  cases  of
 Typhoid, and twelve were cases  of  Typhus fever ;  eight admitted  of some
 doubt.
    Another basis  for  a  division of cases in  order to institute comparison  of
 the  facts belonging  in each, is the issue of  the disease.   Of the fourteen
 cases in private  practice four were fatal.   Of the thirty-eight  in hospital
 practice thirty-one recovered.
    Of the  fatal  cases in private practice,  in  two the  disease  was of the
  Typhoid type, in one the type was considered doubtful, and the only case of
  Typhus in  this group proved fatal.
    Of  the fatal  cases in hospital, two were of the  Typhus type, four were
 of the  Typhoid  type, and in one the case was doubtful.
    The ratio of  mortality between the  hospital  cases, and those in private 
REPORT ON CONTINUED  FEVER.
practice will be observed ; the former being about 13£, and the latter 22|
per  cent, showing, in so far as a comparison of  these two groups of  cases
go, a superiority in the hospital management of the disease.
   Something  should, perhaps, be said concerning the  correctness of the
diagnosis in all the cases set down as cases of  continued fever.   In places
where both remittent and continued fevers prevail, practitioners sometimes
confound the two, and unless the reader  can have faith to believe that this,
or any other error  of diagnosis has been avoided in the present collection
of cases, he can, of course, attach little or no importance to the  results of
the  analysis.  It is obviously difficult for the writer to furnish evidence of
his competency to discriminate, practically, the disease under consideration,
from other affections.  The  reader must estimate, as  he best may, the
grounds for reliability on this  score.  This assurance,  however, may  be
given, that the utmost care has been taken  to admit  into the  collection
those cases only which, in the writer's opinion, were undoubtedly cases of
continued fever, all recorded cases which seemed to him in  the least de-
gree doubtful, having been rejected.
   In proceeding now  to present the results which  may be developed by
the study of the cases under consideration, together  with such considera-
tions as, in connection therewith may be suggested, it will  be most con-
venient to follow  the  order pursued in the analytical  process already per-
formed, adoptmg  as many different  sections as there  are classes in which
the events, symptoms, etc. of all the cases have been distributed.
                            SECTION FIRST.
Age, Sex,  Occupation, Civil  Condition,  Nativity, Habits, Season,  Consti-
   tution and previous health of the  Patient,  Period of residence in this
   Country and in this City,  Duration of the disease before  coming under
   observation.
   Age.—The  ages of the private   patients are given  in  all but two cases,
i. e., in twelve cases.  Of these ten are cases of Typhoid fever.  The  max-
imum age of these cases is thirty-four, the minimum age, seventeen.  The
mean age is 23 7-10.   Of these ten cases, two proved fatal.   The ages in
these two cases were  21 and  34.  The only case of Typhus in  this group
of private cases proved fatal, the age being 25.   The  only  case indeter-
minate as to its being typhoid or typhus, proved  fatal,  the age being 40.
   In the hospital  cases, the  ages  are given in  all but  three  cases.  Of
seventeen cases of the typhoid type  in which  the  ages are  given, in one
case the age was 45;  in  one case  the age was  35; in one  case, 24.  In
the case of the youngest patient the age was  13.  In the other cases 13 
REPORT  ON CONTINUED FEVER.
17
in number, the patients  were between 17  and 24 years of age.  In  six
cases the age was precisely 20.  The mean age is 22 2-17.
   Of ten cases of typhus in which the ages are given, in one case the age
was 50.   In four cases the age was 20, which was  the minimum.  The
mean age is 26^-.
   Analysis of large collections of cases of typhoid fever by Louis, Chomel,
Jackson, and  others, have  established  the existence of certain laws as
respects age in this  disease.   The vast  majority  of cases occur between
the ages of 15 and  30.  Cases occurring after 40  are  extremely  rare,
although they  are occasionally met  with.   Typhus  fever, on  the  other
hand, evinces far less regard for age.
   The results given above, correspond very closely  with those obtained
from observations by the authors just  named, on a  larger scale.   In the
collection of hospital cases analyzed  by Dr. Jackson, of Boston, embracing
two hundred and  ninety-one cases, the average age was found to be  about
22£ years,  which, it will be perceived, is the same, with a slight fractional
difference, as in the analysis of  the hospital cases just made.
   The cases of Typhus in our collection exhibit a higher maximum,  and a
greater mean.   The latter, however, is less than it  would  seem  to have
been in the observations of others.   Prof. Jenner, of the University Col-
lege, London, in a late  report  on  this  subject, states that of forty-three
fatal cases of typhus, nearly one-third were more than fifty years of age.
—[Amer. Journal of Med. Sciences, No. for July, 1850.]
   It remains to compare the fatal cases with those in which recovery took
place, with respect  to age.  The observations of Louis go to  prove that'
the average age of those who  recover is  less  than of those who die with
typ: oid fever.
   Of sixteen cases of  Typhoid in which the ages are given, 4 proved fatal,
 and 12 recovered.  Among the fatal cases was the case presenting  the
 maximum of age (45), and also the case presenting the minimum age (13).
   The mean age  in the  cases that proved  fatal, is 24|.  The mean age in
 the cases in which recovery  took place is 21 8-12.
   Of eleven cases of Typhus, in which the ages are given, two only proved
 fatal.  Among the fatal cases was the case of the maximum age,  50,  and
 the mean age, is 35.  The mean age in the cases that recovered is 25 5-9.
    The above comparison refers to the hospital cases.
    In  the  group of  private  patients, of 8 cases of Typhoid, in which re-
 covery took place, the mean age is 22 6-8.   Of two fatal cases, the age in 
18
REPORT  ON CONTINUED FEVER.
one was 21, and in the other, 34, giving a mean of 27^.   In the only falal
case of typhus the age was 25.
   In so far as our cases afford results, then, they sustain the deduction of
Louis, that  the disease  is less likely to prove  fatal in  proportion  to  the
youth of patients.
   Sex.—In the cases of  Fever analyzed by Louis, and Jackson, by far  the
greater number were of the  male sex.   Some instances,  however,  are
mentioned by Dr.  Bartlett, in  his work on Fever,  of collections of a  large
number of cases in which the  number of females preponderated.
   In the cases which I have preserved, the  number of males very much
exceeds that of females.
   Of the fourteen private  patients, all but two were males.  Of the hos-
pital patients, the number of  males affected  distinctly with typhoid fever,
was 17; of females, 1.   The number of males affected  with typhus fever
was 10; of  females 2.  Of the cases in which the diagnosis was indeter-
minate, five were males and three females.
   The disparity in the hospital cases might  perhaps be accounted for by
the fact that a  larger number of males resort to such  institutions than
females.  This  explanation, however, will  not apply to cases in private
practice:  and, hence, in so  far as from the small -number of this group of
cases,  any inductions are admissible, the  inf-rence  is, that  females  are
much less likely to be attacked with continued fever than males.
   In  the  cases  analyzed  by  Di. Jackson, of Boston, the  average age of
females affected with fever was found to be somewhat higher than that of
males.  The number of female patients in my collection is too small for
comparison on this point.
   Occupation.—With reference to  the occupations of the  patients, no  re-
lations of the disease to any  particular kinds of employment  are devel-
oped.   Of the patients treated in  hospital, three were mariners, six  were
mechanics of different trades, fifteen were laborers, one  was a waiter, one
a  clerk, one a  porter, one  a  foreman in  a  steam mill, one  a  domestic,
(female),  one a chamber-maid, one a steamboat cook, and two were Sisters
of Charity.   Of the  cases in private practice, four were soldiers recently
enlisted, two were  students, one a physician, one a maker of patterns  for
castings, one a laborer, one a housewife, one a female without occupation,
one a male without any particular employment.
   Analysis of much larger collections of cases have failed to show the  ex-
istence of any tendency in  particular vocations to favor the development
of the disease.  That the hospital patients were all in what are generally 
                     REPORT  ON  CONTINUED FEVER.                  19

considered the humbler walks of life, will not be deemed singular, when it
is  considered  that it is for the relief of this class  thai the  institution is
chiefly designed.
   Civil  Condition.—Of the fourteen patients in private practice, one only
was married, a female 34 years of age.
   Of the  thirty-eight hospital patients, one  only was married, one  was a
widow and one a  widower.  This, however,  which  might at first  seem a
striking result, proves little or  nothing respecting any  causative influence
derived from the unmarried state, when it is considered that the average
age of the patients is between twenty-two and  twenty-six years, and  also
that, in so far as the  hospi'al cases are concerned, comparatively  few mar-
ried persons, with any disease, enter the Institution.
   Nativity.—Of  the patients  in private practice, eight were Americans,
three were Germans, one was an Irishman, one  an Englishman, and in one
case the nativity is not stated.
   Of the  Hospital cases, the  nativity of the patients with  typhoid, is  as
follows:   Americans, one; Irish, seven; Germans, ten.  Of the parents
with typhus as follows:   Americans, one;   Irish, eleven;  Germans, none.
Of  the  doubtful  cases  as regards  the type  of  the fever, as follows:
Americans, two;  Irish, five.
   I had doubted  whether it were worth while to take the trouble to ascer-
tain the nativities, but the result, in one point of view,  is certainly curious.
Of twelve patients affected with typhus,  all  but one were Irishmen.  The
reader is doubtless aware that Dr.  Lombard, of Geneva, Switzerland, and
others, have contended that true typhus is of Hibernian origin, and  that its
appearance in other countries is owing to its importation from Ireland.  The
result of the present analysis is n >t  given as sustaining this idea,  for the
recency of emigration is obviously involved, and with respect to  this point,
the facts have not yet been examined;  but the singularity of the  coinci-
dence, if it be nothing more, is worthy of note.
    Habits.—In the hospital cases, the records,  with very  few exceptions,
 are defective  in information respecting the habits of the patients.
    In eight of the cases in private practice, the  habits were good.  In four
 the habits were unknown.  In  one the attack had been preceded by dissi-
 pation, and in one the patient was not intemperate,  but irregular  and
 licentious.
    Season.—Observations  have appeared to show* that while the  typhus
 type of continued fever  is unaffected  by  season,  i.  e., liable  to  prevail
 equally  at anv portion  of the year, the typhoid type,  on  the other hand, 
20
REPORT ON CONTINUED FEVER.
manifests a predilection for the  autumnal  months, although it is by no
means restricted in its occurrence  to the latter.  In New  England, where
typhoid fever is the predominant febrile disease, it is commonly termed the
autumnal or fall  fever.  The dates of the cases under analysis, were as
follows:
   Private Cases—Typhoid.—1845, December, one case;  1846, January,
one case, October, two  cases;  1847, September  two  cases,  October, one
case;  1818,  August, two cases, September, one case; 1849, September,
one case; 1850, June,  one  case.   Typhus—1847,  November,  one case.
Thus eight out of  twelve  cases  of typhoid  fever occurred during the
months of September, October, November and December.
   Hospital  Cases—Typhus.—1848, August,  one case,  November, one
case; 1849, March, two cases, June, three cases, July, one case, August,
one case, October, one case;  1850, January one case, February  one case,
making 12.    Typhoid—1848, October, one case, November,  one  case
December, one  case;  1849,  March,  one case, May, one case,  June, one
case, July, one case, August, two cases, September, five cases, October, one
case, November, two cases, December,  one  case, making 18.
   Thus, nine out of eighteen cas.s of typhoid occurred during the months
of September,  October,  November, and  December, five  occurring  in the
month of September; while of the  twelve cases of typhus, only two oc-
curred during these months, one in October and one in November.
   After the month of December,  1849,  up to the time when my period of
service at the hospital ceased, which was April 1st, 1850, not a single case
of typhoid fever was received.  During  this period, two cases  of  typhus
are recorded, and  two cases in which the type is left indeterminate.
   The result of the ana ysis, therefore,  goes to sustain the correclness  of
the observations,  above  mentioned, respecting  the  relations of the two
types of  continued fever to  the seasons.
   Constitution and health at the time of  attack.—In every one of the cases
in private practice, the constitution of the  patient might  be pronounced
good, i. e., none were suffering under chronic disease, or general ill-health.
The same is believed to be true of the  hospital cases.  In many cases  it
is so stated in  the records,  but in the cases in which  this  statement does
not appear, it is a fair inference that, were it otherwise, the fact would be
recorded.  In no  case is it recorded that the patient possessed a  feeble or
broken constitution.   In so far as  my observations go, then, the conclusion
is, that pei sons not possessing good constitutions, are not apt to be affected
with continued fever. 
REPORT ON CONTINUED FEVER.
21
   The stale of health at the time of attach is known in all the cases occur-
ring in private practice.   In all but two cases it was good.  In one of the
excepted  cases  the patient had a short time before had Pertussis,  from
which, however, he had recovered; in the other case, the patient was re-
duced by lactation, and  was  laboring  under stomatitis materna.  In the
hospital cases, the health is stated to have been  good in seven cases of ty-
phoid, and four  cases of  typhus.   It is not stated to have been poor in any
case, and  in nearly all of the cases in which no mention is made of this
point, it may fairly be inferred that the health was  good, from the patients
having been arrested by the  disease while pursuing their customary avo-
cations, all of which would require for  their performance good health, and
from other circumstances of the history   Hence,  it seems proper to con-
clude that,  in so far  as  the present  collection of observations affects this
point, persons in good health are most apt to be attacked  with  continued
fever.
   By the state of health at the time of attack is  meant, here,  the condition
prior to the first developement of the prodromic symptoms of the disease.
The latter,  which by some are considered to constitute a stage of the dis-
ease, and by others  regarded as preliminary  to it, will form a  subject of
inquiry under another division.
   Period of residence in this  country, and in  this  city.—The  period  of
residence in the country, and town, where cases  of continued  fever are
observed, has important bearing upon several questions relating  to the eti-
ology of  the disease.  If a patient have recently  arrived  from  a foreign
 country,  it  becomes  a subject of inquiry in how far may the  production of
 the  disease be due to  circumstances  affecting him before his  arrival.
 Among the circumstances which may  be suspected of being involved in
 the origin of the disease in these cases, are endemic and epidemic influen-
 ces to which he may have been exposed  prior to his embarkation, the con-
 finement and  hardships of   the  voyage, contagion,  moral influence  of
 change of country, etc.
    Cases  in Private Practice.—One of the cases  was observed in a neigh-
 boring place, and is omitted.   Of the remaining thirteen  cases, eight had
 resided in this city for a  period less than  six months.   Of the  other five
 cases, one had resided in the   city about a year,  one  about two  years, and
 the remaining three had resided for a  longer period.   In four cases the
 patients  had recently emigrated  to  this country.  Among the latter is
 included the single case of Typhus in the group of private  cases.
    Hospital Cases.—Of the   Typhoid  cases the period  of residence is 
22                   REPORT ON CONTINUED  FEVER.

recorded in ten cases, and noth ng on this point stated in eight cases.  In
seven of the ten cases the patients had recently emigrated to this country.
In nine of the ten cases,  the patients had  recently come to  reside in this
city.  The periods in the cases respectively, as recorded, are  as follows:—
six weeks in  the country, and  four weeks  in the  city; ten days in  the
country, and three days in the city; thirteen days in the country,  and  ten
in the city; eight weeks  in the city;  a few months in the  city; five weeks
in the city; three and a half months  in the country, and eight days in  the
city; recently  in the country; a year in the  country, and four months in
the city.
  In the single case in which the patient had not recently come to reside
in the city, the patient had been in the country fifteen months, and in  the
city twelve months.  This was the longest period of residence  in  any of
the Typhoid cases in which the  records contain information  on this point.
  Of the Typhus cases, the period of residence is stated in ten cases, and
the histories are defective on this point  in  two cases.   Of these ten,  the
patients had recently arrived  in this country and place, in eight cases.  Of
the two remaining cases, the  patient  in one case was a native, and perma-
nent resident; in the other case, the patient had  been a resident of the
city for ten years.   The periods in the eight cases respectively, as recorded,
are as  follows;—in  the country six months; five or six weeks in the coun-
try; in the country a month; just arrived in the country; in  the country a
week;  recently in the country,  and six weeks' in  the  city; twelve days in
the country,  and four  days in  the city; just arrived in  the country  and
city.
  Duration of the disease before coming under observation.—In nine of the
cases in private practice, the  disease  was observed from its commencement.
Of the remaining (5) cases, one came under observation on the fourth  day-
after the attack, two on the seventh  day, one on th^ fifth day, and one on
the tenth day.  Of the fatal cases, two came under observation at the com-
mencement of the disease, one  on the seventh day, and  one on the fifth
day.   Of the Hospital cases,  four are deficient in  information on this point.
Of the remaining thirty-four cases, five only came  under observation at the
commencement of the disease;  and by the commencement of the disease I
mean not to include the prodromic  symptoms,  which, of course, nearly
 always exist  for  a greater or  less period  before  application is made  for
medical aid, or the  relief of an hospital.  The duration  of the disease prior
to observation, varied fom two to twelve days; in the  greater  number of
cases,  the period was between four and eight days.   Before  coming to the 
                     REPORT  ON CONTINUED FEVER.                  23

hospital, some had  received no treatment,  others had been  attended by
regular Practitioners, and some by Empirics.
  The  only point of interest under this  head,  which  occurs  to me, is to
ascertain  if there seems to exist any connection  between  the duration of
the disease before coming to the hospital, and the fatal result.  Of the two
fatal cases of  Typhus, one came under observation on the fifth day, and one
on the fourth  day.   Of the four fatal  cases  of  Typhoid, one came under
observation on the  eighth day, one on the eleventh day, one on  the fifth day,
and one on the first day.  Of the  cases of  doubtful  type, the only fatal
case came under observation  on the eighth  day.  The  mean duration in
these cases is about six days, which is about the average duration in the
 cases which did not prove fatal.
                            SECTION  SECOND.
 The Access, its duration and symptoms.  Circumstances supposed to have
   been concerned in the production of the disease.
   By the term access I mean to designate  that period during which the
 disease appears to  be forming,  commencing  with  the first symptoms of
 disorder, and ending when the disease becomes fully developed.   By some
 this period is regarded as a stage of the disease, sometimes called the form-
 ing stage ; others regard it simply as presenting precursors, preceding and
 ushering in the disease, or the prodromic symptoms of the  disease, but not
 intrinsically belonging to it.   Without  stopping to  present arguments for
 either of these views, I  will  proceed to examine the cases under analysis
 with reference to  this period.  The  chief points of  inquiry which  possess
 interest  and  importance, relate  to the duration of the  access,  and to its
 symptomatology.
    Duration.—In  the twelve cases of  Typhoid fever occurring  in private
 practice, the  records are  deficient in information respecting the access in
 two cases.   In the remaining ten cases, without an exception, the period of
 access embraced several days; but in most of the cases the precise period
  is not stated.  The record in six- cases, simpl} states that it  extended over
  several days; in one c;ise, it is stated  four or five  days;  in one,  two or
  three  da>s;  in one, three or four days; and in one the patient had been in
  ill health for three weeks.
    In  the single case of Typhus in this group, the period of access was two
  days.
     The  indefiniteness of these records denotes a feature of the access of the
  disease which writers on the subject Have remaiked, viz., the difficulty  of 
24                  REPORT ON CONTINUED FEVER.

fixing,  with precision,  the precise  date of-its  commencement.   Patients
when asked respecting the time  when they first began to feel ill, generally
reply " several days," " three or  four days," etc., apparently not being able
themselves to decide on the  particular day when they ceased to feel well.
In such instances the symptoms come on gradually and imperceptibly.  On
this account it is not practicable  always to determine  the exact duration of
the access.
  Nor is it an  easy matter to  decide on the termination of the access.
What  denotes the commencement  (or the second stage) of the disease?
This question is not readily answered.   The symptoms of the access are
generally continued, increased  in degree, but  not changed  in character;
nor are any new  characters developed which may serve to indicate, with
certainty, the termination  of the  access.   My rule has  been to pronounce
the access passed, and the fever  established, when the patient is compelled
to take to his bed, i.  e., when he feels no longer able  to sit up.  This rule
is somewhat arbitrary, and is   by no  means perfectly accurate.   Some
patients, from choice or necessity, will keep about much longer than others.
Much will depend on differences in  mental  disposition as  respects appre-
hension, prudence, etc., with regard  to this point.   But, with these objec-
tions, I know  of no  single event, or group of symptoms, more available,
and in the majority of cases, more correct than this.
   In hospital  cases  it is  much  more difficult  to ascertain the duration of
the access than in private practice, patients frequently being received after
the disease is more or less advanced, when they are  unable to give a cor-
rect account of its origin and progress.  On examining the histories I have
collected, I find them very deficient  in information on this subject.   Of the
eighteen cases of Typhoid, the information is very indefinite in twelve cases;
in four cases, the disease appeared to have come  on with a sudden attack.
Of the remaining two cases, in one the access was of several days' duration,
and in the other, four days.  It is to be presumed  that in all instances in
which it could be ascertained that the disease came on suddenly, the fact
was recorded;  and that when the records are silent on this point, the dis-
ease came on, as is usual, with an access of several days' duration.
   Of the twelve cases of  Typhus, the records  are defective  in five  cases;
the attack was sudden in one case, the access was "several days" in dura-
 tion in four cases, five days in  one  case,  and seven days  in one case.   Of
the eight cases of doubtful tpye, the attack was sudden  in one case; the
 access was "several days" in duration  in three cases, two or three days in 
REPORT  ON CONTINUED FEVER.                  25
one case, and in one case the patient had been ill three weeks, (symptoms
not ascertained,) and had recovered sufficiently to go to work, when he was
suddenly attacked.   In two cases, the records contain no information.
   Of the three Typhoid cases proving fatal, the disease came on suddenly
in one,  and the duration of the access  was not ascertained in the remain-
ing two cases.
   Of the fatal cases  of Typhus, the  attack was  sudden in one, and the
duration of the access unknown in the other case.
   In the fatal case among those of doubtful type, the access was of sever-
al days duration.
   The only conclusion to be drawn from the foregoing rather unsatisfactory
analysis, is, that generally the access  extends over  several days, but that
the attack, in a small proportion of cases is sudden—a conclusion according
with general experience.
   The  data do not warrant a comparison of the  two types in  order to as-
certain in which  is the  disease most likely  to commence  suddenly, and in
 which the average duration of the  access is longest ; nor is the comparison
of the  fatal and not fatal cases, in these  respects, of  any value.
    Symptoms of  the Access.— The  records of the cases are far from being
 comprehensive as respects the symptomatology of the access.   This is, in
 part, because sufficient pains were not taken in noting the symptoms,  and,
 in part, because in a large  proportion  of cases, (more especially those in
 hospital,) it is difficult, and, indeed, in many instances impossible to obtain a
 full account of the history prior to  the patients coming under  observation.
 In the cases in which the history embraces  some mention of the symptoms
 of the access, generally the circumstances only which are  striking, or occa-
 sional  in their occurrence, are noted, those being omitted which are con-
 stant or quite common.  I do not, therefore, deem it worth while to count
 the number of  times each particular symptom is mentioned, with a view to
 determine  the relative ratio of its occurrence, but I will  simply give a list
 of the symptoms,  with  brief comments.  They are  as follows :
    Cephalalgia,  a frequent symptom in the  cases of both  Typhoid and
  Typhus ;  anorexia, an almost constant symptom; chills, in a few cases  with
  nLrsmorerarely.oftener^^^
 pain in loins, not so frequent, or prominent symptom as the last ;  sense of
 debility ; lassitude;  cough in three cases of Typhoid, in no case of Typhus
  complicated with soreness in the chest  in one case,  and with pains beneah
  the sternum in one case ; Diarrhea, in one case of Typhus, (a fatal cas*
  and in four cases of Typhoid ; nausea, and in three cases vomiting.  Of
                  C 
 26                  REPORT ON  CONTINUED  FEVER.

 the three fatal cases of Typhoid, the, following are the symptoms of the
 access noted, which are more or less peculiar to these cases ;  in one case
 delirium at night;  and in one case tremulousness in the muscles of the face
 as in mental agitation; in one case vomiting and diarrhoea.
   Of the three fatal  cases  of  Typhus, in two  the symptoms  of  the  ac-
 cess were not noted, and in the remaining case the symptoms were, cough,
 headach, pains  beneath  sternum,  anorexia, moderate thirst, vomiting and
 diarrhoea.
   Circumstances supposed to have been concerned in the production of the
 disease:
   In obtaining  the previous  history of cases  coming  under observation
 pains were not taken  to inquire  concerning the circumstances which might
 seem to stand to the disease in  some causative relation.  In the  majority
 of cases nothing is recorded  on this subject.   Occasionally, however, the
 patients themselves mentioned circumstances to which they attributed their
 illness.   The instances of this kind, and the supposed causes, and the type
 of the disease, are as follows :
   Excesses of dissipation, continued for  several weeks, to which the patient
 had previously been unaccustomed.  (Typhoid.)
  A catarrh, or mild bronchitis, accompanied by cough and soreness in
 chest, in two cases.  (Typhoid.)
   Bathing in cold  water.   (Typhoid.)
  Exposure to cold and wet on the day prior to the attack, the  patient be-
 coming much chilled.   (Typhus.)
  Drinking cold water when heated.  (Typhoid.)
  Falling into the canal, and working all day in wet clothing, the patient
 being obliged to take to his bed on the  following day.   (Typhoid.)
  Several of the patients thought their illness came from " taking cold," but
 without their having had any symptoms which constitute what is called a
 " cold,"  and  the  attack  not succeeded  any notable   exposure.   Many
 evidently referred their illness to cold under the common impression that
 most diseases thus originate.
  Of those who had recently arrived in  this country, the inquiry was gen-
 erally  made, whether sickness prevailed on ship-board  ;  in two instances
 only was it ascertained that this was the fact.   Sometimes  the answers to
 the inquiry were unsatisfactory,  but in  several instances the patients were
certain that no febrile disease existed during the passage.
  In the great maj ority of the cases, no cause for the disease is assigned.
In the few instances given in which causes were  specified, it  will not, of 
REPORT ON CONTINUED  FEVER.                  27
course,  be supposed, from  their being  embraced  in their histories, that
much importance is attached to them.  It is not probable that the circum-
stances  mentioned by the patients  as causes, really were so,  or, at most,
they are only to be regarded, as possibly, exciting causes.   And so far as my
observations go, continued fever frequently, if not generally, occurs without
being preceded by  any events which, even in  the estimation of patients,
stand to the disease in the  relation  of cause;  and, hence, it is a fair pre-
sumption  in those instances  in  which an  attack follows any of the common
causes of disease, that their agency, if they have any, is of a subordinate
kind.
   In three cases facts connected with the development of the disease seem
to have a bearing upon the question of contagion.  One of the cases refer-
red  to,  occurred in private practice.  Twenty days before the development
of the disease, a brother of the patient  arrived in the city on a canal boat,
and was transferred, first to a  hotel, and, two days afterward, to the hospi-
tal.   He  was attended by me  both at the hotel and hospital, but a record
of  the  case was  not made.  The character of his disease was not deter-
mined until after his removal  to the hospital, when it proved to  be a case
of  Typhoid fever,  with the  characteristic eruption, etc.   While  at the
hotel the two  brothers occupied together a small  bed room,  and the then
well brother, not only remained during the night, but officiated as  an attend-
ant throughout the  day.   The type of the disease, developed twenty days
afterward, was typhoid  ; the case was very mild, and unusually short in its
duration,  terminating, with a critical perspiration, on the fifth day.  A  few
rose spots were observed on the chest and abdomen.   In view of the cir-
cumstances just mentioned, it seemed fair to suspect that the disease was
communicated from one brother to the other.
   In the  other two  cases in which a contagious principle seemed to be in-
volved, the  patients were Sisters of Charity at the  hospital.  To the two
Sisters  who had fever, had been  assigned the care of all the fever cases,
(with the exception of  three cases) during the preceding winter,  up to the
time of their illness.  They, alone of all the inmates of  the house, became
affected with fever.   The first  that became affected with fever, (sister H.)
was attacked in February.  She was attacked  early in Lent, and  had con-
formed to the rules of abstinence prescribed  by the  Catholic Church for
this season, continuing her  laborious duties as before.  This is mentioned
as a circumstance to which perhaps, something is due in accounting for the
development of the disease at that  time.  The disease was mild, attended
with some delirium, no abdominal symptoms,  without  an eruption, termi- 
28
REPORT ON CONTINUED FEVER.
 nating  in convalescence on the ninth day.   The case is included among
 those of doubtful type.
   The  second (sister N.) was attacked about a month afterward, in March,
 1850.  Her duties, in consequence  of the illness of sister  H., had been
 for the previous four weeks much increased.   This case was milder than
 the preeeding, and shorter in duration.   It  was unattended by abdominal
 symptoms, and an eruption.   It is also included among the cases of doubt-
ful type.
   That thus the two persons who were especially brought into close and
 continued proximity to the  fever patients, should have  contracted fever,  no
 other case of fever being generated within the Institution, certainly can  be
 less rationally explained by the  law of probabilities,  than by the supposition
 of contagion.
   Assuming that these instances  do  exemplify the operation of  a conta-
 gious principle, the facts accord with the views now generally entertained
 respecting the communicability  of  Continued Fever, viz., that the disease
 may be diffused by contagion, which differs in intensity at  different  times
 and places, but that generally the  disease  is  not  developed  except  after
 long continued exposure to the contagious miasm, or under circumstances
 in which the miasm is greatly  concentrated, and, even then, cooperating
 causes seem often  to be required to determine the attack.
   It is supposed by those who recognize Typhoid and  Typhus as distinct
 types of Continued Fever,  that the  latter is either exclusively, or  much
 more  liable to be communicated than the former.   The first of the instan-
 ces just stated, assuming the supposition of contagion to be correct, would
 establish the communicability of Typhoid.   The two latter instances cannot
 be considered to have  any bearing on this  point, inasmuch as the patients
 had been brought  into  contact with both types of the disease.
                            SECTION  THIRD.
   Symptoms referable  to the general aspect; Expression of Countenance;
 Decubitus.—Characteristic changes wrought in the physiognomy, constitute
 an interesting branch  of the symptomatic history of a  disease.  Such
 changes may involve various morbid effects.   The physiognomy  in health
 consists of  several elements,  the more  important of which are  the com-
 plexion, the facial  muscles, and  the eye.  These elements, singly or col-
 lectively, being more or less modified,  the  general aspect,  and  the  ex-
 pression of countenance will be  correspondingly altered.
   In Continued Fever, some changes in physiognomy almost always occur; 
REPORT ON  CONTINUED FEVER.
29
the changes, although  not uniform,  either in kind or degree, in some in-
stances are striking, and in a measure distinctive.
   Under the  heading of this section, in  the preliminary  analysis, I have
arranged whatever is recorded in the cases under examination.  In several
of the histories nothing is stated relative to this point.  In these instan-
ces  here, as  with regard to other  points, the  inference  is, that nothing
unusual, or striking, was  observed;  but  there probably  existed more or
less of that dullness or listlessness  of expression, which is very rarely, if
ever, entirely absent.
   Directing inquiries to the elements of  the  physiognomy separately, the
complexion comes first in order.  In a  large  proportion of the  cases, the
complexion was altered, the face being reddened, sometimes of a dusky hue,
and occasionally  slightly livid.   These  changes  were evidently due to
capillary congestion.  They  were always more marked in  the cheeks, than
elsewhere,  and sometimes were chiefly observable  in that  situation.   This
state of  the capillary vessels, as will be perceived when we come to speak
of the symptoms referable to the skin, in  many cases  extended, more or
less, over the entire  surface of the  body, but in some instances it was ex-
hibited on the face when  it was not  on any  other part of the external teg-
ument.   It was  always exhibited in the face, if present in  other portions
of the external surface.
   I cannot suppose this symptom to have been peculiar to the  cases that
I  have observed, and hence  I  am at a loss to  understand why it has not
attracted more notice than it appears to  have done with clinical observers,
more especially since, in connection with the humoral pathology of fever, it
would seem to deserve consideration.*
   The redness of the  face resembled  closely  the  appearance which the
surface presents after exposure to cold, the explanation probably being the
same in either instance, viz: retarded circulation of the blood in the capil-
lary  vessels.  On pressure  with the  finger the  redness  disappears, and
returns  after the pressure is removed.  The redness returned less quickly
in proportion to its duskiness or lividity,  showing that the color is an indi-
  * I do not mean to be understood by this remark that this symptom has escaped ob-
servation, but only that, so far as my knowledge extends, it has received less nonce
than would be expected from its presumed frequency, and pathological relations.  VVUh-
out having taken pains  to consult authorities on the pent, I "n»J* c.^/J"™?*
any writer  who has alluded  to it more distinctly thar,  Dr. GerharUf Phl'a^fia'
?See Graves and Gerhard's Clinical Medicine, page 733, and also Dr. ^6Jh^p9.^-
count of Epidemic Typhus Fever in Philadelphia in  1836, published in ^American
Journal of Medical Sciences.]  I do not discover that this symptom is embraced m the
researches of Louis. 
30                  REPORT  ON CONTINUED FEVER.
 cation of the degree in which the forces of the  circulation residing in  the
 capillary system are depressed.  This statement is made from  recollection,
 but is believed to be correct.
   The cases of the Typhus and  Typhoid types  present, on  comparison,
 differences as respects  this symptom.   It was present in a large proportion
 of the Typhus cases.   It is recorded  present in eleven of the twelve hos-
 pital cases of this type, no mention being made of it in the single remain-
 ing case.
   On the other hand, in the eighteen Typhoid cases it is recorded present
 in ten.  In some  of the remaining seven cases, its absence being stated,
 and in others  no mention  made either of  its absence or presence.  In
 none of the cases occurring in private practice is this symptom mentioned.
   The two groups of cases differed also as to the hue of redness.  In the
 Typhus group  the  hue was dingy or dusky, and in one  case  distinctly
 livid.  This is noted in five of the eleven cases.   In  the  Typhoid group,
 on the contrary, in one case only, is the redness recorded as dusky, and in
 one case somewhat dusky.  As a general remark, the intensity of redness
 was greater, in  a marked degree, in the cases of typhus than  in those of
 the typhoid type, in those instances in which  a dusky tint was not ap-
 parent.  In most of the cases of the latter  type, in which the  symptom
 was  present, it  is stated to have been either moderate or slight.  Such
 qualifications are  not given in any of  the cases of Typhus in which the
symptom was present.
  It may be  suspected that the capillary congestion of the  face and
 surface generally, is  dependent on the  complication of pulmonarv disease,
in consequence  of  which, the  free transmission  of blood through  the
lungs is  prevented, and its aeration  compromised.   With reference to
this  point,  I have compared the pulmonary symptoms with  the symp-
tom  now under consideration, in all  the cases, and find  that  this con-
nection does not  uniformly exist.    Several  of the cases in  which the
 congestive  redness  and dusky tint of the face  were marked, presented
pneumonic complication, denoted by cough and expectoration,  accelerated
respiration,  and, occasionally, the physical signs of  inflammation of the
lungs,  but these symptoms  and  signs were absent in  other cases in
which  the  appearances  of the face  were  the same;  and  the  luno-s
 evinced notable disorder and inflammation in cases in which no capillary
congestion is recorded.   To speak with  greater  exactness of the cases of
 Typhus,  congestive redness of the face, and marked disturbance of the 
REPORT ON CONTINUED  FEVER.
31
respiration, were associated in nine cases.  The congestive redness was
present without notable disturbed respiration in two cases.
   Of the cases of the Typhoid type, in but one case  was congestive red-
ness associated  with marked disorder of  the  respiratory  function, and in
two cases in which pneumonitis  existed,  that symptom is not recorded as
present.
   Thus it appears that the condition of  the capillary vessels is not to be
attributed to a  morbid condition of  the  lungs, or to  derangement of  the
functional activity  of the latter organs.    It is worthy  of note, however,
that in typhus, in a large proportion of cases, capillary congestion is asso-
ciated with pulmonary affection, while in typhoid, the absence  of such  a
connection would seem to be the  rule.   It is  highly  probable  that both
pulmonary disorder and  congestion of the surface, may  be effects of  the
same prior morbid condition.   It is not likely that capillary congestion in
Continued Fever is limited to the surface, when it is  present in  the latter
situation.  Internal parts, could  they be observed, might be  expected to
present similar appearances.  The lungs, as is well ascertained, are liable
to become congested during the  febrile  career, and the  form of pneumo-
 nitis which usually occurs as a complication of fever, called pseudo pneu-
 monitis, is usually supposed to result chiefly from passive engorgement  of
 these oro-ans.   This complication, however, is thought to be far more liable
 to occur in  typhus than  in typhoid fever.  The morbid condition then,
 whatever it  be, which determines the congestive redness in the skin, is the
 occasion of congestions elsewhere, which may, or may not be sufficient  in
 degree to  produce a sensible physical change in the congested organs,
 leading  to  marked disturbance of their functions.   In congestions,  per-
 vading&the capillary system of the general circulation, the lungs are espe-
 cially  prone to become  involved.   This  is probably the fact  in cases  of
 typhoid as well as typhus, in  which  congestive redness  of the  surface  is
 observed, but not in a degree  sufficient, generally, to lead to notable pul-
 monary complication, or  marked disorder of  the  respiration.   The latter
 consequences, it would be  expected, should  much  oitener be present  in
 typhus, inasmuch as in this type, not only is capillary congestion present m
 a much larger  proportion of cases,  but it exists in a much greater degree.
 This pathological  reasoning is submitted  as  rationally consistent with the
 facts which preceded and suggested it.
    And now the question can hardly fail to arise in the mind of the reader,
 upon  what  prior morbid condition does the state of capillary  congestion
 depend  Is it dependent on the impairment of the  nervo-muscular forces 
32
REPORT ON  CONTINUED FEVER.
 involved in the circulation of the blood, or is it incident to a morbid altera-
 tion in the blood itself?  This question opens the way for a  wide discus-
 sion, and  would embrace topics of a speculative character.   These I shall
 forego, as foreign to the historical plan of this memoir, and confine myself
 to the inquiry whether the cases in my collection can be made subservient
 to the development of any farther results having a bearing on this inquiry.
   If the congestion of the capillary vessels depends  merely  on the condi-
 tion of the forces carrying on the general circulation, it would be expected
 that in those cases in which the former  was marked, the pulse, the  ther-
 mometer  of the  forces presiding over the  movement of the blood  through
 the  heart and  arteries, would  denote a corresponding  embarrassment of
 the  latter.  A comparison of the pulse in  those  cases  in which capillary
 congestion was present, with those  cases in which it was absent, is there-
 fore desirable.   It is not important to enumerate with respect to this point,
 but  simply to ascertain if,  in my collection  of cases, the presence of capil-
 lary congestion is uniformly  associated with symptoms denoting a degree
 of depression of the forces carrying on the general circulation, greater than
 when capillary congestion is  not present.   The symptoms by which a de-
 pressed or embarrassed  circulation  is to be estimated, relate to the pulse
 and  the impulse of the heart.  As regards the  pulse, in proportion as it is
 frequent, feeble and irregular, the circulatory forces are to  be regarded as
 compromised hy the disease.
   An examination of the cases with reference  to this point, shows, that in
 much the larger proportion of cases in which capillary congestion is noted,
 the frequency and feebleness of the pulse were not greater than  in cases
 in which no capillary congestion was observed.   I counted twenty-two cases
 (including those of typhus, typhoid, and doubtful types,) in which capillary
 congestion was not associated with  unusual  disorder of the general circu-
 lation.  In a few cases (four) this  connection was  found to exist;  and in
 some cases (three) there existed notable  disturbance of the general circu-
 lation without congestive redness.   In view  of these  results, is it  not fair
 to arrive par voie d'exclusion  at the inference that the  source of the retar-
ded circulation in the  capillary system of vessels, in  continued fever  lies
in some morbid  condition  affecting these vessels, or   their contents  more
directly than through  the intervention of  the general  circulation ?  That
this morbid condition relates  to the blood itself, rather than to the vessels
many considerations might be adduced to render probable, but  this would
lead us beyond the circle of our facts.
  In  connection  with the pathological inquiries suggested by the symptom 
REPORT ON CONTINUED FEVER.
33
which has just been considered, it would be interesting and important to
determine, to what extent, and under what  circumstances, the symptom is
present in other diseases than continued fever.   This must be deferred for
want of sufficient data for such a  comparison.
   I proceed  now to consider elements of physiognomy other than the com-
plexion.   These are the facial muscles, and  the eye.
   The muscles of the face may present appearances representing the condi-
tion of the nervo-muscular forces generally, and they may also serve, to some
extent, as indices of the mental state of the  patient; in the latter  point of
view, however, they are generally to be taken in  connection with  the eye,
and both together constituting the expression of the countenance.
   As representing the nervo-muscular forces,  the appearances which  are
found in the records of my cases  are as follows: In two cases, dropping of
the lower jaw is mentioned as a striking symptom.   In both cases, the dis-
ease, judged  by other symptoms, exhibited great severity, and in one of
the cases it proved fatal.   In the  latter case, the symptom was  associated
with extreme prostration, and sliding down  in bed.   In the case that
remains,  the muscular prostration was very great.
    Tremulousness of the muscles of the face, as if  from mental emotions, was
another symptom  noted as present in two cases.   In one of these cases, the
disease proved fatal.  In this case the symptom  was much more marked,
and was associated  with   tremulousness of the hands, and, at ti mes, ina-
bility to protrude  the tongue.
   Abolition of the expression peculiar  to  the individual,  was,  of course,
present in the fatal cases, as it  generally is in different diseases, toward
the close of  life, entering into what is known as the Hippocratic counte-
nance.
   In speaking  of the  two  preceding  symptoms, i.  e., depression of the
lower jaw, and tremulousness of  the facial muscles, it is not to be under-
stood that they were  present  only during  the  last  moments, for, at  this
period, they are not unusual, but  during the career of the fever,  prior to
the last stage.
   The expression  in the greater number of the cases is described as dull,
heavy, stupid, vacant, terms expressing different degrees of the same gene-
ral  aspect.    This  physiognomical appearance, in  a large  proportion of
fever cases, is striking, and, in  a measure, pathognomonic.   There is a lack
of expression, a deficiency, not only of animation, but intelligence, a look of
stupidity and indifference, which,  to  the practised observer, often suffices 
34
REPORT ON  CONTINUED  FEVER.
to reveal, at a glance,  the character of the disease.   This general rule^
however,  is not  without  exceptions.   In one  of  my cases,  the habitual
expression was that of mirthfulness,  and in another case, the patient was
cheerful and generally smiling.  In another case,  the countenance during
the  whole career of  the fever wore  a  marked  lugubrious  expression.
These appearances  are  certainly  rare.  In the great  majority of cases,
patients  with continued  fever manifest  by the countenance, or in  other
ways, neither agreeable nor painful emotions.
   The only peculiarities which I have noted, not included in the foregoing
summary, are, an expression like that of a person confused, and attempting
to collect his ideas; an  expression of astonishment; an expression of wild-
ness, the latter being associated with active delirium.
   The decubitus is a point upon which the records of the case, for the most
part, are silent.   In  a few of the cases, it is stated that the patients lay on
the back, and generally, in connection, the  tendency to  slide downward in
bed is noticed.   These were  invariably cases of great severity of disease,
attended by extreme muscular prostration.  In other instances, it is  men-
tioned that patients voluntarily assumed a posture on the side, as an indi.
cation either of mildness in the disease, or abatement of its severity.  All
who have been accustomed to observe cases of this affection, have noticed
that, as a general remark, the patient lies on the back, in proportion to the
gravity of  the  disease, maintaining the same  position, seldom, or never
changing it of his own accord; and in cases of extreme  prostration, the
body yields to the force of gravitation, and, the head  and trunk  usually
being elevated,  tends  constantly to  slide  downward,  so that unless pre-
vented by a foot-board, or by the attentions of those around him, the feet
will be found sometimes to protrude beyond the bed.

                           SECTION FOURTH.
Symptoms referable to the  Nervous  System.  Mind.    Sleep.   Coma.
          Senses, and  Sensibility.   Muscular Contractions, etc.
   The nervous  system, in Continued Fever, is almost invariably,  if not
uniformly, the seat of some morbid phenomena.   So constantly is this the
case, that, as the reader need not be informed, a doctrine of the pathology
of the disease, which has  many supporters, if, indeed, it be  not still the
commonly accredited theory,  attributes the primary and essential  morbid
changes, constituting, par excellence,  the  disease, to this portion of the
organism.  The symptoms referable to  the  nervous system are various  in 
REPORT ON  CONTINUED FEVER.
35
kind, as well as in degree.   Some of  the  more  prominent of the several
sources of symptomatic events are enumerated in the heading to this Sec-
tion, and I will proceed to consider them under separate divisions.
   Mind.   Under this division, the subject of delirium first suggests itself.
In  much  the larger portion of instances, more  or less  delirium is mani-
fested during the febrile career, but cases are far  from exhibiting uniformity
with respect to this symptom.   The delirium is sometimes active, that is to
say, the patient requires to  be closely watched,  and, possibly, to be placed
under physical restraint.   Oftener it is passive in its character, denoted by
incoherent conversation, and muttering.   In the  lightest shades of  mental
aberration, the patient occasionally forgets where he is, and the  circum-
stances of his illness, but recovers himself  in a  few moments.  This tran-
sient aberration is most apt  to occur on first awakening from sleep.
   What is the relative frequency in occurrence of the two varieties of deli-
rium just mentioned, viz., active and passive delirium; and what relations
does each kind have to the different types of fever,  to  the issue of the dis-
ease, and to associated symptoms'?   These are  the inquiries which are to
direct  the analysis of the data before  us.
   Of the twelve  cases of Typhoid fever in private practice, the delirium
might be pronounced active in one case.   Passive delirium, more or less in
degree, existed in eight cases, and no  delirium was exhibited in three cases.
In the single case of Typhus in this group, the delirium was not active;  it
was active in the single case of doubtful type.
   In the  hospital cases, of the eighteen cases of Typhoid, active delirium
was present in five,  the delirium was passive in  nine, and four  cases exhi-
bited no delirium.
   Of  the twelve cases of Typhus, not one manifested active delirium, the
delirium was passive in eleven cases,  and no delirium was exhibited in one
case.
   Of the eight cases of doubtful type, passive delirium existed in seven, and
no delirium was apparent in one case.
   The above enumerations  show that the existence of more or less delirium
is the  rule in continued fever of either type, but  that exceptions to the rule
occur  in  both  types; that this rule obtains more generally iu Typhus than
in Typhoid, and it is chiefly in cases  of the latter type  that the delirium is
active in  its character.   Should the latter point be established by a suffi-
ciently large number of observations, it may sometimes be available for
diagnosis, as respects the two types, at a period  of the disease before other
distinctive features have become  developed. 
36
REPORT ON CONTINTED FEVER.
  In order that the above results may be  appreciated, the principles upon
which the distinction between passive and active delirium has been made,
requires some explanation.   As in every instance  in which  a division is
based chiefly on difference in degree, the  dividing  line is not easily fixed,
and must be determined by a rule somewhat arbitrary.  Between a slight
shade of aberration, and an  excess of activity of delirium, there is a wide
interval; but this is not the case at the point where the two extremes ap-
proximate ; in other  words,  it is difficult to  say precisely what amount of
delirium ceases to be passive, and becomes active.   The course I have pur-
sued, practically, as nearly as I  can define it, is this—when the incoherency
has been boisterous, manifested by much and loud talking, shouting, etc., I
have considered the delirium active, although the  patient may not have
required coercion.   On the  other hand, occasional, or even frequent efforts
to get up, if the patient be  at once persuaded to lie down,  or to return to
his bed, have not been sufficient to constitute active delirium, but the term
has been restricted in its  application  to cases in which such  efforts  have
been  not  only frequent,  but perseveringly  repeated, rendering  constant
supervision, or even mechanical restraint necessary.
  The characters which belong, in general, to this  symptom, as it is pre-
sented in  continued fever, and its diversities  in  the different cases under
examination, claim further notice than merely to distinguish  them as active
and passive.   I will therefore  devote some space to these points, without
taking pains to obtain numerical results.
  In the majority of cases in which passive delirium existed, the manifesta-
tions consisted in  the  patients talking to themselves, muttering, asking
questions which were irrelevant,  or inconsistent with their situation, fre-
quently relating to business affairs, declaring that they were well, and
desirous to go home, and  in  attempting to get out of bed.   The effort to
get out of bed, seemed sometimes like  sleep-walking, and  when patients
assigned any motive, it generally differed at every separate attempt.  The
request to lie down was usually  readily complied with, and was followed
by quietude for a time, when the effort would perhaps again  be repeated,
and so successively, with intervals of greater or less duration.  It happened
several times, when patients had not given any evidences of mental aberra-
tion which seemed to require them to be carefully watched, that they suc-
ceeded in getting out of  bed  unobserved, and  in partially, or entirely
dressing themselves   An attendant is liable to be deceived by the repre-
sentations of the patient, and suppose that it is  proper to allow him to get
up.   For example, in one of the cases, on the third day, before the diag- 
REPORT ON  CONTINUED  FEVER.
37
nosis had been positively made, I  found the patient,  at the time of my
visit, sitting up, entirely dressed, saying he was quite well, that his mother
had just arrived in town,  and he was going  out to see her.   On being
desired to undress and go to bed, he complied without the least reluctance.
The attendant  had supposed him to  be as much better as he professed to
be, and had not interdicted his  dressing, which he was able  to accomplish,
not being, at that stage of the disease, greatly prostrated.
   In none of the cases does  there appear to have been a persistent delu-
sion, giving a fixed subject and  purpose to the conversation or  movements,
but on the contrary, it would seem  that a constant succession of incongru-
ous ideas characterizes the delirium of continued fever.
   The delirium was observed invariably to be greater  during  the night,
than in the day time.  In some  cases, the  only manifestations  occurred
at night,  the patient apparently being rational during the day.
   \nfour instances, paroxysms of  weeping  and  sobbing occurred, as in
some forms of hysteria, the patients being all  of  the male sex.  In two of
these cases, the disease proved fatal,  and the paroxysm  occurred, in each,
at the latter part of the  disease.  In both these  cases, the  cause assigned
for grief  was,  that the patient had committed some heinous fault  which
would be followed by disgrace.  In each of the two cases in which recovery
 took place,  the weeping  paroxysm  occurred  near the period of  convales-
cence.   In one of these cases, the source of grief seemed to be apprehen-
 sion of death;  in the  other case, the patient said  he  would not tell why he
 wept.  This variety of mental aberration presents a striking contrast with
 the kind of delirium  usually present in  continued fever, which does not
 involve any acknowledgment, or apparent consciousness, either of bodily or
 mental distress.
   A trait somewhat peculiar to the mental condition in fever, is that the
 patient generally replies to questions rationally.  Even  in  cases in which
 spontaneous incoherency is marked,  when  the  attention is directed by a
 question, the mind appears to be  capable of rational action, but immedi-
 ately afterward, perhaps, relapses into its former  dreamy state.
   It does not  follow,  however, because  replies to questions are consistent,
 that they are  therefore correct.  This is far from  being,  the case.  The
 statements given by patients with fever  are  often erroneous, when their
 intelligence appears perfect; and, hence, they are  not to  be relied upon
 for information of the previous history, or the daily events of their illness.
    We are apt, also,  to  be  deceived in estimating the mental condition of
 fever patients by the absence  of manifestations  of  delirium.  In some of 
38
REPORT  ON CONTINUED  FEVER.
 the cases that I have observed, I had supposed, during the progress of the
 disease, that  the  intelligence was in no degree compromised, when,  after
 recovery, patients have assured me that they had a very imperfect recol-
 lection of what had  transpired.   For example, in  a case occurring in pri-
 vate practice, the  patient had been attended by a homoeopathic practitioner
 for several days, until, the friends becoming dissatisfied, he was asked  if he
 did not wish  another physician.   He requested that I should be sent for,
 and daily saluted  me by name, replied  to questions coherently,  giving no
 marked indications of delirium prior to his convalescence, but he  afterward
 informed me that  he had no recollection whatever of desiring my attend-
 ance, or of the fact that I visited him while  the febrile career continued.
 The only explanation he could give of his electing my services was, that he
 had been accustomed to see me at church.
   Of the few  cases in which the delirium was active, it was remarkably
 violent in two.  In both these cases,  the  efforts to get out of bed were al-
 most  incessant, requiring constant vigilance and considerable restraining
 force on the part of  the attendants.   These  delirious effects continued up
 to a few hours of dissolution, both cases terminating  fatally.  In each of
 these cases, the type of the disease was typhoid.
   Cases in which  such activity of delirium is a prominent feature, may be
 considered and treated as cases of encephalitis by those  who are not thor-
 oughly  versed in  the  principles of diagnosis.   The early history of the
 disease, the state of  the  senses, the presence of abdominal and the symp-
 toms  so often  associated  with fever, etc., should, in most instances,  furnish
 sufficient data for a correct  discrimination.
   Cases, however, do occur, in which, owing  to  defective information re-
 specting the duration of the disease, and the previous  history;  to pecu-
 liarities  in the cerebral  symptoms,  and  the absence  of  many  of  the
 distinctive characters of fever, the diagnosis presents great difficulty.   The
following case will serve to  illustrate  this remark, and  at the same time,
furnish an instance of an unusual variety of mental aberration:
  Frederick Brighton, German, aged  13, entered hospital September  9th,
 1849.   He  was incompetent to give any  account of his illness.   From
what was said by  his sister, who brought him to the hospital, I  gathered
that he was  attacked  five days before his  entrance, with  diarrhoea  and
vomiting.  His mother was buried on that day, having died with  epidemic
cholera.  He had  been delirious  from the commencement.   Had had no
recurrence of  diarrhoea or  vomiting since his attack.   It was not ascer-
tained that he had had any medical attendance.  He was actively delirious 
                     REPORT  ON CONTINUED FEVER.                  39

during the night  after his admission;  and  in  the morning succeeded  in
making his way to the verandah  communicating with the ward, and en-
deavored to jump over the railing.   At my visit he was  somnolent, easily
roused, but not to complete intelligence.  Keeps  his mouth in motion du-
ring sleep, as if sucking.  (This  symptom I  have observed in  another
case.)   Skin is cold and dry.   Pulse  92.   Tongue, which is  readily and
fully protruded, is moist and furred.  Says he has no pain.  No dejection
since his entrance, nor has he passed urine.
   Sept. 11.  Somnolent.   Respiration heavy,  with loud  whistling nasal
rale, numbering ten.   Actively  delirious  during night, endeavoring to get
out of bed.   Easily roused so as to open his eyes, but  lies with a vacant
stare, respiration continuing the same.   Eyes not injected; pupil neither
contracted nor dilated.   Skin cool.   Pulse 94,  and somewhat  thrilling.
Flies creep  over the face  without exciting uneasiness.   Commences  to
reply  to  questions, but  fails  to finish sentences.   Protrudes his tongue,
which is covered with a  white  coating; indentations of  the  teeth on the
side of the  tongue.   No dejection.  Abdomen  not distended.   Several
dark petechial spots on  abdomen.   Resists examination  of the  abdomen,
apparently from disinclination to be annoyed.   Passed urine  freely yester-
day afternoon.
   12th.  Somnolent.   Respiration  12.  No dejection.  Urinates in bed.
Active delirium at night.  Skin cool.   Pulse 112.  Protrudes his tongue
readily, which is moist an ! coated.  Resists examination of the  abdomen.
Partially roused without  difficulty, opening his eyes in part only, with  an
absence of expression.
   Treatment.—Tart. ant. and pot.  gr. ss.  hourly.   Head to be  shaved
and vesicated.
   13th.   Symptoms not materially altered.   Pupils  appear dilated, and
do not contract on  opening the eye-lids.   Grinds his  teeth  loudly.  The
antimony  was repeated yesterday several  times without effect.   One grain
was given to-day with no effect.   On attempting to make him protrude
his tongue, (which was ineffectual,) he uttered a loud and  piercing shriek.
No dejection.
   Five drops of  Croton oil were  given on this day with no effect, and  an
enema containing two drachms of the  spirits of turpentine.
   14th.   Died at one, A. M.
   Autopsy — Head.—Moderate congestion  of brain.   No  effusion into
verticles.   Some effusion into arachnoid sac, but quantity  not ascertained,
owing  to escape  of blood into this  cavity.   Consistence of brain normal. 
40
REPORT ON CONTINUED FEVER.
 No exudation of fibrin, or opacity of arachnoid.  No abnormal consistency
 of cerebral substance discovered.
   Abdomen.— Small intestines contained a  thin,  yellowish  substance.
 Colon much  distended  with gas.   Peyer's glands  much hypertrophied
 without ulceration; and corresponding mesenteric bodies greatly enlarged.
 No lumbrici.   Stomach presented several patches of ecchymosis;  mucous
 tunic not softened, but detached with unusual facility.   Spleen small and
 not softened.   Liver presented nothing worthy of note.
   To some of my readers it may appear censurable not to have recognized
 the disease in this case  by the symptoms, but I am bound to confess that
 the diagnosis was  not made prior to the autopsy.
   In another case (which occurred in private practice,) the delirium was of
 an unusual and striking  character.  I saw the patient, in consultation, on
 the seventh day of the disease.  He  had previously manifested  passive
 delirium at night, but  had  seemed rational  in  the day time.  He was
 greatly prostrated at the time of my visit, and the general symptoms de-
 noted that the case would soon terminate  fatally.   In the examination of
 the case, I proceeded to ask several questions, to which he made no reply,
 but regarded me with a fixed, vacant stare.  Suddenly he shouted with a
 loud  and violent  tone, "G----d d----n you, I'll kill  you!"   This was
 uttered with a piercing voice,  and  an expression of countenance which
 combined the utmost imaginable degree of terror and fierceness, rendering
 the  language  more startling  and  terrific than  can well  be  described.
 Shortly afterward, he became  calm, and replied  coherently to questions,
 but before I left the house, he had  two other paroxysms, in which, from
 expressions uttered, he appeared to imagine he was struggling in a mortal
 conflict.   Although his muscular strength was so much reduced  that he
 was unable to rise from the bed, he shouted so loudly as to  be heard over
 the whole house,  and even at a distance  from it.  The case terminated
 fatally the  following day.
   This patient had always been regarded as a man of desperate character,
 capable of almost any act of violence, and was supposed to have  committed
 heinous crimes.  The peculiar kind of delirium seemed to correspond with
 the character of the  individual; and the inquiry suggests itself, may not
 the delirium of fever be influenced, in some instances, to  a greater or  less
 extent, by the habits, occupation, and moral constitution of the patient?
   What relations does delirium sustain to the issue of continued fever ?
   Delirium existed in all the  fatal cases in my collection.   In each of the
fatal  cases of  typhus, it was (of course) passive in its character.    In the 
REPORT ON  CONTINUED FEVER.
41
fatal cases of the typhoid type, it was active in three cases, and  passive in
three cases.  The three  cases, however, in which the greatest degree of
activity of the  delirium  was manifested,  all proved  fatal.  In  the fatal
cases of doubtful type, the delirium in one was  active, and in the other
passive.
   In so far  as any deductions from so limited a number of observations
are  admissible, the conclusions are, that although an  unfavorable progno-
sis is not to be predicated on the fact that delirium is present in a degree
sufficient to be pronounced active,  yet such cases are  more likely to prove
fatal, and that an unusual violence  of delirium should  lead us to anticipate
a fatal result.
   It remains to propose  another inquiry, viz: upon what pathological con-
dition or conditions, is  delirium dependent;  in other words, what  is the
pathological explanation of the delirium in Continued Fever?  This, as well
as other questions which, in the present state of knowledge, are open  for
discussion,  and involve  considerations more or  less  speculative,  I shall
only notice, in so far as  facts can  be  made to bear upon it  With  refer-
ence to the inquiry, whether this symptom  may not  be attributable to
some one or more of  the  events  appertaining  to the  febrile career, the
method suggests itself of comparing the cases with each other to ascertain
whether delirium is  uniformly associated with any other particular symp-
tom, or group of symptoms.  But the symptom under consideration, being
present in the great majority of cases, is apparently not influenced  by the
varied events which enter into the history of Continued Fever.  It would
seem that it must depend on something  incident to that morbid condition
which constitutes the essential nature of the disease.   In all the cases in
which delirium was  not  exhibited, the fever was of  a mild grade, and it
has been seen that it was not absent in a single case of those which proved
fatal.   Hence, it would follow, that the symptom depends  somewhat on
the severity of the disease; a conclusion which accords with the supposi-
tion that it proceeds directly from  the proximate cause of the fever, and »
not occasioned by any of the circumstances subordinate to the disease.
In reasoning thus, it is assumed that the delirium of  fever does not imply
the existence of inflammation of any of the encephalic  structures.   That
it does not, is rendered  sufficiently plain by the symptoms, unless it be
imagined that  inflammation of these structures complicating fever is de-
prived of all its diagnostic features except delirium, and this symptom we-
know does  often occur, in other than fever cases, without involving inflam-
lation.   But positive observations have established that  delirium may
               D 
42
REPORT  ON CONTINUED FEVEK.
exist in fever, in a very  active degree, without encephalic inflammation.
This was the fact in two cases proving  fatal, of those under analysis, in
which active delirium was present.  The autopsies revealed no evidences
of inflammation within the cranium.  In one of these  cases the delirium
was a  more prominent and persistent symptom than in any other case that
I have observed.*
   Lesions of the mucous tunic of  the stomach existed in both of the cases
just referred to, consisting, in one case, in  patches of ecchymosis, and, in
the other case,  in ulcerations.  The observations of Louis, however, show
that active delirium may exist in fever,  irrespective of appreciable eviden-
ces of gastric disease.
   There are several points of inquiry, relating to  the  subject of delirium,
which have  not  been noticed.    Among  these are the  duration of this
symptom, and  the period  in  the  career of the disease when it first
appears.  The latter is a point involved in the discrimination of the two
types of fever  from each other.   In the  typhoid type it  is  stated that
delirium occurs later than  in typhus.   On each of these  points  the data
are  too defective to be of much  value.   This  is owing,  in  part,  to the
difficulty of fixing the date of the commencement of the disease in many
cases, and, in part, to omitting, in the  preliminary analysis, to note the
time when the  symptom first appeared, and the period of its continuance.
To supply  this omission, it  would  be necessary  to go through  with a
re-perusal  of all the cases.   In  examining the facts  as  arranged, with
•reference  to the  points  mentioned, I find that in four  cases  of typhus,
and seven cases of typhoid, delirium commenced early in the  disease, i. e.
during the first week; but it is not to be inferred  that the same might not
have been  true of more or  less of the cases in which evidence  of the
fact does not appear.
   In a considerable  number of  cases, I  find it stated that delirium was
exhibited  early in  the  disease, and diminished, or  disappeared, for some
days before the career of the fever was ended.
   The manifestations of a morbid state  of mind,  irrespective of delirium
deserve some attention.   I have copied all that is contained in the prelimi-
nary analysis relating to this subject,  and  will give the expressions made,
use of in the records to denote apparent  mental conditions of the patients
stating relative proportions of cases in which they respectively occurred in
  •The case referred to was reported for the Buffalo  Medical Journal, Vol. IV.
487, No. for January, 1849. 
REPORT ON  CONTINUED FEVEK.
43
general terms, without taking pains to obtain exact numerical results.  Dull-
ness of  the intellectual operations was the trait most frequently noted in
the cases of either type of fever.  The patients replied to questions after
more or less delay, seeming as if lost in deliberation, or as if the mind acted
very slowly; when not addressed, they took  little or no notice of persons
and objects  around  them,  seldom  asking for any thing,  expressing no
wishes, appearing indifferent, and sometimes  stolid.  This was the general
rule, but with some exceptions.   In a few cases it is stated that the pa-
tients replied to questions promptly, and the  apprehension had, apparently,
lost but little of its normal quickness.   In  by far the greater proportion of
cases, no emotions, either of pleasure or  unhappiness, were exhibited.   To
this rule there were  also exceptions.  In one case, the patient was  much
affected at being ill at the hospital, away from his friends, and shed tears;
in another case, great peevishness existed, the patient constantly complain-
ing and whining ;  in another case, the  patient was disposed to complain,
and was apprehensive as to the result of the  disease.   Impatience at being
questioned, apparent reluctance to  reply, and sullenness, were occasionally
observed; so  also irritability of  temper, which  was an exceptional trait.
These remarks refer to the mental conditions after the fever became estab-
lished, and during its career.  They do  not  embrace the period of access.
In two instances, one of  the  typhus, and the other of the typhoid  type,
 there was a disposition to indulge in  hilarity and  playfulness, as  if  under
 moderate exhilaration from an opiate, or alcoholic stimulus,  and  in these
 cases the approach of convalescence was marked by diminished loquacity,
 and  sedateness.   There  were  strikingly  exceptional instances.   Usually,
 there was nothing like mirthfulness in the  mental manifestations, and a
 smile was frequently  noted as one of the harbingers of convalescence.  In
 the case of a female patient, it is noted that she showed no reluctance to
 exposure of the abdomen, to look for the  eruption, etc., until the time of
 convalescence, when  the usual modesty  of the sex was resumed.
    In conclusion, although the mental characters, aside from  delirium, pre-
 sent diversities peculiar to individual cases,  those belonging to the majority
 of cases, may be summed  up as follows: sluggishness of all the mental
 powers; disinclination to exertion, either of  the attention, or the will; ab-
 sence  of emotional sensibility, of anxiety as to the issue of the disease, etc.
 And, as a general remark, these traits were prominent, and early displayed,
 in proportion to the severity of the disease.
    Sleep  More or  less somnolency existed in a large proportion  of the
 cases under analysis.   By this I mean, that during the day time, and, in 
44
REPORT ON  CONTINUED  FEVER.
 the hospital cases, especially at  the time of the daily record, the patient
 was dozing, and  exhibited  a marked tendency to sleep.   The degree  of
 apparent drowsiness  differed considerably in different cases.   Generally,
 the sleep was not profound,  nor  complete,  the patient lying in a state  of
semi-somnolency, with his eyes closed, readily roused  on being addressed,
 but relapsing shortly into the same state.   This condition is peculiar, and
 in a high degree  characteristic of Continued Fever, being  seldom observed
 in other affections, constituting the symptom known as coma-vigil.
   Somnolency  was  not uniformly present, but it was  much more fre-
 quent in the cases of Typhus, than  in those of the Typhoid type.  Out of
 eleven cases of  Typhus  in which the records contain information  on this
 point, it was absent in but a single case; while out of twenty-one cases of
 Typhoid, it appears  not to  have been present in nine.   Hence, it would
 seem that the peculiar morbid condition of the  nervous system upon which
this  symptom  depends, exists almost constantly in Typhus,  while  it  only
 exists in a little more than one-half the cases of Typhoid.
   Of the cases of doubtful type, it existed  in three, and was absent in two,
information on  this point being deficient in three.
   In order to ascertain whether any connection existed between this symp-
tom  and the issue of the disease, I will give the facts in the fatal cases.
   In the four cases in private practice, which ended fatally, the conditions
were respectively as follows:   (Typhoid.)—In  one  case, vigilance through-
out the whole  career of the disease, with  active delirium; sleep rather
heavy, when it did occur; in one case, somnolency, the patient being easily
roused,  until toward  the close of life, when it became more and more diffi-
cult,  and  finally  impossible; in  one  case,  the record is defective  on this
point.  (Typhus.)—In  the fatal case of this type,  the patient was  somno-
lent, but easily roused, up to the close of life.
   In the hospital cases, as  follows:   (Typhoid.)—Vigilance  throughout
the disease in  one case;  somnolent toward the  close of life, but easily
roused,  in one case;  somnolent,  and roused to only partial intelligence, in
one  case;  part of the  time  somnolent,  but easily roused,  in one  case.
(Typhus.)—Somnolent, but easily roused, in one case, up to the close of life;
somnolent at first, and easily roused,  but became  insensible,  and  died in
that  state, in one case.  In the fatal case of doubtful type, somnolency did
not exist.
   It would seem that an unfavorable prognosis  is  in  no wise to be based
on the presence of this  symptom, when "it is considered  that it does not
uniformly exist  in the cases which prove fatal; nor, when it does exist is 
REPORT  ON CONTINUED FEVER.
45
it uniformly in a marked  degree;  and  when  it is  also considered that it
exists in a large proportion of the cases which terminate in recovery.
   It is worthy of remark, that the somnolency of Continued Fever does not
often eventuate in insensibility, or coma.  In but two cases of Typhus, and
one case of  Typhoid, do the  histories show such a  tendency.  A practical
consideration connected with this fact is, that the presence of this symptom
need not deter us from prescribing anodyne remedies, or opiates, with the
hope of  substituting for the  somnolency peculiar to  fever, more complete
and refreshing sleep.  If the somnolent condition  of a fever  patient de-
noted a comatose tendency, the use of such remedies might be expected to
favor such  a tendency, and  would,  therefore,  rationally, be injudicious.
Experience, probably, will be found to sustain the conclusion, that, under
these circumstances, these remedies may be administered with impunity, if
not with advantage.
   Coma.   This term is here employed to designate a  degree of stupor
from which the patient could be but partially roused, or, with  great diffi-
culty roused,  or, in some instances, a state of complete insensibility; and to
these conditions occurring during the  career of the fever prior to a  few
hours before  death.   As occurring  shortly before death, they are more
properly considered under the head of mode of dying, in which connection
they will be referred to hereafter.
   Considered under these limitations, Coma occurred in but a very small
number of the cases analyzed, viz.,  in  two cases of Typhus, and in two of
 Typhoid.   In three of these cases, the  disease proved fatal.  In the case in
which recovery took place, the comatose condition  was accompanied by
loud, stertorous respiration,  constituting  what may be termed  apoplectic
coma.   As  this event is of rare occurrence in  fever, and one which cannot
but be regarded as rendering the situation  of the patient imminently criti-
cal, some farther account of this case may be interesting.
   William McDonald, Irish, laborer, single,  aet. 27, entered hospital June
6th, 1849.
   The person who brought him to the  hospital, stated that he had been ill
ten days, and that he had arrived in this country about a month previous.
The patient was incompetent to give a history of the symptoms;  said  he
did not know  how long he had been ill.
   7th  inst.   Present Symptoms.   He lies most of  the  time in a dozing
state, but is easily roused.  Eyes  are not suffused.   Aspect stupid.  Face
presents slight dingy redness.   Manifests aberration of mind by incoherent
replies to questions.  Does  not mutter.  Appears  not  greatly prostrated. 
46
REPORT ON CONTINUED FEVER.
Lies on his back, without changing his position, but moves his upper extre-
mities frequently.   Takes some notice of persons  around him.   Respira-
tions 32.  Sibilant rale through  nares.  Has not been observed to cough.
Tongue furred, quite dry in the centre, moist at sides.  Skin  moist, and
temperature somewhat increased.   Pulse  120, well  developed.   Has had
two dejections since his entrance on yesterday.   Has urinated freely.  Ab-
domen and chest thickly covered with a faint, dusky eruption, which seems
either to have  faded, or to be  not fully developed.  Abdomen soft;  no
tenderness on pressure.  Gurgling in right iliac region.  Has taken, since
his entrance, Sulph. Morphiae, gr. 1-8, once.
   Treatment:  S. Morphias, gr. 1-6; Tart. Ant. et Pot., gr. 1-4—every six
hours.  Weak milk porridge for diet.
   8th.  This patient remained yesterday without any notable variation in
symptoms, until 8, P. M.   It was then observed that he was more somno-
lent.  Pulse 140.   Respirations  36,  and  labored.   At 10,  P.  M., the
respirations became stertorous, but he was still roused without difficulty.
The stertor continued at intervals through the night.  I visited the patient
at 6  o'clock this morning.   The  respiration  was  then loudly stertorous.
Pulse 146, and well  developed.   Skin hot.   He could be  roused, with
difficulty,  so as to open his eyes, and to endeavor  to  protrude his tongue,
but the latter effort was ineffectual.   When  he opened his eyes, the right
upper lid dropped considerably.  He  retains  sufficient muscular  strength
to raise himself into a sitting posture, and to change his position in bed.
He passed urine last night, and had three dejections in bed, unconsciously.
Has not vomited.  I directed the hair to be  cut close to the scalp, the ice-
cap to be  applied, the head elevated, sinapism to the neck;  (it had already
been  applied  to the  feet and hands.)  Tart. Ant. et Pot.,  gr. ss., to  be
repeated in twenty minutes.
   1-4 before 8, A. M.; a manifest improvement in symptoms.  The stertor
is nearly gone.   Lies with his eyes  open,  and  takes  some  notice.  Pro-
trudes partially his  tongue, on being requested.   Pulse diminished in fre-
quency, and, notably, in volume and force.   Skin  moist.   No  nausea.
Antimony to be continued in doses of gr. 1-4,  and omitted, if nausea occur.
Ice to head continued, and warm applications  to extremities.
   11  A. M.  Patient again stertorous, but can be partially roused.   Anti-
mony discontinued.   Blister, 6x4, to nucha.
   At 4, P. M., symptoms  are not given, but  the following prescription is
recorded: Iodid. Potassii,  grs. v, every two hours.
   9th.   Stertorous respiration continued during the  night, at some times 
REPORT  ON CONTINUED FEVER.                  47
increased, and at some times diminished. Since 4, A. M., respiration has been
free from stertor,  and tranquil, except that the expiration is almost con-
stantly attended by a groan.   He is apparently conscious this morning, but
does not speak.   He moves his arms when requested, and as requested, but
slowly, and with difficulty.  He partially protrudes  his tongue, which is
covered  with a thick moist coating.   Pulse is 120.  Had free dejections
in bed during night.   Has urinated freely.  He lies with his eyes open,
and appears to take notice.  Pupils not dilated.
    He has taken Iodid. Potassii, grs. v, every two hours, and ice has been
 almost constantly applied  to the head.
    Treatment for to-day as follows:—Iodide of Potassium, grs. v, every four
 hours.   Proto-chlor.  Hydrarg. gr. 1, hourly.   Continue ice-cap.  Essence
 of beef has been given frequently, and is to be continued.
    10th.   Passed a restless night, but without stertor.   Had  one dejection
 in bed.   Takes notice of persons around him.  Respiration now easy and
 tranquil.   Protrudes his  tongue, and essays to speak, but cannot enunciate
 distinctly.  Tongue covered with  a thin  white coating.  He  appears to
 comprehend whatever is  said  to him.
     Treatment:  Sulph. Quinise, grs.  ij, every four hours.   Cont. essence of
 beef.
     P. M.   Has  had three dejections.   They occurred in bed, but he has
 cognizance of  them, and endeavors to get out of bed at that  time.   No
 stertor.   Lies awake; urinates  freely.   Pulse (figures not  legible)  well
  developed.
     Omit  Quinia, and give, per enema, Tinct.  opii,  3j.   Apply blisters
  behind ears.   Sptts ether  nitrosus, 3j, every four hours.   Omit essence
  of beef.
     11th.   Rested well part of the night, and part of the time was restless.
  This morning,  aspect  more  intelligent,  appears to comprehend all that is
  said to him, but cannot  control the muscles  sufficiently to enunciate  dis-
  tinctly.   Respirations 40;  skin  hot.  Pulse 120, well developed.   Tongue
  dry at tip.  One dejection this morning, pretty large.  Got up to defecate.
  Urinates freely.  Blisters have  vesicated well.  Ice is still applied to the
  head.   Has some carphologia.
     Treatment:  Sup. Tart. Pot., §ss.;  Nit. Pot,  3ij.; Aquas, Oj.  To be
   drank during the day.
     12th.   Restless early part of night, but after taking Tart. Ant. and Pot.,
   Kr i  became more quiet.   This  moming quite as comfortable as yester
   day '  He is now sitting in defecating chair.   Tongue cleaning.   Manifests 
48
REPORT ON CONTINUED FEVER
 more intelligence, and can enunciate better than yesterday.  Four dejec-
 tions since yesterday morning.   Secretion of urine abundant
    Treatment:  P. Doveri, grs. iij.; Tart. Ant. and Pot., gr. \—every four
 hours.   Omit Sol. Sup.  Tart and Nit. Pot.
    13th.   Aspect better.  Tongue improving.  One dejection.  Skin less
 hot.   Pulse 108.  Respirations tranquil, and 32.
    Treatment: Tart. Ant. and Pot.,  gr. •£, every four hours.
    14th.  Had  an uncomfortable night.    Respirations accelerated  and
 labored.   Cough troublesome.   Aspect as good  as yesterday.   Seems
 bright;  understands what is said, and raises himself briskly in bed.  Re-
 spirations  30; expiration attended  by a sibilant nasal  rale.  Pulse 120,
 well  developed.   No dejection.   Urinates freely.  Tongue moist and clean-
 ing.  Continues to enunciate  imperfectly.
   Cont. Treatment.
   15th.   Good  night  Aspect improved.  Pulse  108, less  developed.
 Skin  perspiring.  Tongue  cleaning.  Respirations 36, and not labored.
 Enunciates better.  No dejection for 48  hours.   Cough has  become a
 troublesome symptom.  Expectorates considerable puruloid looking matter.
   16th.   Restless night.  Respirations short, frequent, and labored.  Has
 expectorated considerable muco-purulent matter.   Skin warm  and moist.
 Pulse 112.  Had large  dejection this morning, moulded,  and natural in
 appearance.   Respirations 24, and now easy.
   Treatment: Carb. Ammonias, and  Tart.  Ant.  and Pot, if respirations
 become accelerated or  labored.
   17th.   Aspect better.  Comfortable  night.   Skin  cool.  Pulse 100.
 Copious muco-purulent expectoration continues.   Respirations easy.
   18th.   Symptoms  continue the same.   Distinct relative  dullness  on
 percussion over the left side,  posteriorly, at the  inferior  angle  of  the
scapula, with a loud mucous rale; on right side, posteriorly, sonorous rale.
He continued to improve,  but exhibited some  delirium until  the 25th,
 when it is noted that the pulse were 140, temperature of surface increased,
copious purulent expectoration continuing, and respirations 32.
   27th.  Aspect and symptoms improved, but still some delirium at nio-ht;
copious purulent expectoration.  Pulse 108.   Skin cool,  and perspiring.
Chest dull  on percussion on  the  left side, laterally and posteriorly, and
anteriorly at inferior third.  Respiration  over dull portions, tubular.  No
rales perceived.
   On the 29th, he was up and dressed.
   July 1st, he was walking about, and from this date, he convalesced rapidly. 
REPORT ON  CONTINUED  FEVER.
49
  Remarks.   The history of this case is given in detail, on account of  the
occurrence of coma, with apoplectic stertor, and the recurrence of this con-
dition, in a somewhat paroxysmal manner.  The investigation of the case,
I regret to siy, as is now apparent,  was incomplete,  at the time these
symptoms became developed.   The chest should have been examined at
that time, for, although no cough was noticed anterior  to, or or in connec-
tion with the  coma, it is not  improbable that physical exploration would
then have revealed the existence of pneumonitis, the existence  of which,
subsequently, was apparent.   The  occurrence of a muco-purulent expecto-
ration, which  became at once a prominent symptom, together with cough, is
presumptive  evidence that pneumonic inflammation had been present for
some time, for it would not be expected that a purulent formation would
have accompanied the inflammatory attack from its very onset.  Assuming
that pneumonitis existed, and its characteristic symptoms masked by those
appertaining  to the brain, it becomes an interesting question whether the
cerebral affection may  not have been, in a measure, dependent upon the
pneumonic inflammation.  It would be improper to discuss this question,
inasmuch as  the data must be assumed.
   In this pathological  aspect, the  case is one of those which enforces the
importance of physical  exploration of the  chest, under circumstances in
which  pulmonary disease may be  present, with  an  absence  of  rational
symptoms directing  inquiry  in that  direction, the attention,  as in  this
instance, being absorbed with prominent cerebral symptoms, which,  as is
well known, occasionally mask affections of other organs.
   Senses and Sensibility.  This division  will embrace several sub-divisions.
Under the head of Sensibility, the occurrence of pain in different parts of
 the body will form the chief  topic of  inquiry.   The morbid conditions of
the different  senses, but, more particularly, the eye and ear, will next claim
attention.
   The part of the body most frequently the seat of painful sensations in
Continued  Fever,  is the head.  I will  examine the cases, therefore,  first,
 with respect  to this symptom.
    Cephalalgia.  Of the cases in  private practice, this symptom  is not
 mentioned in seven, and was present in all the remainder, viz., seven.
    Three of the cases in the records of which this symptom is not mentioned,
came under observation,  respectively, on the fifth, sixth and seventh day
 after the fever was established.  In  the remaining four cases, the fever
 was observed from its commencement.
   In the seven cases  in which the symptom was present,  it was not  uni-
                 E 
 50                  REPORT ON CONTINUED FEVER.
 form in degree.   It existed in  a marked degree in  but two cases—in the
 other cases being more or less  prominent-   It continued from two to four
 days, except in one case, in which it continued seven or eight days.   In the
 latter case, it was moderate in  degree,  and the fever was of a very mild
 grade of intensity.
   In the single case of Typhus in this group of cases, which was observed
 from its commencement, the presence of this symptom is not stated.
   In three of  the fatal cases  in this group, nothing  is mentioned  of the
 presence of this symptom.   In  the remaining fatal case, it existed  at the
 commencement of the disease.
   Hospital Cases.  Of the cases of the Typhoid type, cephalalgia is noted
 as present in four only.  In thirteen cases, nothing  is stated  relative to
 this symptom.
   In ten of these  thirteen cases,  the  febrile  career had continued for a
 period not  less than five days,  before  coming under observation.   In one
 of these cases, the fever had  continued but one day before observed; and
 in one case, it was observed from  the commencement,  i. e., so soon  as the
patient was compelled to take to his bed.  In two of these cases, the dura-
 tion of the disease before coming under observation could not be ascertained.
   In none of the three fatal cases, in this group, is this symptom stated to
have been present.   One of these cases entered on the second day—the two
others, several days after the commencement of the febrile career.
   In none of the cases of this group in which the symptom was present, did
it continue beyond the fourth day.
   Of  the  cases  of  Typhus,  cephalalgia  is  noted  as present in  but
 two.   In one of these  cases, it  existed for the first  day only, the case
being observed from  the time the patient took to his  bed.   In the other
case, it  lasted two  days,  the  previous  duration of  the febrile career not
being ascertained.   Neither of  these cases proved fatal.
   In eight cases of  this group,  nothing is noted relative to the presence or
 absence of  this symptom.  In two cases, it is noted  that no  pain existed.
 In two of the cases in which nothing is stated relative to the  symptom, the
 fever was observed from the commencement of the career.
   Of the cases of doubtful type, cephalalgia existed at the early part  of the
 disease,  in two;  of the remaining  six  cases,  in two it is stated that
 this symptom was not present,  and in four, nothing is said  relative to it.
In one of these six cases, the fever was  observed from the commencement
 of its career; and  in  one, the  patient entered on the  second day.   In the
 other four cases, the duration of the fever prior  to observation was, in one 
                       REPORT ON CONTINUED FEVER.                    51

case, three days;  in one, five days;  in  one, eight  days; and in one,  six
days.   In the single fatal  case in this group, nothing is stated relative to
cephalalgia, the case coming under observation on  the eighth day.
   These results show, First—that cephalalgia,  in  Continued  Fever, is not
a symptom incident to  the disease after the first few  days of its continu-
ance.   Second—that this  symptom is present during  the first  four days,
in  a certain  proportion of  cases, but  not  invariably.   The numerical pro-
portion of  cases in  which it is present, the cases under examination do not
afford  the means of  estimating, so many  of them coming  under observa-
tion after the period in the disease had  passed  to which it is  limited, and
the  details  of the previous  history  often being  imperfectly  obtained.
 Third—it is not a symptom which appears to  have  any connection with
the issue  of the  disease.    Fourth—in  degree, the symptom is variable,
occasionally  being  intense,  but, in  the majority  of  casts, not  severe or
prominent.
   It will, of course, be understood  that  this symptom is now under con-
sideration  as it is  presented during the febrile  career, after  the access  of
the disease.   It is  much  more  uniformly present  during the  access than

subsequently.*
   In  general, it is  obvious  that this symptom  possesses small importance.
either in a pathological or  diagnostic  point of  view, in  Continued  Fever.
  * 1 wish to state that, in conducting:  the present analytical  examinations, my rule is,
to obtain results,  and draw deductions, before  referring to the works of Louis, and
others,  in order to ascertain the  correspondence or disparity of  these results and
deductions, with those therein contained.   When 1 express  general conclusions with
respect to Coutinued Fever, I always mean those only which the data before  me autho-
rize me  to draw.   If these conclusions diner from  those arrived at by other observer
and by  means of an analysis or a larger number of cases, then it becomes a question
how is the difference to be explained.   This question, however,  it does  not enter into
the design of this report to discuss.  Nor, as will be observed, do I make it a point to
state always  how my results and conclusions do compare with those previously obtained
by others.   I have done so, thus far, in some instances, but not uniformly.  My reason
for not devoting much space to these topics is,  that to give them adequate consideration
would swell, too much, the size of the  present report.  Besides, the report purports to
consist only of observations based on an examination of cases that have passed under
my  own observation.  I am  led to introduce  this note in the present connection, by
having noticed, after this Section was written, that the facts developed by  the researches
of Louis, respecting Cephalalgia, differ considerably from those I  have presented.  In
his collection of cases, this svmptom was found to exist in a much larger proportion of
cases, and to have a longer duration.   Why this disparity exists, I am not  prepared fully
to say\ but perhaps it maV be  explained by apposing that in  making inquiry reJatve
 o this symptom, Louis embraced the period of the access of the d.sease  w  ch m the
plan I have pursued, was excluded.  This would  also account for the longer continu-
ance of  the symptom in the cases observed by  him.                        ,.mB.„
  It is highly  interesting, after  having worked out results, to see ^how^comp,re
with those which have already become the  property of science; and ™££**%.«
repeated analytical investigations of the same disease, consists in th s compan-on. witn
a view to investigate the causes of  differences  which may be found to exist. 
52
REPORT ON CONTINUED FKVK.R.
 When  unusually prominent, however,  and  intense,  it may occasion  per-
 plexity in the mind of the practitioner.  This happened in one of the cases
 occurring in private practice.   The  pain  in  the head, in this case, was so
 severe for  the  first  three days, being accompanied by increased suscepti-
 bility  to  light and sounds, together with  considerable  general  nervous
 excitability, that I was  not  without  apprehension  lest the affection might
 be encephalitis.  The practical importance  of not confounding this affec-
 tion with fever, is  too obvious  to require remark, and has  been already
 alluded  to under   the  head  of  Delirium.   Fortunately,  instances  are
 extremely rare in  which there exists much ground  for  hesitation  in the
 discrimination.
   The disappearance of Cephalalgia, even when  it had  been severe, after
 the lapse of a few days, is an interesting fact in the history of the disease.
 I would remark that in  observing  cases, it appears often as if  this fact
 were owing, not  so much  to  the  cessation of  the  morbid condition upon
 which the  cephalalgia depends,  as on the induction of a mental state,  ren-
 dering  the patient unconscious of suffering  from the persistence of  that
 condition.
   The  cases in which, after the career of the fever was established, pain
 in any other part of the  body than  the  head, was experienced, are very
 few.   The histories of  ihe  private  cases contain no account of any other
 than cephalalgic  pain.  It is possible that various  painful sensations may
 have existed, but if any had been present except in a very slight degree, it
 is probable they would have been  recorded.
   In  the  hospital  cases—(Typhoid)—pain in the  limbs  was  the sub-
ject of complaint,  in one case; in  back, knees, and other  joints, in  one
 case; and  pain "all over," in one  case.   Typhus—pain in  the  lower
 extremities, was complained of in one case.   Doubtful type—pain in upper
 extremities, in one case; in the chest and legs, in one case;  in the back  and
 eft hypochondrium, in one case; and in the  back and limbs, in one case.
   It may be remarked, that slight, unimportant  uneasy sensations,  which
 might have been mentioned, would  perhaps not be recorded;  so  that in
 the instances above enumerated, the pains were probably somewhat promi-
 nent as symptoms.
   In a very large proportion of the cases,  especially after the first three or
 four days, the patients made no  complaint—frequently declaring they were
 comfortable, and sometimes  that they felt very well.  The latter reply  was
 most apt to be returned by those who were the most seriously ill.  I have
 sometimes  noticed that a patient  who replies  to a general question as to 
                     REPORT ON  CONTINUED FEVER.                   53

his feelings, that he is  pretty comfortable, on  being inquired of more par-
particularly, if he has not some pain somewhere,  will apparently deliberate
for a time, and afterward refer to some part as the seat of painful  sensa-
tions.   Oftener, after saying he is comfortable, if he be asked  whether he
has not  pain  in the  head, abdomen,  back,  etc., he answers in  the affirma-
tive.  These observations show that the absence of suffering  is due, not
alone to the absence of conditions calculated to occasion distress, but to
the blunted perceptions incident  to the disease.
   A blunted  perception  of morbid sensations was evidenced by various
other circum  tances; such as indisposition to changes of position, even when
the position was such as would ordinarily produce  uneasiness;  creeping of
flies over the face, apparently unnoticed, etc.  Circumstances that will be
noticed  under other Sections, will serve to illustrate  the  same condition.
So that diminished general sensibility may  be  said  to  belong to the symp-
tomatology of Continued Fever.  And it is  probably true that, other things
being equal,  this symptom is, in  some measure, proportioned  in degree to
the gravity of the febrile disease.
   I pass now to the Senses.   And first,  the Eye.
   Eye.   The observations respecting the eye, relate  almost exclusively to
 the presence or  absence of vascular congestion of the  conjunctiva.   In
two cases only  was diminished mobility of  the retina noted.   The tone of
expression  given  to the  countenance  by the  eye, has  been  already con-
sidered, under the head of the general aspect.  Yellowness of the conjunc-
tiva existed in one case.   In a few cases it  is stated, that, while the patient
 slept  or dosed, the  eye-ball was partially uncovered; but pains were not
taken to record observations with respect to this point. Increased suscepti-
bility  to light is not mentioned,  except  in a single instance—the instance
 already referred  to, in which cephalalgia existed in a severe degree, occa-
 sioning the  suspicion  of encephalitis.   As  respects vascular congestion, of
 the cases in private practice, suffusion, in a marked degree, is noted in one
 case; and in one case, the conjunctiva was moderately injected.   Both of
 these were cases of  the  Typhoid  type,  and in neither did  the disease
 prove fatal.   In all the remaining cases, including the case of Typhus and
 the case of doubtful type, nothing is stated relative to the appearance of the
 eye.  It is not stated that the eye was suffused or injected, in  the instance
 in which there existed increased  susceptibility  to light.
    Of the hospital cases— Typhoid—-the eye was  suffused in four cases.
 In three of these cases,  the  degree of  suffusion is denoted by qualifying
 adjectives, as follow:—slightly, in one; moderately, in one; and  somewhat, 
54
REPORT  ON CONTINUED FEVKR.
 in  one.  In  three  cases, it is noted  that  the  eye was not  suffused; and
 nothing is recorded in eleven cases.  It is fair to conclude, that in nearly, if
 not quite all the cases in the record of which nothing is said on the sub-
 ject, no congestion existed.  Of the four fatal cases of this  group, in three
 nothing is stated relative to the congested appearance of the eye; and in
 the remaining case, it was suffused.
   Of  the  cases of Typhus, the eye was suffused, or injected, in six cases;
 and in  no  instance  were qualifying adjectives used to denote a light  degree
 of  congestion.   In two ca«es, nothing is stated relative to  the appearance
 of the  eye;  and it was not suffused,  nor injected, in four cases.  Con-
 junctival redness was present in the two fatal cases in this group.
   Of the cases of doubtful type, nothing is stated  in five cases; it is stated
 that no suffusion existed  in two cases;  slight injection existed in one case.
   In the use of the terms suffusion and injection, the former was  applied
 to  a watery appearance,  with  some redness, and the  latter to a  greater
 degree of  congestion, in which the  vascularity was more marked.
   A suffused,  or injected condition of the eye, thus,  is present in a certain
 proportion of cases of either type of Continued Fever; but the numerical
 ratio of the cases in which it exists, is not deducible from this analysis; the
 fact of  the absence of this symptom not being noted in a considerable num-
 ber of  cases, although the presumption is, that  it was not  present in  the
 cases,  in the records of  which it is  not mentioned.  The above enumera-
 tions, however, show, that it is oftener met with  in  cases of the Typhus,
 than in the Typhoid type;  and that it is  less in  degree in  the latter than
 in the former.   The symptom, when present  in  a marked   degree,  there-
 fore, has some diagnostic value.
   The  inquiry arises,  whether  this symptom be not dependent  on the
 general capillary congestion, which, as has been seen in a preceding Section,
 is exhibited, in a large proportion  of cases, on the face and surface of the
 body generally.  It would be a rational supposition that this was the case;
 but on  comparison  of  cases, it appears  that the two symptoms are by  no
 means  uniformly associated.  Not  only capillary congestion  of the  skin
 does not exist  in all cases of  a congestive  appearance of the conjunctiva,
 but the latter may  be  absent  in cases in which the former is present.   Of
 the two cases in private practice in which the conjunctiva was  reddened,
 nothing is  stated respecting the skin  in  one case, and in  the other case,
 congestion of the face co-existed.    Of the  Typhoid hospital cases, in which
 conjunctival  congestion existed, nothing is stated  with respect to the skin,
in one  case;  capillary congestion of the  skin co-existed in two cases, and it 
REPORT ON CONTINUED FEVER.
55
did not co-exist in one case.   Of the cases in which conjunctival congestion
is recorded absent, capillary congestion of the skin existed in three cases.
  Of the Typhus hospital cases in which conjunctival congestion existed,
nothing is stated respecting  capillary congestion of the skin, in one case;
capillary  congestion of the  skin  co-existed in five cases, and was not
record( d  absent in a single case.   Of the cases in which conjunctival con-
gestion was recorded  absent, capillary congestion of the skin was present
in four, i. e., in all the cases.
   Hence, it  appears, as  already stated, that the two  symptoms are not
constantly associated.  This, however, does not  prove  that they may not
both be effects of  the same pathological condition—circumstances, which
we are not  able to appreciate, occasioning  the manifestation  of  either,,
exclusive of the other.
   Hearing.  Bluntness of the perception of impressions received by the sense
of hearing, as a general remark, obtains in Continued Fever after the first
few days of the febrile career, if not from the very commencement.   This
rule, in so far as the present collection of cases is  concerned, would seem
to  be  without an   exception.   In no case is it noted that, after the third
day, there existed a morbid susceptibility to sounds. The only instance in
 which  this is  stated  to  have been the  case at  any portion of the  febrile
career, was  the case already alluded to, in which unusual cephalalgia and
 increased sensibility  to  light existed.   Merely dullness of hearing, cor-
 responding with dullness as respects other senses, may be considered  as
 belonging in the category with diminished general sensibility, and is proba-
 bly due to a mental condition.
    But in a considerable proportion of cases, the sense of hearing  is affected
 specially, and in a degree disproportionate to  the state  of  the mental per-
 ceptions.
    Deafness, more or less, is noted in the records of six of the fourteen cases
 m private practice.  Of  the hospital cases, this symptom is stated to have
 been present  in five of the eighteen cases constituting the  Typhoid  group;
 in five of  the twelve cases of  Typhus;  and  in two of the eight cases of
 doubtful type.  Generally, in the cases  in which it is  not  stated that the
 symptom was present, nothing is said on the subject.   It is fair to presume
 that in all, or  nearly all of the cases in which the symptom was discoverable,
 or sufficiently marked  to be observed, it  was embraced  in  the records.
 But it was not always easy to determine  as  to its existence.  In cases of
 marked  somnolency,  or stolidity,  and  when persistent  active delirium
 existed,  it was sometimes difficult to appreciate the existence of deafness. 
REPORT  ON CONTINUED FEVER.
Hence, I do not suppose that the above enumerations possess much value
in endeavoring to ascertain the precise ratio of frequency in the occurrence
of this symptom.   But here, as in many other instances, arithmetical accu-
racy is not of great practical importance.   It is sufficient to form a rough
estimation of the probabilities of its occurrence.
   Nothing appears, on an examination of the cases, to denote a connection
between this symptom  and other  events  of the  febrile career.   It  was
present in cases of a mild  as well as severe grade of  intensity.   It  was
observed in cases of both types, but oftener in Typhus.   It was associated
sometimes with somnolency and delirium,  but  was also  noted in cases in
which the latter symptoms were slight or absent.   Of  the hospital cases,
of both types, which proved fatal, it was noted as present in two.  In one
case it was noted  absent;  and  in the  histories of  the  three  other cases,
nothing is said relative to its presence or absence.
   It was observed that, when deafness existed,  it  frequently, if not gene-
rally, persisted through the  febrile career; and, in  some instances,  con-
tinued for some time after convalescence was established.
   It was by no means uniform in degree; sometimes occasioning only some
bluntness of hearing—but in some cases rendering it necessary to speak
quite loudly in order to be heard.
   In some cases patients complained of the difficulty they experienced in
hearing, and in other cases it did not appear to excite their notice.
   No other facts relating to the  sense of hearing were recorded, except
that in two instances, in connection with deafness,  the patients complained
of a noise or buzzing in the ears.
   As regards the  senses of smell and taste, pains were not taken  to record,
or to make observations.
   Involuntary Muscular Contractions.  Involuntary muscular contractions
were noted in so small a number of instances, that it will not be tedious to
notice them and their peculiarities, individually.
   Of the cases in private practice, involuntary muscular contractions are
stated to have existed in three.  In one of these, they consisted  in subsul-
tus tendinum, and visible twitching of the hands during sleep.   The patient
in this instance, recovered.   The disease, in  its general features, did not
present great gravity.
   In one of the other instances, there existed marked tremulousness of the
hands and the tongue, at  the commencement of the disease.  So promi-
nent was this  symptom that, for the first day,  the  affection was  supposed
to be delirium tremens—the character and the  history of the patient being 
REPORT  ON CONTINUED  FEVER.
57
unknown.  This case ended fatally on the fourth day, and was of the Ty-
phus type.
   In the remaining case, there existed tremulousness of  the hands and
muscles of the face, when the patient was first seen on the fifth day.  The
case ended fatally on the ninth day.   This case was of the Typhoid type.
   Of  the hospital  cases—Typhoid—in one case,  in which  recovery took
place,  some  tremulousness of the hands was observed, on one day.  The
case was one of severity.  In  another case, there existed  subsullus and
marked tremulousness of the hands, together with inability, on one occa-
sion, to protrude the tongue.   This case ended fatally on the tenth  day.
   Of the cases of Typhus, subsultus was noted in but one case. This was
a case of considerable, but not very great severity, ending in convalescence
 on the seventeenth day after entrance—the patient entering  twelve days
 after illness  commenced.
   In the two fatal cases  of this type, in one the  power of  articulation was
 lost toward  the close of life—the patient not  being  unconscious.   In the
 other case,  much difficulty  was experienced  in protruding the tongue-
 repeated efforts being required.  Coma became developed in  the latter case.
   Of the cases of  doubtful type, tremulousness of the muscles, toward the
 close  of the disease, was noted in the case which proved  fatal.   Nothing
 under this head appears in the records of the other cases in this group.
   The instances in which this  symptom is recorded  as present, are  fewer
 than  I should have estimated before the analysis was made.  A symptom
 so obvious and important would not be likely to be overlooked or omitted
 in the history.  It is, however, possible that it may have  been present,  in
 the form of subsultus, and in a  minor degree, in some cases in  which it was
 not manifested at  the diurnal examinations and records, and, hence, have
 been omitted.
    It  will be observed that in most of the cases in which involuntary mus-
  cular contractions were  noted, the disease ended fatally.    In view of this
 fact,  taking also into consideration the fact that the symptom is one of rare
  occurrence, its presence is of bad omen, as respects the prognosis.
     Carphologia.   This symptom properly belongs among the aberrations of
  the sense of vision, consisting in voluntary motions directed  toward illusory
  objects in the air, or on the bed-clothes.   It was noted in three cases.   In
  one case, of the  Typhus type, it was observed only on one  day.   The dis-
  ease  in this instance was severe, but did not prove fatal.
    In one case, the type was Typhoid, and the disease ended fatally.   The
  case  was characterized  by vigilance, and very active delirium, up  to a few 
58
REPORT ON CONTINUED  FEVER.
hours before death.  It was a prominent symptom in this case, in the latter
stage of the disease.   In the remaining case, the type of the fever is classed
as doubtful.  The patient entered  the hospital on the third day after the
attack; but the fever had supervened  on an illness of three weeks'  dura-
tion, (the character of  which was not ascertained,) from which he had but
recently recovered sufficiently to return to labor.   Convalescence was pro-
nounced  in this case on the sixth day after his entrance.
   Pulling up of the bed-clothes, I do not find noted except in one case.  It
may possibly have existed, and, not being apparent at the time of the daily
examination, escaped being recorded.   In the  case in which it was present,
it was associated  with  Carphologia.   This case was the last of the three
cases mentioned above.
   Prostration.   By  prostration,  I mean  exhaustion, or reduction of the
force inherent in the voluntary muscular system.   Under this head I shall
make a few general remarks, based on an examination of the cases, without
any enumerations.  The latter cannot,  in this instance, be made of much
avail, inasmuch as we  have  no means of measuring, with  precision, the
deterioration of voluntary muscular  power.  We can only form estimates
which are  but rough approximations  to correctness, and  these must  be
expressed by terms somewhat indefinite.  For examples, we may say, that
the prostration is moderate, slight, considerable, great, very great, etc.
These expressions, obviously, have relative significations,  which, taken in
the connection in which they are used, may be sufficiently explicit for prac-
tical purposes, but they lack that definiteness which is desirable in data for
for numerical results.
   In  a  certain  sense,  fever invariably induces a considerable degree of
muscular prostration.   The event selected to  indicate the  commencement
of the febrile career, is evidence of this fact.   Patients are compelled to
take to the bed.   They are  unable to maintain the erect  posture, or to
continue, except for a  short time, efforts of locomotion.   In saving of a
particular fever patient, he is greatly prostrated—it is not to be understood
that the  powers of a healthy, vigorous man  are taken  as the standard of
comparison; but that his muscular strength is reduced considerably  below
an  average of the  degree  of diminution incident to the  febrile  state.
Judged  by this rule, in the majority of the cases  which form the subjects
of the present analysis, the prostration was not great.  The patients gene-
rally were able to raise themselves in bed, to change their position by their
own efforts, etc.  The  loss of muscular power was not so great as in many
protracted chronic diseases in which the patient is obliged to keep the bed. 
                     REPORT ON CONTINUED FEVER.                  59

In a considerable proportion of cases, patients were able, with the assistance
of an attendant to get out of  bed, in order to pass their evacuations, for
change of  bed-linen, etc.  Sometimes they were able to remain sitting for
some time; and,  when this was not  the case, it frequently appeared to be
owing rather to giddiness, than to a deficiency of muscular force.
   The loss of muscular power  was often more apparent than real.   There
was ability to exert considerable voluntary effort, but a mental indisposition
thereto.   The nervous, rather than muscular force, was  at  fault.   The
streng h was more oppressed than reduced.  Owing to mental dullness, it
was difficult, sometimes, to rouse the patient to a trial of voluntary effort;
and in cases in which marked  somnolency, or  a tendency  to coma existed,
it was not easy, on this account to form an estimate of the  amount of mus-
cular ability retained by the patient
   In cases in which the fever was of a mild grade of intensity, there existed
moderate  or even slight prostration, patients being able  to  assist  them-
selves  with  very  little  aid  from  others.  Extreme  prostration  always
occurred in connection with  other symptoms denoting unusual gravity of
disease.   The converse of this, however, was not  true.   In  some of the
cases  attended with most danger, and  some of  those ending fatally, the
 muscular  strength was retained in a surprising degree.  In two fatal cases
 of the  Typhoid type, characterized  by active, persistent delirium, the mus-
 cular efforts  were  almost constant, and quite  strong  up to a few  hours
 before death.   One of  these  cases terminated on  the ninth day,  and the
 other on  the  third  day after coming  under observation.  The  mode of
 dving, in each, was by asthenia, or,  perhaps, more properly, necrmmia—the
 system  of involuntary  muscles  exhibiting reduction of force to  a degree
 incompatible  with life—the  voluntary muscles remaining active.   This is a
 curious fact.
   It follows from the above observations, that while an unusual degree of
 prostration is an unfavorable sign in Continued  Fever, the preservation of
 considerable  muscular  force  is not to  be considered  as, correlatively, a
 favorable  sign.
   In  several of the cases, I have observed a fact which has an important
 practical  bearing upon  the treatment of fever,  viz.,  an   improvement in
 strength during  the febrile career.   In the histories of the cases, it is occa-
 sionally noted that the prostration,  at first apparent, diminished while the
 disease was yet in progress.   In these cases, the  patients  had not received
 proper  care  in  the way of  nursing, or medical attendance;  and  in some
 instances, according to the views of the writer, the management had been 
60
REPORT ON  CONTINUED FEVER.
not only defective, but injudicious.  As respects  the average degree of
muscular force presented in a series of fever cases,  much, I am persuaded,
will  depend on the  therapeutical system  pursued.  This, however, is a
topic which will more appropriately come up under the head of the Treat-
ment of Continued Fever.
   On  consulting the Treatise  on Fever by Louis, the  reader  will  find
that the results under the head  of Strength, appear to be at variance with
the foregoing.   If I may be permitted a criticism upon the observations of
that distinguished observer, under this head, I should say, that he does not
seem to distinguish between  the absolute loss of muscular power and  the
reluctance  to exert it.   If the reader will carefully peruse his  remarks on
this topic, I think he will discover sufficient evidence of the correctness of
this criticism.
   Louis gives an account of some cases in which the muscular strength
was retained  sufficiently for  the patient to  keep about several days after
the fever was  established.   Agreeably to the rule I have adopted, these
patients would not be  considered to be laboring  under established fever
prior to the time they took to the bed.   As I have before stated, this rule
is  somewhat arbitrary, and does not  mark the commencement of  the dis-
ease, with exactness, in  all cases.  Nevertheless, it seems to me to answer
better  as a point of departure for the origin of the disease, than any other
event,  or collection of events, that can be selected.

                            SECTION FIFTH.

Symptoms referable to the Digestive System. Appetite.   Thirst.   Tongue.
   Sordes.  Parotitis.  Nausea,  and Vomiting.  Alvine Dejections,  tym-
  panites.   Tenderness of Abdomen.  Gurgling.
   Morbid  conditions  of the digestive system are involved in important
questions  relating to the  diagnosis, pathology and  therapeutics of Con-
tinued  Fever.   That portion of  the symptomatology  of the disease, there-
fore, which is  embraced in this Section, opens a field of inquiry from which
interesting,  if not useful, results  may be  hoped for.   I will take up the
several sub-divisions of  the Section in the order in  which they are enume-
rated in the caption.
   Appetite.  The importance of noting negative as well as positive facts,
here, as in  several other instances, being overlooked in recording the histo-
ries of  the cases under analysis,  the data are too  defective for any statis-
tical results.   In a large number of the cases  nothing is stated relative to
the appetite.  It cannot be  doubted, however, that anorexia exists in the 
REPORT ON  CONTINUED FEVER.
61
vast majority of cases of Continued Fever; and it is to be presumed, that
this symptom was  present in most of the cases in which the records are
silent on the subject.
   In a few cases it is noted, that appetite existed—the patients declaring
that they took the food given  to  them  with some relish.  In connection
with this fact should be stated, what will be noticed hereafter under the
head of  Treatment, that the majority of the patients were  allowed milk por-
ridge  and essence of  beef, for  diet, during the  greater part of the febrile
career.  In two hospital cases,  of the Typhoid type, the patients said that
the diet was agreeable; in one  case of Typhus, the same is noted; and in
another  case of the same type,  it is stated that the patient had some appe-
tite.   In all the other cases, both  in private and hospital practice,  either
anorexia existed, or nothing appears in the histories relative to this subject.
The reader may haye some curiosity to know if there were any characters
distinguishing the three cases  in which food  was  relished, and the  single
case in which it was desired.   Of the two Typhoid cases, one proved fatal.
The patient,  in this case, was passively delirious during the  early part of
the disease, but  the  mind  subsequently became  clear.   He was  greatly
prostrated.   Evacuations were passed in bed, not unconsciously, but from
inability to restrain  them.  Death occurred,  twenty-six days  after the
attack, by exhaustion, (necrasmia.)  In this case,  anorexia existed part of
 the time.   In the other case, the  disease was of a mild grade; the patient
 being convalescent eight days after entering hospital, and quite well on the
 nineteenth day.   In the two Typhus cases, both patients recovered.  The
 disease, in both, was of medium severity.   In both, pulmonary symptoms
 were prominent.   In one, it  is stated that  food was relished  through the
 febrile  career ;  in the  other, appetite  was stated to exist  only on one
 day__the  second day after admission.   No circumstances  thus  appear
 which can afford any explanation of the  deviation  from the general rule, as
 respects the  appetite, in these  four cases.
    I would remark, that I do not feel confident that the four cases just men-
 tioned,  were the only instances in which food was relished, not being satis-
 fied that  proper pains were taken to make inquiries and notes relative to
 this point, during the examination of patients.
    Thirst.  Of this symptom,  as of that just noticed, owing to want of care
 to record  negative facts, I cannot submit any statistics as respects the fre-
 quency of its  occurrence,  its  duration, etc.  In  a large proportion of  the
 cases, the records contain no reference  to thirst.  I will not presume that
 it did not exist in any of these cases, but I am confident it was not a pro- 
62
REPORT ON  CONTINUED FEVER.
 minent symptom in  any of them during  the time they were under obser-
 vation, after the fever became established.   In three of the cases in private
 practice; in three of the hospital cases of Typhoid, in two of Typhus, and
 in one of doubtful type,  thirst is mentioned as a symptom  continuing, more
 or less, through the febrile career.   In all these cases, save two, the thirst
 was moderate in degree.   It is also worthy of remark, that in all, save the
 two last  referred to, the disease was of a mild grade of  severity; and in
four of the cases, very  mild.  In the two cases in which  thirst was more
 than moderate, the disease proved  fatal.   One of these  cases  was among
 the number in which food  was  relished; and in  this case, the  thirst was
 considerable.   In another instance, thirst was associated with the relish for
 food.
    In addition to  the  nine cases in which,  as just stated,  thirst existed
 through the career of the fever, it is  noted  to have been present in the
 early part of  the disease in several instances, viz., in four cases of Typhoid,
 three of Typhus, and two of doubtful type.   It will be recollected that in a
 large  proportion  of  the hospital cases, the patients did  not come under
 observation at the earliest stage of the  disease.   It is altogether probable
 that, in several of these  cases, this symptom  had  existed  and ceased prior
 to the period  when the records commenced.
   The cessation  of the  symptom is readily explained by attributing it to
 the bluntness of perception which usually characterizes  the disease after
 the first few days.  The morbid conditions which had occasioned the sen-
sation  of thirst, probably continue; but  the faculty of perceiving these
conditions, or of  suffering in  consequence of  them,  is  no longer acute.
This idea is confirmed  by a fact above  noted, viz.,  that in  most of the
cases in which thirst  continues through  the career, the disease is of a mild
grade—less obtuseness  of sensibility belongs to its progress.   It is also
confirmed by another fact which I have  very generally observed, but which
is not noted in the histories, viz., that although the sensation of  thirst may
not create sufficient uneasiness to lead the patient to ask  for drink, never-
theless, when  it is presented, he almost always takes it with readiness, and
frequently with avidity, showing the existence of the  symptom,  but as it
were, latent, owing to the mental apathy peculiar to this disease.
   Tongue.  The  morbid  appearances  of the tongue are observed  with
attention in  all diseases;  but in few, if any, are they generally reo-arded as
possessing greater interest and importance than in febrile affections.  Some
practitioners attach a  significancy and value to particular conditions of this
organ,  which close investigation  probably will not warrant.   Certain ap- 
REPORT  ON CONTINUED FEVER.
63
pearanccs are supposed to stand in a fixed  relation  to certain  pathological
conditions of other parts,  and of the system at large; or, they are thought
to foreshadow the issue of the disease, or to indicate particular methods of
treatment.  These notions, which it might be presumed  involve both truth
and error, are  partly empirical and  partly speculative—that  is to say, in
some instances, theoretical views have doubtless  had more or less to do in
originating  them; but it is  also frequently claimed that they are corrobo-
rated by experience.  In either case,  the analytical investigation of a large
number of  recorded observations, is the  proper  tribunal for adjudication.
By ascertaining  precisely the position which every appearance occupies in
the natural history of the disease,  its importance as a symptom  or sign is
determined.
   There are two points of view in which the appearances of the  tongue in
Continued Fever are to be studied.   First, the different appearances which
are found in cases of the disease, considered collectively, their relative fre-
quency of occurrence, their relations with other symptoms, etc.    Second,
the different appearances which are successively  presented during the pro-
gress of the disease, in individual cases.   In both points of view, the ap-
pearances are vaiious.
   Of the fifty-two cases which are the subjects of the  present analysis, the
 histories  contain an account of the appearances which the tongue  presented
 durino- the febrile career, in all but two cases.   In not  one of these  cases
 did the tongue retain a perfectly normal  aspect  through the career of the
 disease.   The nearest approximation to this was in  one of the cases in
 private practice—(Typhoid)—in  which  the disease  was of  a  very mild
 grade, the patient being convalescent on the fifth day.  In this case the
 tongue remained perfectly natural  in  appearance until a couple  of days
 before convalescence, when the superior  surface became slightly  opaque,
 hardly enough  so  to  be called furred, and not more  than is  habitually
 observed in many persons who call themselves well.   In all the other cases
 morbid appearances, more or less considerable, were presented.   The dif-
 ferent appearances presented in the different cases, involve varying degrees
 of  dryness of the  surface of the organ,  together with resistance to  the
 touch; coatings varying  in  thickness;  varieties in color;  smoothness,
 fissures,  etc.;  aberrations of muscular contractility, or  an inability to pro-
 trude  it facility of performing this act, etc.   I  will  take  up  the  more
 important of these appearances separately.
    Dryness of the Surface.   More or  less dryness of the tongue was present
 in a large  proportion of  the cases, viz., in six of the fourteen cases in pri- 
64
REPORT ON CONTINUED FEVER.
 vate practice; in fifteen of the eighteen hospital cases of Typhoid, ten of the
 twelve cases of Typhus, and five of the eight cases of doubtful type ;  making,
 in all, thirty-six of the fifty cases in which the appearances of the  tongue
 were noted.
    The dryness differed in degree  in the different cases; in  some being
 slight, in other cases extreme, and in others, moderate.   In several cases,
 the dryness was accompanied with hardness, that is, the surface presented
 an appearance as if desiccated or  baked, offering firm  resistance to the
 touch.   This was observed  in two of the cases in private practice;  in three
 of the hospital cases of Typhoid, in four of the cases of Typhus, and in
 one of the cases of doubtful type.
   The dryness, in some cases, extended  over the  whole superior  surface,
 and, in other cases, was limited to the centre—a moist margin, of  variable
 width, existing on either side.   The latter  was  observed  in  one of the
 cases in private practice;  in eight of the hospital cases of  Typhoid, in four
 of the cases of Typhus, and in two of the cases of doubtful type.
   The dryness was in no case observed  at the commencement of the
 febrile career.   In all  the cases that came  under observation at the com-
 mencement, the dryness did not appear  until several  days  had elapsed;
 and in every instance in which dryness was  present  at the  time the case
 was first observed, the disease had  existed  for several days.   This condi-
 tion, therefore, although so  frequently present in  Continued Fever, does
 not belong to the early stage.
   What does this symptom  denote? in other words, what are the causes
 which produce it?   Diminution of  the secretions from the salivary glands
 and mucous follicles is, doubtless, a cause; but it is not, probably, the sole
 cause.  It proceeds, in  part, from the condition of  the mind incident to
 Continued Fever.   Owing to the apathy as respects painful sensations, the
 patient appears to experience little  or no  discomfort from the dryness and
 hardness  of the tongue.   He, therefore, does not move  the orcan suf-
 ficiently  to  diffuse  the scanty salivary secretion  over its surface.  The
 tongue, moreover, participates in the inertia of the muscular  system.  It
 remains  motionless.  The somnolency which obtains in the majority of
 cases, contributes to this  symptom.   The patient lying most of the time
 somnolent respiring through the  mouth,  (the nasal  passages frequently
 being more or  less obstructed,) the surface of the tongue is desiccated by
the current of air passing over it.
   The correctness of the above explanation is proved by the following con-
siderations :—Patients very seldom make any complaint of the condition of 
                     REPORT ON  CONTINUED FEVER.                   65

the tongue, however dry and hard it may be.   The dryness and hardness
do not come on during the early part of the  febrile career; nor,  (as has
been seen in the preceding Section,) do  somnolency, muscular inertia, and
mental apathy.  The former and  the latter occur concurrently, at the same
period in the febrile career; and, as a general remark, it will probably be
found  that they disappear together.  Finally, the degree of dryness and
hardness will be found to bear a certain  degree of correspondence with the
ataxic symptoms just mentioned; nor are the  former present, as a  general
rule, in  cases in which the latter are absent.  In evidence of  the state-
ments last  made, I have examined,—-first, the symptoms referable to the
nervous system in all the  cases in which dryness of  the tongue was not
present, and the results  are as follows:—of the eight cases in private prac-
tice, in which dryness of the  tongue was not noted, in one, the tongue
could not be inspected, except at first owing to parotitis; in one, the patient
died on  the third  day; and in  one, the records contain nothing on the sub-
ject.  Of the remaining five cases, somnolency, muscular inertia, and men-
tal apathy, were not  marked in one case, and  were almost  absent  in each
of the other  cases, all of which were extremely  mild as respects the grade
of severity of the disease.  Of the hospital cases, in the two instances of
 Typhoid, in which dryness of the  tongue was not noted, active delirium,
followed by coma, existed in one  case, the patient dying on the sixth day;
in  the  other case, ataxic  symptoms were absent   In the two  cases of
 Typhus, in  which dryness of  the tongue was not noted, in one case, the
tongue  could not  be inspected,  owing  to parotitis, and in the other case
there existed hilarity and playfulness,  without either somnolency, muscular
inertia, and  mental  apathy.   Of the  three cases of  doubtful type in which
dryness of the  tongue was not present, in each case the nervo-muscular
symptoms just mentioned were  absent.  Second, I have  examined  the
symptoms referable to the nervous  system in the cases in which dryness
and hardness of the tongue existed, and find in all but two, (in which the
records  are defective,) evidences of the  presence of somnolency, muscular
inertia, and mental apathy—in other words, of ataxic  symptoms.  As the
histories do not state the degree  of  these symptoms, I am unable to ascer-
tain whether, in that respect, they corresponded with the degree of dryness
which the tongue presented.
   In conclusion, then, we are warranted in saying that, although dryness
and hardness of the surface of the tongue denote deficiency of the secreted
fluids  poured into the mouth,  they are to a considerable extent dependent
                 F 
06                  REPORT ON  CONTINUED  FEVER.
on the condition of the mind and  muscular system, and may be considered,
to some extent, as measuring the disorder of the latter.
   Coating.   In forty-seven  of the fifty cases in which the  appearances of
the tongue were noted, it was more or less coated during the febrile career.
Of the remaining three cases, (all of  which were of the Typhoid type,) in
one there does not appear  to have been  any coating;  in  one, there was
none  for the first two or three days after the case came under observation;
but the tongue could not be inspected afterward, owing  to parotitis, affect-
ing both sides;  and in one,  there was merely a slight opacity, hardly suffi-
cient  to  be called a coating.   Under the  head  of  Coating,  I mean to
include all instances in which a morbid secretion,  or exudation, was depo-
sited  on the superior surface of the tongue.  It is common  to distinguish a
furred or frosted tongue, from one  which is coated, the latter being applied
when the morbid  deposit is of an appreciable thickness.   For the sake of
convenience,  however, I have  used  the term Coating in  a sense  broad
enough to embrace  the former as well as the latter.   The coating varied
much in .the different cases as  respects thickness.   All  of  the histories do
not contain precise information on this point, but, in the  majority of instan-
ces, it is stated either that the tongue was thickly coated,  or  thinly coated, or
merely furred.  The enumerations with regard to  these three modifications
of coating are as follows:—Of the eleven cases in private practice, in which
coating is noted,  it is simply stated,  that the  tongue  was coated in three;
it was thickly coated in four; it was thinly coated in two, and furred in two.
 Of the eighteen hospital cases of  Typhoid, it was  coated in four;  thickly
coated in two; thinly coated in six; furred in five, and no coating existed
in one case.   Of the twelve cases of  Typhus, it was coated in five ;  thickly
coated in three; thinly coated in two; furred  in  one  case,  and the organ
could not be inspected, owing to the  existence of parotitis, in one case.
   Of the eight cases of doubtful type, it was  coated in four; thinly coated
in two; thickly coated in one case, and furred in one case. The cases of the
different types of Continued Fever presenting respectively these  differences
 in thickness of the coating, are not uniform in number, but the discrepancy is
 not such as to warrant the  conclusion that either modification is more likely
 to occur  in the  Typhus, than in the Typhoid type.  Not less disparity
 would, very likely, be found on comparing different collections of cases of
 the same type,  than in the  comparison, in this particular, which these cases
 afford of the two  types.   We should not  expect to discover in  the varieties
 of this symptom any traits  distinguishing one type of the  fever from the
 other, inasmuch  as  these  varieties  are  based on differences  in  degree 
REPORT  ON CONTINUED FEVER.
61
merely, not in kind, and,  moreover, are common enough  in  other, and,
indeed, in almost all affections.
  There seems to be no room for the inquiry whether the coating has any
connection with any other  particular  symptoms, or group  of  symptoms,
belonging to the natural history of Continued Fever.   Occurring, as the
symptom does,  in almost  every  case  of  Continued Fever, it must be
dependent on some one or more of those morbid changes which constitute
the elements of  the febrile  state.   Farther than this, in the present state
of knowledge, we are unable to  carry the explanation  of this, as well  as
various other symptoms appertaining to the disease under consideration.
  The only remaining points of inquiry which occur to me under this head
are, first, to examine the  histories of  the few cases in which  the tongue
was not coated,  in order to see in what  respect they differed from the
others; and, second, to compare some of the cases in which the  tongue wbs
thickly  coated, with some of those in which the coating was thin, in  order
to see if the degree of  coating affords, to any extent,  a criterion of the
severity of the disease.
  As already stated, in but three  cases is  the  absence of coating noted,
and in one of  these cases the  tongue could not be inspected after the first
two or  three days, owing  to  parotitis.   The  patient, in this case, at the
time she was attacked with fever, was  suffering from stomatitis materna,
and the tongue presented a characteristic reddened, excoriated appearance.
One of the remaining cases was the  case  in which the tongue preserved
its  normal  appearance save a very slight  opacity.  This case was distin-
guished for its mildness, and short duration.  In the other case, the tongue
was reddened, glazed, and  somewhat fissured.  The patient, in this case,
had been ill eleven days before entering the hospital.   It is highly proba-
ble that there had existed coating of the tongue, which had exfoliated prior
to his entrance.    The case was one of medium  severity, and was  not dis-
tinguished  by any peculiar features.  Convalescence was pronounced  on
the fourteenth day after his entrance.  It will be observed that the circum-
stances appertaining to each of these cases were such that the latter are
hardly to be considered exceptions to the general rule, as regards  the uniform
existence of more or less coating of the tongue in the present collection of
cases of Continued Fever.
   With regard to the second  point of inquiry, I have examined and com-
pared cases sufficiently to ascertain that the thickness of the coating cannot
be  considered as denoting the gravity of the disease, or the  danger of  the
patient.   Whether, in  the  larger  proportion of severe or  fatal  cases, 
68
REPORT ON  CONTINUED FEVER.
the tongue may be thickly, or thinly coated,  I am not prepared to say—
the present collection of cases is too small  to  afford statistical results ade-
quate to the  settlement of this question.  But that, if any such  law exists,
the exceptions are sufficiently numerous and striking to render its applica-
tion to individual  cases nugatory, my cases afford  sufficient evidence.   Of
two of the fatal cases  of Typhoid, the tongue was merely furred in one,
and, in the other, at first furred,  and subsequently thinly coated.   In one
of the fatal cases of Typhis, it was thinly coated.   On the other hand, in
several  cases  in  which  the tongue was  thickly  coated, the disease was
mild.  In the fatal case of  Typhus occurring in private practice, in which
death occurred on the  morning of the fourth  day, the tongue presented a
normal  aspect, except  that  it was tremulous, for  the two first days,  and
became  thickly coated  on the third day.
   It appears pretty obvious that very little importance is due to the degree
of coating on the tongue in any  of the practical relations, or bearings, in
which the symptoms of disease are to be considered.*
   The coating of the tongue, in the majority of cases, appeared early in the
disease,  preceding dryness.    The  tongue, however, was not thickly coated
at first, in several cases in which  it became so at a subsequent period.  It
was frequently at first  simply furred,- and  in  the  progress of the disease
became  thickly coated.  As a general rule, the coating became  thinner
toward convalescence,  and gradually  disappeared—leaving the appearance
of  the  organ  healthy.  In a few cases,  however, the tongue  continued
somewhat coated  after convalescence was established.
   The color  of the coating was generally white, or dirty white,  sometimes
yellowish.   In seven cases it became  of a dark color.   Four  of these were
cases of Typhoid;  two in private practice, and  two in hospital; two were
cases of Typhus, and  one was a case  of doubtful  type.  In one of these
cases the disease proved fatal, but in  the other cases the disease was either
mild, or  of a medium grade of intensity; so that  there is very little, if any,
foundation for the idea that the dark, or black color of the coating, in cases
  * The foregoing results relating to dryness of the surface of the tongue, and coating,
appear to  present a striking disparity on comparison with those developed by the
researches of Louis.  He found in a considerable number of cases, the tongue natural, or
nearly so. This was true of grave and fatal cases as well as of those of a mild grade.  The
appearances which the tongue presents are so obvious, and offer so little room for error
of observation, that, with every disposition to distrust my own ability as an observer, I
cannot admit the supposition of incorrectness, in the histories I have collected.
  In the cases  analyzed by Dr. Jackson, the tongue appears to have  been more uni-
formly altered  than in  the cases  analyzed by Louis.   Dr. Jackson says, " with few
exceptions the  tongue was noted as coated, or furred." 
REPORT ON  CONTINUED  FEVER.
69
 of fever, denotes extreme danger.  This idea is entertained by some, who
 regard the coating as representing a perverted  state of the fluids, and the
 dark color as denoting putrescency.
   Exfoliation of the coating during the career of the disease, occurred  in
 three cases—one case being of the Typhoid, one of the Typhus, and one  of
 doubtful type.  In the first of these three cases the tongue became subse-
 quently dry and  hard, and another coating succeeded.   In the two other
 cases the tongue, directly after the exfoliation,  was moist, and  of natural
 color,  and the occurrence of  a second  coating is not  mentioned.   In each
 of these three cases the disease was mild.
   A scabby appearance  was noticed  in a few cases, viz., two cases of Ty-
 phoid, and two of doubtful  type.   This appearance was owing apparently
 to dryness  and coating co-existing, the morbid  deposit on the  tongue be-
 coming cracked and subdivided into small portions, which were  partially
 detached.
   In two cases, one of Typhus, and one of doubtful type,  the coating was
 in discrete patches; but in all  the other  cases it was  either diffused over
 the whole superior surface, or extended across the base,  and, more or less,
 toward the  tip, or  covered a  margin on each side of  the whole length  of
 the organ.
   The pathological explanation of coating does not fall  within the scope
 of this report but the reflection arises,  how little we know of the causes  of
 this symptom in any, and all of its varieties—in other words, of the morbid
 changes of  which the symptom is the immediate effect.   Its mysterious
 character is perhaps less appreciated  on account of its being so common.
 But that a  morbid  product  should be deposited  on  the surface of the
 tongue, without any other appreciable evidences of disease of that organ.
 that the  presence of this product should so often denote the continuance
 of disease, and its disappearance signalize the occurrence of convalescence*
 's certainly a curious fact, and  one which, in the  present  state of know-
 ledge, cannot be accounted for.  All that is known of  this symptom, as  a
 symptom, or sign, has been obtained by observing its association with other
 events, and in all diseases, as well as in Continued Fever, its special sig-
 nificancy is quite limited.
   Redness  of the tongue.  The superior  surface  of  the tongue was red-
 dened in seven cases of the  Typhoid, and in one case of  doubtful  type.
 This appearance was not observed in any of the  cases of  Typhus.   In one
of the cases of Typhoid the redness was associated with stomatitis materna
or the sore mouth of nursing women, under which the patient was laboring 
10
REPORT ON CONTINUED FEVER.
 when  attacked  with fever.  In two of the remaining cases, the  disease
 proved fatal.  In one of the fatal cases, the disease was characterized  by
 active delirium.  Vomiting was not present,  nor diarrhoea.   The only
 gastric symptom was thirst,  which was, at first,  considerable.  At the
 autopsy, in this  case, there were found  punctated redness and softening of
 the  mucus  membrane, together with  several  ulcerated  patches.  The
 papillae of the tongue were unusually prominent in this case.  In the other
 fatal case, vomiting, and other  gastric symptoms, are not mentioned, and
 diarrhoea did not exist.  Moderate tympanites and abdominal  tenderness
 were present.   At the autopsy the stomach was not examined.  In the
four remaining cases the disease was not severe, save in one case.  Symp-
 toms indicative of disorder of the digestive tube, in  these cases, respect-
 ively, were as follows:—In one, moderate diarrhoea—no vomiting.   Conva-
 lesced on the tenth day after entrance, and left the  hospital on the six-
 teenth day.  The redness of the tongue, in this case, continued after con-
 valescence was established.   In onet neither vomiting, nor other symptoms
 of unusual gastric disorder were present,  and diarrhoea  did  not exist
 In one,—the same as in the last case.  This case was tolerably severe.   In
 one, no vomiting or other gastric symptoms, and diarrhoea was not prominent.
 In the case  among those of doubtful  type,  no gastric  symptoms were
 present, but moderate thirst, at first.  Diarrhoea did not exist, and  disten-
 sion and tenderness of the abdomen were absent.
   The fact that in no case of Typhus was redness of the tongue present,
 is perhaps worthy of note.
   I have given this summary of the other symptoms referable to the diges-
 tive  system in the cases in which a reddened tongue was observed, because
 the idea still  prevails, to some extent, with  practitioners, that this appear-
 ance denotes either inflammation, or notable irritation of the mucus mem-
 brane, lining the digestive canal, and more particularly the stomach. In so far
 as symptoms are concerned, the above instances afford  no evidence  in sup-
 port of  this  hypothesis.  The  fatal  case  in which the  stomach was ex-
 amined, it is  true, was characterized by  gastric  disease which was not indi-
 cated by gastric symptoms during life.   The researches of Louis, however,
 have established, conclusively, that in fatal cases of Continued Fever there
 does not  exist any constant connection between the  appearance  of the
 tongue, and the  existence of lesions of the stomach.
   Tremulousness of the tongue.  Tremulousness was observed in seven
 cases, viz., in three of Typhoid, and  in four of Typhus.  Three of these
 were fatal cases.  In  the other  instances  in which this appearance wa3 
REPORT  ON CONTINUED FEVER.
71
noted, the disease was not of very great  severity.   Nor was  this appear-
ance associated with singultus, tremor of other muscles, or marked disorder
of the ©ervous system, in any case excluding the  fatal  cases.   In one of
the cases the tongue continued somewhat tremulous during convalescence,
and even at the time the patient left the  hospital,  six days after convales-
cence was established, remaining, also, somewhat reddened.  A tremulous
state of the tongue, then, cannot be considered as representing  a condition
of the muscular system in general, nor as an indication of the degree to
which  the nervous system is  affected.  And although, as it would  seem,
it is apt to occur in cases which prove fatal, its presence need  not affect
very materially the  prognosis,  since it also  occurs  in cases in which the
disease  is of a medium grade of intensity.
   Difficulty of protruding the tongue.   This existed, to a greater or  less
extent,  in six cases, viz,  in two of  Typhoid,  three of Typhus, and in  one
case of  doubtful type.   In two of the Typhoid cases the difficulty was not
great.   The patient only did  not readily  succeed in the effort to protrude
the tongue.   In the other Typhoid case the  patient was wholly unable to
accomplish the protrusion,  but this inability  existed during one day only.
This was the day before the decease;  and on  the day of the decease he
succeeded in protruding the tongue without great difficulty.   In this case,
also, there was loss of the power of articulation for the last two days of life.
The patient could  be roused to make an effort to speak, moving his lips,
but uttering no articulate voice.   In  the two Typhus cases the difficulty
of protruding the tongue was great.  One of these cases was characterized
by apoplectic coma, and there existed great difficulty in moving the  upper
extremities, as  well as the tongue.  In the other case the patient exhibited
unusual somnolency, which eventuated in coma.   This case ended fatally.
In the case of doubtful type, there existed inability to protrude the tongue
on the first day of  entrance,  unusual feebleness of intelligence co-existing.
The patient could not be made to reply to questions.   The ability to pro-
trude the tongue was recovered  on the  following day, and, at the same
time, there was improvement in the state of the intellect.   In all the cases,
save one, the difficulty in  protruding the  tongue,  corresponded, in degree,
with the diminished power of exerting acts  of the will  to produce volun-
tary motions; and in the excepted case, the difficulty was inconsiderable in
deo-ree.  It would seem, therefore, that  this symptom, in so far as it may
possess any special significance, is more a criterion of  the condition of the
mind, than of the muscular force.
   A remark suggests itself  in  this connection which  is not limited in its 
72
REPORT ON  CONTINUED FEVER.
 application to cases of  Continued Fever.  It is, that patients whose intelli-
 gence is so far  compromised that they cannot  be made to reply to ques-
 tions, may often be induced to protrude the tongue, or to make an effort
 to do so.   The mental apprehension seems sometimes  not to extend be-
 yond the request to perform this single act.   I know of no way of account-
 ing for this curious fact except that, as the inspection of the tongue always
 enters into the  daily examination of cases of disease, it  becomes so asso-
 ciated with the  visit of the physician, that, if a patient retains mind enough
 to recognize his medical attendant, he almost  instinctively apprehends the
 request to protrude the  tongue.   It requires,  from the  association just
 mentioned, less mental effort  than to understand  and comply with other
 requests.
    More or less hesitancy in protruding the tongue was frequently observed,
 although pains were not taken to note observations concerning this point
 in the histories.  It appeared, often, as if the patients took time for delibe-
 ration before exerting the act of volition, and the protrusion was made very
 slowly,  as if the organ were not fully under the control of the will. This,
 doubtless, proceeds from the same mental  condition which, when greater
 in degree,  leads to difficulty in performing  the  act or entire inability to
 accomplish  it.  Instances were  also  noticed in which, when the tongue
 was  protruded,  the patient seemed to  forget to withdraw it, and it was
 necessary to request him to do so.
   A few appearances were noted in addition to those already considered,
 which I will mention, in order to embrace all that the histories contain with
 respect to the tongue.  The tongue itself became fissured, or cracked,  in
four cases,  all of  the Typhoid type.  In one of these cases, the fissures
 did not heal for several days after convalescence was established.  In all,
 the fissures, or  cracks,  occurred while the  surface  of  the  organ  was dry
 and hard.   The superior  surface was noticed to be remarkably smooth  in
 several  (five) cases; and  in three of these  cases it presented a glazed ap-
 pearance.   The  smoothness  was apparently owing to dryness, the tongue
 being clean, and the glazed appearance to dryness with  a thin stratum  of
 coating.
   Finally, in one case, indentations of the teeth on the sides of the tongue
 were Doted.
   Variations in the volume and form of  the tongue, if they existed, were
 not recorded.
   The different  appearances of the  tongue found in the cases collectively,
 having thus been considered,  it remains to direct attention to the second 
REPORT ON CONTINUED FEVER.
73
point of view under which this  class of  symptoms are to be studied, viz.
the different  appearances which are  successively  presented in individual
cases.  This view of the subject has been, in a measure, anticipated in the
foregoing remarks.   To  present the facts  under this view accurately and
comprehensively, it would  be necessary  to give an account of the succes-
sion of appearances in almost every case  distinctly; for, very few cases are
to be found in which precisely the same  appearances are presented, occur-
ring  in the same order of succession and  time.   But  this minuteness of
detail would not subserve any  interesting or important purposes, since it
is, obviously, impracticable to deduce any fixed laws regulating  the suc-
cession  of appearances, or to arrive at any practical results.  It will suffice,
therefore, to  dismiss this branch of the subject with a few general remarks.
The cases differed  considerably as respects the number and  kind  of ap-
pearances which, respectively, they presented during  the febrile career.
In some cases the tongue remained simply furred; in others, it was furred
at  first, and  thickly coated,  subsequently;  in  others, it  was furred,  or
thickly  coated, early in the career, becoming moie or less dry subsequently,
and sometimes alternately moist and  dry at different times.   In a smaller
proportion of  cases the various other appearances  occurred—in some cases
one only of these appearances, and in others several—viz., tremulousness,
redness, fissures, etc.  All this, indeed, would be inferred from the account
previously given of  the various  appearances under distinct heads.   And it
would  be sufficient to  say, under this  division  of  the subject,  that the
analysis reveals nothing with reference  to the number and succession of
appearances in individual cases,  which has any  marked  bearing on the dis-
tinctions between the two types of fever, or the relations of the tongue to
other symptoms; moreover, the number and succession of appearances do
not  differ in any striking particulars in the cases which proved fatal, from
some of those which ended in recovery.
   In conclusion, with respect to  the appearances of the tongue in Continued
Fever,  judging from  the results  of the present analysis, their value, as
symptoms, cannot be considered very great.  Here, as in the case of other
symptoms, it does not enter into my plan to  inquire to what extent similar
appearances are to  be observed in other  diseases than Continued  Fever.
This, it is obvious, is a very important  inquiry in order to determine in
how far the phenomena  described  are peculiar to the  disease under con-
sideration.   With regard to this comparison, the most accurate and exten-
sive  collection of recorded observations  are  doubtless to be found  in the
researches of Louis.  But as regards the class of symptoms just considered
               G 
74
REPORT ON CONTINUED FEVER.
 every practical  reader is already aware that those which have been enu-
 merated  are  not, in an  eminent degree,  distinctive of Continued Fever,
 although, probably several  of  them are oftener found  in connection with
 that disease  than in most  other acute affections.  As a general  remark,
 however, they do not possess any very special significancy; in other words,
 they have not in the  present  state of knowledge very important bearings
 on the diagnosis, pathology, prognosis, or therapeutics.   The results of
 enumeration and comparison in their application to this class of symptoms,
 are rather negative  than positive.  But here, as in other instances, by tend-
 ing to disprove  some errors which are more or  less in vogue, these results
 are of scarcely less value, than if they disclosed important practical truths.
   Sordes.  The presence of Sordes on the teeth, or lips, or on both, was
 noted in fourteen cases, viz., in six cases of Typhoid; (two cases in private,
 and four in hospital practice;) in six cases of  Typhus, and in two cases of
 doubtful type.  In  six of these cases the deposit was confined to the teeth;
 in six it extended to the  lips,  and  in two cases its situation  is not men-
 tioned.  In all the cases in which it was observed on the lips, it  also existed
 on the teeth.   In five of the cases in which sordes was present, the disease
 proved fatal.  In eleven of the cases the tongue was either dry, or dry and
 hard.   In thirteen of  the cases, the tongue was more or less coated; and
 in the remaining case the tongue could not be inspected, owing to Paroti-
 ditis.   In no  case in which sordes was present,  could the disease  be called
 mild, and  in  most of the cases, exclusive of those which proved fatal, it
 was severe, and attended by considerable prostration.   In the  other cases
 the grade of  intensity was not far from medium;  and in the latter cases
the sordes was not abundant.
   This symptom very rarely occurs in the  early part of  the febrile career.
 In  one of the cases, however, it  appeared, and the deposit was abundant,
 on  the third day.  At the same time  that the sordes appeared on the teeth
 and lips, in this case, the  tongue, which  for the two  previous days had
 been  natural  in appearance,  became  thickly coated.   The  rapidity and
 abundance of  the deposit  in this instance, show, pretty conclusively, that it
involves some change in the  character of the  secretions of the mouth.
 This  case was of the Typhus type, and ended fatally on the fourth day.
   In so far as the changes in the salivary fluids giving rise  to sordes are
concerned, they do not belong intrinsically  to the disease, or, at all events,
if they uniformly take place, they are very unequal in degree, inasmuch as
the deposit is observed only in a limited number of cases.   Its presence is
to be  regarded as denoting gravity, since, in three-sevenths of the cases in ■ 
REPORT  ON CONTINUED FEVER.
75
which it was observed, the disease proved fatal, and in no instance in which
it occurred was the disease mild, but generally it was severe.  Neverthe-
less, it was absent in some fatal cases, and by no means uniformly present
in cases which were of a severe grade.   There seems to be no foundation
for the idea, which has been  entertained, that it is specially significant of
adynamia.   Nor  does  it indicate, more than a dark color of the coating of
the tongue, a  putrescent  state of the fluids.  Co-existing, as it does, with
more or  less coating of the tongue, it seems fair  to infer that it proceeds
from a cause common  to both; and  being  also found generally in connec-
tion with dryness of the tongue, we may presume  that it is, in a measure,
owing  to the  mental  condition which, as has been seen, induces, in  part,
the latter condition.
   Haemorrhage from the  Gums.   Oozing of blood from the gums occurred
in two cases, both of  the  Typhoid type, one in hospital, and the  other in
private practice.   In one case (private  practice) the  disease was mild, un-
attended by delirium,  accompanied by mild diarrhoea, tongue thinly coated,
convalescence dating from the twenty-first day.   The  hemorrhagic  effu-
sion occurred in the latter part of the disease, blood exuding pretty freely,
so as to color  constantly the saliva, and  to form incrustations on the lips.
In the other case the disease  proved fatal  on the tenth day.  The  hemor-
rhagic effusion occurred on the sixth day, forming bloody incrustations on
the lips.  He complained of soreness in the throat, and a sense of dryness
in  the  mouth.  Diarrhoea  did not exist  in this  case.  The tongue was
coated, at times somewhat dry, and tremulous.   In neither of these cases
did hemorrhage occur from the bowels, or  from any part except the  gums.
   An herpetic eruption about the mouth was observed in one case.  Lest
the  occurrence of  this symptom may suggest a suspicion that the disease
was, in this case, remitting fever, in which herpetic eruptions in that situa-
tion are apt to occur, it may be stated  that no doubt could exist as to  the
diagnosis,  the characteristic  maculae, together with other  distinguishing
traits,  being present.
   Parotiditis.  In five cases,  the parotid gland on one, or  both sides, was
the seat of inflammation, proceeding to suppuration in all but one case, and
in the excepted case death took place before sufficient time had elapsed for
 the suppurative process to be completed.  In two of these  cases the disease
was Typhoid, in one,  Typhus, and  in  two the type was doubtful.  One of
the cases occurred in private, and the other cases in hospital practice.  In
the first case in which this complication occurred,  the patient entered  the
hospital, March 29, 1849.   Prior to this case  I had never met with this 
76
REPOKT ON CONTINUED FEVER.
complication in Continued Fever.   Two other cases occurred at the hospi.
tal in November, 1849; and the remaining hospital case was in December,
184'J.  The case in private practice occurred in May,  1850.
  In two of these five cases the disease proved fatal.
  It is due, to  the importance of this intercurrent affection to devote to each
of these  cases some special  consideration.   In the first case, the patient
entered the hospital five days after taking to his bed.   The parotid of the
riiiht side began to 6well on  the second day after his entrance.   It became
greatly enlarged, hard, painful, with erythema of the surface, and proceeded
to suppuration, opening below  the ear, and  also into the meatus auditorius.
A large quantity of pus, and  sanguinolent  fluid, was discharged  through
these two orifices.  The discharge of purulent matter continued during the
career of the fever, and for several weeks afterward.  A portion of cellular
tissue about the size  of the end  of  a finger, sloughed, and  came away
through the orifice below the ear.  Owing  to the swelling,  and the pain in
moving the jaws, the  patient  could  not, for several days, open the mouth
sufficiently for  the tongue to be inspected.  Convalescence was dated on
the fourteenth  day  after his entrance.  This was  a case of Typhus,  pre-
senting  the characteristic  eruption  of that type.   Diarrhoea,  tenderness,
and  meteorism  were not present.   Passive delirium,  with  getting out of
bed, somnolency,  some subsultus, and  on one day  carphologia,  were noted
in the record of this case.
  In the second case, it is not stated whether the patient had been  confined
to the bed before  entering the hospital.   On  the seventh day after his
entrance, swelling of the left parotid commenced.   The swelling was con-
siderable, accompanied with  redness, soreness, and  pain.  In this, as in all
the other cases, before suppuration  was accomplished,  the swelling was
remarkably hard, or resisting  to the  touch.  Eight days after the  com.
mencement of  the  swelling, fluctuation  being apparent, an incision was
made, and a large quantity of  pus evacuated.  In  two or three days after-
ward, another  and distinct collection  of  pus was opened.   The discharge
continued,  but  gradually diminished,  and at the time of the decease, the
swelling  was much reduced, and the quantity of pus small.   This  case ter-
minated  fatally on the twenty-third day after entrance.  Diarrhoea, mete-
orism, and  tenderness were absent in this case.   Delirium, and other ataxic
symptoms, were  not  prominent.   The  disease  did not seem to be  of a
severe grade of  intensity, and death, apparently,  was determined by the
affection  of the parotid.   This case is  included among the cases of doubtful
type.   No autopsy was had.  In the  third case, the affection of the paro- 
REPORT ON CONTINUED  FEVER.                  77
tid commenced four days after convalescence was pronounced.  Properly
the affection in this instance should be classed among the events of conva-
lescence, or the sequelae.   The patient had entered the hospital twelve days
before the  date  of  convalescence.  He had not taken to his bed before
entering the hospital, but had been ill for about twenty days, making strong
efforts to keep about, and resist yielding  to the disease.   The swelling, in
this case was  large, tender, hard, and painful, and the  surface reddened,
and it proceeded to suppuration.  An incision was made when fluctuation
was discovered, but the abscess also ulcerated and discharged through the
meatus auditorius.   Diarrhoea, meteorism, and tenderness were not present
in this case.   Delirium was also absent.  Eryepelas of the  face succeeded
the parotiditis.  The patient was  quite well  forty days after his entrance.
This  case,  also, is embraced among the  cases of doubtful  type.
   In the fourth case, swelling of the right parotid commenced on  the sixth
day after the patient entered  the  hospital, and  ten days after the attack.
The patient was a female.  The  swelling  was large,  somewhat livid, with
redness, tenderness, and pain.   On the day succeeding  that on which the
swelling of the right parotid commenced, the left began to enlarge, and it
soon  became greatly swelled, reddened, painful, and  tender.   The inflam-
mation on  both sides proceeded to suppuration.  On  the twelfth day, fluc-
tuation being apparent in both sides, an incision was made, giving exit to
a copious purulent  discharge.   A portion  of cellular  tissue protruded
through the  orifice on  the  left side, and sloughed away.   There was no
discharge  into  the meatus, in this  case.   There was no diarrhoea in this
 case,  but moderate tenderness, and  meteorism.   Delirium  was  slight.
 Moderate  somnolency existed.  It was difficult to fix the day of  convales-
cence.  She sat up on the twenty-fourth day  after her entrance, and  the
 last record was made on the twenty-eighth day, when there was still some
 discharge  from the abscesses.   This case was of the  Typhoid type.
   In  the  fifth  case, the fever had existed  five  days before the patient
 received medical  attention.   In this  case the patient was  a female.  She
 was  suffering from nursing sore  mouth when attacked with fever.   On the
 seventh day  after the attack, the right  parotid began to swell, and became
 greatly enlarged, hard,  reddened,  and  painful.   Death  occurred  on the
 ninth day, the affected parotid still being greatly enlarged, and resisting to
 the touch.  This case was of  the Typhoid type, and occurred in  private
 practice.  It was  characterized  by mild  diarrhoea, tenderness, meteorism,
 passive delirium,  somnolency  eventuating in  coma,  the  patient  dying
 in the latter state. 
78
REPORT ON  CONTINUED FEVER.
   Parotiditis  is  certainly a  much rarer complication of Continued Fever
 than would appear from the proportion of instances in which it was  present
 in this collection  of cases.   It is not mentioned in  the researches of Louis,
 nor  is it alluded  to in  the  treatise by Bartlett.   In Christison's  work on
 fever, and  in Copland's dictionary, I find it referred  to, as  an event which
 occasionally occurs toward  convalescence,  in some cases, proving critical,
 and  therefore desirable.  These views are not sustained by  the  facts in the
 cases that  have come under my observation.  In all,  save one, the affection
 occurred before  convalescence  was  to  have been  expected,  and  in the
 excepted  case it  occurred  after convalescence was  declared.   In all the
 cases it was a serious complication, not only adding to the sufferings of the
 patient, but increasing  the  severity of the disease, and, in one instance, it
 appeared to be the determining cause of a fatal issue.
   That this affection should have occurred in five out of thirty cases coming
 under observation between the dates of the first and last of the cases in
 which this complication existed, is  a  remarkable fact, of which I can offer
 no explanation.   It may possibly be suspected that  a contagious influence
 was  transmitted  from patient to patient;  but there  is no  ground for this
 hypothesis.  The specific form of parotiditis was not  prevalent at the hos-
 pital during the  period these cases transpired, nor, except  in one instance,
 were the patients  brought into contact with any  other patients laboring
 under this  complication.  It occurred in  two patients  in  the same ward,
 successively, with a few days' interval.   In the other two hospital cases,
 the  patients were not in wards in which any case  had occurred, and the
 case in private practice had no connection whatever  with the cases at the
 hospital.   The fact  can only  be considered as  exemplifying  what  Syden-
 ham and others  have remarked—that fever,  at different times  and places,
 may be characterized by peculiar and various  local tendencies, and  science
 is no better  prepared  to explain their occurrence now, than at any past
 period in medical history.
   Nausea  and Vomiting.  Nausea and vomiting occurred  in a very small
 proportion  of the cases, viz., of the cases in private practice, in three; of those
 in hospital, Typhoid, in three  cases;  Typhus, in one; doubtful type, two.
 The  vomiting, in all  these cases, was slight, and in all  it occurred early in
 the career  of the fever, as follows:—of the  private cases, in one instance it
occurred once  before  the case came under mv  observation, and may have
been owing to remedies; in another instance  remedies were rejected for
the first  few days; in  the third  instance slight vomiting early  in  the dis-
ease. Of  the hospital cases,  Typhoid, in one instance, it is noted that the 
REPORT  ON CONTINUED FEVER.                  79
 patient vomited early in the disease; in another instance the patient vomited
 on the day of attack and not afterward, and in the third instance remedies
 were rejected on the first day.  In the single case of Typhus, the patient
 vomited two or three times early in the disease.   Of the two cases of doubt-
ful type, in one  the patient vomited once on the second  day, and in the
 other case vomiting occurred several times during the first few days.
   Vomiting occasionally occurred after the administration  of antimony, but
 the instances in which this symptom was obviously the result  of that
 remedy, are not included  in the  above.  It is to  be recollected that the
 present  enumeration  embraces only  those  instances in  which vomiting
 occurred after the  febrile career was  established.  This  symptom  occurs
 in a larger  proportion of cases, if the  access be included.  It is also to be
 borne in mind  that in a  considerable number of  the  hospital  cases the
 febrile career had continued for a greater or less period before the patients
 came  under  observation.   In some  of these cases vomiting may have
 occurred, and the fact not have been noted in the previous history.
   I should  state that  in the great majority of cases in  which the occur-
 rence of vomiting is not noted to have occurred, no mention is made of this
 symptom in the histories.   It is, however, quite improbable that in any of
 these cases it should have occurred after the patient came under observa-
 tion, and not been  embraced in the record.   Certainly this  could not
 have been the case if the symptom had been in any degree prominent.
   In one of the cases in  which vomiting occurred, the disease was fatal.
 The stomach, in this case, at the  autopsy, was found  to be normal in size,
 the mucous membrane of a dingy brown color, notably thickened,  and some-
 what softened,  without redness  or vascular injection.  The vomiting,  in
 this case, occurred  only two or three times, and in  the  early part of the
 disease.  It was not a  prominent symptom.  In two fatal  cases in  which
 the stomach exhibited  lesions, ulcerations existing  in one case, vomiting is
 not noted to have occurred.
    The  foregoing  facts are  chiefly important in a negative  point of view,
 that is to say, they go to  show that nausea and  vomiting rarely occur in
 Continued  Fever,  and when they are present, they are not prominent as
 symptoms, and are confined to the early part of the febrile career.    Nega-
 tive results of this kind are sometimes scarcely less valuable than those
 which are positive.  In this instance the infrequency  of vomiting is impor-
 tant to be taken into account in the discrimination of Continued from Re-
 mitting  Fever, the symptom occurring much more frequently in the latter
 disease. 
 80                  REPORT ON  CONTINUED  FEVER.

   Pains in the stomach, and other  gastric symptoms, inclusive of  tender-
 ness on  pressure over the epigastrium, aie not mentioned in any of the
 histories.  It  is  possible that had  attention  been  directed  carefully to
 these  points,  something might  have  been  observed  worthy  of being
 recorded.   Any  evidences of gastric disorder, however,  which were promi-
 nent, would not have been likely to  have escaped notice.
   Alvine Discharges.  Questions relating  to the nature of the distinction
 between the two types of Continued  Fever,  (Typhus and Typhoid,)  and
 to the practical discrimination of  each  from  the other,  involve  especially
 morbid conditions of  the intestinal tube and  their symptomatical expres-
 sions.  The facts, therefore,  embraced under  the  heads which remain to
 be considered in this Section, are  to be studied with care in each type
 separately, and the results compared.
   Typhoid.   Cases in Private Practice.  Of  the thirteen cases,  diarrhoea
 was present in twelve.  It was mild in degree, or slight, in seven of these
 cases.   It was severe and persistent in  but one case.   It was confined to
 the early part of the career of the  fever  in four cases.  It  followed  the
 operation of cathartics in four cases.
   Cases in Hospital.  Of the eighteen cases, diarrhoea was present in nine.
 It was mild, or slight in degree in all but two cases, and one of these cases
 was fatal.   It was  limited to the  early part of the  career of  the fever in
 three cases, and in one of these cases continued but for a single day.   It
 occurred in the latter part of the  disease in one case.  It  continued, more
 or less, through the career in five  cases.
   Typhus.  Diarrhoea followed a cathartic in  the  single  case of Typhus in
 private practice.
   Hospital Cases.   Of the  twelve cases,  diarrhoea was present in four.
 The discharges were thin, but not too frequent in one case not included in
 the above.  In all  the cases it was very mild,  being  present but a single
 day in one case.   It was limited to the early part  of the  career of the fever
 in three  cases.  It occurred  in the latter part of the career in  one case.
   Adding the cases in private practice to those in hospital, diarrhoea was
 present in twenty-one of thirty-one cases of Typhoid; and in five of thirteen
 cases of  Typhus.  Moreover, in degree it was more uniformly  slight in the
 cases of  Typhus.  This  comparison, then, goes to  show that  diarrhoea
 occurs more frequently in the Typhoid  than in the  Typhus type  of fever,
 and that, although mild  in degree in the great majority of cases of both
types, it  is more uniformly slight in Typhus.
   I should define the sense in which I have used  the term Diarrhoea,   I 
REPORT ON  CONTINUED  FEVER.
81
have not applied the term to express  the character of  the dejections,  so
much as their frequency.  The character of the dejections, as will be seen
in an appropriate connection, were in a large proportion  of cases not ascer-
tained.   They may have been thin in  some cases  in which their frequency
was not much, if at all  increased, and  in  these instances diarrhoea would
not be noted to  exist.   The patient was not considered to labor under diar-
rhoea while the  dejections numbered only one, and  occasionally two in the
twenty-four hours.   This explanation will  serve,  in some measure,  to
explain the greater frequency of this symptom  in the  cases analyzed  by
Louis, a fact which  I find  on reference to his work since  the foregoing
results were written.  Louis  evidently considers  liquid dejections as con-
stituting diarrhoea.   Were it practicable to apply  this rule to my cases, the
number of instances in which this symptom  was  present, would, probably,
be greater.
   The reader will have observed that the proportion of instances of  diar-
rhoea is greater in the cases in private practice  than in those in hospital.
Why is this ?   The only explanation which offers itself  is, that, in most of
the  cases  in  private practice, cathartic,  or laxative remedies were pre-
scribed, while they were administered very rarely in  the cases at the hos-
pital.  The latter fact is important to be taken into  account in the conside-
ration of the abdominal  symptoms in  the latter cases.   It will  be noticed
that in four of the cases in  private practice the diarrhoea followed, and
apparently was occasioned by cathartic remedies.  The practical considera-
tions connected  with this point will come up more appropriately under the
head of the Treatment of Continued Fever.
   With  a view to  the   comparison of  the fatal cases with the average of
those not fatal, as respects  this  symptom,  I will  examine the  former  to
ascertain in how many  instances diarrhoea was present.   Of the two  cases
of Typhoid, and the single case of doubtful type, in private practice, proving
fatal, diarrhoea  was  present in  all.  It was a  prominent and persistent
symptom in one case; moderate, and  easily  relieved in  one case,  and the
degree is not stated in the remaining case.   It was  present, after the ope-
ration of a cathartic, in  the  case of Typhus in this group.   Of  the  four
fatal cases  of  Typhoid, of those in hospital, diarrhoea was present in two.
In one of these cases, it existed  early in the disease, and  was followed  by
obstinate constipation, resisting several drops of Croton  oil.   In another of
these cases costiveness existed.*  In one case  only  was the diarrhoea con-
* This case is reported in full under the head of Delirium. 
82
REPORT ON  CONTINUED FEVER.
siderable and troublesome.   Of the two fatal cases of Typhus, in hospital,
diarrhoea was not  present in either case.  The dejections were thin in one
of these cases, but not too frequent
   The connection of this symptom with  lesions of the intestinal tube is an
interesting point of inquiry, but this will be  more appropriately considered
in connection with the latter subject.   Costiveness,  more or less, was pre-
sent in five cases of Typhoid occurring in private practice.   In one of these
cases bloody stools took place;  in one, the costiveness was followed by diar-
rhoea  on the administration of  a cathartic;  in one the costiveness  fol-
lowed diarrhoea present in the early part of the disease;  in one it existed
throughout  the career, except  that a cathartic excited hypercatharsis; in
another case it continued, but cathartics occasioned profuse discharges; in
another case it continued until the fourth day, and was followed  by severe
and  persistent diarrhoea.   Costiveness was present in five of  the Typhoid
cases in hospital.   In one of these cases, it followed  diarrhoea, and in an-
other case it was followed by diarrhoea.
   In four cases no dejection occurred for three days, and in two cases none
for four days.
   Of the Typhus cases in hospital, and in private practice, costiveness
existed in three.   In one of these  cases no dejection occurred for several
days, and in two,  none for four days.
   The character  of the  evacuations, as  already stated, in  a large propor-
tion  of cases, was  not  observed.   This was  owing to the difficulty of pre-
serving them distinct, and  retaining them until the time of the daily visit.
In two  of the cases in  which the records contain  information  on this
point, the dejections are  stated to  have  been moulded, and natural in  ap-
pearance.  These cases were of the Typhoid  type.  In six cases of the same
type, the evacuations were thin and yellow,  and  in one case thin and of a
brown color.   Of  the cases of Typhus,  in a single  instance only was  the
character of  the evacuations noted, and in  this  case they were thin  and
yellow.
   Hemorrhage from the  bowels occurred in two cases, both of the Typhoid
type.  In both cases, the  disease terminated in  recovery.   One  of the
cases occurred in private practice,  and the other in hospital.  In the former
case, the discharge of blood occurred on  two occasions, castor oil having
been given  a few hours previously to each  time.   The hemorrhage was
pretty copious, and attended by considerable exhaustion, but on each occa-
sion  it speedily ceased after the administration  of opium and the  acetate of
lead.  Moderate tenderness over the abdomen existed in this case, but no 
REPORT ON  CONTINUED FEVER.
83
tympanites.  Costiveness existed throughout the disease in this case, and
laxatives were not ventured upon except in the two instances referred  to.
In the other case, copious bloody evacuations also occurred on  two occa-
sions, which ceased speedily after the exhibition of enemas of morphia and
tannin.   They were attended by considerable prostration.   The  dejections
at other times were thin  and yellow.  No abdominal  distension or tym-
panites existed in this case, but extreme tenderness, especially in the right
iliac region.
   The dejections were passed in bed, more or less frequently in six cases of
 Tyhoid, (two in private practice and four in hospital,) and in four cases of
 Typhus, (all in hospital.)  Of the Typhoid cases marked by this  event, two
 were fatal; and in but one of the fatal cases of Typhus is this event stated
 to have occurred.
   Evacuations in bed may be involuntary from  paralysis  or relaxation of
 the sphincter muscle  ; they may arise from unconsciousness, an unconscious
 act of volition, if this expression  be allowable ; or they may be  due to in-
 difference.   On  examining the histories of the  cases in which  this event
 is noted, I cannot discover that it is to be explained, in either  instance, by
 the  first of the  causes  just mentioned.   It did not occur  under  circum-
 stances of muscular prostration in which this explanation is admissible. In
 two instances it occurred in connection with a comatose condition, in which
 the second explanation would perhaps apply.  In the remaining cases, it
 was apparently owing to mental indifference.  The patients  did not appear
 to appreciate the impropriety of the act, or have any concern for the con-
 sequences ; although they  were easily  roused,  and manifested in their
 replies to questions more or  less intelligence.  Nor were they  annoyed by
 the contact of excrement with their persons.  In  two of the cases the de-
 lirium was active.   In none of the other cases, excluding the cases of coma,
 was somnolency  a  marked symptom, but in all more or less, delirium was
 present.   In  several of  the  cases, the  patients passed  evacuations in bed
 only occasionally, and in  two or three instances,  only once or twice during
 the continuance of the disease.
   It was found practicable to prevent this accident many times by carefully-
 watching patients, asking them frequently if they did not desire to evacuate
 the bowels, and occasionally placing them on the defecating chair, even if
 they expressed no  disposition to have a dejection.
    Tympanites.   This symptom was considered present only in those cases
 in  which there was obvious distension of the abdomen, as well as resonance
 on percussion.  This  signification should be defined, since it is stated that, 
84
REPORT ON CONTINUED  FEVER.
by French writers, the term (or its synonym  meteorism) is applied to  all
cases in which resonance is present, whether the abdomen appear distended
or not.
  Typhoid.  Cases in private practice.  In ten cases, nothing is stated on
this  point.  In  the remaining  ten cases, tympanites existed  in  three.   Of
these three cases, it was moderate in  degree in two, in one  case  existing
only on one day, and  it was extreme in one, which was a fatal case.
   Cases in Hospital.  The histories of all the eighteen cases contain informa-
tion  on this point.  Tympanites was present in twelve cases.   It was mo-
derate in all cases save one, and was considerable in the  latter case.  Ty-
phus.  In the single  case in private practice, tympanites was not present.
In the twelve hospital cases, (the histories 6f all of which contain informa-
tion  on this point,) tympanites was present in eight.  Of these cases it was
moderate in degree in three, slight in four, and in one case the degree is
not stated.  Adding together all the cases of Typhoid  on the  one hand,
and  those of Typhus  on the other, tympanites thus was  present in sixteen
of the twenty-eight cases of the former  type in which  this symptom was
mentioned ; and in eight of the  thirteen cases of Typhus, proportions not
very far  from being equal.
  As respects degree, there does not seem to be any ground for distinction
between the two types.   It would, perhaps, be fairer to compare the hos-
pital cases of Typhoid and Typhus, excluding the cases in private practice,
since all  the cases in  the latter group, save two, were of the  former type.
In this view, tympanites occurred in a  ratio exactly equal in the two types,
viz.,  12-18 of the cases of Typhoid,  and 8-12 of the cases of Typhus, i. e.,
in both 4-6.  These  results are not what I had anticipated.    I had sup-
posed this symptom  was considerably more frequent in its occurrence in
^he  cases of Typhoid than in those of Typhus.
  I  know not how to explain the comparative infrequency of this symptom
in the cases in private practice, except by reference to the fact which was
adduced in explanation of the greater frequency of diarrhoea  in the  latter
group of  cases.   The inquiry arises, what  connection has tympanites with
diarrhoea?  With reference to this inquiry, I have examined the  cases in
which tympanites was present, in order to ascertain in how many of these
cases diarrhoea co-existed.   In  the four cases in private  practice in which
tympanites was  present, more or less  diarrhoea existed in all.   In  the Ty-
phoid hospital cases, diarrhoea co-existed  with tympanites  in eight, and tym-
panites was present without diarrhoea in four.   In the eight cases  of Ty-
phus in  which  tympanites  existed, in all diarrhoea did  not  co-exist.   In 
REPORT  ON CONTINUED FEVER.
85
one case it is noted  that the discharges were thin and yellow, but not too
frequent.
   These results are curious. In so far as these cases afford data for statisti-
cal inferences,  it would seem that, in the Typhoid type, tympanites, in the
majority of cases, is accompanied by diarrhoea, but that the former is pre-
sent without the latter in all cases of Typhus !  Of course the number of
observations is much too limited  to authorize such an induction ;  neverthe-
less, the contrast is  too striking to be considered wholly fortuitous.
   With respect to the concurrence of  tympanites and diarrhoea, it should
 be added, what will suggest itself to the  reader as a corollary of the above
 facts, that diarrhoea, in  both Typhoid and Typhus, but (according  to the
 above  data) oftener in the latter,  is  present  without tympanites.  This
 symptom was  present in all the  fatal  cases of  Typhoid, save one ;  and in
 each of the fatal cases of Typhus, save one.   Of the Typhoid cases, it was
 extreme in one case, moderate in two cases, and the degree is not stated in
 the remaining three  cases in which the symptom was present.   Of the
 cases of Typhus, it was moderate in one case, and  the degree not stated in
 the other case in which the symptom was present.
    Abdominal tenderness.  Typhoid.  In two of the histories of the cases
 in private practice, there is no  allusion to tenderness on pressure over the
 abdomen.   In the remaining eleven (Typhoid) cases, more or less tender-
 ness was present in eight.  The tenderness was considerable in degree in
 one case, and  either moderate or slight in the remainder (seven) cases.  Of
 these  cases, the tenderness was either confined to, or more marked in the
 right iliac region'in four cases, and in the other cases the situation is not
 stated.  In the Hospital Typhoid  cases; information is contained on this
  point  in the histories of all.   Of the eighteen cases, more or less tenderness
  was present in eleven.   The tenderness was either moderate or slight in all
  but three  cases.   It is noted as especially marked in the right iliac regnoi
  in two cases,  and in both iliac regions  in four cases.
     Typhus.   Slight tenderness existed in the single case of Typhus in pri-
  vate practice.  Of the Hospital cases of Typhus, information on this point
  is contained in all the histories.  Of  the twelve cases, tenderness existed in
  jive   In all it was slight in degree.  The situation of the tenderness is not
  noted except in one case.  In this case, it  existed around the  umbilicus  ;
  it was present at the early part of  the disease, and disappeared during the
   febrile  career.  Bringing the two  types into comparison  as respects this
   symptom, it  was present in nineteen of twenty-eight cases of  Typhoid, and
   in six of thirteen cases of Typhus, showing a considerably larger proportion
   in the former. 
86
REPORT ON  CONTINUED  FETER.
  In order to ascertain if there exist any constancy of connection  between
this symptom and  that last considered, viz., tympanites, I have examined
the histories of all  the cases in which tenderness existed, and enumerated
those in which tympanites co-existed.  Tenderness with tympanites existed
in ten cases of Typhoid, (three in private practice and seven in hospital,) and
in four cases of Typhus.   In other words, tympanites did not co-exist in
ten of the cases of  Typhoid in which  tenderness was present, and in ten
of the cases of Typhus in which tenderness existed, tympanites was absent.
   On comparing, now, the number of cases in which tenderness was present
in both  types, with the number of cases in which  tympanites existed, it is
obvious,  not only  that tenderness exists  without tympanites  in  a certain
proportion of cases, but that tympanites is present without tenderness in a
certain proportion  of cases.   Thus  there  exists no relation of  dependency
between  these two symptoms, since  either may be  present without  the
other.
   It remains to inquire respecting the connection of  tenderness with diar-
rhoea.   Of the Typhoid  cases in  which  tenderness was present,  diarrhoea
co-existed in ten, (five  in  private  practice and five in hospital.)   Tender-
ness was  present without diarrhoea in nine cases, (three in private practice
and six in hospital.)   Of the cases of Typhus, tenderness co-existed with
diarrhoea  in two.   Tenderness was present without diarrhoea in four cases.
Diarrhoea existed without tenderness in four cases of  Typhoid, and in two
cases of Typhus.
   These  results  show that  the  two symptoms, tenderness and diarrhoea,
are not connected by any kind of mutual  dependency ; and if they spring
from the  same  cause or  causes, circumstances may occasion the develop-
ment of  either symptom to the exclusion of  the other.  In the fatal Ty-
phoid cases, tenderness was present in four cases, it was not present  in two
cases, and its presence or absence was  not  stated  in one case.  It  was
present in each of the three fatal  cases of  Typhus.   It was considerable in
degree  in two of the cases of Typhoid, moderate in one case,  and the de-
gree is  not stated  in the  history  of one case.   It was moderate  in degree
in all the cases of Typhus.
   Gurgling.  By gurgling, I mean a sound,  or a sensation appreciated by
the touch, or both, when  pressure is  made over the abdomen, more espe-
cially in  one or both of  the iliac regions.   Of the cases  of Typhoid, this
symptom was present in twelve,  (four in the private and eight in the  hos-
 pital cases.)  Its  absence was noted in two  cases,  and  in the remainder,
nothino- is said on this point.   In  most  of the latter it was  undoubtedly 
REPORT ON  CONTINUED FEVER.
87
absent at the  time the daily examinations of records were made.  Of the
cases of  Typhus, this symptom was present in seven, and in all the other
cases nothing is recorded on  the  point.   Gurgling was associated  with
tenderness on pressure, tympanites, and diarrhoea, as follows :—with tender-
ness on pressure in nine cases  of  Typhoid and  in two cases of Typhus ;
with tympanites in eight cases  of Typhoid, and in three cases of Typhus ;
with diarrhoea in six  cases of Typhoid, and in three cases of Typhus. These
enumerations  suffice to show that there  does not exist any uniformity of
association of this symptom with the three symptoms just mentioned, either
individually or collectively.
   In the fatal cases of Typhoid nothing is stated relative to this symptom
in five ; it was  present in the  two remaining cases.   Of the fatal cases of
 Typhus, it was  present  in one case, and  nothing is stated in the  two re-
 maining cases.
   It will have been observed, that in the foregoing consideration of abdo-
 minal symptoms, the cases  of doubtful  type have been excluded.  The
 facts with respect to the  presence or absence of these symptoms  in  these
 cases, and the relations of the symptoms to each  other, are exhibited in
 the following tabular arrangement of the hospital cases of doubtful type :
          | Case 1. | Case -2. | Case 3. | Case 4. |  Case 5.  |  Case ti. |  Case 7.  |  Case 8.
                               [fatal.]
Tendemesss.	absent	absent	present	present	absent	not stated	present	present.
Tympanites.	present	absent	present	absent	absent	present	present	not stated.
Gurgling. 1 present		present	present	present	not stated	not stated	not stated	not stated.
Costiveness.	present	not stated	present present		present	not stated	not stated	not stated.
Diarrhffia.	absent	absent	absent	absent	, absent	absent	| absent	absent.
SECTION  SIXTH.
   Cutaneous Eruptions.   The cutaneous eruptions incident to Continued
Fever furnish, agreeably  to the views of some  distinguished observers,
striking  traits of distinction  between the two types  denominated  Typhus
and  Typhoid.  I shall, therefore, study the eruptions in the cases grouped
after difference in type, separately, and compare the  two types as respects
the results.  It should, however,  be premised that in arranging the indi-
vidual cases into the divisions of Typhus and Typhoid, considerable impor-
tance was attached to the characters, &c, of the eruption. 
 88                     REPORT  ON CONTINUED FEVER.

    Typhoid.  The  characters, etc., which are said  to  distinguish what is
 called the Typhoid eruption are as follows:—It is generally  limited to the
 chest and abdomen, but  occasionally extends  to the extremities.  It may
 be copious,  particularly over  the  chest  and abdomen,  but  often it is the
 reverse, the spots being  few in number.   The eruption is of a  rose red
 color, [rose spots,  taches roses,] the spots are oval, appearing somewhat
 elevated, the redness momentarily disappearing on pressure.
   In the histories of the  Typhoid cases  in which an eruption was present,
 the appearances, etc., were generally described, but  in  some instances, it
 is simply stated that it  was marked by the  Typhoid characteristics.   I may
 fairly assume that in all cases  in which variations from these characteristics
 were present they were noted, and that when the presence of the eruption
 is stated without special  description, it exhibited the distinctive characters
 above mentioned.
   A rose eruption was present in nine of  the twelve cases in private prac-
 tice, and in fourteen of the eighteen hospital cases, i. e., in twenty-three of
 thirty cases.  In all the cases in which it  was not stated as present, the
 fact of its absence was  stated.   It was  present in a degree to be  called
 copious  in/we cases in  private practice, and in two hospital cases, i. e., in
 seven cases.  In the other cases the number of spots varied from four or
 five to fifty.   In one case only were they so few as four  or  five.   In one
 case there were only five or six.   In one case there were only  ten.  In all
 the others  there  were  over fifteen.  The eruption extended to the upper
 and lower extremities in three private, and  in one of  the  hospital cases, in
 all four.  It extended  to the face in one of the private cases, and was asso-
 ciated with erythena of the face  in that case.
   The date of the development of the eruption can  be ascertained in only
 a few of the  cases.  In  many of the cases the disease  had commenced
 several days before they came under  observation, and  the  eruption was
 apparent from the first.   In six cases in which the histories afford infor-
 mation on this point, the dates were respectively as follows:—In one, the
 second day after  taking to the bed: In  one, the seventh day:  In one, the
fourth day:  In one, the third day:  In  one,  the  fifth  day: In  one, the
 second day.  The three first of these cases occurred in private practice, the
 three last in hospital.  These few cases suffice to show that the interval
 between the time  that  patients take to the  bed, and the appearance of the
 eruption, is by no means  uniform.
   Data for  determining the duration of the eruption are furnished in only
five cases.  In these cases it continued as follows:—In one case, six or 
REPORT ON CONTINUED FEVER.
89
seven days:  In one,  twelve days:  In one, eight  days:  In one, six days,
up to the day before  the decease  of the patient: In one, ten days.   The
duration, thus, in so far  as  these few  observations enable us to judge, is
far from being uniform.   The only variations from the distinctive traits of
the Typhoid  eruption, which  have  been mentioned, were as follows:—In
one case it was noted that in some of  the  spots the redness did  not disap-
pear on pressure.   This was the only  deviation  from the typhoid charac-
teristics in that case.   In one case,  some of the spots were vesicular, the
contents of the vesicles being subsequently absorbed.
   The size of the spots is not given in  the history of any case.  It is stated,
however, in some of the  cases, that the spots were of different sizes.
   Of the two fatal cases of Typhoid  in private practice, the eruption  was.
present and copious in one case, and absent in the other  case.
   Of the four fatal hospital Typhoid cases, the eruption was  prerent in,
two, and absent in two.   It was not  copious in either of the cases in which,
it was present.  Sudamina, or  miliary vesicles  were not carefully looked
for at the examinations of the patients.  Their presence is only  noted  in  a,
single case in the Typhoid group.  In  this case they  were observed, on
the fourteenth day, on the epigastrium, the patient having  perspired pro-
fusely on that day.  They were  gone  on the following day.  It is very
probable that they may  have been  present in other cases in which they
were not noticed.
   A  petechial eruption  was observed  in one of the cases  in the TyphouV,
group.   The ecchymoses were not numerous, but sparingly scattered over
the abdomen and  lower  extremities.  The rose eruption was not presenl,
in this case.   The case proved fatal, and the petechial spots were observed
on the cadaver.
   Typhus.  The  characters which are said to distinguish the  Typhus-
eruption are  as follows:—The spots are  smaller in size  than in Typhoid;
orbicular, not oval; not elevated; redness not disappearing readily on pres-
sure; of a darker  red or dusky hue.   They are  more frequently  numerous*
and extend oftener to  the extremities.
   Of the thirteen cases of  Typhus  in my collection, an  eruption was pre-
sent in every case.  The eruption presented in all the distinguishing traits
above mentioned, except  that in one case  some of the  spots appeared
slightly  elevated.   This  case  presented,  thus, a combination of  the
eruptions of both types.  The color  was somewhat livid in two casea
It had  a  pink hue  in  one case.  In  eleven  of the cases the eruption.
was  copious.   In two cases it was imperfectly developed.  It extended
              IT 
90
KEPORT  ON CONTINUED FEVKR.
 over the extremities,  more or  less, in eleven cases.   In the two cases in
 which it was  imperfectly developed, the disease proved  fatal, in one case
 on the fourth, and in the other case on the thirteenth day.   Iii the remain-
 ing fatal  case in this  group,  the  eruption was  copious.   The date of the
 development of the eruption, and  its  duration,  are  determinable  in  still
 fewer instances than in the Typhoid group.  In one case  it appeared the
 second  day after the patient  took to his feed.   In another case  it did not
 become developed until  the eighth day.  It continued six or seven days in
 one case,  and  five or  six days  in another case.  In the  histories of the
 remaining cases the data for determining these  points are insufficient.  A
petechial  eruption was present  in one case, appearing  on the fourth day
 after admission.   The spots were observed  on the lower extremities,  and
 were of the size of the head of a pin.  This  patient had  sloughing of the
 nates.  The disease did not prove fatal.
   Sudamina are not noted to  have  been  present in any of  the cases in the
 Typhus  group.   As remarked of the Typhoid  cases, it is not improbable
 that  they may have been present in  some instances and  escaped  notice,
 since care was not taken to examine for this form of eruption.
   On comparing  the two groups as respects the foregoing  results, it will
 be perceived that, with few and  slight  exceptional  circumstances, the rules
 of discrimination which were enumerated, in so far as the present collection
 of cases  is concerned, are sustained.  I may add that this conclusion is
 unexpected, my impression having been that the exceptional circumstances
 would be found to be more numerous and striking.
   It remains to submit the facts with  regard to eruptions in the cases of
 doubtful type.   Of the eight  hospital  cases of doubtful type, an eruption
 was present in three.   In one of these cases two or three rose-spots  only
 were observed.   This  was a  fatal  case.   In one  case the eruption  was
 small and faint, and confined  to  the inferior part of the chest on either side,
 the  redness disappearing on pressure.  In the third case, the eruption
 appeared on the sixth  day, and was copious,  extending over the upper and
 lower extremities.   It  was of  two kinds.   The  larger  number of spots
 appeared somewhat  elevated, and the redness  disappeared on  pressure.
 Other spots were not elevated, and  the redness did not  disappear on pres-
 sure.  The eruption continued five or six days, gradually fading until it dis-
 appeared, which is the usual course with the eruptions in Continued Fever.
   In the remaining^* cases  no eruption was present.  In the single case
 of doubtful  type in  private practice, an eruption had  existed prior to the
 case coming  under  my  observation, but the characters  were  not ascer- 
REPORT ON  CONTINUED FEVER.
91
tained.   This was a fatal case.   In the other fatal case two or three rose-
spots were observed, and no autopsy was had in this case.
   No inquiries occur to me  suggesting comparisons of the eruption with
other associated symptoms in individual cases.

                           SECTION SEVENTH.
jSymptoms referable to  the  Respiratory Apparatus.   Cough.   Expectora-
   tion.    Pain  in  Chest.   Pneumonitis.   Aberrations of  Respiratory
   Movements.   Epislaxis.   Singultus.
   Cough.  More or less cough was present in ten cases of  those  in the
 Typhoid group, five being  in private practice, and five in hospital.   Of
these ten cases, the  cough was moderate, or slight in seven, and a promi-
nent symptom in three.   It was  present only during the early part of the
febrile career in three cases.   It was protracted  into convalescence  in one
case.  It occurred in connection with pneumonitis in two cases.   In  one of
these cases the existence of that complication is demonstrated  by recorded
physical  signs; in the other case physical signs are not stated, but the-
existence of the complication is evidenced by the rational symptoms.
   Of the Typhus group more or less cough was present in eleven cases.
Of  these  eleven cases, the  cough was  moderate, or slight, in  four,  and a
prominent symptom in seven.   It was present only during the early part
of the  febrile career, in a  single case.   It was protracted into convales-
 cence in tioo  cases.  It  occurred in connection with pneumonitis in five
 cases, in three of which that complication is determined by recorded physi-
 cal  signs; in the other two cases it is evidenced by rational  symptoms.
   The  periods in the career of the fever of which the pneumonitis com-
 menced  in the  cases of either  type, are  not  given  in  the analysis pre-
 liminary to this Report, save in one instance, and the importance of deter-
 mining this point is perhaps not sufficient to compensate for the trouble of
 re-perusing the histories of the cases in which this complication existed.   In
 the case just excepted, the pneumonitis became developed  twenty-seven
 days after the admission of the patient.   Convalescence, which was appa-
 rentlv postponed by the occurrence  of this secondary affection, was  not
 pronounced  until the  thirty-second  day after his admission.  The case
 referred to was in the  Typhoid group.
    It is  not improbable that in some cases, in  both  groups slight cough
 may have occasionally been present and escaped notice.  In most of  the
 cases in which  the  histories do not  show that it was present, nothing is
 stated  on the point but it is not probable, and  indeed hardly possible, that 
02
RETORT  ON CONTINUED FEVER.
 such an omission could have occurred in any instance in which this was in any
 degree a prominent symptom.   In six cases of Typhoid, and six of Typhus,
 more or less expectoration is stated to have accompanied the  cough, but I
 am not sure that in all the other cases in which cough was present, it  was
 wholly unattended by expectoration.   In two cases of  Typhoid, and three
 of Typhus, the expectoration is stated  to have  been muco-purulent.  As
 respects the existence of pneumonitis, 1 am not satisfied that this complica-
 tion did not exist, to some extent, in other cases than those in which it is
 now practicable to determine it to have been present.   In general,  physi-
 cal  exploration was not practised in cases in which the symptoms did  not
 point to the existence of this  complication;  and it is certain that pneumo-
 nic inflammation may be present without being denoted  by rational symp-
 toms, even cough and expectoration being absent.
   The foregoing results, however, suffice to show that cough and expecto-
 ration are symptoms incident to Continued  Fever, without forming a neces-
 sary element of the disease; and that pneumonitis becomes developed in a
 certain ratio of cases,  the average frequency of both, in so far as the present
 collection of cases is  concerned, being indeterminate.   But these results,
 imperfect as they may be, are interesting and striking, when considered and
 compared  in the different  types.  It will  be perceived  that while  cough
 was recorded present  in only one-third of the cases of  Typhoid, it was re-
 corded present in eleven-thirteenths of the cases of Typhus.  Admitting that
 these results are not  perfectly exact, it is fair to conclude that it was pre-
 sent in a much larger proportion of cases of the latter, than of the former
 type.  Moreover, it was a prominent symptom in only one fifth of the cases
 of Typhoid in which it was present, and in more than one-half of the cases
 of  Typhus.  Pneumonitis was present  in  but  two of the thirty cases of
 Typhoid,  and in five of the thirteen cases of Typhus.   The.se comparisons
 show a liability to pulmonary affections, considerably greater in the Typhus
 than in the Typhoid type of Continued Fever.
   Of the six fatal cases of  Typhoid,  the  presence of  cough  is not men-
 tioned in the histories of five, and in the single remaining  case, it was not
 a prominent symptom.
   Of the three fatal cases of Typhus, it  was present in all.   It was a promi-
 nent symptom in only one case;  it was present only in the commencement
 of the disease, in one  case, and it was moderate  in degree in the remaining
 case.  It  would  thus seem that the presence of cough, and its  prominency
 as a symptom, need not affect unfavorably the prognosis in either type of
Continud Fever. 
REPORT ON CONTINUED  FEVER.
93
  Pain in the  Chest.   This symptom is recorded  present in but one case
of Typhoid, and in this case it accompanied the development of  pneumo-
nitis on the twenty-seventh day after the admission of the patient.   It was
recorded present in one case of Typhus, occurring in connection with cough
at the early pait of the febrile career, and situated beneath the  sternum.
   Aberrations of Respiration.   Aberrations of respiration,  more or less in
degree, and differing  in kind, appear in the histories  of nine of the thirty
cases of Typhoid,  (four in  private  practice,  and  five in hospital,) and in
ten of the thirteen cases of  Typhus, thus showing a great  preponderance
in the latter type of the disease.  In eight of the histories  of the  cases in
the Typhoid  group, it is recorded that the respiration was  unaffected, and
nothing is  stated on this subject in the histories of thirteen.  In the histo-
ries of the three  cases of Typhus in  which some aberrations of  respiration
were not  noted, nothing is stated on the subject.  The varieties of disor-
der in the  respiratory  movements, and  the number of cases in which  they
were noted, are as follows:—increased frequency in three cases of  Typhoid,
and in eight cases  of  Typhus;  diminished frequency  in three cases of Ty-
phoid, and in none of Typhus; sighing respiration,  in two cases of  Typhoid,
and in three cases  of  Typhus; panting on slight exertion in one case of
 Typhoid, and one case of Typhus;  stertor in two cases of  Typhus; catch-
ing (inspiration  shortened and quickened) in  one case of  Typhoid, and in
four cases of Typhus;  irregularity in rhythm in three cases of Typhus;  sibi-
lant nasal rale,  in four cases  of  Typhoid,  and in two cases of  Typhus;
dilation of the aloe nasi, in one case  of  Typhoid and  in  four cases of Ty-
phus.   These variations were, of course, more or less associated  in different
cases.  It  should also  be stated  that the aberrations of respiration occur-
rino-  toward the close of life, in the cases  which   proved fatal, are not
included,  since  they  are, under  such  circumstances, incident  to  the
mode of dying, and do not, strictly speaking,  belong  to the career o thef
disease.
   It is of some interest to determine the relative frequency  of these several
kinds of aberration in  cases of the  two forms  of Continued Fever; hut a
more interesting point  of inquiry  relates  to their connection with the  ulte-
rior morbid conditions upon which they are dependent.   Some of the symp-
toms  that  have been enumerated, are expressions of disorder of the nervous
system, others are occasioned  by the state of the pulmonary organs, and
some may involve either  or both.   To bring  the  results of the analytical
investigation to bear on this point of inquiry, a collection of cases might  be
divided into two groups, in the one group pulmonaiy disease being present as 
94
REPORT ON CONTINUED FEVER.
a complication of the fever, and in the  other group this complication being
absent   The two groups should then be studied and compared with respect
to the presence of the several symptoms just mentioned.  Symptoms present
without the evidence, physical and rational, of pulmonary disease, it would
be fair to refer to a nervous origin ; on the other hand, those present in cases
in which a pulmonary complication existed, might be due to it, or they might,
still, originate  in the nervous  system; but if they exclusively existed  in
the  group distinguished by the presence of pulmonary complication, they
should be considered incidental to the latter.   This interrogation of re.-ults
is but imperfectly available in the present investigation, because, from neg-
lect of physical  explorations, it cannot be positively determined in what
cases pneumonic complication was absent.  I will, however, under distinct
heads, institute,  so far as practicable, a comparison in the manner pointed
out  regretting that the  data are not  more satisfactory.
  Increased Frequency of Respiration.  In four of the cases of Typhus
in which this variety of  aberration was present, pneumonitis undoubtedly
existed.   Of the remaining four cases of Typhus  characterized by this
symptom, in all cough co-existed.   In one case the cough was accompanied
with sanguinolent  expectoration.   In  another case  the  respirations were
much accelerated (56 per minute the maximum)  with  labor, and panting
on exertion.  In this case pneumonitis  may be suspected to exist.   In an-
other case, muco-purulent expectoration accompanied the cough, and occa-
sionally  the expectoration was  streaked with  blood.   Dilation of the aloe
nasi also co-existed.   Either pneumonitis or bronchitis must have existed
in this case as a complication.   In the  remaining case, the cough was a
prominent  symptom.  Thus, all the  Typhus cases attended with accele-
rated breathing,  were complicated with pulmonary disease.
  Of I he three cases of  Typhoid in which the respiratory movements were
accelerated, the  recorded data are  quite insufficient  for determining the
presence or absence of pulmonary disease in one  case.  Nothino- is  stated
with respect to cough.   The respiration was catching, with dilation  of the
ala3 nasi;  coma and stertor  succeeding.  In another of the cases nothing
is stated relative lo cough.  The respiration in this  case was moderately
accelerated, the  maximum being  24.  In the  remaining case  pneumonitis
was evidenced by cough and rusty expectoration.
  In conclusion, then, with respect to this symptom, in all  but two of the
eleven cases in which it  was present  in both types, it was accompanied by
evidences  of  pulmonary complication; and  in   the two excepted  cases
the data are too  defective for any definite inferences.   I should  state that 
REPORT ON  CONTINUED  FEVER.
95
in  speaking of acceleration of the respiration  as  a symptom, I  mean  a
degree of acceleration sufficient  to  attract  attention.  The histories of all
the cases do  not embrace an enumeration of the  respiratory movements.
When these did not appear to  be increased they were  not always enu-
merated.   Hence, it may  be  that a slight increase above the average nor-
mal frequency may  have  existed in some instances when it was not suffi-
ciently apparent to excite notice.
   Diminished  Frequency of  Respiration.  In none of the three cases  of
 Typhoid  in which this  symptom was present, does the history afford evi-
dence of  pulmonary complication.  In one, it is staled that  no cough
existed, and in the other  two cases, nothing is recorded on that point.   In
the first case the respiration  is  noted to be  somewhat slower and  deeper
than in health.   Cerebral nervous symptoms, in this case, were not promi-
 nent.   In one of the remaining cases cerebral symptoms were  prominent,
eventuating in coma.  This  case  proved fatal.  In the other case,  the re-
 spiration was but slightly retarded, and more  heavy than in  health.   In
 this case,  about the average of cerebral  symptoms were present.   In so
 far as  these  few  and imperfect  observations  go, diminished  frequency
 of respiration  is  not to  be  attributed  to  morbid  conditions of the lungs;
 and this accords with the view of this symptom generally entertained.
    Sighing.  By this I mean occasional, or frequent  sighing,  not a con-
 tinuously suspirious respiration.   Of  the two cases of Typhoid in which
 this symptom was noticed, in one, cough was present at the early part, but
 in a trifling degree.  In  the other case cough did not  exist.  Of  the three
 cases of  Typhus in which the symptom was present, in one, cough and san-
 guinolent expectoration was present; in one, slight cough had existed, but
 did not continue up to the time that the case came under observation; and
 the remaining case was complicated with pneumonitis.  If the character of
 this symptom be taken  in  connection with these results, it can  hardly be
 doubted that it is due to a morbid condition of the nervous system.  It is
 to be borne in mind that the co-existence of pulmonary disease in a certain
 proportion of cases, does by no means  establish any connection between a
 symptom present in  such cases, but also present in other cases in which
 pulmonary disease is  absent.  To prove  such a connection the symptom
 should be present exclusively in cases  characterized by  pulmonary disease.
  I have  been accustomed to  regard frequent sighing  as of bad omen in
  fever.   This idea is, in some  measure, sustained by the fact  that in  two
  of the five cases  in which the  symptom was noted, the disease  proved
  fatal. 
96
REPORT ON CONTINUED  FEVER.
    Panting on slight exertion.  This was noted in one of the above cases of
  Typhoid in which sighing occurred, unconnected with any marked symp-
  toms of pulmonary complication.  In  the other case cough and other
  pulmonary symptoms were prominent, and it is highly probable that pneu-
  monitis exi."led.
    Stertor.  In both of the cases of Typhus in which this symptom occurred
  other than as an immediate foreiunner of death, pulmonary symptoms were
  prominent, pneumonitis existing in one case, if not in the other.   This, how-
  ever, obviously, is not a symptom due directly to the condition of the lungs.
    Inspiration shortened and quickened.  In the single case of  Typhoid in
 which this aberration is noted, the existence of secondary disease  of the lungs
 is indeterminate from the history, no pulmonary symptoms being recorded,
 while cerebral symptoms were prominent.   In the four cases of Typhus
 cough and other pulmonary symptoms were  prominent, and in  three of the
 cases pneumonitis was marked.   In two of the five cases presenting this aber-
 ration, the disease proved fatal.  This symptom I  have been accustomed to
 regard as an expression of a morbid condition seated at the nervous centre,
 rather than in the pulmonary organs.  The correctness of this  view is  not
 disproved, although  it is in no wise sustained by the above results.
   Irregularity.  Of the  three  cases of  Typhus  in which this symptom
 was  noted,  in  one  case  the history affords  no  evidences of   the exist-
 ence of pulmonary complication.   In the  two other cases pneumonitis  co-
 existed.   This, like  the preceding aberration, is generally  attributed to a
 nervous origin ; and the fact that, in one of the three cases in which it was
 present pulmonary disease did not co-exist, suffices to  show that it is not
 necessarily dependent on the latter.
  Dilation of the aloe nasi.  In the single Typhoid case in which this was
 noted, the data are insufficient to determine either the presence  or absence
 of pulmonary disease.   In the  three Typhus cases, cou-h existed in all.
 Ft was prominent in one, and the  expectoration was streaked with blood;
it was moderate  in  one;  and  in  the  two remaining  cases, pneumonitis
 existed.
  Sibilant nasal rale.  This  symptom  has no  special  reference either to
the nervous system, or pulmonary organs, but is probably dependent on the
state of the nasal passages.
  The foregoing examination of  cases with  a view to determine  the con-
nection subsisting between the several aberrations  of the respiratory move-
ments, and the secondary  affections of the pulmonary organs occurring  in
Continued Fever, may not seem to furnish results sufficiently numerous and 
REPORT  ON CONTINUED FEVER.
97
explicit to compensate for the  labor which it has cost.  I should perhaps
hardly deem them deserving of the space which they occupy in the report,
were it not  that, possibly, they may serve to suggest the application of a
similar method of comparison in a larger series of cases with the facts re-
lating to the pulmonary system more satisfactorily recorded.
   The  reader may be surprised that  in connection with  the subjects era-
braced in  this  Section, I do not adduce the appearances  presented on
dissection of the pulmonary organs, in  the instances in which the disease
proved fatal.   The reason for this omission  will appear in  the  Section
devoted to the Autopsical Observations, where it will be perceived that the
post  obit histories of  the fatal cases are very  imperfect as  respects the
pulmonary organs.
   Epistaxis.   Epistaxis was noted in eight of the cases of Typhoid (three
in private practice  and five in hospital).  In three cases it is noted that this
symptom did not occur.   In the remainder nothing is said either of its ab-
sence or presence.   In nil the above eight cases  the hemorrhage occurred
from the nostrils, more or less  in quantity.   In a few cases (three) not in-
cluded in this enumeration, it  was observed that  sputa detached from the
posterior nares  were tinged with blood.  This may have occurred in other
instances and have  escaped observation.   It is also not impossible that
epistaxis may  have occurred in some of the cases not under observation
 from  the  commencement of  the disease,  the fact  not being  ascertained,
 although, generally, if not invariably, pains were  taken to inquire whether
this symptom entered into the previous history.   In most of the cases in
 which  nothing  is stated  relative to this point in  the history,  it is fair to
presume the symptom did not  occur.   Here, as in other instances, the im-
portance of recording negative facts was not  sufficiently borne in  mind.  As
 respects the period in the career of the Fever when epistaxis was observed,
in  all  but  three instances this is stated  in the  preliminary analysis.  In
these three cases it is simply stated that it occurred  early.   In the  other
cases the periods were respectively as follows :—In one case, on  the 8th
 and 10th days;  in one, on the 8th day;  in one, daily, up to the 7th day, and
 sometimes  profusely;  in one, on  the  10th day;   and in  one, on the  26th
 day.  The ratio in which this symptom was  observed in many cases is very
 nearly the  same as in the 303  cases of  Typhoid Fever analyzed by Dr.
 Jackson.   Of the quantity of  blood which escaped, and  the precise num-
 ber of times the hemorrhage took place, the histories do not contain infor-
 mation.  Pains were  not  taken to ascertain the former more especially.
 Generally speaking, it was slight and I am quite certain that no appreciable
               I 
98
REPORT  ON CONTINUED FEVER.
 effect upon the progress of the disease was produced by it.   In none of the
 cases in which epistaxis occurred, did  the disease prove fatal; and two of
 the three cases in which it was noted that this symptom did not occur, were
 fatal cases.  Of the cases of the  Typhus group, epistaxis was noted  in but
 two.  In one of these it occurred several times early in the febrile career;
 in the other case it occurred once early, and once afterward.  In one of
 the cases the disease proved fatal.   In none of the cases of Typhus is it
 noted that the sputa from the posterior nares were tinged  with blood.  In
 three of the cases in  this group the absence of this symptom is noted.  In
 the other cases nothing is stated on the subject   Comparing the foregoing
 results  in the  two  groups, this symptom  occurs oftener in Typhoid than in
 Typhus, the ratio  being a little more than one in four of the former,  and
 one in six and a half  in the latter type.
   Singultus.   This symptom was observed  in two cases, one of  Typhoid,
 and the other of doubtful type.   In the  former case  it was a troublesome
 symptom for several  days.   The disease proved  fatal, but this symptom
 ceased  toward the close of  life.   It  was unaccompanied  by  involuntary
 movements of  the voluntary muscles.   In the other case, it  occurred on
 the day after the admission  of the patient, four  grains of opium having
 been  administered  the night  previous.   The respiration was, at the same
 time, somewhat labored, and the inspiration shortened and quickened.   This
 case became complicated with pneumonitis.
  In  the foregoing enumerations and comparisons with respect to the symp-
 toms referable to the  respiratory system, it will here be observed that the
 cases of doubtful type (with the  single exception  in the preceding  para-
 graph) have not been included.   It is probably not of much importance to
 present the facts in the histories of these cases belonging to this class, but
since it  has been done hitherto, it will render the  report defective to  omit
them, and  as the readiest  mode of  accomplishing the object they are
arranged in the following tabular form:—
1 Cough pro-minent. Accelerated respiration. Probably Pneuniooitis	2 Respira-tion slight-ly acceler-ated. Nothing stated as to Uough.etc-	3 Slight Cough cotitinued into con-valescence No aberra-tion of re-spiration stated.	4 No Cough or expec-toration. Respira-tion accel-erated ala nasi dilate	5 Moderate Cough. Expecto-ration streaked with blood Short and catching respiration FATAL.	6 Slight Cough. Respira-tion unaf-fected.	7 Cough and expecta-tion. Respira-tion labor-ed and catching Physical siyns of Pneumon-itis. Epistaxis several time».	8 No Cough Respira-tion unaf-fected. Epistaxis several times.	9 Slight Coughand substenal pairs. Respira-tion nor-mal. Sputa from pos-terior nares ting-ed with blood.
 
REPORT ON CONTINUED FEVER.
99
                          SECTION EIGHTH.

  Symptoms referable to the  Circulation.  Pulse, Capillary Congestion.

The points of interest  in this  section, relate, for  the  most part, to the
pulse, and  the circulation in the capillary vessels of the cutaneous surface.
As  respects the pulse, the question arises, how shall the facts contained in
the histories  be presented ?  In frequency, and  other characters of the
pulse,  no two of the cases are precisely alike, and, therefore, they cannot
be  enumerated in classes.   Moreover, in individual cases, the pulse was in
no  instance entirely uniform throughout the career of the disease, and fre-
quently varied, not only daily, but at different periods of the same day.
In  order to exhibit, as concisely and  comprehensively as practicable, the
facts which the  histories  contain, the  readiest and best method is to ar-
range  them in a tabular form.   I shall adopt this method, assigning a dis-
tinct table, respectively, to the cases of Typhoid,  Typhus, and those of
doubtful type.  These tables  will, in general, embrace all the facts with re-
spect to the circulation  contained in  the histories.  To this there are few
exceptions, arising from an omission to include all  the  details  in the  pre-
liminary analysis.  In the private cases, it will be observed, that the facta
are expressed in general terms, with  less regard  to details and precision.
This arises from the symptoms in these cases not having been noted daily
at  the bed side, as has been  before stated.   In the hospital cases, usually,
the frequency and character of  the pulse, etc., were daily recorded, but to
this rule there were occasional exceptions.   Generally speaking, so soon as
convalescence was declared,  this particularity  in recording was no longer
continued.   In the majority of cases the pulse, etc., as well  as other classes
of  symptoms, were only noted once daily, generally in the forenoon.   The
histories, therefore, do not embrace all  the variations which may have oc-
curred during the day,  except  in some instances.   When this is the case,
in the  tables which follow, the letters  A. M. and P.  M.,  are attached to the
figures denoting the frequency of the pulse.   When these letters are not
attached, it is understood that observations were made only in the forenoon;
and the  numbers following each other, without these letters, express the
frequency  of the pulse on  different days. 
TABLE EXHIBITING THE PULSE, ETC., IN TWELVE CASES  OF TYPHOID IN PRIVATE PRACTICE.
©
O
In early part
 of disease,
  80 in trie
  morning,
and at even
ing from 90
   to 100.
Larger than
normal, but
not full nor
 hard.  For
several days
before  con-
valescence,
normal, and
no exacer-
bations,
 From 80 to
90 at A. M.,
and from 90
to 100 at P.
M.
    3
 Moderate
  febrile
movement.
Details not
  stated.
    4
 Moderate
  febrile
movement.
Details not
  stated.
On the 10th
day (the 1st
of observa-
 tion) 100,
 feeble and
intermitting
 Became
more deve
 loped, and
regular, and
  less fre-
   quent.
 Two diur-
nal exacer
  bations.
     6
  Ranged
from 100 to
120 in early
 part of fe-
brile career,
  In latter
 part  from
 80 to 90.
  In early
 part, 120.
 Gradually
 abated du-
 ring latter
   part.
 Moderate
 exacerba-
tions in the
 afternoon.
  Ranged
 from 88 to
 95.  Mo-
 derate ex-
acerbations.
!     9
  Ranged
from  86 to
92. No ex-
acerbations,
 Pulse well
developed.
     10
 At first to
 100, and
rose to 120,
being below
110 only on
 one day.
 Evening
 exacerba-
tion well de-
veloped and
at first large
and strong.
Fatal case.
    11
  Ranged
 from 80 to
100.   Dis-
tinct even'g
 exacerba
tions.   Ca-
pillary con
gestion.
TABLE EXHIBITING THE PULSE, ETC., IN EIGHTEEN HOSPITAL CASES OF TYPHOID.
    12
 Pulse 6th
day,(first of
 observa-
 tion) 120.
Rose to 130
 140, and
 150, and
became ex-
tinct.
Fatal case.
       1        |       2
 Ranged from   120, and well
80  to  90.   Noj developed  at
regular exacer- first. Third day
 bations
Ranged  for se-
veral days, f»om
88 to 96;  then
from 100 to 120
and became
feeble.    Fatal
fifteen  days af-
ter  admission,
nnd  twenty-six
days  after  at-
tack.
Mean frequen
cy, 96 4-5.
Mean frequen-
cy, 84 1-3.
                  160 A. M.
                small and fee-
               ble; and at P.M.
                too rapid and
               small to be enu-
                  merated.
               Moderate capil.
               lary  congestion
                of the surface.
               Fatal third day
               after admission.
  * The numbers in this ease and the subsequent cases, denote the frequency at the successive notations, taking
frequency was not noted.
At first, 125.
Third day, 1 0.
Fifth day, 96.
Sixth day, 80.
Capillary  con-
gestion confin'd
to the face.
Mean frequen-
cy, 102 1-4.
       5
120.
120 small.
80.   96.  98.
*note below.
  6
96.  96.
86.  72.
 108 well devel-  128 well devel-
 oped.   Fourth  loped, thrilling.
  day 120, and   120 thrilling.
  rather feeble.   120 less thrill'g,
 108, moderately  120 moderately
 developed.  120,  thrilling.
 well developed.  124 thrilling.
 112. 128.  108.  104 soft.
    100.  84.     100 soft.
 Even'g exacer-  92 soft.
  bations.  Ca-   100 swell.  4.
 pillary  conges-  Mean frequen-
 lion. Mean fre-  cy, 109 1-5.
 quency, 109 8-9 J
no notice of some days, in some of the
Third day 88,
and  somewhat
thrilling.
86 soft.
96 somewhat
thrilling.
104 thrillinrr.
84.  80.  72.
Meau frequen-
cy, 87 1-7.
cases in which the 
TABULAR  VIEW  OF EIGHTEEN HOSPITAL CASES—(Continued.)
      10
Second day,92.
Third day, 94.
Fourth day, 112.
Fifth  day, not
noted.
Fatal sixth day-
after admission.
11	12	13
104 tolerably	100. 92.	72 well deve-
developed.	Somewhat	loped.
93. 120, thril-	thrilling.	72. 72. 72. 96.
ling.	104 soft.	72 small.
100. 92.	104. 92.	76. Capillary
100, 112.	120. 96.	congestion of
100. 108.	104. 100.	surface, contin-
100. 96.	104. 108.	ued to time of
Capillary con-	96 soft.	convalescence.
gestion confined	66 somewhat	Mean frequen-
to face.	thrilling.	cy,76.
Mean frequen-	88. 96.	
cy, 102 3-11.	104 feeble, and somewhat thril-ling. 110 and quite feeble. 100 feeble and unequal in force 112 thrilling. 96. Not acce-lerated. Mean frequen-cy, 100 6 10.	
      14
112  small  and
rather thrilling.
108  small  and
feeble.
(Haemorrhage
from bowels on
this day.)
108 more deve-
loped.
108 well deve-
loped.
104 soft and fee-
ble (second
haemorrhage.)
96 small and
feeble.
100  tolerably
developed.
120 tolerably
developed.
96.  72.  72.
Slight  capillary
congestion con-
fined to face.
Mean  frequen-
cy 99  7-11.
      15
120 well deve
loped, and thril
ling.
100 moderately
developed.
100 well deve-
loped.
108 tolerably
developed.
120 soft.
132 soft.
160 exceedingly
feeble and irre-
gular.
Fatal following
morning, tenth
day after admis-
sion and attack.
and
      16
112  small
feeble.
120 full and
strong.
64.   76.  Ca
pillary conges
tion confined to
face.
Mean  frequen
cv, 93.
      17
84,tolerably de
veloped.
92,  developed,
but soft.  88.
80.  84.  80,
Moderate capil-
lary congestion
of surface.
Mean frequen
cy,  84 1-3.
      18
120.  116, soft
and feeble.
120, quite small
and feeble.
8S.  92.    100,
rather small.
120 (Parotitis)
100.  100.  100
very small.        pj
80.  84.   Con-    «
siderable capil-    o
lary congestion    §
of the surface.
Mean frequen-    3
cy.101 4-6.      n
                 o


                 a
                 M
                 D
                 >=4
                 H
                 <
                 W 
102
REPORT  ON CONTINUED FEVER.
12 108. 100 well developed. 108 soft and feeble. 100 soft 90 feeble. 88 76. Capillary congestion of surface. Mean frequency, 95 5-7.						
11 125 soft and compressi-ble. 120. 120. 108 well developed. 104. 100. 108. Capillary congestion of face. Mean frequency, 112 1-7.						
10 120 soft and feeble. 128 soft and feeble. Impulse of heart not appreciable 140 very feeble. 128 more developed. 112. 108. 96. 100. 100. Capillary congestion of face and extremities. Mean frequency, 114 6-9.						
9 First day not accele-rated. 100 well developed. 80. 96 soft. 120 small and soft. 120. 100 well developed. Not accele-rated. Capillary congestion. of surface. Mean frequency, 102 1-3.						
a Not appre-ciable when the patient entered. Second day 144, small and feeble. Capillary congestion of face and hands. Fatal on the third day of admission, and seventh after attack.						
7 112 small. 120 small. 108 quite small. 100 more developed. 88 quite small. 72 small and feeble. 82 exceed-ingly small and feeble. Impulse of heart not appreciable. Pulse quite irregular. 76 less irre-gular. 64 occasion-ally inter-mitting. More deve-loped.		> a 'o. ss O	J 8 <d >: tuD 3 C eo o <_ u o		CD 3 cd s	00 00 >-. a 3 CD 9 V
6 120 small, and feeble. 120 very small. 112 very small. 120 scarcely appreciable. 120 small. 100 small. Not accele-rated. The small-ness in this case was owing to an anomalous division of the radial artery, a small branch only passing in the usual di-	o □ a o o II	discovered until the ninth day.			o a a a	o ■ 3 ■""' 3 —«
o >dd ddoddcjddood to <» * ° £ £-c« 2 §	a	u 5 3		03		
4 100 A. M. 120 P. M., (well deve-loped.) 120 small and feeble. 130 A M. 136 P. M. 120 A. M. 120 P. M. 120 A. M. 130 P. M. (thrilling.) 64 A. M. 120 P. M. 64 A. M. 76 P. M. 94 A. M. 96 P. M. 100 A. M, 100 P. M. 88 A. M. 88 P. M. 80. 68.						
3 120 soft weak, and occasional-ly intermit-ting. 120 soft and compressi-ble. At P.M.120 120 at A.M. 120 at P.M. 120 tolera-bly develop-ed and re-gular. 104. 108 A. M. 108 P. M. 110 A. M. 104 P. M. 100. 104. 100. 108. 100. Capillary	§ • - o to «* V h bjD 9 3 CO o <_ u o		a	V 5 3 cr CD	< 03	o r—1
2 96 well de-veloped. Progres-sively in-creased to 100, and 125,and be-came small. Day before decease 12C Capillary congestion of surface. Fatal eighth day afier admission, and thirteen after attack.						
1 7ery small »nd irregu-ar. Second day more deve-oped. Third day leveloped md but lit-le accele-ated. 1th day, 96. 5th •« 80. 5th •« 80. [th » 56. Capillary ongestion »f surface, omewhat ivid.						
p Irt ® 
1
104 soft and com-
pressible.
80.
52 and somewhat
irregular.
Capillary conges-
tion of surface.
Menn frequency,
78 2-3.
TABLE EXHIBITING THE  PULSE, ETC., IN  EIGHT  HOSPITAL CASES OF DOUBTFUL TYPE.
                                                                                             7
104 rather small
and feeble.
120.
108.
116.
116.
100.
80.
Capillary conges-
tion of surface.
Mean  frequencv,
106 2-7.
120 soft and com-
pressible.
112 small and
feeble.
96 well developed
96.
88.
Capillary conges-
tion of face.
Mean frequencj',
104 2-5.
92.
84 somewhat
thrilling.
100.
100 thrilling.
108.
104.
112.
120.
112.
108.
120 thrilling.
112 quite small
120 small and
thrilling.
46 thrilling.
Fatal 23 days af-
ter admission.
Complicated with
Parotiditis.
Capillary conges-
tion of face.
Mean  frequency.
109 1-13.
128 full and thril-
ling.
120 compressible
jerking.
84.  72.
Capillary conges-
tions of face.
Mean frequency,
101.
130 extremely
small and feeble.
108  more  deve-
loped.
88.
84.
96.
Mean frequencv,
1011-5.
Maximum 120.
Not noted daily.
Moderate  capil
lary congestion of
face and extremi
ties.
96 well developed
96.
96.
92.
90.
Capillary conges-
tion of face, and
upper extremeties
Mean frequency,
94-
OS 
104
REPORT  ON CONTINUED FEVER
  The foregoing tables suffice to show, in the first place, that there exists
considerable  diversity in the frequency, and other characters of the pulse,
both in  diflerent cases of  Continued Fever, and in diff rent periods of the
febrile career in individual cases.
  It is  probably never the case that  the  pulse remains  wholly unaffected
throughout the febrile career.  A near approximation to this is apparently
presented in the table of Typhoid hospital cases, No. 13.  In this case the
pulse was but 72, except on one day, when it was 96—the mean frequency
being 76.  This patient, however, had been confined to the bed eleven days
before entering  the hospital, during which  time it  is altogether probable
that the pulse had been more or less accelerated.
  The numbers given in the tables do not furnish a perfectly accurate re-
presentation  of  the condition  of the  pulse, since, generally, observations
were made but once daily, and various transient causes are liable to affect
the pulse at the time of the daily examination.  To render this portion of
the histories complete, the pulse should have been enumerated in each case
several  times daily, and the mean result taken, together with the variations.
  The variations which in most of the cases are apparent on different days,
in part, doubtless, denote fluctuations incident to the progress of the disease;
but they are also, in part, to be referred to extrinsic circumstances affecting
the condition of the patient, among which are to be included the influences
of remedies.
  On comparing the frequency of the pulse in the two types, Typhus and
Typhoid, it is found that, it is considerably greater in the majority of cases
of the former than of the latter.  The average mean in  thirteen of the hos-
pital cases of Typhoid is 95 7-13 ; while in nine cases of Typhus, the ave-
rage is  105 4-9.   The fatal cases are excluded  from  this calculation.
Greater frequency of the pulse, then, characterizes Typhus, a result which
accords with the observations of others.  Instances of a high maximum are
oftener  presented in Typhus.  In the table of Typhus cases, exclusive of
the cases that proved fatal, the pulse had a maximum of 140 in two cases
in which recovery took place, and it was 136 in another  case.   In the
cases of Typhoid, on the other  hand, the highest maximum was  128, and
this was attained in but a single case.  Two of the fatal cases presented a
greater frequency, 160.
  An examination of the tables will also show that instances of feebleness,
and  irregularity of the pulse occurred oftener in cases of Typhus  than in
Typhoid.
  In general terms, I should say, that the frequency of the  pulse is  a 
REPORT ON CONTINUED  FEVER.
105
pretty good criterion of the severity of the disease.  This opinion, however,
is not based  on a careful examination of all the cases in order to compare
the pulse, as regards  frequency, with the  grade of severity.   This would
require not a small degree of labor.   But if this be a  general rule, it is not
without exceptions, for, in some  of the  cases  in my  collection, the pulse
numbered  120, when,  in other particulars the disease was mild, and milder
than in other cases in which the frequency of  the pulse was less.   It did
not exceed 120, the day before the decease in one of the fatal cases, and
in another, in so far as data were preserved, it  fell below this number.  In
a case  which has  recently fallen  under my  observation, not  included in
this collection, the pulse, two days  before the fatal issue,  was but slightly
accelerated.   There can be no doubt if the pulse exceed 120, except for a
transient period, that  the case is of dangerous severity ; and the danger
increases in more than a geometrical ratio  if it  rise above  this point.
   A deception  occurred  in one of  the cases of Typhus (No. 6) which de-
mands  a passing notice.   The pulse had  been daily noted as " small," or
" very small,"  and, on one day, " scarcely appreciable."   This symptom,
although  in other  respects the disease did not appear  to be of  a severe
grade of intensity, was regarded as denoting danger, and stimulants were
 directed more freely than would have been the case had not the pulse pre-
sented  this character.   On the ninth day, I discovered that  there  was a
 bifurcation of the radial  artery, one branch pursuing the usual course, and
 the other winding over the radius, the former being  much the smaller of
 the two.   From the position of the bed, I had always examined the pulse
 in  the  arm in which  this peculiarity existed.   The same anomaly I have
 met with in several other instances.   The neglect to discover it in this in-
 stance  affecting materially the treatment,  may serve  to suggest the impor-
 tance of looking for a similar  explanation in cases in which smallness and
feebleness of the pulse are marked.
   It will be observed  on reference to the tables, that a few cases presented
 a minimum  in  the number of  the  pulse considerably below the normal
 average.   In No. 16 of the hospital Typhoid  cases,  the pulse, on one day,
 was noted 64.   In No.  1 of the Typhus cases, it was, on one day, 52.  In
 No. 1 of the cases of doubtful  type, it was on one day 52.   In  all these
 cases this  reduction in the number of the pulse occurred at the commence-
 ment of convalescence,  and was of transient  duration.  In none of these
 cases was  there reason to suppose  that the pulse, in health, was habitually
slower  than the average.  Marked slowness of the pulse, then, occasionally
characterizes convalescence in Continued Fever.  Oftener the pulse con- 
106
REPORT ON CONTINUED  FKVER
 tinued somewhat accelerated after convalescence, by other symptoms, was
 fully declared.   Generally speaking, a return to a normal state, as respects
 frequency and other characters of the pulse, is one of  the best criterions of
 a favorable termination of the disease.
   With respect to exacerbations of fever, in a large proportion  of the cases,
 observations  having been made but once daily, the histories are silent.
 In  some instances, however, it is noted that exacerbations were present,
 and in a few instances the data suffice  to show that they were  absent.
 The only conclusion to be drawn from these limited facts is, that they may,
 or may not occur during the-career of Continued Fever.   To determine
 the probability of their occurrence, statistics much more extensive than the
 present collection of cases furnishes, are  requisite.
   The presence  of capillary congestion  of the  face, extremities, or entire
 surface of the body  is noted, in the tables, among the symptoms referable
 to the  circulatory system.  This  symptom, it will be perceived, is  present
 in a much larger proportion 6t the cases of Typhus than in those of the
 Typhoid type.   The pathological signi6cancy of this symptom has  already
 been commented on (section third.)  On examination of the pulse  in the
 cases in which this symptom is noted, in the tables, the fact already stated
 (page 32d) may be verified, viz., that it does not depend on causes affect-
 ing  the general  circulation, i. e., the circulation through the heart and
 arteries, since it does not sustain any relation to symptoms denoting that
 the forces carrying on the general circulation are compromised in a special
 manner.   In  other words, in the  cases in which capillary congestion is no-
 ted, the pulse does not invariably denote an enfeebled or disordered circu-
 lation,  but, on the contrary, in some of  the cases in  which the capillary
 congestion was marked, the arterial  circulation was  less disturbed,  as indi-
 cated by the pulse, than in  other cases in which that  symptom was not
 present.  The occasion of the capillary  congestion  is, therefore, obviously
 inherent in the capillary system,  and, perhaps, in the blood itself.   In the
remarks on this point in section third, it was stated that pulmonary  conges-
 tions are said to be  more liable to occur in Typhus than  in the Typhoid
type of Continued Fever.  This has been confirmed by the results devel-
 oped in the preceding  section.   A  comparison of these results with the
greater frequency of capillary congestion  of the  surface in cases of Typhus,
 favors the supposition that the same condition of the capillary vessels, or of
the blood, may affect internal organs ; and that the greater frequency of
pneumonitis, in Typhus, is in this way susceptible of explanation. 
REPORT ON CONTINUED  FEVER.
107
                             SECTION NINTH.
        Symptoms (Exclusive of Eruptions) referable to the Skin.
  The Symptoms (exclusive of Eruptions) referable  to the  skin, may be
distributed  into  those relating to  sweating and  moisture, to  dryness, to
temperature, to congestive  redness, to Erysipelas, and to gangrene.   The
phenomena belonging to  these several classes  are commingled, more or
less, in individual cases; and, hence, they are to be  considered, not only
under separate heads, but as they are presented  together  in combination,
succession, or alternation, during  the progress  of fever.   I will proceed,
first, to inquiries  respecting each of the  above  divisions  distinctly, taking
them up respectively in the order enumerated.
  Sweating and moisture.   In a considerable number of the cases of both
types, sweating, more or less free or profuse, occurred either once, or oftener,
durino- the  febrile career.  It was so noted in  fourteen  of twenty-seven
cases of Typhoid, in which the histories contain information on  this point.
Of  these fourteen cases, seven were in private practice, and seven were in
hospital.   These cases are exclusive of the instances in  which sweating
occurred  either  coincident with, or shortly before convalescence, or as a
precursor of death.   In  a certain number of cases the termination of the
disease, either fatally, or in convalescence, was characterized by this event,
but as occurring under these  circumstances it will be more  appropriately
considered in a subsequent section.  In eight of the fourteen cases, sweat-
ing occurred more than  once during the  febrile career; in seven of the
eight cases it occured several times, and in the remaining case twice.   The
periods of the disease at  which  it occurred, were varied; in  fact, among
these fourteen cases,  each day of the febrile  career would probably be
represented.   Perspiration in a lesser degree, constituting what was dis-
tinguished in the histories as moisture of the skin, occurred, in ten of the
twenty-seven cases of Typhoid, viz.:  in four of the cases in private prac-
tice, and in six of those in hospital.  In  these cases the skin was  either
moist almost  constantly during the febrile, career, or, generally, the moist-
ure was present more or less frequently for hours, or days, in the course of
the disease.   It will be perceived, by the above enumerations, that sweating
occurred  in  a larger proportion  of the  cases  of Typhoid, than  merely
moisture of the skin—a curious fact, worthy of passing notice with a view
to its possibly being found to possess  some significancy in  connection with
other facts.
  Sweating occurred in a  proportion of  the Typhoid cases in private prac- 
108                 REPORT ON CONTINUED FEVER.
tice larger then  in those in hospital, being present in seven-ninths of the
former, and in only four-ninths of the  latter group.   As  this disparity is
not susceptible of explanation by reference to difference in  circumstances
in the  two groups, it probably shows that, in the proportion of instances in
which  this  symptom is present in Typhoid Fever different collections  of
cases should not be expected to exhibit uniformity.
   Of the twelve hospital cases of Typhus, sweating was noted in the  histo-
ries of five.  It occurred several times in one of these cases; once only, in
one case; and twice in two cases.   Moisture of the skin was noted in but
two cases.   Thus, as regards sweating, results do not show a marked dif-
ference,  in the two types,  in the frequency of its occurrence; but simply
moisture of the  skin was less frequently observed in Typhus  than in Ty-
phoid, occurring  in  the ratio  of 1 to 6  in the  former, and 1 to 3  in the
latter.
   Of  the eight cases of doubtful type sweating was noted in four.  Moist-
ure is  noted in a single case; and  in one case the history is deficient in in-
formation respecting the symptoms referable to the skin.
   Adding together  the  cases  of the  three  groups  above mentioned  in
which the  condition of the skin was noted, the sum total is 46, and of this
number sweating occurred in 23, i. e., in precisely one-half.
   The sweating was not in all cases equal in degree; pains, however, were
not taken to determine differences in this particular with  exactness, which,
it is obvious, would be difficult, if not  impracticable.  The terms free, pro-
fuse, copious,  and bathed in sweat, were frequently employed in the histo-
ries to express the quantity of secreted fluid present on the surface,  but in
other  histories it is simply stated  that sweating had occurred, or was ob-
 observed at the  time of the examination.   In one case of typhus it is stated
 that the hands  were corrugated from  the profuseness of perspiration. This
 has been styled  the washer-woman's sweat, and  has been thought to be a
 fatal sign.  In the case in which it was noted the disease ended favorably.
 In one case of Typhus, in which sweating occurred twice; on the first occa-
 sion  it was quite profuse, and limited to the forehead and face ;  on  the
 second occasion, it was copious on the face, and extended, but in a less de-
 gree,  to the chest and upper extremeties.  As a general remark the sweat-
 ing during the  career of the Fever was not attended,  or immediately  fol-
 lowed by  any marked abatement of the severity of the disease, but,  on  the
 contrary,  judged by the symptoms, the effect was the  reverse.   This may
 be enumerated  as the rule, and I am not aware that there were any ex-
 ceptions to it.   No exceptions were  noted  in  the  preliminary analysis of 
REPORT ON CONTINUED  FEVER.
109
the cases, and in several instances it  is stated that this event was not con-
nected with any improvement in the  symptcms.
   The foregoing results, it is believed, conflict with the ideas generally
entertained by practitioners respecting the frequency with which sweating
occurs in Continued Fever, and  the  degree and the kind of importance to
be attached to it.  Perhaps this is one of the many instances which might
be cited to illustrate  the influence of theoretical or preconceived no-
tions in frustrating the  lessons of  experience, unless that experience  be
based on observations recorded  and  analyzed.  It is a current belief that
sweating generally proves salutary when it occurs in Continued Fever—a
belief originating, probably, in the ancient humoral hypothesis of a specific
 morbid  material being eliminated through the cutaneous secretions ;  and
 apparently sustained  by the instances in which this symptom is regarded
 as critical from its occurring concurrently with convalescence.  Its correct-
 ness, however, is disproved by the facts which numerical investigations dis-
 close, showing the large number of cases in which the event occurs, and,
 at different periods of the  disease, without affecting, apparently, in a  favor-
 able manner, its character or progress;  showing, moreover, as will be seen
 hereafter,  that  it occurs during the febrile career, without improvement,
 in a larger proportion of  cases, than that in which it signalizes  convales-
 cence.   If this view of the subject be correct,  the propriety of pursuing
 measures, during the career of Continued Fever, to  produce sweating is
 more than questionable.
    It would be interesting to ascertain upon what ulterior conditions,  or cir-
 circumstances, appertaining to Continued  Fever, sweating is dependent.
  With reference to this point of inquiry, it would be important  to establish
 any relations subsisting between this event, and other phenomena belong-
 to the  natural history of the disease.  I have examined the histories of  se-
  veral of the cases characterized by sweating, in order to discover a clue to
  some connection of this kind, but  without success.  It occurs, not only at
  different periods of  the disease, but apparently irrespective of the circula-
  tion, the temperature of  the skin, and other symptoms.    The  antecedent
  morbid condition, or conditions, upon which  it depends, and  the circum-
  stances involved in  its production,  are unknown.  All that can be said of
  its  causation is, that it is an event incident to  the progress of Continued
   Fever, belonging  in  the category  with other incidental events, such as ac-
   celeration of the  pulse, coating of the  tongue,  somnolency, etc.—all of
   which are not more rationally explicable than iL
     This fact should be mentioned,viz: in the majority of the instances in which
    weating occurred,  it took place during the  night, or, commenced  during 
110
REPORT ON CONTINUED  FEVER.
 the night, and was  continued into the day.   It is not noted in any of the
 histories that it was preceded by exacerbation of fever, but this may have
 been true of some cases without having been observed, the examination of
 the patients, and records of symptoms, being made, for the most part, in the
 morning, and the occurrence of exacerbations, therefore, not always ascer-
 tained.
   It remains to inquire respecting the occurrence of sweating and moisture
 in the cases which ended fatally.   In nine of the fatal cases included in the
 above  enumerations, sweating was noted in four, a  proportion, it will be ob-
 served, not far from that  in which it is found  in the cases terminating in
 recovery.   Hence, this event has no particular  bearing on the prognosis.
 Of these nine cases, moisture was noted in three, which is also  not very far
 from the proportion which it bears in the cases which recovered.   It is to
 be borne  in mind, that in these enumerations, as well as in  those which
 have preceded, sweating and moisture at, or toward the close of the career
 of the  disease, are not included.
   Dryness.  The skin, if perfectly normal, is neither moist nor dry, but
 presents a medium state, conveying to the touch a sensation which  is best
 described by applying  to  it, figuratively, the term mellow.  It has been
 seen, that in Continued Fever, deviations  from this condition are  apt to
 occur in consequence of increased secretion from the sudorifarous glands,
 causing moisture, or sweating.
   Deviations of an opposite kind may occur, in consequence of diminished
 secretion from these glands. The surface then communicates to the touch
 a  sensation of dryness.  Dryness of  the skin, more or  less, occurs  in the
 great majority of the  cases of Continued Fever.   Of the thirty cases of
 Typhoid,  I  find but four  in which it appears from the  histories that this
 condition of the skin was  entirely absent during the  febrile career.   This
 was true of but one of the twelve hospital cases of Typhus.  In several
 of the cases, however, the records do  not afford positive information on this
 point—viz: in ten cases of Typhoid, and one case of Typhus.   This  defect
 in the histories of these cases probably was owing to  not always apprecia-
 ting the importance  of noting the presence of a symptom so familiar  and
 almost  universal as this.  Had the skin remained moist, or mellow, through-
 out the disease, in any of the cases, I am quite  sure  the  fact would  have
 been embraced in the histories.
   The occurrence of dryness was very variable, as respects the period or
 periods of  the disease  when it was observed ;  its duration ; and also its
relation to other conditions of  the external surface.  In  five cases, it ap- 
REPORT ON CONTINUED FEVER.
Ill
peared early, and  persisted through the greater part of the febrile career.
In other cases, it was not observed until the disease hud made more or less
progress ;  and, generally, it was present at intervals, alternating with other
cutaneous  symptoms.  It was so irregular in these  particulars, as also  in
its  degree of intensity,  that it would be  difficult to condense, by means of
classification, the facts contained in the histories of all the cases.  The brief
and very general account contained in the foregoing paragraph, will suffice
for the  historical  portion of this division of the symptoms referable to the
skin.
   Dryness of the surface would seem to be a more consistent event in con-
tinued fever than moisture  or sweating, since observations show that all the
glandular  secretions of the  organism are diminished in this disease.  It is,
however, as little susceptible of  rational explanation as the opposite condi-
tions already considered.   Like most of the phenomenal manifestations of
fever, it is so connected  with  the  primary,  essential, morbid changes, in
which the disease  consists, that while these remain  undiscovered, we can
hardly  hope to penetrate completely its causation.  We can only study it
in its various relations.
   As a  symptom, it obtains so invariably in continued fever of both types,
and also in other affections, that it is of small or no value in diagnosis, and
has very little pathological  significance.
    Temperature.   Heat of  the skin  existed,  more or less, in most of the
cases.   In a few instances, however, the temperature did not appear to  be
increased  beyond what belongs to a state of health.  The heat was associa-
ted with moisture, and, more rarely, with sweating;  but generally, dry-
ness co-existed.   In some cases  the heat continued pretty steadily through-
out the disease, and in other  cases it occurred  at intervals, and was of
variable duration.   That peculiar pungent or acrid heat called Color Mor-
dicans,  which is regarded by some writers as characteristic of the  Typhus
type, was  noted  in but  two cases, one of the Typhus, and  the  other of
doubtful type.
   The  increase of temperature was of different  gradations, from a slight
elevation  above the natural warmth, to a degree to which, in a hyperboli-
cal  sense, the term burning might be applied.   Coldness of  the surface
was not noted in a single case.
   Of temperature, as  of dryness, it may be  said, and for similar reasons,
that the conditions of  the skin in this respect are of little account  in diag-
nosis, and have no special pathological significance.
   When associated with dryness, heat may in part be explained by the  di- 
112
REPORT ON CONTINUED FEVER.
 minished evaporation.   It is not, however, wholly accounted for in this way,
 but it involves a positive increase  in  the  disengagement of caloric, as is
 evidenced by the fact that it co-exists in some instances with moisture, and
 even sweating.  To inquire concerning the rationale of its  production un-
 der these circumstances, would be to travel beyond the  limits of the facts
 before us.
   As a general  remark, applicable  to  the divisions previously considered,
 as well as to the subject of  temperature, it may be said  that in estimating
 the  severity of the disease, and  the prognosis, by the symptoms referable
 to the skin, no very definite or positive inferences are to be drawn from any
 of the deviations from the state  of health, considered by themselves ;  but
 a return or  approximation to normal conditions, other things being equal,
 must, of course, be regarded as favorable.
   Gangrene.   Gangrenous ulceration of  the  skin occurred in  but  a
 single case,  which was  of the  Typhus type.  It appeared on the tenth
 day after the admission of the  patient into hospital.   The parts affected
 were  the  Sacrum, and a  small space  over the  Scapula.  In the  lat-
 ter situation the affection was slight,  and, of short continuance.  Over the
 Sacrum a considerable eschar followed, leaving a large and troublesome ul-
 ceration, which did not heal for several  weeks after convalescence was pro-
 nounced.  The patient, finally, completely recovered.   This  case in other
 respects did  not exhibit unusual  severity.
   In a very  few instances (three or four, as near as can be determined by
 recollection) some erythema over  the Sacrum,  or nates,  was observed
 which disappeared on the application of astringent washes, and the use of
 air cushions, without proceeding  further.
   It has been noticed that in this disease, blistered surfaces are apt  to  de-
 generate into troublesome ulcerations.  The opportunities afforded  in  the
 present collection of cases for verifying this point were extremely limited,
 vesication very seldom entering into the treatment.  In  the few instances
 in which blisters were applied, no such  result followed.
   Erysipelas did  not occur in  any case during the  febrile career.  It
 became developed  in one case,  succeeding  Parotitis, after convalescence
 was established.  It was situated on the face, and was treated  by the ap-
 plication of ice to the part affected.   It  was of short duration, and did not
 attain a great degree of severity.
   Having thus considered, under distinct heads, the  several divisions of
 the symptoms referable  to the skin, it  remains to  give  some account of
these symptoms as they were associated in individual  cases.  In many of 
REPORT ON CONTINUED FEVER.
113
the cases all the varieties of the foregoing cutaneous phenomena were pre-
sented, either in combination, succession, or alternation, during the career
of the disease.  Not only were variations  observed  in the same case on
succeeding days, but uniformity frequently did not exist at different pe-
riods of  the  same day.   Since the laws regulating these fluctuations are
but little understood, and very little pathological or practical importance be-
longs  to them in the present state.of  knowledge, they are chiefly inte-
resting as  comprising a part  of the natural history of the disease.  The
readiest  method of exhibiting them as contained  in the histories of all the
cases, would be to arrange them in a tabular form, in the mode adopted in
other sections.  This I have done for convenience of examination and  re-
ference in writing the foregoing remarks.  It  will, however, answer every
purpose, and economize space, as well as the patience of the reader, to se-
lect a few cases from those of each type, as illustrations, giving the symp-
toms referable to the skin which were noted on each day during  the career
of the Fever.  This plan will therefore be adopted.

                                Typhoid.
   Case 1.—1st day, 6kin cool ;  2d, warm and moist ; 3d, cool, and bathed
 in perspiration ; 4th, warm and moist ;  5th, moist ;  6th, perspiring freely;
 7th, perspiring  profusely ;  8th,  warm and  mellow ; 9th, warm ; 10th,
 warm aud dry; 11th, perspiring copiously; 12th, warm and moist ; 13th,
 warm and mellow ;  14th, perspiring  profusely ; 15th, warm and  moist ;
 16th, warm and mellow ; 17th, cool and moist ;  18th, cool and moist.
   Case  2.—1st day, skin hot and dry  ; 2d, dry and warm ;  3d, warm ;
 4th, warm and mellow ; 5th, warm  and dry ;  6th, warm and mellow.
 Deep congestive redness  of face and extremities.
   Case 3.—1st day, skin rather hot, perspired at night  ; 2d, warm and
 mellow;  3d, hot and dry;  4th, warm and moist, and at night profuse per-
 spiration ; 5th, rather hot and dry ;  6th, perspired at a. m., and profusely
 at p.  m.;  7th, hot and bathed in perspiration, dry before decease, this case
 proving fatal.
    Case 4.-1 st day, skin hot and dry ;  2d, warm and moist ; 3d, hot and
 dry  4th, cool ; 5th, warm and mellow; 6th, warm ; 7th, warm and dry;
 8tn,  moist ; 9th,  warm and dry; 10th,  warm; 11th, warm  and dry ;
 12th, warm  and dry ;  13th, warm ; 14th, warm and dry ; 15th, moist,
 16th, warm  and  dry ;  17th, warm and  dry ;  18th, warm and mellow.
 Congestive redness of the face.
J 
114
REPORT ON CONTINUED FEVEK.
                               Typhus.
   Case 1.—1st day, skin hot, and heat acrid ; 2d, cool ; 3d, normal tem-
perature and  dry; 4th, cool ;  5th, cool ;  6th, warm  and very dry ;  *7tb,
mellow ; 8th, cool ;  9th, copious  perspiration, confined to forehead and
face ;  10th, warm and dry ; llth copious perspiration on  face, extending
in a moderate degree to the upper extremities, sudamina, deep congestive
redness, somewhat livid.
   Case 2.—1st day, warm and moist ; 2d,  dry, and temperature increased ;
3d, cool ; 4th, warm and mellow;  5th, mellow, temperature somewhat in-
creased ;  6th, cool and moist ; 7th, cool and moist.   Dingy congestion of
face and extremities, at first considerable, gradually  diminishing, but not
disappearing  entirely until after convalescence was pronounced.
   Case 3.—2d day, cool and dry;  3d, noted that skin presented no change.
Congestive redness.   Fatal on the  third day.
   Case 4.—1st day, cool ;  2d,  cool ;  3d,  warm and dry; 4th, warm, and
at p. m., hot ; 5th, moist;  6th, moist and cool ;  7tb, warm, and at p. m.,
moist.

                           Doubtful  Type.
   Case 1.—1st day, hot  and dry;  2d, hot and dry;  3d, warm and dry;
4th, warm  ; 5th, dry and rather hot ;  6th, dry and rather hot ; 7th, face
covered  with  perspiration, and remainder of the body dry; 8th, hot and
dry; 9th,  hot and dry ;  10th, hot  ; llth, dry, but less  burning heat ;
12th dry, not hot.   Some  congestive redness of face.   This case proved
fatal.
   Case 2.—1st day, hot and dry ; 2d, dry, acrid heat, (calor mordicans;)
3d,  warm  ;  4th,  moist,  perspired freely  during the  night; 5th, moist.
Congestive redness of face.  Parotiditis and erysipelas occurred, after con-
valesence was pronounced in this case.
   The enumeration of days in  the foregoing  cases is dated from the  time
the patients came under observation.

                           SECTION TENTH.

            Symptoms referable to the Genito-urinary System.

   The facts, contained in the histories, relating to the subject of this sec-
tion, are quite insignificant.  In the great  majority of  the cases,  the quan-
tity and other  characters appertaining  to the urine were  unobserved.
This was in consequence of the  difficulty of  preserving, in a separate 
REPORT  ON CONTINUED FEVER.
115
vessel, the evacuation of each patient, and retaining it for my inspection:
a difficulty by no  means insurmountable, but which, to my regret, was not
persistingly  overcome, the  attempt having  been  commenced, but  aban-
doned.  The present collection of cases furnishes no  data for determining
what deviations from the conditions of health ordinarily obtain in contin-
ued fever.   In a few instances,  some  unusual  symptoms   referable to
the urinary system presented  themselves,  attracting  notice, and  were
consequently noted.   They are as follows :—Copious lithatic deposit was
observed in two Typhoid cases, occuring in private practice.  In these cases
this deposit took place during the whole course of the disease.
   In the history of one case of Typhus, it is noted occasionally, during the
progress of the disease, that the urine was high colored,  and  without sedi-
 ment, but two  days before convalescence was pronounced,  the  secretion
 became more abundant, and deposited a copious lateritious sediment.
    In one case of Typhoid in private practice,  there was, for a time, inability
 to void  urine, requiring the catheter.   The  inability in this case did not
 proceed from unconsciousness,  the patient experiencing fully the desire to
 urinate, but being unable to accomplish the act.  This was early in the dis-
 ease, and  may, perhaps, have been owing to anodyne remedies, which,  as
 is well known, occasionally are attended with such an effect.
    In another  Typhoid case in private practice, there was some difficulty in
 evacuating the bladder, for a day or  two, which,  perhaps, was due to  the
 same cause.
    In several cases, it was noted that the urine  was  passed in bed.  This
 was owing to the same mental indifference  which accounts  for the evacu-
 ation of the bowels in bed; and the two events generally co-existed.
    These few and meagre observations are all that I have to report.

                           SECTION ELEVHXTH.

 Duration of the disease.  Circumstances attending Convalescence.   Seque-
    lae.   Mode of dying.   Fatality.
    Duration.—In  order  to  determine, accurately,  the duration  of the
 febrile  career, it is necessary that  the periods of its commencement and
 termination should be fixed with precision.   It has been  seen, in a previous
 section, that it is not easy to decide, in all cases, upon the exact time when
 the  access, or forming  stage closes, and the fever  begins.   The circum-
 stance  selected to  denote  the period  of commencement, in the present
 analysis, is, confessedly, wanting that degree of precision which could be 
 116                 REPORT ON CONTINUED  FEVER.
 desired.  It is, in a measure, arbitrary, and is adopted only because, in the
 opinion  of the writer, it supplies, in the majority of cases, a criterion as
 accurate and as readily available, as any that may  be fixed upon.  The
 circumstance referred to, is a sense of disease or  debility sufficient to
 lead the patient to desire to take to the  bed.   This marks  the date of the
 fever proper, or of the  second stage if  the access be included among the
 stages of the disease.         *
   Now, what shall serve as  the index to the day of convalescence?  The
 rule adopted by Louis, is to consider the day of convalescence  that  on
 which the patient begins to take some solid food.   In following this rule,
however, it is plain that he determines  the fact of convalescence, prior  to
 the patient's taking food, from other circumstances.   That is  to say, when
 the patient is distinctly convalescent he allows solid food for the first time,
 and the latter is, therefore, merely an indication of his decision, not, neces-
 sarily, a criterion of  the fact of convalescence.   The applicability of this
 rule will involve the withholding of solid food prior to convalescence, on the
 one hand, and that it should be invariably given so soon as convalescence
 is pronounced, on the other hand,  both of which provisions may not be  in
 accordance with the course pursued by all practitioners.   Notwithstanding
 these objections, I am not aware that  a better criterion has been suggested.
 But instead of following the rule laid  down by Louis, it  appears to me
 preferable to do what it  would seem  Louis virtually  does, viz: decide on
 the  day of convalescence  from   an  ensemble of circumstances.   If the
 febrile movement, as  determined by the heat  of skin, acceleration of pulse,
 etc., have ceased, clearness of the intellect returning, with refreshing sleep,
 and the patient has a desire for, and relish of food, he may be pronounced
 convalescent.   Some one or more  of  the above conditions, in  some  instan-
 ces, may be wanting,  and, still, the other circumstances  be such that con-
 valescence may properly be declared.  Judgment, and some experience are
 requisite to decide correctly;  and, with  every qualification  on the part of
 the observer,  it will  not infrequently be a matter of some doubt as to the
 particular day which should limit the termination of the febrile career. Dif-
 ferent practitioners would not fix upon the same day in all cases, owing to
 differences in the mode of  estimating the circumstances upon which the
 opinion is based.  Perfect exactitude and entire uniformity, in short, as re-
 spects this point, are not practicable; and yet, sensible physicians, in the
 majority of instances, will  act with sufficient correctness  for  all practical
 purposes.   The exercise of judgment in a  similar  way, would  answer
 equally well  in  designating the commencement of  the disease, without re- 
REPORT ON CONTINUED FEVER.
117
course to an arbitrary event  like that which the writer has adopted.  But
there is this material difference in the two instances, viz., it very frequently
happens that cases do not come under observation at their commencement,
and hence, it  is desirable to  fix upon something which will serve to mark
the date at a period when we have nothing to rely upon but the  history
given by the patient or friends.   Under these circumstances we can almost
always ascertain at what time the  patient took  to the bed, when  we are
able  to obtain very little information of the symptoms, and history in other
respects.   On the other hand, a  patient does not pass from our observation
usually, until  he is considered convalescent; hence, there is not the same
necessity, or advantage, in determining the time of convalescence by refer-
ence to an arbitrary standard.
   It was an ancient belief, which is not yet entirely obsolete, that  there is
 an intrinsic tendency in  Continued Fever to  terminate  after  the  lapse of
 a certain numbers of days, dating from the commencement of  the  disease.
 That the doctrine of critical days, as  these days were termed, originated in a
 fancied virtue inherent in the days,  or numbers by which they were desig-
 nated, is evident from the foregoing considerations.   The difficulty of de-
 ciding the duration, to a day, in a large proportion of cases, renders it im-
 practicable either to establish, or disprove,  by observation, that doctrine.
 This, however, has been  attempted  within a few  years.  Dr. Welch, of
 Edinburgh, Scotland, enumerated the days in  690 cases,  collected from dif-
 ferent sources, and he found that, of this number, 470  ended on some of
 the days  considered  critical.  Subsequently  Dr.  Davidson, of the same
 place, analyzed a collection  of cases, considerably less in number,  with re-
 ference to this point, and arrived at different results.  Statistics by differ-
 ent  persons, with an equal  allowance of good faith, may be expected thus
 to differ.   The termination, as well as invasion of the disease being seldom
 so well defined but that one of two or three days  might be selected, a dis-
 position to credit or discredit the doctrine of critical days would  afford a
 bias which would hardly fail to determine the preference of critical or non-
 critical days according to the preconceptions of the observer.
    Insdetermining the duration of the disease, then, in  the cases under in-
 vestigation, rigorous  accuracy is not claimed, but only an approximation
 thereto, sufficient for all practical purposes exclusive of  the doctrine of cri-
 tical days.                                                   .
    In about one half of the hospital cases (17 of  38) the histories do not
 contain a  definite statement of the commencement of the disease, i.  e., of
 the time the patients had  been confined to the bed prior to entering the 
118
REPORT ON CONTINUED FEVER.
hospital.   In many instances it was impracticable to obtain information on
this point, and proper effort was not always made to obtain it.   Patients
were received at different  periods of the disease, and hence, the space of
time from the date of their admission to the date of convalescence, is not a
fair representation of the duration of the disease.   In a considerable num-
ber of  cases, however, it may be supposed  that the differences in the time
that had elapsed before entering the hospital would  compensate for each
other, and, the cases of different groups might  be considered uniform  in
this respect.  Hence, the cases of the  two types may be compared  as re-
gards  the duration from the date of admission.   The  time of convales-
cence was generally fixed, being determined  by so marked an abatement
of the  symptoms as to denote that the febrile career was at an end.  In a
few cases, however, this was impracticable, owing to the  existence of com-
plications, continuing after the febrile career was ended, symptoms of both
being so intermingled, that chronological limits of the latter were not dis-
cernible.
   Another point of inquiry relates to the time of remaining in hospital, i. e.,
the number of days, or weeks, from the date of admission, to the date  of
discharge.  Here various causes are operative aside from disease, and the
amount of debility remaining after convalescence is established.   Some pa-
tients are anxious to leave the  hospital as soon as possible, and  do not re-
main as long as  prudence would dictate; others, having  no better asylum,
are desirous of staying as long as possible.  Still, on  the principle of com-
pensation for differences, the cases of the two types may be considered uni-
form in this particular, and a comparison instituted.
   The facts contained in the histories of the cases under examination rela-
ting to the foregoing objects of enumeration and comparison, are presented
in the  following tables :—
TABLE EXHIBITING DURATION IN  TWELVE TYPHOID CASES IN
                        PRIVATE PRACTICE.
	f 1	2	3	4	5	6	7	8	9	10	11	12	
No. of days from													
time of taking to													
bed, to date of			about	about		about							
convalescence.	16	11	18	21	28	15	11	10	14	9 Fatal.	5	9 Fatal.	Total 149. Mean 14 9-10.
 
REPORT OW CONTINUED  FEVER.
119
TABLE EXHIBITING DURATION,  ETC., IN EIGHTEEN HOSPITAL TY-
                          PHOID CASES.
No. of days from time of taking to bed, to convales-cence. No. of days from admission to hos-pital, to date of convalescence. No. of days from date of convales-cence to date of discharge,ordate of last record. Fatal cases. No. of days from taking to bed. Do. from admis-sion. Length of time in hospital.	1 4 23	2 26 15 15	3 8 11 19	4 8 9 17	5 18 12 4 16	6 13 9 22	7 18 12 4 16	8 14 13 7 20	9 14 5 19	10 10 6 16	11 6 6	12 15 7 22	13 32*	14 25 14 30 44	15 31 21 13 34	16 14 6 10 10 16	17 9 7 16	18 Cu re i 5' p re o orq o *-d re "-i o	Total 120. Mean 20. Total 187. Mean 13 5-14. Total 135. Mean 10 5-13. Total 258. Mean 19 13-15
* Complicated with pneumonitis.
TABLE EXHIBITING DURATION IN 12 HOSPITAL TYPHUS CASES.													
No. of days from date of talking to bed to date of convalescence.	1	2 Fatal. 13th day af-ter in-vasion.	3 19	4 19	5	6 9	7	8 Fatal on the 7th day.	9 13	10 14	11 17	12 10	Total 74 days. Mean 14 4-5
No. of days from admission to hos pital to date of convalescence.	8	Fatal 8th day.	12	14	18	9	13	Fatal on the 3d day.	13	14			Total 131. Mean 11 10-11
No. of days from date of convales-cence to dismis-sal from hospital or dale of last re-cord.			16	Com-plica-ted with paroti-tis. 37	5		9		Re-main'd in hos-pital 6 weeks. Trans-ferred to sur-gical depart-ment for es-char on sacrum	16	21	11	Total 115. Mean 16 3-7. Total 221. Mean 27 5-8.
Length of time n hofpilal.		8	28	51	23		22			30	38	21	
 
120                 REPORT  ON CONTINUED FEVER.
TABLE EXHIBITING DURATION IN EIGHT HOSPITAL CASES OF
                       DOUBTFUL TYPE.          __________
No. of days from time of taking to bed to date of convalescence.	1 9	12	3 14	4	5	6 14	7 9	8 5	Total 63. Mean 10J. Total 53 Mean 7 4-7 Total 89. Mean 17 4-5. Totul 128. Mean 25 3-5.
No. of days from date of admis-sion to hospital to date of conva-lescence.	6	10		Fatal 23rd day, complica-ted with parotitis.	5	9	9	5	
No. of days from date of convales-cence to date oi discharge from hospital, or oi last record.	5	5	17		Parotitis superve-ned. 35	Parotitis superve-ned. 27	Remain ed in hos-pital. Sis-ter of Charity.	Sister of charity	
Length of time in hospital.	11	15	26		40	36			
   The shortest term of duration, as will be perceived by consulting the ta-
bles, was five days.  In two  cases, one being in private  practice, and one
among the hospital  cases of doubtful  type, this was the length of the fe-
brile career.   The history in each of these cases leaves no doubt as to the
fact that the disease was Continued Fever.   In both cases the  fever was
of a very mild  grade, but the  diagnostic  features were  unequivocal.  In
both instances  it seemed most rational to attribute the origin of the disease
to contagion.   There were exceptional cases as respects  duration.   In no
other case did the fever run its course in a less period than nine  days, and
in all hut five instances, the duration was longer.   The maximum of dura-
tion was twenty-eight days,  the case occurring in private practice.  This
case was treated homceopathically for ten  days before  coming  under my
observation, the patient being kept on rice water for diet.
   It will be observed that  the average duration  of  the  Typhoid cases in
private practice is  considerably less than the average of those of the same
type in hospital, 14 9-10 being the mean number of days in the former, and
20  the mean number of days in the latter.   I can offer  no  explanation of
this disparity.  It  should, however, be considered  that the cases in  hospital
in which the criterion for determining the commencement of the disease was
ascertained,  are few in number—being only six.  On comparison of the
average duration of the hospital cases of Typhoid, with that  of the  cases of
Typhus, the  latter are found  to have a shorter career, the mean number
of days being 14 4-5, while the mean number of days of the former, as just
stated,  is 20.  This disparity accords with the results of analyses  by
others. 
REPORT ON CONTINUED  FEVER.
121
   The disparity is less, if we compare the hospital cases of the two types as
 respects the duration  from the time of admission into hospital to the time
 of convalescence.   The mean number of days of the Typhoid cases from
 the date of entrance to the date of convalescence is 13 5-14, while the mean
 number of days of the Typhus cases is 11 10-11.   The  probable explana-
 tion of this result  is, that in cases of  Typhus the symptoms sooner  assume
 a degree of gravity  to lead the  patient or friends to seek hospital relief.
   Although the career of the disease is shorter in the majority of cases,
 in Typhus, patients are nearly as long in hospital before convalescence, be-
 cause they enter sooner than in cases of Typhoid.
   Again, on comparing the hospital cases of the two types as respects the
 duration from  the time of convalescence to the date of  the last record,  or
 discharge, the disparity is in favor of the Typhoid type, the mean number
 of days being in the latter 10 5-13, while in the Typhus type it is  16  3-7.
 This  result would  go to show that the system  recovers sooner from  the ef-
 ects  of Typhoid than Typhus fever,  or, in other words, it shows that the
 latter form of fever, although shorter in its career, produces a graver influ-
 ence  on the organism.  The length of time in the hospital in cases of the
 two types, corresponds with the above result,  the mean number of  days  in
 Typhoid being 19 13-15, while in Typhus it is 27 5-8.
   It  remains to notice the  duration in the cases ending fatally.  Of the five
 fatal  cases of Typhoid type, the duration of the disease in  each was as fol-
 lows:—after the attack, nine days in two cases; twenty-six days in one case;
 ten days  in one case.   In  the other cases the dates of the invasion were
 not precisely ascertained.   The duration after admission into hospital of the
 latter cases, were  as follows:—three days in one case; six days in one case.
 Mean duration of  time the cases were  under observation, 8 1-5.   Of the
 three fatal cases of Typhus the duration in each was as  follows:—three
 days  in one case;  thirteen days in one case; seven days in one case.   Mean
 duration of time these cases were under observation, 6 1-3.   The mean pe-
 riod of duration when the  disease proved  fatal,  is considerably  greater in
 the cases of Typhoid  than  in those of Typhus,  being 13-5- in the cases of
 the former in which  the date of the attack was ascertained, and  8  in  the
 cases of the latter type.  In so far as these few cases afford data  for re-
 sults, then,  Typhus,  when it proves fatal, runs a shorter  career than Ty-
phoid, a conclusion which accords with the observations of  others.
   Of the two fatal cases of doubtful  type, the duration  was in one, eight
 days,  and in the other, twenty-three days,
   There are several  points of inquiry connected with the subject of dura- 
122                 REPORT ON CONTINUED FEVER.

tion, in addition to those which have been noticed.  One of these is the in-
fluence of age  upon duration;  another is the  influence of  early or late re-
ception into hospital; the effect of seasons is another, etc.  The number of
cases in this collection is  not sufficiently large  for enumerations with refe-
rence to  these  questions.
   Circumstances attending  convalescence.   The  circumstances  attending
convalescence are of interest with reference to the pathological inquiry  in
how far  they may be considered to have contributed  to the favorable ter-
mination of the disease; in other  words whether, or not, they are critical
in their  character.   Of the ten  Typhoid cases in private practice which
terminated favorably, convalescence in one case was preceded by profuse
perspiration for several nights'; and in one  case it  is stated  that convales-
cence was accompanied  by profuse perspiration.   In  one case  diarrhoea,
which had existed moderately  during the progress of the disease, was some-
what increased  at the  time of convalescence.   Of  the  remaining seven
cases, it is stated in four that no evacuations occurred which could be re-
garded as critical; and in three there is nothing stated on the subject.  The
occurrence of an  event which was suspected to be critical, would  hardly es-
cape being recorded;  and, hence, it is fair to infer that in  all the cases ex-
cept the three first mentioned nothing of the kind  was observed.
   \nfive of  the  above ten cases, convalescence was established by a grad-
ual  abatement of symptoms, and  the  histories of the  remaining  five cases
do not furnish data for determining whether the  disease ceased  suddenly,
or not.   In the latter group are included the  two cases in which  perspira-
tion occurred at, or near the time of convalescence.
   Of the fourteen Typhoid hospital cases which terminated favorably, con-
valescence was accompanied by perspiration in two.   In one of these cases
the perspiration was profuse.   In one case diarrhoea continued, but not in-
creased.  In one case, the contents of a  small abscess on the thigh were
 discharged on the day preceding that on  which  convalescence was pro-
 nounced.  Nothing is stated of any event which  might be supposed to be
 critical in the  histories of any of the remaining cases.  In two  cases, the
 occurrence of  convalescence was  apparently postponed by the existence of
 pneumonitis, and in one  case, the same was due to parotitis.
   Of the ten  Hospital cases  of Typhus which terminated favorably, con-
 valescence was preceded or accompanied by perspiration, in four.   In none
 of the remaining cases does  the histories  contain aught which could be
 regarded critical.  In two cases, pneumonitis co-existed, and continued after
 the  febrile career had ended; and in one  case, the same was true of pa-
 rotitis. 
                     REPORT ON CONTINUED  FEVER.                 123

   Of the seven cases of doubtful  type which ended favorably, convales-
cence was accompanied by profuse perspiration in one case.   Pneumonitis
existed at the time of convalescence in one case.
   In the preliminary analysis of the Hospital cases, pains were not taken to
ascertain whether the febrile career ended suddenly, or by a gradual abate-
ment of the symptoms.
   The above results show a small number of cases in which there are any
appreciable circumstances,  connected with convalescence, that may be sup-
posed  to have contributed to the  favorable  termination of the disease.
The instances in  which  diarrhoea continued, are  hardly  entitled to consid-
eration in this point of view.  Perspiration,  which occured in nine of forty-
two cases, it may at  first be supposed, was a critical event.   But when it
is considered how large  is the proportion of cases in which sweating occurs
during the career of  the disease, prior to its occurrence in connection with
convalescence, (viz. in twenty-three of forty-seven,) there does not seem to
be sufficient ground to attribute to  it much, if any,  agency in determining
the favorable termination.   From the frequency of  its occurrence, irrespec-
tive of  convalescence,  it might, perhaps, be expected to occur at, or near
the time  of convalescence,  in about one-fifth of  the number of cases, by
the law of probabilities, having no connection  with the convalescence be-
yond that of coincidence in time.  Assuming that there does exist some
connection, other than this,  it would  by no means follow that the perspira-
tion contributed  to the  convalescence.  The  former  may  be an effect of
the latter, instead of  being involved in its causation, or both maybe effects
of the same favorable change in the  morbid actions constituting the dis-
ease.  To discuss the latter points, would be to  engage in  speculative in-
quiries ; but, as it seems to me, a comparison of the ratio of the occurrence
of perspiration in Continued Fever,  without any amelioration of symptoms,
with the ratio  of its occurrence, at or near  the time of convalescence,  suf-
fices to disprove the supposition  that there  exists any connection between
these events.
   Sequelae.—Under this heading, I will include occurrences worthy of note,
which transpired  from the  time  convalescence  was  established, up to the
periods when the cases passed from  observation.    The  system,  after  the
febrile career, is liable to disorder, or disease, of various kinds, and, at some
times and places,  it has been observed  that  particular affections are apt to
ensue, showing a predisposition to certain sequete derived from the disease
through which patients have just passed.   No special tendency  to subse-
quent affections characterized the cases in this collection, and, in the great 
124
REPORT ON CONTINUED FEVER.
majority of instances, convalescence was  not retarded by any  untoward
event.   The occurrences which were noted, are as follows:—
  In the group of cases in private practice, convalescence was marked by
unusual  characters in but a single case.   In  the case referred to, the pa-
tient, for several days, exhibited a delirous excitation of ideas,  and  vari-
ous delusions, the most prominent of which was, that he had acquired great
wealth, that he owned steam boats, &c, and, among other extravagances,
he entertained the strange conceit that he had remunerated his  medical
attendant with a munificent fee !   This patient, during the febrile career,
did not manifest marked delirium, replying coherently to questions, but he
recollected very little that transpired in the course of his illness.   The de-
lirum  above mentioned  became  developed  after all  the other  symptoms
denoted convalescence, and indeed when he was able to sit up a portion of
the day.  The  delusions suddenly vanished.   He said he thought the mat-
ter all  over, and discovered the fancifulness of the ideas, which  had, for a
few days, afforded him so much satisfaction.  The discovery did not induce
any depression, he continued  to convalesce rapidly, and has  enjoyed excel-
lent health for the two  years that  have now elapsed since  his recovery.
May not the delirium, in this case, have been due to an exuberence of that
which  occasions the pleasurable sensations incident to returning health ?
  Of the Hospital Typhoid cases, in one the  formation of a small quantity
of pus near the rectum occured during convalescence.  The parts healed
readily after the purulent discharge.   In one, diarrhoea and  indigestion
occurred,  which were of short duration, and were probably due to impru-
dence  in diet.
  In one,  hysterical  paroxisms  occurred.  In  one,  a submaxillary gland
became swelled, but the swelling subsided  and disappeared in a  few days ;
and subsequently  formation of pus occured on the thigh  just below the
trochanter, and in the axilla.   These abscesses discharged for several days,
and the parts then healed, the patient leaving the hospital quite well, thirty
days after convalescence was pronounced.  In one,  perspiration occurred
for several nights, and on one night slight  delirium.
  Of the Hospital cases of  Typhus, in one the patient seemed dull, and
apparently experienced  some difficulty in arranging  his ideas.   In  one
several  furunculi  on   the  legs appeared  in succession,  and,  in  the
same  case, during the  time  of convalescence, the  gums were  spongy,
and bled for a few days.  The latter was not the effect of mercurialization.
In one, a furunculus appeared  on the  ankle, several days  after  convales-
cence, and the patient complained of pains in the loins, which were relieved 
REPORT  ON CONTINUED FEVER.
125
by the application of a sinapism.   In one, parotitis followed convalescence,
and this was succeeded by erysipelas of the face.
  Of the cases of doubtful type, in one, cough and substernal pain occured,
relieved  by a blister.   In  one, vomiting, probably  occasioned by impru-
dence  in diet.  In one, considerable febrile movement was observed on one
day;  and in one, parotitis commenced eight days after convalescence was
pronounced.
  The foregoing list shows  nothing like uniformity in the few  sequelae
which  were noted, nor  were  any of  the  subsequent affections of serious
import.  It is to be  borne in mind that the histories, for  the most part,
embrace only the time elapsing after the cases came  under  observation,
up to the date of the discharge.   Most of the patients  were lost sight of,
after leaving the hospital.  In the instances, which are exceptions to this rule,
it is not recollected that any have experienced  disease up to the present
time.
  In  none of the  cases did  relapse occur.   I have  never  witnessed what
might properly be called a relapse, after the career of Continued Fever was
ended.  A recurrence of febrile movement from persistence of some of the
complications of the disease, or supervening affections, has  been observed,
but not a recapitulation of the phenomena necessary to constitute Contin-
ued Fever.
   I have not noticed in this connection the instances in which complications
and symptoms, developed during the  career of the fever, continued, re-
tarding  recovery, and modifying the  symptoms of convalescence.   This
was the case with respect to  pneumonitis in several coses, and parotitis.
Deafness, congestive redness, diarrhoea, coated tongue, tremulousness of the
tongue, acceleration of the pulse,  etc., were observed in  convalescence,  as
well  as  during the febile  career, but this  has been already stated under
divisions treating of these affections and symptoms distinctly.
   Mode of Dying.—The mode of dying in  fatal cases of Continued  Fever,
is not uniform.  I will consider the diversities in this particular, as  arran-
ged into two kinds—first,  dying by  apncea,  and  second,  by asthenia.
Death by apnoea may be occasioned  by any cause  acting directly  to sus-
pend respiration.  The cause may be in the respiratory organs, but oftener
it is situated at the cerebral centre, destroying the instinctive want of res-
piration necessary to maintain the involuntary movements  involved  in that
function.  Death by asthenia is occasioned by causes acting more directly
on the circulatory forces, affecting the vis nervosa upon which the contrac-
 tile property of the heart  depends; or depriving the  heart  of  its  proper 
126
REPORT ON CONTINUED  FEVER.
 stimulus,  the blood, either by diminution of its quantity, or impairment of
 its quality.   These  two general modes are  not infrequently commingled
 in fatal  cases of Continued Fever.   Asthenia  may contribute to induce a
 condition of the cerebral centre, in consequence of which,  death occurs
 from apnoea  sooner  than it would  have resulted   from the  former mode
 alone.   Both modes are so conjoined in some cases, that  it is not easy to
 decide which really  determines the fatal issue.  I will proceed to enumer-
 ate the fatal  cas^s, giving the duration of each,  and the  mode of dyinu-
 which appears most probable from the histories.  The circumstances con-
 nected with the last moments of life are not  always  detailed, so that the
 mode of dying cannot be asserted with positiveness  in all instances.
   The fatal cases in private practice :—
   1 (Typhus,) Death on the 4th day, by asthenia.
   2 (Typhoid,) on the 9th day, by asthenia.
   3 (Doubtful type,)  8th day, by asthenia.
   17  (Typhoid,) 9th day,  by apnoea.
   The fatal Hospital cases  :—

   1 (Typhoid,) Death  on  the 3d day after admission, previous duration
 not ascertained, by asthenia.
   2 (Typhoid,) on  the 15th  day after admission, and  the  twenty-sixth
 after the date of the attack, by asthenia.
   3 (Typhoid,) on the  6th day  after  admission,  previous duration not
 ascertained, by apnoea.
   4 (Typhoid,) on the 10th day after admission, and date  of  attack,  by
 asthenia.
   5 (Typhus,)  on the  8th   day after admission, and  13th after date of
 attack, by apnoea.
   6  (Typhus) on the 3d day after  admission,  and seventh after date of
 attack, by apncea.
   7  (Doubtful type) on the  twenty-third day after admission, previous
 duration not ascertained, by asthenia.
   Fatality.—The ratio of  mortality  in  fifty-two cases,  upon  which  this
 report  is based, is a fraction over 21  per centum.   In the  Hospital cases,
 it is 18 8-19  per cent, while in  the cases in private practice, it is 28 4-7
per cent.  The  ratio  of mortality is a  fraction greater  in the cases of
 Typhus, than in those of Typhoid.   The proportion of instances in which
the disease proved fatal, is not large, judged by the average rate of mortal- 
REPORT ON  CONTINUED  FEVER.
127
ity of this disease, and it is proper to state that  the  proportion of fatal
cases would  have! been less, if all the Hospital cases of Continued Fever
had been included  in the collection.  A  few cases, which  were probably
cases of Continued  Fever, were rejected  because there  seemed  some
room for doubt as to the  correctness of diagnosis, and a few were excluded
inconsequence of meagreness of  the histories; but every fatal case of the
disease is embraced in the analysis.
                          SECTION TWELFTH.

                       Examinations after death.
   In the few examinations which were made after death, the object was
not to ascertain the appearances of all the organs, in order to gather from
this source a  complete assemblage of negative as well as positive facts.
Time and  opportunity were wanting for so minute and  thorough an inves-
tigation as  would be requisite for that object.   The more important of  the
vital  organs, in some cases, were inspected  ; in  some instances  the dissec-
tion was limited to the display of  the lesions which are most characteristic
of this disease.   In the four fatal cases in private practice no examinations
after death were made.
   Of the seven fatal cases in Hospital, examinations more or less extensive
were made in five.  The morbid appearances disclosed in  these five cases,
respectively, were as follows:
   No. 1.  (Typhoid.)  Autopsy  twelve hours after death.
   ffead.—Moderate  adhesion of  dura mater.   Arachnoid  membrane dia-
phanous;  a little serum beneath the  membrane  at dependent portion of
brain.   Some  effusion  at base of  brain,  quantity could  not be  estimated,
being commingled with  blood which escaped  on removing the  brain from
the skull.  Large veins  between convolutions, congested.  A considerable
number  of red points on section of cerebral substance.   Ventricles empty.
Consistence of brain's substance  normal.
   Chest.—Slight, old adhesions  over small space in right  chest.  Several
ounces of sanguinolent effusion (say 5 or 6) in left chest.  No  adhesion in
this chest; no lymph.  Pleural membrane presented nothing to attract no-
tice.   Lungs on both sides  free from morbid appearances, presenting  the
amount  of hypostatic congestion generally found in autopsical examinations;
crepitating throughout.
   Heart.—Slight effusion of transparent serum.  Organ rather below nor-
mal size.  Left ventricle empty.   Left  auricle contained  a small quantity 
128
REPORT ON  CONTINUED  FEVER.
 of fluid blood.  Right ventricle contained fluid blood, with some small, soft
 coagula.  Right auricle moderately distended with blood, mostly fluid.
    Abdomen.—Colon and  coecura greatly distended with gas, small intes-
 tines moderately so.  Dividing the ileum close to the coecum, and, length-
 wise, for several feet upward, the glands of Peyer were found to be enlarged>
 projecting two or three lines above the surface of the surrounding mucous
 membrane.   From fifteen to  twenty patches were counted, the enlarge-
 ment diminishing, progressively, upward.  No ulcerations, nor discoloration
 perceptible.  .Mucous surface appeared healthy.  Numerous  enlarged soli-
 tary glands  visible, some  as large as small peas.   Mesenteric glands,  in
 portions of mesentery corresponding to diseased glands of Peyer, greatly
 their enlarged.   At lower portion of ileum they were as large as filberts;
 the enlargement was less and less, in correspondence with the diminution of
 the size of  Peyer's  glands upward, and they ceased to be visible  at a point
 corresponding to the limit of the latter.  On  section on  the Mesenteric
 glands, some presented a red, and some a white color; none were found  to
 contain pus or other fluid.
   Stomach.—Presented punctuated redness, or ecchymoses.   No capilli-
 form redness.   Size normal. Mucous membrane softened.  Several ulcer-
 ations varying in  size and form, the largest half an inch in  length, and
 three or four lines in width, superficial, apparently having penetrated only
 the mucous coat.   These appearances were limited to the larger curvature.
 The  organ at this part was easily torn, a rent occurring in removing it from
 its vascular splenic attachments.
   Spleen somewhat enlarged, but not softened.
   Liver congested.   Otherwise  normal.
   This case was characterized by active delirium, which  persisted through
 the whole career of the fever.  The absence of the evidence of encephalic
 inflammation in  connection with this fact, is deserving of note.   A report
 of the case in full, together with the above autopsical appearances, is given
 in the Buffalo Medical Journal, vol.  IV, page 487, et seq. (No. for January
 1849.)
   No. 2. (Typhoid.) The examination in this case was limited  to the abdo-
 men,  and even here was cursory.  The omentum was adherent to the intes-
 tines, and the intestinal  convolutions were adherent to each other.  These
 adhesions, for the most part,  were easily ruptured, but in  some situation*
 they were so firm that the force required to separate the adherent parts,
 occasioned rupture of the tube.  In several instances, in  separating  the
 parts united  by firm adhesions, small  quantities of  purulent matter es-
caped. 
REPORT ON  CONTINUED FEVER.
129
  On longitudinal section of the intestinal tube, recently cicatrized ulcera-
tions of Peyer's glands were apparent near the ileo-ccecal valve.  One of
these was as large as a quarter of a dollar.  The abrupt termination  of the
mucous  membrane  formed a  ridge  surrounding  these  spaces, defining
their boundaries.  The parts that had been ulcerated were covered with a
delicate, smooth surface,  like serous  membrane.   The glands of  Peyer,
for several feet above the coecum, presented ulcerated  patches varying in
size and form, which were mostly cicatrized as just described, but in some
of those  situated higher  in  the tube,  the healing  process was not com-
pleted.   The  mesenteric  glands were enlarged, but  none larger than a
large pea.
   Death occured in  this case  fifteen  days after admission, and twenty-six
days after  the date of the attack.
   A report of this case is contained in the Buffalo Medical Journal, vol. V,
page 271.
   The case was  interesting in consequence of its affording a fine illustra-
tion of cicatrization  of intestinal ulcerations completed,  and in progress of
completion.  The patient died evidently of chronic peritonitis.
   No. 3.  (Typhoid.)  Autopsy fifteen hours after death.
   Head.   Considerable  congestion of  the veins of  the superficies  of the
brain, and  numerous red points  on section of the cerebral  substance. Some
effusion into arachnoid sac, precise quantity not ascertained.   No effusion
into ventricles.    No softening of brain.   Not the least opacity of arachnoid,
nor  effusion beneath it.
   Abdomen.  Colon distended  with gas ;  small intestines collapsed.   The
latter  contained  a  small quantity of  thin yellowish matter.   Peyer's
glands  hypertrophied, so as to project above the surrounding  mucous sur-
face ; especially an elliptical patch near the coecum.   The ileum within the
space of about  three feet above the coecum  presented  several elevated
patches of different sizes.   No ulcerations.  Mesenteric glands correspond-
ing  to the  lower portion of intestines, much enlarged.   No lumbrici.  The
stomach, on its  internal surface, presented several patches of ecchymoses.
The mucous tunic was not softened, but easily detached from the middle
coat.
   Spleen  small, and did not seem softened.
   Liver presented nothing worthy of note.
   Bladder much distended with urine.   Other organs not inspected.
   The history  of this case from the time it came under observation, up to
 the termination, is given in full  in this  report—see page  203.   It  was re-
               K 
130
REPORT ON CONTINUED  FF.VER.
 garded as a case of cerebral disease prior to the autopsy.   The case affords
 another illustration of great predominance of cerebral symptoms without en-
 cephalic inflammation. It is also worthy of note in this case, that not only was
 diarrhoea  absent, but costiveness existed in an extreme degree,  resisting
 several drops of croton oil.  It illustrates the fact that the absence of diar-
 rhoea, and the existence of obstinate costiveness do not  affurd grounds for
 an inference that the glands of Peyer are unaffected.
   No. 4.  (Typhoid,) Autopoy, about fourteen hours after death.
   Abdomen.—Peyer's  glands hypertrophied,  and,  nigh to the coecum, a
 large ulceration of the size of half a dollar.   Enlargement  of the mesen-
 teric glands,  greatest at  the  portion of mesentery corresponding to the
 lower portion  of the  ileum, and gradually diminishing in an upward direc-
 tion.   Hypertrophy of Peyer's glands gradually diminishing in degree, in
 ascending the tube.   Spleen  softened.   Liver presented  no morbid ap-
 pearance.   Other organs not inspected.
   This case  terminated  fatally  on the  tenth day, by asthenia.   The his-
 tory of this case affords an illustration  of the coexistence  of costiveness
 with follicular disease and ulceration.  The  febrile career was not  charac-
 terized by any peculiar circumstances.
   No. 5.  (Typhus)
   Head.—Moderate adhesion of dura mater to calvarium.   Slight flow of
 serum on dividing the arachnoid.   Arachnoid  membrane transparent,
 Veins situated between the convolutions, injected.  A little serum at the
 base of the brain.  A few red points  on section of the cerebral substance.
 No softening.   No effusion into ventricles.
   Chest.—The lungs  anteriorly presented nothing unusual.   Posteriorly
 they were deeply conjested, and  solidified.   This  was  greater in some
 lobules than in others.   Some  lobules emphysematous.
   About an ounce of  clear serum  in pericardium.  Left  auricle  and ven-
 tricle contained a small  quantity of fluid blood, without coagula.   Right
 ventricle contained a small, soft coagulum, a portion of which  was white;
 no fluid blood.   Size and consistence of heart normal.
   Abdomen.—Coecum and colon greatly distended with  gas,  external ap-
pearance of intestiues  normal.   On dividing the ileum, the paches of Peyer,
for the space  of several feet  above  the coecum,  were distinctly  visible,
numbering,  in  all, about a dozen.   The lowest were  somewhat softened,
The  appearance of the mucous membrane, otherwise, normal.  A little
thin  yellowish  matter adherent to  the mucous membrane.   Spleen  not
enlarged, but softened.  A few mesenteric glands, at the lower portion of 
REPORT ON CONTINUED FEVER.
131
the mesentery, enlarged to the size of a small pea.  Liver presented noth-
ing abnormal.  Stomach normal in size, mucous lining of a dingy brown
color, notably thickened, and somewhat  softened.  No redness,  nor  vas-
cular injection visible.
   This case terminated fatally  on the eighth day after admission, and the
thirteenth after the date of the attack.  The mode of dying was by apncea.
An  eruption, having the typhus characters, existed over the abdomen,
chest and extremities. Diarrhoea was not present, but slight meteorism and
tenderness on pressure.  The  respirations were accelerated, ranging  from
40 to 56.  Deep  congestive redness of the  surface existed, and  the  con-
junctiva was injected.  There was present somnolency,  muttering, and
toward the close  of life, the power of  articulation was lost.   The  pupils,
also, were somewhat dilated, and their mobility  impaired.   It is sufficiently
clear, from the foregoing summary of symptoms, that  the case was one of
 Typhus. 
 
        SECOND  CLINICAL  REPORT
                              ON

CONTINUED     FEYER,
                      BASED  ON AN

       ANALYSIS  OF  FOBTY-EIGHT  CASES.
  During the summer of 1850 I devoted the leisure  hours that I could
command to the preparation of a clinical report on Continued Fever, based
on an analysis of fifty-two cases, the histories of which I had preserved.
This report  was  published in successive numbers of the Buffalo Medical
Journal, from August, 1850, to  January, 1851, inclusive.  The recurrence
of the duties of the winter season rendered it necessary to leave the report
unfinished.  It remained to treat of the question of the identity of the dif-
ferent types of Continued Fever, the subject of diagnosis, and the manage-
ment of the disease.  These topics  I proposed to take up during the pre-
sent summer.  In  the mean time, during a service of six  months at the
Buffalo Hospital of the Sisters of Charity, an additional number of cases of
Continued Fever have passed under observation, the histories of a large pro-
portion of which were  noted, and are preserved.   An analysis of  the latter
will enable me to combine and contrast the results of a similar investigation
of the two  collections of cases.  This is a sufficient inducement to enter
upon the  labor with reference alone to personal gratification and  improve-
ment. Entertaining, however, the hope that the fruits  of the investigation 
134
REPORT  ON CONTINUED FEVER.
may not be devoid of interest for others, and that they may possess some
value as contributions to medical science, I propose, under  the title of a
" Second Clinical Report on Continued  Fever,"  to present such facts and
inductions as may be developed by the study of the cases recently collected,
considered separately, and in connection with the collection of cases upon
which the former  report was based.  The Hospital records for  the six
months' service from Oct. 1, 1850, to April 1, 1851, contain the histories of
forty-eight cases of Continued Fever.   This number added  to those ana-
lyzed during the last summer, will make precisely one hundred cases.  The
two reports, therefore, will embrace an enumeration and comparison of the
events contained in the  number of recorded cases of Continued Fever just
mentioned.
   An hundred cases of Continued Fever, I am aware, will seem but a small
number to those who are accustomed to see large hospital wards constantly
crowded with persons laboring under  this disease.  With a view  to the
interest and perhaps importance of the results of numerical investigations, I
could wish that  the collections were larger, and I have not been without mis-
givings lest, on account of the limited amount of data, the time and trouble
bestowed upon  them might  be greatly disproportionate to the fruits  they
are capable of yielding.  But, on the other hand, had my records contained
many more cases to be added to those upon which this Report is based, the
labor of the analysis, enumerations, and comparisons would wholly preclude
the  undertaking.   It is  not  improbable that in the overplus of materials
may consist the  chief obstacle in  the way of such investigations by some of
those whose opportunities for observation are  much more extensive  than
mine.   When Louis resolved  to spend  a series of years in the collection of
data for numerical  analysis,  he not only relinquished the duties of  private
practice, but his  mind was relieved  even of the  responsibility of directing
the  management of the diseases, the phenomena of which it was  his sole
business to  record.  And  when he entered upon the task of classifying,
enumerating and comparing  the facts which he had gathered in the wards
of La Charite,  he  intermitted the  labors of observation and registration,
and, retiring into the country, devoted his whole attention, for many months,
to analytical researches.  Few persons would be satisfied thus  to conse-
crate their time and energies to purely scientific  toil, and of those  inspired
by a similar zeal in behalf of medical  science,  how few are  able to divest
themselves of the  many daily cares  and duties which  almost of necessity
occupy a large share of the exertions of mind and body! 
REPORT ON CONTINUED  FEVER.
135
Small, comparatively, as is the number of cases I have collected, and less
complete, in some respects, than  could be desired, as are the histories, I
venture to think that they may furnish results not  altogether valueless.
Without the encouragement of such an expectation, it would, assuredly,  be
worse than folly to undertake a task which will consume the leisure  hours
of several weeks.  Should the Report repay but poorly the trouble of peru-
sal, it may perhaps moderate a disposition  to complain, to consider that  its
preparation  has cost vastly more  labor than will be  requisite to discover  its
demerits, and  that the reader  is therefore much less unfortunate than the
author.
   The histories of the cases upon which the former Report was based, were
recorded wholly by myself.   It is proper to state that this is not true of  all
the cases in the  present collection.   In a considerable proportion of the
latter, the recording of symptoms and events was entrusted to Mr., now Dr.
Sandford Eastman, at that time  a  resident student at the  Hospital.  The
patients  were daily examined,  and the  notes  revised  by me.  In several
particulars the daily records are more full than would have been practicable
had the  whole duty been performed by myself, but in some points they are
probably less so.  In the accuracy  of the events and symptoms registered
by Dr. E., I have entire confidence, and I avail myself of this occasion  to
express my  indebtedness  to his industry and fidelity.
   Of the forty-eight cases  forming the subjects of the present analysis,
twenty-nine presented unequivocal evidences of the Typhoid type of Con-
tinued Fever;  ten were considered, as unequivocally, cases of Typhus, and
nine are classed under the head of cases  of doubtful type; under the latter
head  are included all  the cases  in which there might be some ground of
uncertainty as to the correctness of the diagnosis, had  they  been placed in
either of the preceding classes.  The reasons for this uncertainty in a cer-
tain proportion of the cases of Continued Fever which fall under observa-
tion, will be considered hereafter, in connection with the subject of diagnosis.
   Of the twenty-nine cases of  Typhoid fever, seven proved fatal.  Four of
the ten cases of Typhus ended fatally.   All of the nine cases of doubtful
type recovered.  Eleven, thus, of the whole number of cases, i. e. 48, were
fatal.   The number of deaths is  precisely the same  as in the first collection
of cases, making twenty-two, out of the one hundred cases.
   I shall arrange the facts and considerations to be submitted in the fol-
lowing Report, in the same divisions before adopted, assigning to each divi-
sion a separate section.  In many of the points of investigation, the interest
and importance  of the results  are  restricted to  those cases which are 
136
REPORT ON CONTINUED  FKVER.
considered to belong either to the Typhoid or Typhus type of  Continued
Fever.  In all such instances there will be no advantage in referring to the
cases of doubtful type.   It should be added, that in  this, as in the former
collection, the uncertainty as to the  diagnosis of the cases of doubtful type
concerns solely the question as to which of the two types, Typhus or Typhoid,
they belong.  No doubt exists as to  their having been cases of  Continued
Fever.
  For convenience of reference to corresponding portions of the first Report,
the number and page of  the sections will  be prefixed to the sections of the
present Report  having the same headings.

                            SECTION FIRST.
Age, Sex,  Occupation, Civil Condition, Nativity, Habits, Season, Constitu-
  tion and previous Health  of the  Patient.   Period of residence in this
  Country and in this  City.  Duration of  the Disease  before coming
  under Observation.   [Page 16.]
The ages of the patients are :		given in twenty-	six cases	of the	Typhoid type,
and are respectively	as follows				
50,	38,	35,	35,		28,
27,	26,	24,	24,		23,
22,	21,	20,	20,		20,
20,	19,	18,	18,		18,
17,	H,	15,	14,		12,
  Average age 22 9-13.
  This differs in a fraction only from the mean obtained in the former analy-
sis, which was 22 2-17.   The  coincidence developed'by the two  analyses is
in accordance with the law of the disease,  as respects  age, stated  in the
first Report.
  Of the Typhus cases, the ages are given in eight,  and are as follows:
         54,         26,          25,          24,         21,
         19,         17,          24,
The maximum, and the mean  are higher than in  the Typhoid cases.  The
average is 26 1-4.   In the first Report it was found, in ten cases, to be 26
1-2.   Here, too, is the difference of a fraction only—a coincidence striking,
and also in accordance with a  law of  the disease.   Comparing the average
age of the fatal cases, with the average of the whole number, the following
is the  result:—In  six fatal cases  of Typhoid the  average  age was 31.
The patient with the maximum age (60) died.  The law that the average
age of those who die with this form of the disease, is greater  than the ave-
rage in favorable cases, is here exemplified,  as it was in the former analysis, 
REPORT ON CONTINUED FEVER.
137
but in a more striking degree in the present collection.   The age of a patient
affected with Typhoid Fever is thus of some account in the prognosis.
   Of the  typhus cases,  the average age in three of  the fatal cases was  ,
24 1-3, being less than the average in the  cases that recovered.
   Sex.—Of the forty-eight  cases, thirty-three were  males,  and fifteen
females.  Of  the twenty-nine  Typhoid cases, twenty-one were males, and
eight females.   Of the  ten Typhus  cases, seven were  males, and three
females.  Of  the cases of doubtful type, five were males, and four females.
The relative  number of  females is considerably greater than in the first
collection of cases.
   Occupation.—In the histories of the twenty-nine Typhoid cases, the occu-
pations noted  are as follows:—laborers, fourteen; domestics, (females,) six;
cook,  (male,)  porter in hospital, fireman, boatman, wheelwright, and far-
mer, each one case.   In three cases the patients were  too young  to  have
any occupation.  In nine of the Typhus cases the occupations were as fol-
lows :—laborers five; boatman, domestic,  Sister of Charity,  candidate  for
the Sisterhood, one case of each.
   The  patients,  as will be  perceived, were mostly of the  class, in social
position, who would be expected to resort  to a charitable institution for the
relief of the sick.
   Civil Condition.—Of twenty-eight cases of the Typhoid type in the histo-
 ies  of which the civil condition of  the patients  is noted, twenty-six  were
 ingle, and two married.
   Of nine cases of  Typhus, in eight the  condition was single,  one patient
 ojy being married.
   All the nine patients with Continued Fever of doubtful type were single.
   The great preponderance of  the  cases in  which the patients were single,
 s probably to be explained, first, by the  fact  that the disease, more espe-
 ially the Typhoid form, affects in preference the young; and,  second, a very
 >rge proportion of all the patients  who are admitted into the hospital with
  afferent diseases are  unmarried, and  are  led to seek  admission in sickness
  inconsequence of not having homes of their own.
   Nativity.— Typhoid cases: nineteen  were  Irish; five Germans; three
  Eo-lishmen;  two Americans.
    typhus cases: eight were Irish, and  two Americans.  In  the two latter
  ca$ the disease was contracted within the Hospital.  It is worthy of notice,
  thain  all but  the two  cases in which the  disease was contracted at the
  hosjtal, the patients  affected with Typhus were from Ireland.  Nearly the
  samresults obtained in the first collection. 
138
REPORT  ON CONTINUED FEVER.
   Habits.—The habits of the patients as respects intemperance, etc., were
 generally not ascertained.
   Season.—Of the twenty-nine  Typhoid cases, in one the commencement of
 the disease is dated in September, three days before my service commenced.
 The remaining twenty eight cases occurred as follows:
                   In October,  eleven  cases;
                   In November,  eight eases;
                   In December, eight cases;
                   In January and February no cases;
                   And in March one case.
 The predilection of this type of Continued Fever for the months of  October,
 November and December is thus exhibited.   It may be suspected  that the
 above facts are owing in  part to the diminished influx of immigrants during
 the winter, inasmuch as  it will presently appear that a large  proportion  of
 the patients had recently arrived in this city.   That  this  explanation is not
 applicable is  shown by the  Hospital  Register during the summer season,
 when the floating population of the city is largest.  From April to  Septem-
 ber, inclusive, 1850, I find during the  six months,  respectively, the number
 of cases recorded as Typhoid fever to have been as follows:—April, May, and
 July, in each, two cases;  August, five cases; September, two cases.   In all,
 thirteen cases.
   The ten cases of Typhus occurred as follows:
                   September 30th, one case;
                   October, one case;
                   December, two cases;
                   March,five cases;
                   April, one case.
   During the six months from April to September, inclusive, I find the fol
 lowing cases of Typhus registered:
                   April, two cases;
                   May, four cases;
                   June, one case;
                   July, three cases;
                   August, three cases;
                   And September, two  cases.
                   In all, fifteen cases.
   These results accord with the  more extended observations from  whh it
has been deduced that while Typhoid fever is much more liable to  occr in
the autumnal, than in other months of the year,  typhus occurs irrespitive
of season. 
REPORT ON  CONTINUED FEVER.
139
   Constitution and Previous Health of the Patients.—The constitution and
previous health are not noted in the histories of seven of the  Typhoid cases.
Of the remaining twenty-two cases, in  twenty the  patients possessed good
constitutions, and were attacked while in excellent health.  In one case, the
patient, a porter in the  hospital, was laboring under a  chronic ulcer of the
leg of long standing;  and in one case the patient  had chronic conjunctivitis.
   Of the Typhus cases, the histories are defective, in these points, in four.  In
all the remaining six cases, the constitution and  general  health were good.
Of the cases of doubtful type, in a single case only is it stated that the patient
was not in perfect health.   In that case the patient was attacked with fever
in the hospital, having entered  for, and still laboring under chronic conjunc-
tivitis.   In the remaining cases, save  one, the history of which is silent on
 he subject, the health and constitution were good.
   So far as  these results  go,  they concur with those  presented  in the first
Report in leading to the conclusion that persons having good constitutions,
and in good health, are  those most  likely to be attacked  with continued
fever.
   Period of Residence in this  Country and in this City.— Typhoid Cases.
The facts pertaining to these points are noted in the histories of twenty cases,
and are presented in the following table:
Period of Residence in Country.                   Do. in  City.
1. Nine months.	Two months.
2. Four months.	One week.
3. Two and a half weeks	Entered day of arrival.
4. Twelve months.	Two months.
5. Three months.	Ten days.
6. Sixteen months	Sixteen months.
7. Five weeks.	Four weeks.
8. Two weeks.	Entered day of arrival.
9. Six months.	Four months.
10. Four weeks.	Not stated.
11. Four years.	Two months.
12. A few months.	Entered day of arrival.
13. Eight months.	Eight months.
14. Twenty-one months.	Twenty months.
15. Two weeks.	Four days.
16. Two weeks.	Four days.
17. Five weeks.	Two weeks
 
140
REPORT ON  CONTINUED FEVER.
    18. Recently arrived.                       Recently arrived.
    19. Four weeks.                            Three and a half weeks.
    20. Four weeks.                            Three and a half weeks.
   In the nine remaining cases the histories are defective as respects the points
under  consideration.  It is not noted in a single case that the patient was a
permanent resident of the city.
   It will be apparent on reference to the foregoing table, that this, as well as
the first collection of cases, affords a  striking illustration of the law developed
by the researches of  Louis, viz., that Typhoid fever is prone to affect those
" placed  in circumstances entirely  new  to them," which are incident to
recency of residence.   It may be said  that the inmates of an hospital in a
thoroughfare like Buffalo, would be expected to consist chiefly of persons
lately arrived, they being far more likely to resort to such an institution than
the settled inhabitants of the place.   It is true that a large proportion of the
patients admitted with all diseases are of  the former class; but the prepon-
derance is not nearly so great in the aggregate of other affections as it is in
Typhoid fever.   In this connection  it should be stated, that Typhoid fever,
although occurring occasionally among the fixed population of this city, is by
no means a common disease,  and, until within a few years  past, was almost
unknown.  During the six months that the  cases in  this collection were
recorded, it was by  no means prevalent, unless  among  the same class of per-
sons, recently arrived, which furnished the cases at the hospital.  My private
practice not  embracing many patients  of this  class, I am unable to say to
what extent it prevailed among them.   The cases coming under my observa-
tion, aside from those in hospital, during the period first mentioned, included
only two or three cases, excepting  a few cases of infantile  Continued Fever,
which  perhaps would appropriately be called Typhoid.
   Typhus  cases.—Of all but two of the  ten cases of Typhus, the  histories
contain information on these points, which is presented in the following table:
   Period of  Residence in Country.                    Do. in City.
         1.  Five weeks.                              Not stated.
         2.  Five weeks.                              Five days.
         3.  Eight  days.                              Three days.
         4.  Eleven days.                             Three days.
         5.  A few days.                              Ten days.
         6.  Eight  days.                              Three days.
         7.  Resident in Hospital.
         8.   Do.         Do. 
REPORT ON  CONTINUED FEVER.
141
  Taking into consideration the infrequency of Continued  Fever of the Ty-
phoid type, and the still rarer occurrence of Typhus, in this place, except among
foreign immigrants,  it seems probable that the remote  special  cause of the
disease was generally imbibed prior to the period of residence in this city, if
not prior to arriving in this country.
   Duration of Disease  before  coming under Observation.—In none of the
cases, except those originating within  the hospital,  were the  patients under
observation from the very commencement of illness, and  the duration before
admission presents  considerable diversity in the different cases.   In  several
instances the patients had been  ailing for several days, but had kept up until
they entered the hospital,  but in most cases they had been confined to the
bed for one, two, three,  four or more days.  The variations, as  respects this
point,  are obviously  due, in a great measure, to circumstances  extrinsic to the
disease.   More or less delay in  getting admission might arise from various
causes, and patients would wait, some  longer,  and  some  for a  less period,
before seeking to be admitted.   For these reasons, there would be no object
in presenting  the facts pertaining to the duration of the disease before coming
under observation, contained in the histories of the individual cases.
   There is one fact, however, relating to this point which is worthy of notice.
The duration  of the disease before the patients entered the hospital, as a
general remark, is strikingly shorter in the cases of Typhus, than in the cases
of Typhoid.   In one-half the cases of Typhus it is stated that the patients did
not take to the bed  prior to entering the hospital; and of the remaining five
cases the histories are defective in information on this point in three;  in one
the patient took to the bed the  day before  admission; and in the other case
the patient was attacked in hospital.
   Of  the twenty-nine cases of Typhoid, it is stated that the patients had not
taken  to the bed before admission, in only five cases!
   The fact that  patients with Typhus enter earlier in the disease than those
affected with the Typhoid type  of Continued Fever, is probably significant of
another fact,  viz., that  the onset of the former impresses the patient more
strongly with a sense of greater gravity of the malady.

                             SECTION  SECOND.

 The Access, its Duration  and Symptoms.  Circumstances supposed to have
   been concerned  in the   Production of the Disease.   [Page 23.]
   Duration.—The  access, in other words  the  prodromic,  or forming  stage
of Continued Fever, embraces the period which elapses from  the  commence-
ment of ailment to  the time when the disease is established, or the febrile 
142
REPORT ON  CONTINUED FEVER.
career fairly entered upon.   But the symptoms of this period generally merge
so imperceptibly into those which follow, that it is often extremely difficult to
draw the line separating the former from the latter.   And especially to deter-
mine the time when the access ended, and the fever began, in cases which do
not come under observation until after the  latter epoch, would  generally be
impracticable, unless some circumstances be fixed upon which shall serve as a
sign or criterion of the  point which we wish to establish.   In my former
Report it was suggested to  select as the juncture at which the commencement
of the febrile career should be dated, the day on which the patient, from the
amount of  debility, etc., feels no  longer able to sit up, but is compelled to
take to the bed.   This is an arbitrary rule,  not claimed to be always accurate,
but it may be doubted if  any other uniform test can  be suggested which, in
the average of cases,  is more reliable; and it  has the advantage of being
readily and exactly determinable in the great majority of instances.  It will
seldom happen that  we  cannot  ascertain,  either from the patient, or from
others, how many days have been spent in  bed.  With an equal amount of
debility, etc., some patients will take to  the bed sooner than others.  Various
circumstances, moreover, may prevent patients from yielding to an inclination
to take to the bed, and stimulate them to make strong exertions to keep up,
and even continue at labor as long as possible.   Some of the patients in this,
and the first collection of cases, had not only kept about, but had rode many
miles, or walked a considerable distance to the hospital, when the presence of
the eruption, and other symptoms, showed that the fever had been established
already several days.   Other  patients differently situated, or of a different
mental constitution, take to the bed on the first indications of ailment.  These
cases, it may be presumed, will compensate for each other, so that, in the long
run, the event fixed upon will be found to  be sufficiently precise for all prac-
tical purposes, and, at all events, as much so as any other test equally available.
   In the histories of a large proportion of  the  cases forming the present col-
lection, it is not definitely stated  how long the patients had been confined to
the bed.   This  omission was owing  to inadvertence.  In  ten  cases of the
 Typhoid type in which the facts with respect to this point  were ascertained,
the duration of the access was as follows:—
       Four days,        ....        Three cases.
       Three days,       ....       Three cases.
       Six days,         -              -       -        One case.
       Attack sudden,   -                               Three cases.
 The period from the  first symptoms of ailment is given in the histories of 
REPORT ON  CONTINUED FEVER.
143
most of the  cases,  but the defect is  in  not stating  how  long, if at all, the
patients had  kept  their beds.   The foregoing  cases  suffice to show that the
access is sometimes sudden, but in other cases,  having a duration varying
from  three to six days.
   In the  histories of Typhus cases the duration of the access is specified as
follows:—
      Three days,         ....        Two cases.
      Two days,          ....       One case.
      Four days,          -        -       -       -       Two cases.
       Attack sudden,     -        -       -       -       One case.
In two of the remaining cases it is noted  that the duration was ' several days.'
   The foregoing results do not afford any confirmation of the law, deduced
from extensive observations, that the Typhus type of Continued Fever oftener
commences with a sudden attack, or is  ushered in  by an access of shorter
duration than Typhoid.   The cases, however,  are too few  to render the com-
parison in this particular of much value.
    Symptoms of Access.—In all  save a very few cases, the symptoms of the
 access were  not observed, the patients  not entering the  hospital until this
 period  was  passed, and more or less  progress made in the febrile career.
 Information respecting the previous history was generally obtained from the
 patients themselves—a source not always perfectly reliable,  owing  to the
 condition of mind incident to Continued Fever.  The replies to questions may
 be coherent and rational, but nevertheless incorrect, while perhaps there are
 no manifestations of delirium,  nor any  deliberate intention  on the part of
 the patient  to  deceive.   Of the  more  prominent of the early events that
 mark the access, however, most  patients retain  a clear recollection, certainly
 during the early part of the febrile career, and  comparatively few entered
 the hospital  at an advanced period of the disease, when the  reliability of
 their statements would be invalidated  by the  mental condition just referred
 to.   In some of the cases an account of the symptoms of the  access is defect-
 ive or wholly wanting, because the patients were plainly incompetent to give
 information  on  the subject.  The questions  generally were  confined  to the
 more prominent events,  such as cephalalgia,  chills, diarrhoea, etc.   The
 records are not uniformly so full with respect to these as could be desired.
    Chills.—In twenty-one cases of the Typhoid type, the histories state dis-
 tinctly that  chills were,  or were not present.  And  of this number of cases
 one or more chills marked the access in all but one case, i. e. in twenty cases.
In one case,  it is stated,  no chill occurred.  The degree of chill, and its 
144
REPORT ON  CONTINUED FEVER.
duration, and whether rigor accompanied, are not stated.   In four cases it is
stated, a recurrence  of chill was experienced, and in two of these cases, a
third chill took place.
   With respect to an  increase of heat after the chill,  sensible to the patient,
or rather sufficient to attract his attention,  positive information is contained
in the histories offifteen cases.   It occurred in twelve of  these cases, and  in
the remainder, three, was not noticed.
   Perspiration occurred after the chill in ten of  the fifteen cases the histories
of which contain information on this point.   In five no perspiration followed.
   Of the ten cases of Typhus the  symptoms of the access were not recorded
in the histories of five.  This proportion of cases in which the records  are
thus defective, is probably  significant of the fact that the mind, earlier, and
more uniformly becomes affected  in  this type of Continued Fever, so  as  to
render information  concerning  the previous  history more uncertain, or not
reliable.
   Of the five cases  in which an account is given of the access, a chill occur-
red in four, and in  the remaining  cases it is not stated whether this symptom
 occurred or not.   A recurrence of the chill took  place  in one of the four
 cases.  It is stated  that the chill was followed by increased heat in  two cases;
 and of these,  perspiration  succeeded  in  one, and it did not follow in  the
 other case.
    Cephalalgia.—Of the Typhoid cases it is stated positively with respect to
 this symptom in twenty-three.  Cephalalgia  occurred in twenty-one of this
 number, and was absent in two cases.
    Of the Typhus cases, it is stated positively in six.   Cephalalgia occurred in
four of this number, and was absent in two.  In the histories of  some cases
 this symptom is said to have been severe or intense, but generally the degree
 of pain is not expressed.
    Pain  in the loins, is stated to  have  been present in fourteen cases  of the
  Typhoid type.  It is stated to have been absent in two cases.  Of the remain-
 ing thirteen cases it is presumed to have been absent in several, at least, from
 the fact  that it would probably have been included  in the  previous  history
 had it been present.
     Of the Typhus  cases the presence of this symptom is affirmed in one case
  only, and it is stated  to have been  absent in two cases.   In seven the histo-
  ries do not contain information on this point
     Pain in the limbs, is stated to have been present in sixteen of the Typhoid
  cases.   The histories of the remaining cases are silent with respect  to  this
  symptom. 
REPORT ON  CONTINUED FEVER.
145
  It is stated to have been present in two cases of Typhus, and nothing stated
on the subject in the remaining cases.
  The patients were not questioned with respect to a symptom which, as all
observers are aware, is a common attendant on an attack of fever, viz, lassi-
tude, or a painful sense of fatigue.
  Nausea and Vomiting.—In the histories of fifteen Typhoid cases, it is stated
positively with respect to these symptoms.  They were  present in twelve of
that number, and  in one case nausea existed without  vomiting.   Generally
these symptoms were  slight.  In two of the fifteen cases they were  not
present
   In the histories of the Typhus cases it is only recorded that in one case
there was no nausea nor vomiting.  Nothing  is stated on the subject in the
remainder.
   Diarrhoea.—The  histories  of the  Typhoid  cases  contain  information
respecting this symptom in twelve.  Of this number, it was present in seven,
and absent in five.  It is to be presumed that it was not a prominent symptom,
to say the least, in the cases, the histories of which are silent with respect to it.
   It was absent in six of the cases of Typhus, and is not stated to have been
present in a single case of that type.
   This symptom might have been present in some cases in which it is stated
to  have been absent, if simply looseness of evacuations, without increase in
number, were considered  to constitute diarrhoea,  after the custom of the
French.   It would not be stated that diarrhoea had existed except in cases in
which the dejections were more or less frequent.
    Thirst is stated to have been present in twelve cases of  Typhoid and two
cases of Typhus.   Its absence is not noted in the history of a single case of
either type.  In a large proportion of the cases in the histories of which the
presence of thirst is noted, it is stated to have been intense.
   Anorexia is stated to have been present in twelve cases of Typhoid, and in
four cases of Typhus.   Its absence is not noted in a single case of either type.
    Cough is not mentioned as a symptom of the access save in two cases of
 Typhoid, and  one case of Typhus.
   Epistaxis is noted to have occurred in the histories of three Typhoid cases;
and its absence is noted in  five cases of the same  type.   It is not  noted to
have been present in any case of Typhus, and its absence is noted in only a
 single case.
    Causation.—The  patients  were generally asked if  they could  attribute
their illness to any particular cause or causes; if they had ever before had an
attack of fever; and, if immigrants, whether any disease  prevailed in the
               L 
146
REPORT ON  CONTINUED FEVER.
vessels which brought them to this country, or at the places of their residence
about the time of their leaving.
   The histories of twenty of the forty-eight cases contain nothing relative to
either of the points just mentioned.  The facts pertaining to the remaining
twenty-eight  cases, which are noted, are as follows:
   In two of  the Typhoid cases the patients said the disease commenced with
their taking cold.   The same was stated by  one of the patients affected with
fever of a Doubtful type.
   In six Typhoid cases  the patients, immigrants, declared that there was no
sickness, but  sea-sickness, on board the vessel  in which they came over, nor
at the  places from which they came.  The only exception to  this statement
is, that one patient said there wras a person ill on  board the  vessel, but he
did not know -with what disease.   In  the histories of  those cases of Typhus
in which the  patients were immigrants, nothing is stated relative to sickness
on the voyage,  or before sailing.   In  no case of either type is  it stated that
the patient had been in  proximity to  persons  laboring under  fever.   These
facts, in so far as they go, while they show the  liability of immigrants to be
attacked  with fever, shortly after  their arrival, and, considering the infre-
quency of continued fever in this  city, render the supposition  probable that
the special cause of the disease, in the cases referred to, was introduced within
the system prior to their reaching this  country, do not supply any illustrations
of the agency of contagion in the production of the disease.
   In the history of one case of Typhoid it is stated that the father and mother
of the patient were, at the same time, in  the hospital with Continued Fever, the
father being affected with Typhus, and in the case of the mother the disease
being of Doubtful type.  In two of the Typhoid cases the patients were bro-
thers, both cases being in progress at the  same time.
   In two cases of  Typhus the patients came over in the same vessel, both
cases progressing  at the same time.
   In two other cases the patients came over in  the same vessel,  one case being
of Typhus, and the other of Doubtful  type.
   In one case of  Typhus, and one of Doubtful type, the patients were brother
and sister, and came over in the same vessel.
   These  facts probably show community as respects exposure  to the special
remote cause of the disease.
   In one case of Typhus the patient stated that he had not changed his linen,
or any of his  clothing, from the time he embarked in Ireland, up to the date
of his admission into the  hospital!
   One patient  affected with fever of Doubtful  type stated that he had been 
REPORT ON  CONTINUED FEVER.
147
accustomed to sleep in a small room in which were lodged from fifteen to
twenty persons.
   In but one case of Typhoid does the history state that the patient had ever
before had fever.  In  this case the patient stated that he had  had  fever a
year before in Ireland, both his parents being affected with the disease at the
same time.  In one case of Typhus the patient said he had had fever twenty-
five years before.  In two cases of Doubtful type the  patients said they had
previously had fever, one three years, and  the other two years before.   The
small proportion of cases in which the previous occurrence of fever is stated,
is obviously the point most worthy of note, and it is to be remarked that in
these cases it is by no means certain that the disease referred to was Continued,
or indeed any form of essential fever.
   In several of the cases the probable source of the disease was in contagion.
 I will give the circumstances favoring this view of the causation in the cases
 referred to, respectively.   The cases  were of the following types:  Typhoid,
 three cases;  Typhus, two cases; Doubtful type, two cases.  In all seven cases.
   Of the Typhoid cases, in  one case the patient, four or five weeks  before
 being attacked, was with a brother affected with fever.  He had slept with
 him at night, and labored during the day time.   In another case the patient,
 who had lately come to this country,  a short  time before being attacked, (the
 time is not definitely stated,)  had taken care of  a friend  affected with fever
 who came over in  the  same vessel.  In the  third  case  the patient was
 employed as a porter in the  hospital.  He was in the general ward  much of
 the day  time, and slept in the ward  at night.  There had been, a short time
 before he was attacked, several fever  patients in the ward, and he  had had
 particular charge of  them at night.   He had had a chronic  ulcer of the leg,
 and had  also had erysipelas.   The ulcer had  healed about two months before
 he Avas attacked with fever.
    Of the  Typhus cases, in one, the patient was a Sister of  Charity attached
 to the hospital.   She was  attacked while nursing  in the  general  ward in
 which there had been cases of fever  of both the typhus and  typhoid types.
 In the other case, the patient was a candidate  for the Sisterhood,  and was
  attacked while rendering services in  the same ward.
    Of the cases of Doubtful  type, in  one, the patient was a surgical patient
 laboring under chronic conjunctivitis, who was frequently in the general ward
 in which fever patients were received.  In the other case the patient was one
  of  the Sisters of  Charity who was assigned to  the general ward,  and had
 lately nursed fever patients affected with the typhus and typhoid form of the
  disease. 
148
REPORT ON  CONTINUED FEVER.
   Adding  together the cases in the present and former collection in which
 the  causation  of  the disease appeared to involve contagion, the sum is ten,
 i. e. ten of the one hundred cases.
   The cases  most clearly due to contagion  are those in which the patients
 were Sisters of Charity.   In the former  Report it was stated that the two
 Sisters to whom  had been  assigned  the  care of nearly all  the fever cases
 during the winter, alone, of all the  inmates of the hospital, became affected
 with fever.   The two Sisters, and the candidate for the Sisterhood, included
 n the present collection of cases, had  also special care of fever cases, and of
 the Sisters to whom other duties were assigned than  nursing fever patients,
 none have been affected with fever.   There have been  ten Sisters of Charity
 attached to  the hospital during the past two years, and of these the four that
 have had Continued Fever have been  those who have been especially brought
 into contact with fever patients.
   An interesting  circumstance  connected with these  cases is, that they all
 occurred during the Lenten season, as  also the case in  the person of the can-
 didate for the Sisterhood.  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, proba-
 bly,  the system less able to resist, or eliminate the miasm of contagion.

                             SECTION THIRD.
 Symptoms referable to the general aspect, and  expression of countenance.
   [Page 28.]
   The complexion, or color, of the face, was almost uniformly altered from
 that of health.  Redness, due to capillary  congestion,  was present in twenty-
 six of the twenty-nine cases of Typhoid, and in the remaining three cases its
 absence is not affirmed.   Its presence was noted in  all of the ten cases of
 Typhus.  The redness now referred to, is that described in the first Report,
 resembling  the appearance of the surface after exposure to cold.   It is not a
flush, like that occasioned by mental emotions, or  occurring in connection
 with  excitement of the circulation by exercise, or with high febrile movement
 The latter is frequently, if not generally, observed in the early part of the career
 of Continued Fever, and is noted in some of the histories in this collection; but
 the congestive redness, as it is called in the records, is evidently owing to a
 •passive accumulation in  the capillary vessels.  The  color is more dull than
 when the face is flushed, and  the temperature is but little, if at all, percep- 
REPORT ON  CONTINUED FEVER.
149
tibly raised.  It is especially marked on the cheeks, and is sometimes con-
fined to the cheeks, but without being circumscribed by a sharp border.
   The redness differs, in  different cases, in degree.  Of the twenty-six  cases
of Typhoid in  which it was more or less  present,  it was characterized as in-
tense in but a single case; it was slight in six cases, and in the remaining  cases
it was either moderate, or considerable.   In the cases of Typhus, the redness
was intense in five eases,  and in no case was it but slight.  In proportion to
the intensity of the congestion, the surface presented a dusky or dingy  hue.
   The  disparity  between  the two  types of  the Fever,  as respects this
symptom, is a  distinctive  point worthy of note.   The redness is rarely intense
in Typhoid, although more or less present in nearly all cases; but in Typhus
it would  seem to  be  uniformly present, and  is intense in a  much larger pro-
 portion of cases.   A dusky or dingy color of the  face  is,  thus, somewhat
 distinctive of the  latter type.
   A symptom so constantly associated with the disease, although not of a
 very striking character, must  have some pathological significance, especially
 if it be not a symptom common to other affections.  Of the extent to which
 it is associated with  different diseases I cannot speak from an adequate num-
 ber of recorded  observations, but all observers are aware that it occurs in
 connection with  affections involving obstruction of the general  circulation.
 Thus it  is  present  in diseases  of the  heart, in  pneumonitis, pleuritis with
 large effusion, etc.   The  symptom, under these circumstances, is induced
 purely by physical  causes of  an obvious character.  That the  symptom is
 not  due to these causes in Continued  Fever, is  rendered probable by the
 facts presented in the former  Report   These facts show that it does not sus-
 tain relations  with symptoms  referable to the heart and lungs, which should
 exist if it were incident to morbid  conditions of these organs mechanically
  obstructing the general  circulation.   The reader is referred to the first Re-
  port for  these facts.   A  fair inference therefrom  is, that the capillary conges-
 tion arises from  an  obstacle inherent in the capillary system.  And if, as is
  probable, this obstacle pertains to the blood itself, rather than to the capillary
  vessels, the symptom under consideration is to be regarded as favoring the-.
 humoral doctrine of the  pathology of Continued Fever.
    The face is not the only seat of capillary congestion in  Continued  Fever-
  The same condition generally obtains, more  or less, over the surface  of the-
  body,  as will  be seen in  the section devoted to the  symptoms referable to,
  the skin.  It is always present on the face, if it exist in other portions of the-
  cutaneous system, and is invariably more marked in the former situation.  It
  is sometimes  to be observed on the  face when it is not obvious elsewhere. 
150
REPORT ON CONTINUED  FEVER.
   It is of importance to bear in mind that the same condition of the capillary
system, it is probable, obtains in internal organs.   This may be presumed,
especially if the source of the congestion is considered to be in the blood
itself.
   Congestive redness of the face was usually apparent from the  time the
patients came under observation.  It continued generally through the greater
part of the febrile career, varying somewhat in degree.  In some cases it
persisted  after convalescence was declared, but in  other cases it gradually
diminished and disappeared on, or shortly before convalescence.
   A circumscribed flush of the cheeks was noted in  several cases, viz; in six
cases  of Typhoid, in two cases of Typhus, and in  two  cases of  Doubtful
type,— in all, ten cases.  This symptom, which is somewhat characteristic of
primitive pneumonitis, appears to be significant of the  same affection  occur-
ring as a complication of fever.   Of the six Typhoid cases in which it was
present, pneumonitis undoubtedly co-existed in four,  and probably in the
two remaining cases.  Of the two Typhus cases, pneumonitis was present in
one, and probably present  in the other.   The two cases of  Doubtful type
were complicated with pneumonitis.
   The expression of countenance, as indicative of the condition of the mind,
was almost invariably more or less modified.   The terms used to denote the
appearances in this respect are, vacant, dull, heavy, listless, indifferent.   In
one case, characterized  by violent delirium, the  expression indicated terror.
Brightness of expression was observed  to accompany improvement  in other
symptoms.  A decided  change for the better was  frequently revealed by a
glance at  the  countenance of the patient.  Patients affected with fever, al-
most invariably present, during the febrile career, a grave, sedate expression,
and a smile on approaching the bed side, is often the harbinger of convales-
cence.  There are some exceptions to this remark.  In  a few cases embraced
in the first collection, the countenance  throughout the febrile career wore
an aspect of mirthfulness and good  humor, the patients presenting, on con-
valescence, a more serious expression, thus reversing the general rule.   This
was true of one of the cases of the Typhus type in the present collection.

                           SECTION  FOURTH.

Symptoms referable jto  the  Nervous System.   Mind, Sleep, Coma, Senses
   and Sensibility, Muscular Contractions, etc.  [Page 34.]
   Delirium was present in a large proportion of the cases.  Excluding the
cases in the histories of  which the facts with respect to this symptom were 
REPORT ON  CONTINUED FEVER.
151
not recorded, of the remaining thirty-eight cases, more or less delirium exist-
ed  in thirty.  The proportion of cases  of the two  types, Typhus and Ty-
phoid, in which the symptom was present, is as follows: — of twenty-two
cases of Typhoid, of which the  histories contain information on this point, it
existed in seventeen.   Of nine  cases of Typhus, it existed  in eight.   It
existed in five of seven cases of Doubtful type.
   It is interesting to see how nearly the above results  approximate to those
developed by the  analysis of the first collection of cases.   The proportion of
cases in which delirium was present in the two collections respectively, is a3
30-38 is to 43-52.   Comparing the two types, Typhus and Typhoid, in the
two collections, with respect to this symptom, in  Typhoid, the relation is as
 17-22 is to 23-30;  in  Typhus, as 8-9 is to 11-12; in the cases of Doubtful
type, as 5-7 is to 7-8.   It is hardly to be supposed that the close approach
to equality in these results, is  due  simply to  accidental  coincidence, and,
therefore,  it may be inferred that these results express laws of the disease as
 respects the numerical ratio in which, in a given number of cases of either
 type of the fever, this symptom may be expected to be present
    It will  be observed  in this,  as in the  former collection, that delirium is
 present in a much larger proportion of  cases of the Typhus, than of  the
 Typhoid type.
    In  the great majority of the  cases in which more or less delirium existed,
 it was passive in its character, that is, the patients were not violent,  so as to
 require restraint.   Great  activity, or violence, characterized the delirium in
 only one case of Typhoid, and  in this case it was a very prominent and per-
 sistent trait  In two cases of Typhus it assumed somewhat an active charac-
 ter, for a short time, but much less in degree than in the  Typhoid case just
 mentioned.  The cases varied considerable as respects the duration and  de-
 gree of the delirium, as well as the period in  the febrile career at which it
 appeared.  It became  developed earlier in the course of the  disease, as well
 as more constantly, in  the  cases of Typhus, than in the cases of Typhoid.
 In some cases it continued through  the greater part of the febrile career; in
 other eases it was of short continuance.   It was only observed, in some cases
 during the latter part  of the  career; in other instances it  appeared at an
 earlier dnte, and  ceased some   days before convalescence.    Occasionally it
 occurred  at irregular intervals  during the disease.  It was almost  invariably
 more  marked during the night than during the  day time, and frequently
 existed only at night.
    The manifestations  of delirium consisted in incoherent talking, and efforts
 to get out of bed; in some cases the  former only, and in other  cases both 
152
REPORT ON CONTINUED FEVER.
 conjoined.  The hysterical character described in the former Report as occur-
 ring in a few cases, was not observed in any of the  cases  in  the  present
 collection.
   In nearly all the cases in which more or less delirium was not present, or
 not apparent, the fever was of a mild grade of intensity.
   In the  fatal cases the facts with respect to delirium are as follows: — Its
 presence was noted in the histories of all the fatal Typhoid  cases save two,
 i. e. in five of seven cases.   Of the two cases in which its presence is not no-
 ted, in one the patient died from intestinal perforation, an event which has
 been found to be more likely to occur when the disease  is mild, than  when
 it is severe.  In the other case the patient died on the second day after ad-
 mission, in apoplectic coma.   Of the five Typhus cases in which it was pre-
 sent, it was a  prominent symptom  in all  save one.   In the history of the
 single excepted case, it is distinctly noted that no manifestations of delirium
 were observed.  This exception is important, especially when  it is considered
 that the excepted  case was the only one in the Typhus group in  the his-
 tory of which the  absence of delirium is noted.   It suffices to show that
 absence of delirium does not, in itself, justify  a favorable prognosis,  while
 the burthen of facts undoubtedly favors the conclusion that, generally, this
 symptom  denotes a certain degree of gravity in the disease, and that, being
 a prominent feature in a larger proportion of fatal cases than in those ending
 in recovery, it should influence, in proportion to its prominence, unfavorably,
 the prognosis.
   The delirium, in  Continued Fever, in the great majority of cases, is  passive,
 the patients remaining quiet, but talking  irrelevantly, and incoherently; or,
 in  addition thereto, making  efforts to get up, but easily persuaded, for the
 time, to desist, or return to the bed.  Sometimes, but this is rare, the deliri-
 um is noisy, the patient vociferating, or shouting; and occasionally some dif-
 ficulty is experienced in persuading him to keep in bed.   In  a small  propor-
 tion of cases the delirium is  remarkably persistent and violent, constituting
 the most  prominent feature of the disease.   Three instances of  the  latter
 description are embraced in the one hundred cases I have analyzed.  Two of
 these are  included  in the first collection.  The delirium, in these cases, com-
 menced rather early, and continued without cessation, or abatement,  up to a
 few hours before death.  The manifestations consisted  in loud talking and
 incessant attempts to get out of bed, rendering considerable restraining force,
 and constant care on the part  of the attendants, necessary.   Both cases were
fatal.   Both were of the Typhoid type.  These cases are distinguished, not
 by the occurrence of active delirium, for this was true of a few other cases, 
REPORT ON  CONTINUED FEVER.
153
but by its steady continuance, as well  as violence.  It is important to be
aware of the fact  that  Continued Fever may be characterized by an exces-
sive predominance of this symptom.   Without this knowledge, and due care
in the diagnosis, the disease may be thought either to consist in, or to in-
volve encephalic inflammation—an error of some practical moment;  or, worse
than  this, it may be considered to consist in merely a functional affection of
the brain — mania.   The reports of superintendents of insane asylums, state
that such cases  are occasionally sent  to these institutions, the patients  being
thereby exposed to the injury of a journey thither, as well as having failed to
receive the treatment which a correct appreciation of the disease might have
suggested.
   In illustration  of the  class of cases of  which  I have been speaking, a
summary of the more  important points in  the history of the single case in
the present collection may be interesting.
   The patient wTas a German laborer, aged 27 years.  The case was one of
those in which  the  disease  was attributed to contagion.   Four weeks before
being attacked, he  had  taken  charge, at  night, of a brother  affected with
fever. He had slept with him, and labored, as usual, during the day. He was
 seized with pain in the head, etc., about ten days before entering the hospi-
tal.   Four days before his admission, he got bled on account of the cepha-
 lalgia.   The  next day he  became actively delirious.  He had no medical
attendance  prior to his entering the hospital.   These facts pertaining  to the
 previous history were not ascertained  until after the  decease of the patient.
 He spoke no  English, and, moreover, was incompetent, from the condition of
 his mind, to give any account of himself.   From the resemblance of the de-
 lirium to that in the two cases previously observed, and from the associated
 symptoms, I had no difficulty in arriving at the diagnosis.   On his entrance,
 Oct  28th, he was actively delirious, constantly talking, and endeavoring to
 get out of bed.   Head was hot, skin warm, tongue (which could but imper-
 fectly be examined) appeared to be dry and hard.  Face presented consider-
 able  congestive redness,  which  was also apparent on the upper extremities.
 Pulse  120,  and  moderately developed.   Abdomen  meteorized.   He was
 apparently quite deaf.  Did not reply to questions.   Eyes not injected.
    I  had resolved, after observing the two former cases of this variety of the
 disease, if another instance should ever present itself, to resort to opiates freely,
 in conjunction with antimony.   I accordingly prescribed, in this case, on the
 first day, S.  morphia, gr.  1-4  hourly, which was continued until one and a
 half grains  had  been taken.   Tartrate of antimony was  given in doses of
 gr. 1-8 every half hour,  and continued for six  hours.  This was at evening, 
154
REPORT ON  CONTINUED  FEVER.
when he had just entered.  At 10 1-2 P. M., he was sleeping quietly, and
he continued to sleep a portion of the night.
  On the 29th, the delirium, at morning, was moderate;  pulse 108; respi-
rations 18; meteorism, and tenderness  in right iliac region; tongue dry and
fissured, protruded slowly and incompletely;  one copious  dejection, not in-
voluntary.   The directions for treatment were to apply cold to the head, an
emp. vesicat to nucha, and, if the delirium increased, to resort to morphia
and antimony, repeated at short intervals until he became quiet.
  30th. The record for this day, made by me, is as  follows: — "Passed a
wakeful night, with constant, active delirium.  His efforts to get out of bed
(except during  night  before last, when he obtained some sleep) have  been
incessant.   He  requires constant watching, and occasionally restraint.  The
expression of the face denotes apprehension, suspicion, and a fixed purpose.
Judging from  his countenance, and efforts, his impulse is to escape from a
situation of imaginary danger.  Sometimes he does not reply to  questions;
sometimes he replies  coherently, and  sometimes incoherently.  He  seldom
speaks of his own accord, but occasionally talks with a loud voice.
  The tongue is dry and hard, and partially protruded, after being requested
several times.   One copious dejection.   Abdomen tympanitic.  Perspiration
stands in drops on the face, and is moderate over the  body and extremities.
Pulse 128, small, and feeble.  Respirations, 32.   Complains of pain in the
head.  Had passed no urine, and catheter was introduced,  drawing off about
thirty-two ounces."
  During this  day, 2 1-2 grains of morphia were administered  in hourly
doses of gr.  ss.   At 4 1-2 P. M., he was sleeping, and  had been quiet for
nearly two hours.  Respirations, 24, inspirations shortened and  quickened.
Perspiration in drops on the face.  Pulse  148, very small and feeble.  Ab-
domen  tympanitic.  The treatment  directed was,  morphia, pro re nata;
camphor, grs. Us, dissolved in chloroform, hourly; brandy, §ss. hourly.  He
was  somnolent most  of the night, and died at  7,  A. M., the  following
morning.
  The autopsy, performed twelve hours after death, disclosed the character-
istic lesions of Peyer's  glands, and the mesenteric ganglions; slight sub-arach-
noid effusion; about an ounce of serum (estimated) in the arachnoid cavity;
moderate congestion of brain; no exudation of fibrin or opacity of arachnoid;
cerebral substance normal.
  In two of the three cases resembling each other in the  predominance of
active persistent  delirium, post-mortem examinations were made.  The ap-
pearances in the case in the first collection which was examined, are given 
REPORT ON  CONTINUED  FEVER.
155
in the former Report.  In  neither were there any appreciable  evidences of
encephalic inflammation.   Indeed, the symptoms are insufficient to sustain
the supposition that the delirium is due, in  such cases, to an inflammatory
condition.   The phenomena which are associated with active delirium in en-
cephalitis are not present   In each of the three cases  bleeding early in the
disease was  practiced,  but without any relief.   The  free use of morphia,
although it succeeded in overcoming, for a time, the delirium, and inducing
quietude and somnolency, exerted no favorable effect upon the issue of the
disease.
   It is to be observed, that the three  cases ended in death.   So far as my
experience goes, therefore, persistent, violent delirium is to be regarded as a
fatal symptom.
   The fact should be noted that the case just detailed was of the Typhoid
type.   The three cases were cf this type.
   In the former Report  a  few remarks were offered in connection with the
inquiry, " upon  what  pathological condition, or conditions, is delirium in
 Continued  Fever dependent ? "   Observations have  abundantly established,
that it is not due to inflammation, and hence, the occurrence of encephalitis,
 as a complication of the  fever, is not to be  predicated  upon  this symptom,
 however prominent it  may be.  This  is an  important practical fact.   Is it
 not frequently overlooked ?  That this symptom is  incident  to the morbid
 condition, whatever it be, which is the essence of Continued  Fever, appears
 to be, as intimated in the former Report, a fair conclusion, in accordance with
 what may be enunciated as a rule of pathological reasoning, viz., that when-
 ever any symptom, in a large proportion of cases, is observed to be associated
 with a disease, and found, by a proper analysis of cases, not to be dependent
 on any of the other appreciable events entering into the history of the dis-
 ease it  is to be considered as sustaining a direct  relation with that which
 constitutes the proximate  cause of the disease.   If, for example, Continued
 Fever involves, as  its prime,  essential morbid  condition, a special  morbid
 change in  the blood, the delirium, so frequently incident to the progress of
 the  disease, is a result of the circulation of this morbid blood within  the
 brain, and it would be expected, what, as  a general rule, is true, that  the
 degree of delirium should correspond with the gravity of the disease.
    As reoards the  mental conditions, irrespective of delirium, in this, as in
 the former collection of  cases, hebetude was the prevailing trait.  The mind
 appeared to act slowly and with more or less difficulty.  The patients,  when
 awake, took but little notice of what was passing around them;  their replies
 to questions were short; they seldom seemed to manifest a disposition to 
156
REPORT ON CONTINUED FEVER.
describe or explain their sensations, and very rarely showed any anxiety as to
the issue of the disease.  There were considerable variations in  the degree
of indifference and sluggishness,  and, as a general remark, it obtained earlier,
and  was more marked in  cases  of  Typhus,  than in  those of Typhoid.
Promptness in comprehending and replying to questions; an increased  dis-
position to make inquiries, to indicate  wants, and  a returning appreciation of
their situation, are among the more obvious of the indications of  a favorable
change in the progress of the disease.
   The statements of fever patients with respect to the events  that transpire
in the case, from  day to  day, are not to be relied upon.   Their replies to
questions  may be  sufficiently reasonable, but quite the reverse of the  truth.
For  examples, they may say that they have slept  well, when the whole night
has been passed  in busy delirium, and vice versa; they may say they have
had  dejections  from  the bowels, when none have occurred, etc.  They  fre-
quently appear to  reply to questions  without any reflection, and entirely at
hazard.  But even if they are stimulated to direct  their thoughts to any
point, the recollection is apparently unable to discriminate between what  has
really occurred, and the ideas that have passed  through the mind.  The
memory may be tested  by asking the time of the day, the day of the week,
when the preceding visit  was  made, etc.   Patients are often wholly unable
to answer these questions  correctly.   It is therefore obvious that histories of
cases made  up of the statements of patients, would be likely to contain  not
a little that was erroneous.
   Sleep. — A disposition  to somnolency was noted in several of the histories,
viz.,  in thirteen cases of  Typhoid, and in three cases of Typhus. The propor-
tion  of cases in which this symptom appears, is considerably less than  in the
former collection, and, inasmuch as it  is seldom stated that the symptom  was
not present, I am led to think that it may not  have been noted  save  in the
cases in which  it was  more especially marked.   In all but one case  the
patients were easily roused, but lapsing into the somnolent state directly after-
ward.   In five of the seven fatal  cases of  Typhoid, this  symptom was pre-
sent, and, of the two excepted cases, in one active  delirium existed, and  in the
other case the patient died in apoplectic coma the  day after admission.   Judg-
ing by the results of  the present analysis, it would seem that this symptom
indicates a severity of disease greater than the average, and this accords with
the results obtained by  Louis and Jackson.
   It is not  to be understood that in the cases in which this symptom  was
present, it continued throughout the febrile career.   It was present more or 
REPORT ON  CONTINUED FEVER.
157
less, in  some cases only of temporary duration, and sometimes observed at
different periods in the same case.
   In nine of the thirteen  Typhoid cases characterized by somnolency, deli-
rium, to a greater or less extent, entered into the history.  Patients were
sometimes somnolent during the day time, with slight, if any manifestations
of delirium, and at night talkative, and attempting to  get out of bed.
   Delirium, hebetude, and somnolency, which were thus frequently exhibited
almost  simultaneously in the same case,  are probably dependent on a similar
morbid condition, each  denoting  an enfeebled state of the cerebral organs.
At the first blush this explanation may not appear to be applicable to delirium,
but it will be found to be the most rational view, on a little reflection.   The
mental aberration in the  great majority of cases has been seen to be passive; the
manifestations do not display increased  energy of mental action, but the pa-
tient talks and acts  under the influence of dreamy delusions,  somewhat as
 when the brain is oppressed by intoxication carried beyond the bounds of ex-
citement.  These delusions are generally not persistent, but constantly vary-
 ing. The mind has not sufficient strength to preserve the same train of
 ideas.   Hence the incoherent muttering which generally characterizes the
 delirium.  It  may be supposed  that in the few cases in which the delirium
 is said to be active or violent, that there must be increased functional activity
 of the brain, and that  these are exceptions  to the general rule.  The  most
 rational mode of accounting for the character of the  delirium in these cases,
 is, that the insane delusions are of a character to rouse energetic expressions
 and actions  by exciting emotions of apprehension  and terror.  This  being
 the case, the vigorous and continued efforts of the patient to resist  restraint,
 do not denote increase  of nervous power, more than in delirium tremnes, to
 which affection, the  mental condition  in fever referred to, bears a strong
 analogy.
    The term somnolency, in the foregoing remarks, it will  be understood, of
 course, is not  intended  to be applied to  veritable sleep, but to that state, some-
 times  called coma-vigil, in which the patient lies in a semi-unconscious state,
 apparently, but  not in reality sleeping,  from which, usually,  he  is  readily
 roused, and to which he relapses so soon as the efforts to rouse him are dis-
 continued.  With respect to true sleep, the patients were daily asked whether
 they had slept much,  or little, during  the night, and their replies  recorded.
 Very  little importance, however, is to be attached to the information thus ob-
 tained.   Patients oftener reported that they had slept well than the reverse,
  and they frequently made  this report  when  the night had been, in reality,
  much disturbed.   Sometimes want of  sleep, and inability to sleep, were the 
158                 REPORT ON  CONTINUED FEVER.

subjects of complaint   This was more  apt to be the case when  the disease
was comparatively mild, and the nights were passed more quietly, and appa-
rently more comfortably than in other instances in which no such complaints
were  made; the explanation of which probably is, that in such instances the
powers of the mind  are less compromised, and the patients are  able to ap-
preciate causes of discomfort, which, in graver forms of the disease, although
existing to a greater extent, do not produce as much conscious impressions,
nor are the impressions  so well retained in the memory owing to weakness of
this retentive faculty.
   Coma.—Sudden, or  apoplectic coma is  an event which occasionally be-
comes developed in the  progress of Continued Fever.  It occurred in four of
the cases first analyzed, but in one case only in the present collection, the case
ending fatally.  In two other  cases there  was an approach to the sudden
development of the comatose state.
   The following is a condensed history of the case, in the present collection,
characterized by the occurrence of complete and  fatal coma: — Patrick En-
right, Irish, laborer, of good constitution, aged 38, single, entered  hospital at
noon, Dec. 10.   He was attacked four or five days previously, with pains in
head, loins, and limbs, which still continue.    Has had loss of appetite, great
thirst, some nausea and vomiting, bowels moved daily, complained of vigi-
lance.  He did not present, on his  entrance, high febrile movement; pulse
not much accelerated, and was  well developed.  Tongue moist and coated.
Skin warm, and rather dry.   At evening he appeared comfortable.
   At 1, A. M., the next day, he was  found in the following condition, viz.
face and  upper extremeties covered with  cold clammy perspiration; body and
lower extremities warm;  pulse small and feeble, and accelerated; unconscious;
respiration irregular, labored, with puffing of the cheeks in expiration;  froth
exuding from mouth; difficulty of deglutition.
   Sinapisms were  applied to extremities, and to nucha; friction with dry
mustard to arms; brandy and ammonia, internally, freely administered.
   Some improvement in the symptoms followed,  which was but temporary,
and death occurred at 1, A. M.
   The morbid appearances within the brain, fourteen hours after death, con-
sisted in  considerable congestion of the veins of  the superficies;  moderate
increase of sub-arachnoid effusion, and about an ounce of serum in the arach-
noid  cavity.   The characteristic intestinal lesions of Typhoid fever were
present in a marked degree.   The kidneys presented some degree of granular
degeneration.
   It is not easy from these appearances to deduce the  explanation of the 
REPORT ON  CONTINUED  FEVER.
159
sudden coma and death.   My own impression is, that the symptoms and ter-
mination are most rationally accounted for on the supposition of effusion into
the arachnoid  cavity, as the  result, probably, of vascular engorgment, and
perhaps a morbid condition of the blood itself.  Under this- supposition, me-
chanical compression of the medulla oblongata was the cause of death,  and
the preceding  phenomena.  To this lesion, as one liable to occur, and occa-
sion a fatal termination in some cases in which the loss of consciousness, etc.,
are not developed so suddenly as to constitute apoplectic coma, I shall refer
in other connections.
   Of the two cases mentioned in which there was an approach to a condition
similar to that  in the case just given, some account  may possess interest.
Both cases are included among those of Doubtful type.  In one case the pa-
tient entered on the sixth day after the first symptoms of illness.   There were
no indications of unusual severity of disease.   The day after his admission,
in the morning, the symptoms were as follows: — face and hands moderately
congested; skin warm and dry; tongue dry and coated, of a dark color;
some  appetite;  much thirst; no dejection, no  abdominal tenderness; pulse
104, tolerably developed; no cough, respirations 16; incoherent talking dur-
ing night; some carphologia this morning; restless, frequently changing his
position.
   At 6, P. M.,  copious perspiration,  extremities cold and clammy; pulse
140, small and feeble; respirations irregular, catching,  and he was supposed
to be moribund.  Sinapisms were applied, a blister to  the nucha, and stimu-
lants (brandy and ammonia) freely administered.   Snow was applied to the
head.  He began to improve at about 10, P. M., and on the day following,
the record states  that he was rational, skin warm and moist, pulse  88, res-
pirations 12 and regular, etc.   Convalescence was soon established.
   In  the  second case, the patient  entered on the sixth day  after the first
 symptoms of illness, and presented the symptoms of fever of a moderate grade
 of intensity.  On the  evening of the day of his admission, the record states
 that  the respiration became much embarrassed, perspiration copious, and he
 was nearly comatose.  The symptoms more in detail, and the therapeutical
 measures pursued, are not stated.  On the following day he was quite com-
fortable, pulse  72, skin warm and  moist, respirations  16, etc.  He reported
 that he  slept well during the  night.   Convalescence, in this case, was not
 declared until eight days after admission.
   In these two cases there seemed to be an approximation to that condition,
 suddenly  induced,  which, in  the  case  previously given, ended in  fatal
coma.  The pathological  explanation of the latter is probably measurably 
160
REPORT ON  CONTINUED FEVER.
 applicable to the former.   The condition, whatever it  be, seems to be analo
 gous  to  that which in some  of the  cases was developed more gradually,
 determining the mode of dying.   To  these  cases reference will  bo made
 hereafter.
    Cephalalgia. — An examination of the histories of the cases with respect
 to this symptom confirms  the  several  conclusions stated in the first Report.
 The presence of the symptom was noted in fourteen of the twenty-nine cases
 of Typhoid; in four of the ten cases of  Typhus, and in six of the nine cases
 of  Doubtful type;  that is in twenty-four or precisely one-half of the forty-
 eight  cases.  This is  a statement of  the proportion of cases in which the
 symptom existed after the patients came under observation.   It is not a fair
 illustration of the frequency with which the symptom occurs, for, in most of
 the cases, the patients were not transferred to the hospital at the very begin-
 ning of the febrile  career.   It  is to be borne in mind  that, in this enumera-
 tion, no reference is made to cephalalgia as entering  into the access of the
 disease, but only to its presence  after the febrile  career is entered upon, in
 other words, after the time that the patients took to their beds.   Had all the
 patients been under observation from that period, the proportion of cases in
 which the  symptom was present would  doubtless have been larger.  It is
 probable that the cases are  few  in which it is not present, more  or less, in
 the early part of the febrile career.  It  almost uniformly disappears after the
 fever has  continued for several days.   Hence, in many, if not most  of the
 cases in the histories of which it  is not noted, it had doubtless existed, and
ceased before the patients came under  observation.   The  duration  of the
symptom, in the cases, respectively, in the histories of which it was noted, was
as follows:

                                Typhoid.
         One day,                                 Three cases.
         Two days,                               Three cases.
         Three days,                               Three cases.
         Four days,                               Three cases.
         A few days,                              One case.
         On ninth  day, and not previously,          One case.

                                Typhus.
         One day,                                 One case.
         Four days,                               Two cases.
         Five days,                               One case 
REPORT ON  CONTINUED  FEVER.
161
                            Doubtful  Type.
         One day,                                One case.
         Two days,                               One case.
         Three days,                              Two cases.
         Four days,                               One case.
         Few days,                               One case.
   In but three cases is it noted that the headache returr.el during  the ca-
reer of the fever,  In one of these  cases it was present in a slight degree
from the seventh to the tenth days inclusive.  The disease was mfld in this
<case, and accompanied by spinal  tenderness.   In one  case it was  present
from the thirteenth to the seventeenth days inclusive, but in this  case  ft
occurred in connection with external  otitis.   In the remaining case it occur-
red  on the  twelfth day, with an aggravation of symptoms after apparent
convalescence.
   The symptom was present in five  of the seven fatal cases of  Typhoid, and
in two of the two fatal cases of Typhus.
   The diminished  acuteness of the  perceptive faculty, which is incident to
Continued Fever after its continuance for a few  days, affords  an adequate
explanation of the fact that cephalalgia belongs only to the early stage of the
disease.
   So  far as deductions are  admissible from the small number of  Typhus
cases in this collection, it would seem that this symptom is less frequen th
present  after the  fever is established, and  its duration  less  than in the
 Typhoid type.
   The records of the cases do not state  the severity of the cephalalgia, not
whether it was limited to particular portions of the head, save that in  a few
instances it is noted that the seat of the pain  was in the forehead.
   Dizziness, when the  head  was  raised,  was complained  of  in  several
cases.
   In this, as in the former collection, pains elsewhere than in the head were
■complamed of in a very few cases only.   The following are all the facts that
the histories contain relative thereto: —In two  Typhoid  cases, on the  third
day after admission, complaint was  made of pain  in the bowels;  in one case
•of the same type, pain in the loins on the second  day; in one case do., pain
 in arms and feet on the twelfth and thirteenth days? in one case, da, pain in
 limbs and loins on the second day;  in one case, do,,  pain in the joints on the
sixth day;  and in one case,  pain  in knee and elbow, with spinal tenderness,
on the fourteenth day.
   In me  Typhus case, pain in the shoulders and  hips was complained of on
               M 
162
REPORT ON  CONTINUED FEVER.
 the fifth day;  and in one case of Doubtful type, pain in the abdomen on the
 second day.
   The interest in this enumeration lies in the  small  number of cases in
 which  pains were  experienced, the  shortness of duration of  the pains, and
 their unimportant  character.   In this, as in the former collection, painful
 symptoms were  recorded only when mentioned  by patients of their own
 accord, or in answer to a general inquiry as  to their condition and feelings.
 Patients were not asked if they had pain in such and such parts.   It is prob-
 able that to leading questions the replies might have been frequently in the
 affirmative, but their correctness could not be relied  upon, owing to the men-
 tal condition in Continued Fever which has been described.   It is  reason-
 able to suppose that the absence of  painful sensations in other parts of the
 body than the head,  as well as the cessation of pain in  the latter situation,
 does  not denote  freedom from morbid conditions  ordinarily attended with
 suffering, but diminished sensibility.
   As respect  lesions  of sensibility, the foregoing results are quite different
 from those developed by  the numerical investigations of Louis.   In a large
 proportion of the cases of Typhoid fever analyzed by that eminent observer,
 abdominal pains  were more or less present.  I can only  account for this dis-
 parity by supposing that  in recording histories, Louis interrogated patients
 specifically for this symptom.   I do not doubt that  if this  course had been
 pursued with the patients in this, and the former collection, abdominal, and
 other pains would have  been  affirmed in a considerable number of cases.
 The answers would doubtless have been  correct in a certain  proportion of
 cases, for patients with fever may really be conscious of pains, which, from
 the peculiar condition of mind causing a reluctance to make any effort,  they
 do not complain of, or mention, unless their attention is  directed  to the sub-
ject.  The results of my analysis, which relate to subjective symptoms,  it is
 to be  considered, embrace, for the most  part, only the  instances  in which
 these  symptoms were sufficiently prominent  to  impel  patients  to speak of
 them  without addressing  leading questions.  The reason for this is stated in
 the preceding paragraph.
  Eye.  The conjunctiva presented  increased redness, more  or less, in ten
 cases of Typhoid, in three cases of Typhus,  and in  four cases of Doubtful
 type, making, in all, seventeen of the forty-eight cases.
  The proportion of cases in which the presence of this symptom was noted,
 is somewhat greater than in the first collection, which may be owing to atten-
 tion having been  directed to this point with more care.
  Moderate yellowness of the conjunctiva was observed in two Typhoid cases. 
REPORT ON  CONTINUED FEVER.
163
  Deafness.  Dullness of the sense of hearing sufficient to constitute notice-
able deafness, is noted in the histories of eighteen of  the forty-eight cases,
viz., in  ten cases of  Typhoid, five  of Typhus, and three of Doubtful type.
It varied  in  degree, in some cases  being considerable, and in other cases
slight.  It was  sometimes the occasion  of complaint with patients.  When
present, it generally made its appearance early,  continuing throughout  the
febrile career, and, occasionally, after convalescence was established.
  The  proportion of cases in which  this symptom was appreciable (as it is
not in all cases in which it may be present, for reasons  specified in the former
Report) differs somewhat, but not greatly in  the two collections, the relation
being as 18-48 is to 24-52, or 9-24 to 6-13.  It was present, thus, in
forty-two of the one hundred cases.
   In this, as in  the first collection, it was present in a larger proportion of the
cases of Typhus, than in those of Typhoid, the relation being as 5-10 or
1 — 2, to 10-29 or slightly  over 1-3.    In  the  first  collection  its  relative
frequency in  the two  types was as 5- 12 to 5- 18.   In this  point of view
the results of the two  analyses show a pretty near correspondence.  External
otitis, leading to suppuration and purulent discharge  from  the ear, occurred
in two  Typhoid cases.
   Involuntary  Muscular Contractions.   As in the first collection of cases,
the instances in which involuntary muscular  contractions attracted notice, are
very few.   The facts, contained in the histories,  are as follows:
   Of the Typhoid cases, which ended in recovery, in  one, moderate subsul-
tus was observed on the eleventh and fourteenth days  after admission;  and
in  one, tremor of facial muscles when the patient spoke, on the eighth  and
 ninth days.   Of the cases of the same type ending fatally, in  one, subsultus
 on the second day, and  tremor of the upper extremities on the fourth  day,
 which was the day before  the death of the patient; in one, tremor of the
 upper extremities on the twelfth day.
    Of the Typhus cases, in  one case, slight tremor of the body and limbs
 was observed on the tenth day.  This case ended in recovery.
    Of the cases  of Doubtful  type, in one, subsultus was observed on the eighth
 and ninth days.  This case  ended in recovery.
    Tonic contraction of muscles, which occurred in a few of the  cases analyzed
 by Louis, and  also in those analyzed  by Dr. Jackson, of Boston, was  not
 noted in any of the eases included in this or the former collection.
    Carphologia.   This symptom  is mentioned  in the history of two  fatal
 cases of  Typhoid, in both of which muscular tremor of the extremities occur-
 red.   It is not stated to have occurred in any other  cases. 
164
REPORT ON  CONTINUED FEVER.
  Under the head of prostration I have nothing to add to what is said, on
this point, in the first Report.

                             SECTION FIFTH.

Symptoms referable  to  the  Digestive System.   Appetite, Thirst, Tongue,
  Sordes,  Parotitis,  Nausea, and  Vomiting.  Alvine  dejections,  Tympan-
  ites, Tenderness of Abdomen, Gurgling.   [Page 60.]

  Appetite.  Of the forty-eight cases, the histories are deficient in statements
relative to the appetite in ten.   As respects the remaining thirty-eight cases,
the patients were asked if they desired, or relished food, and the information
thus obtained, noted.  In  twenty-seven  the  patients declared they had  no
appetite, whenever asked, which was usually several times during the progress
of the disease.  Of course the stage of  convalescence, and the period just
preceding  convalescence, are  not now referred to,  more or less  return  of
appetite almost invariably signalizing a favorable change in the disease tend-
ing toward  recovery.  In eleven of the  thirty-eight cases, the  patients said
that they had some desire for food, or that the food they received (which was
essence of beef, and milk porridge) was  acceptable.
  With reference to these results some allowance is  to be made  for the
uncertainty which, as has been seen, belongs to all the subjective phenomena
of the career of Continued  Fever.  I  do not feel sure that the patients always
spoke the truth when they said they  desired or relished food, but there is no
way of disproving or confirming their statements.  The results,  to  say the
least, suffice to show that the idea of  food does not affect the mind with dis-
gust in all cases of fever.   It is probable, indeed, that in a certain proportion
of the cases,  some appetite was felt.   And7 again, it is  to be considered that
the liability to error may apply to the cases in which patients declared they
had not, as well as to the cases in which  they affirmed that they had a dis-
position to  take  food.   It  is certain that patients affected with fever, after
the disease  has continued for some days, do not, in  many instances, refuse
nutriment, or take it with manifest  reluctance.  Sometimes,  however, there
is a strong repugnance to it.  It is  very rare that they ask  for food, even
although it  may be  readily taken when presented.   The  condition of the
mind sufficiently accounts  for the latter  fact; and it  is hig'hly  important to
bear in mind, that, in so far as willingness to receive food, or even  the exist-
ence of appetite, should  have an influence on the propriety of administering
nourishment, we must act without waiting  for  any spontaneous expressions
on the part of the patient.  The mind does not take that cognizance of thft 
REPORT ON  CONTINUED FEVER.
165
instinctive wants of the system which belongs to health.   This is evidenced
by various other particulars.
   The presence of appetite is noted in a very much larger proportion of cases
of the Typhus than of the Typhoid  type.  Excluding three cases in which
nothing is noted on this  point, of the seven remaining cases of Typhus, in
five the patients said that they relished or desired food.
    Thirst.  In ten cases the histories do not state either the presence or ab-
sence of this symptom.  Of the thirty-eight remaining cases, it existed to a
greater or less extent.  In nineteen of these cases the thirst was great during
the early part of the febrile  career.  In  a few cases it  continued to be a
prominent symptom throughout the disease, but generally, although intense
at first, it  lessened as the disease advanced.   In  some cases it was present
only for the first few days.  In only one case is it stated that  there did not
exist thirst at first, and in this case it became developed afterward.  Informa-
tion respecting  this symptom, was obtained by questioning  the patients, but
frequently patients asked  for drink, and  complained  of  suffering from this
source.  This was true more especially at  the early part  of  the disease, and,
afterward, as I often noticed, although  patients did not, of their own accord,
indicate their desire for drink, if offered to them it was eagerly  taken.
   Thirst is, thus, a pretty constant symptom, more  marked at the commence-
ment of the febrile career, diminishing, or ceasing  as  the disease  progresses,
 which, in  part, at least, is probably in consequence of the bluntness of per-
ceptions, the  consciousness of the morbid  condition  upon which  it depends
being thereby impaired.
    Tongue.  In no instance did the tongue preserve a normal aspect through-
 out the disease.  The morbid  appearances were varied, not  only  in different
cases, but at different periods in the same cases.   Without  investigating the
 connections which these appearances had with other symptoms, with a view
 to determine, by that mode, the pathological significance  and value which
 belong to them respectively, as was done in the former analysis, I  will simply
 give  enumerations of the cases in which  the more prominent appearances
 were observed, bringing into comparison  the different types, and  the results
 in the two analyses.   The appearances of  the tongue were noted  in all cases
 but one; that is in forty-seven cases.
    Dryness of the superior surface of the organ, more or less in degree, extent,
 and duration, was noted in the histories  of  twenty cases of Typhoid, eight
 cases  of Typhus,  and six cases  of Doubtful type; in all, thirty-four, of
forty-seven cases.  The first analysis gave this symptom  in thirty-six offifty
 cases.   In both collections seventy, of ninety-seven cases. 
166
REPORT ON  CONTINUED FEVER.
   There was notable resistance to the touch, or hardness of the superior sur-
face, in ten  cases of  Typhoid, in two  cases of Typhus, and in two cases  of
Doubtful type;  in all, fourteen, of forty-seven cases.  The first analysis gave
this  appearance in  ten, of fifty cases.  In  both collections, twenty four,  of
ninety-seven cases.
   The dryness was  rarely observed at the  early part of  the  febrile career,
and was generally either confined to, or more marked on a central strip  of
the surface of the organ.   It existed in every fatal case save one, and  in the
excepted  case, the patient died  suddenly, with apoplectic coma, the second
 ay after coming under observation.
   Coating, varying in thickness, color,  and  continuance,  was present  in
twenty-seven cases of Typhoid, in ten cases of Typhus,  and in eight cases  of
Doubtful type;  in all,  forty-five, of forty-seven cases.  The  first analysis
gave forty-seven  of fifty cases.  In  both collections, ninety-two, of ninety-
seven cases.  The color of the coating is not generally mentioned.  It is sta-
ted to have been dark in two cases only, in both of which the disease ended
favorably.
   A scabby appearance was presented in four cases of  Typhoid, in one case
of Typhus, and in  no  case  of  Doubtful  type;  in  all, five, of forty-seven
cases.   The first analysis  gave four, of fifty cases.   In both collections, nine,
of ninety-seven cases.   The surface exhibited fissures, or cracks, in five cases
of Typhoid, in one  case of Typhus, and one case of Doubtful type;  in all,
seven, of forty-seven cases.   The first analysis gave four, of fifty cases.  In
both collections, eleven, of ninety-seven cases.
   It had a very smooth, or glazed appearance  in three cases of Typhoid,  in
one case of Typhus, and in  no case of Doubtful type;  in all, four, of forty-
seven cases.   The first analysis gave five, of fifty cases.   In both collections
nine, of ninety-seven cases.
   A reddened aspect is noted in the history of four cases, all cases of  Ty-
phoid.   The first  analysis gave eight cases, all of the Typhoid type.  In both
collections, twelve, of ninety-seven cases.
   Great difficulty in protruding the tongue existed in three cases of Typhoid,
in two cases  of  Typhus, and in no case of Doubtful  type;  in all, five of
forty-seven cases.   The first analysis gave six, offifty cases.   In both collec-
tions, eleven, of ninety-seven cases.   In each of the cases in this  collection,
in which great difficulty in protruding the tongue  was  noted, the disease
proved fatal.
   As respects any striking  points of distinction between the  two types, Ty-
phoid  and Typhus, these results are negative.   The  only  feature which 
REPORT ON  CONTINUED FEVER.
167
would appear, from my observations, to have any bearing on  the diagnosis,
is redness of the tongue.  This was observed in  a small proportion of the
cases of Typhoid in both collections, and in not a single case of Typhus.
  The comparison  of the results in the two analyses, for the most part exhib-
its a similarity which is worthy of remark,  as evidence that symptoms which,
at first view, appear so uncertain, and, as it were,  accidental, as the different
appearances of the  tongue, are, nevertheless,  restricted in  the frequency of
their occurrence within  certain numerical limits.
  As already stated, the tongue frequently  presented, in individual cases,
during the  progress of the disease, more  or less of the various appearances
that have been mentioned.   The general facts with respect  to this point,
which were stated in the former Report, are equally applicable  to the present
collection  of eases.   In order, however, to illustrate  the manner  in which
these  appearances occur in succession in Continued  Fever, I will  give in a
tabular form, the facts pertaining to the tongue as daily noted in the histories
of six cases of either type, selecting one-half from the cases ending favorably,
and the other half from those which were  fatal.
  In the following table the cases selected are placed in the separate columns
numbered 1, 2, 3, etc., and the appearances  noted on  every day of the dis-
ease, in each case, are given in the column assigned to that case; 
TABLE SHOWING THE APPEARANCES OF THE TONGUE IN SIX CASES OF TYPHOID FEVER ON DIFFERENT DAYS DURING THE PROGRESS
                                                    OF THE DISEASE.
No. Days.	Case No. 1, recovered'	No. 2, fatal.	No. 3, recovered.	No. 4, fatal,	No. 5, recovered.	No. 0, fatal.
Day 1.	Moist and furred.	Not noted.	Dry and coated in cen-tre, moist and clean at sides.	Dry and coated.	Moist and thinly coated.	Moist and clean.
" 2.	Moist and furred,	Moist and coated, except at tip.	Dry and thickly coated, hard in centre, moist and clean at sides.	Coated, protruded slow-ly, tremulous, dry at tip, moist at base.	The aame.	Moist and thinly coated.
" 3.	Moist, white coating, reddened at tip and sides.	The same.	Dry, hard, and scabby, in centre, moist at sides.	Dry and coated, pro-truded with difficulty.	The same,	Dry and reddened.
" 4.	Coated at base, and	Moist and coated, and	Coated, hard, and fis-	Dry and smooth, coated	Coated and rather dry.	Dry and hard in centre,
	clean at sides and tip.	reddened at tip and sides.	sured at centre, moist at. sides.	in centre, moist at sides.		moist at sides.
" 5.	Thinly coated at base, smooth and glazed to-wards tip, dry in cen-	Coated, dry and scabby.	Moist and coated.	Protruded readily, dry, cracked, thin coating.	Moist and coated.	Dry, hard and coated in centre, moist at sides.
'« 6.	tre. Moist, and covered with loose, thick, scabby coating.	Dry, hard and scabby.	Coated and dry, and fis-sured at centre, moist and furred at sides.	Died.	Moist and coated.	The same.
" 7.	Moist, loose coating at	Moist, thickly coated at	Dry and fissured at tip,		Moist and clean except	The same,
	centre, clean at sides.	base, clean at sides, reddened at tip.	moist at base and sides.		at base.	
" 8.	Moist, heavily coated.	Heavily coated except a small space at tip.	Cleaning.			Moist and thinly coated.
" 9.	Dry and ooated at cen-tre, moist at sides.	Not noted.	Not noted.			Dry and thinly coated.
"10,	Coated and Dry.	Less dry and coated.	Moist and furred.			Moist nnd furred.
"11.	Moist and coated.	Dry and coated.	Moist and cleaning.			Dry, coated and hard in centre, moist at sides.
"12.	Dry and fissured, coated and hard at centre, moist and clean at sides.	Cleaning.				Coated dry, hard in cen-tre and fissured, moist at sides.
"13.	Dry, coated, hard and fissured.	Nearly clean, somewhat reddened.				Moist and coated.
"14.	Rather dry, fissured.	Moist, reddened, and somewhat coated.				Dry at centre, moist at
" 15.	Clean, moist and fissur-ed.	Died.				Dry and fissured at cen-tre, moist at sides, (in-testinal perforation.)
" lfi.	Moist and clean.					The same.
■• 17.	Clean.					Di*d.
 
TABLE SHOWING THE APPEARANCES"OF THE TONGUE
IN SIX CASES OF TYPHUS FEVER ON  DIFFERENT DAYS DURING THE PROGRESS

   OF THE  DISEASE.
No. Days.
Day  1.

  "  2.
  "  3.
No. 1, recovered.
Moist and coated.
The same.
Coated and dry.
Coated and dry.

Moist, coated, dark.

Same appearances.
Same appearances.

Moist and nearly clean.

Not noted.
Moist and lightly coated.
No. 2, fatal.
Could not be made to
  protrude the tongue.
Not noted.
Moist, thin  white coat-
  ing, several superlicial
  ulcerations.
Same appearances, pro-
  truded quickly.
Not noted.

Not noted.
Moist and  furred, pro-
  truded readily.
Moist and furred.

Moist, thinly coated.
The same.
Dry in centre, moist at
  sides.
Moist and furred.
The  same.   Dysenteric
  symptoms  superven-
  ed, and death on the
  52d day.
No. 3, recovered.
Moist and coated.

Moist and thinly coated.
Moist.
Moist and thinly coated.

Moist and cleaning.

Moist.
No. 4, fatal.
Not noted.

Moistand thinly coated.
Moist and furred.
Moist and coated.

Dry and furred.

Moist and thinly coated.
Same appearances.

Same appearances.

Same.
Dry and hard.
Smooth, clean, and dry.

Moist and furred.
Dry und hard.  Died.
No. 5. recovered.
Not noted.
Not noted.
Moist and coated.
Moist and thickly coated

Moist and coated yellow

Dry in centre.
The same,

Dry and hard in centre.

Not noted.
Moist and furred.
No. 6, fatal.
Dry and coated.

The same.
Moist and nearly clean.
Clean  and  somewhat
  dry.
Thinly  coated  dry in
  centre.
Moistand thinly coated.
Clean,  dry, and some-
  what fissured.
Clean  and  somewhat
  rlrv.
Died.
Oi
to 
170
REPORT ON  CONTINUED FEVER.
   So far as the facts contained  in  the present collection of cases are devel-
oped, they go to confirm the correctness of the general conclusions submit-
ted  in the former Report, with respect to the importance of the tongue in
furnishing indications in Continued Fever.  The special attention bestowed,
by some practitioners, on the various appearances which this organ  assumes
during the progress of the disease, and the  significance attached to these
appearances in the prognosis, and treatment, are, for the most part, based on
notions purely speculative.
   Sordes.  The presence of this symptom is noted in the histories of seven-
teen of forty-seven cases in which the record of the phenomena  pertaining
to the digestive system is presumed to be complete.   The first analysis gave
fourteen, of fifty-two cases.   In both  collections, therefore,'it was present in
thirty-one, of ninety-nine cases.
   The symptom was present in each of the fatal  cases of Typhus, viz., in
four, and in four of the seven fatal cases of Typhoid; in all, eight, of eleven
cases.   Thus, the proportion  of cases  in which it was observed that ended
fatally, is as eight to seventeen, and, in the first collection, as three to seven.
   Of the seventeen cases in which it is noted to have occurred, ten were cases
of Typhoid, six were  cases of Typhus, and in one the type was Doubtful.
It was present, thus, in a larger ratio in the cases of Typhus than in those of
 Typhoid.
   The periods in the disease, dating from the time the patients entered the
hospital  (which it is to be borne in mind was very rarely at the commence-
ment of the disease), when sordes was  first observed, in the cases respectively,
are as follows:
                                 Typhoid.
Second day,
Fourth day,
Fifth day,
Sixth day,
Fourteenth day,
Fifteenth day,

First day,
Third day,
Eighth day,
Tenth day,

Fifth day,
Typhus.
Doubtful  Type.
Two cases.
One case.
Two cases.
Three cases.
One case.
One case.

One case.
Two cases.
Two cases.
One case.

One case.
It is evident that sordes denotes a certain degree of gravity of disease, for 
REPORT ON  CONTINUED FEVER.
171
 it is not observed in mild cases, and is present in a proportion of the cases
 which prove fatal, considerably larger than in those which end  in recovery.
 Nevertheless, it occurs not unfrequently in cases which recover, and is by no
 means present in all cases that  are fatal.   Hence, an unfavorable prognosis
 is not to be based on  its presence, nor  a  favorable prognosis on its absence,
 although, in estimating  the  probabilities of the  issue  of  the  disease, the
 symptom is not without weight.
   Hemorrhage from the gums.  This symptom is noted in the histories of
 two cases, the same number as in the first  collection.  In  one case the dis-
 ease was Typhoid, and in the other case the type was Doubtful.  It occur-
 red in the former case on the fifth day  after the patient entered the hospital,
 and continued until the eighth day.  The case became complicated with pneu-
 monitis.   The  disease was not very severe, convalescence being pronounced
 on the sixteenth day after admission, and the  twenty-sixth  after the date of
 attack.   In the latter case the haemorrhage occurred on  the third day after
 admission, and is only noted to have occurred on that day.   Convalescence
 was pronounced in this case, on the eighth day after admission, and the four-
 teenth after the date of attack.   In the first case  petechia?  occurred on the
 abdomen and  limbs, being  intermingled, in the former situation, with the
 characteristic rose eruption.   The petechia? were  true ecchymoses, not the
 maculae of Typhus.
   Inasmuch as in three of the four cases in which, in both collections, this
 symptom was observed, the disease terminated  in recovery, it is  to be infer-
 red that its occurrence need not affect unfavorably  the prognosis.
   An herpetic  eruption about  the mouth, is  noted  in the histories of three
 cases, viz., two  of Typhus, and one of Typhoid.
   Parotiditis.   This complication did not occur in any case.   In this respect
 a  comparison of the two collections exhibits a striking contrast, the first
 analysis having given five cases.  These results go to show that parotiditis is
 not to be regarded as an intrinsic element  of the disease, but one of the
 events which are due to certain special  tendencies  incident to the disease at
 particular times or places — tendencies, the nature and source of which are
 not susceptible  of explanation with our  present knowledge of the pathology
 of fever.
   Nausea and vomiting.  The occurrence of vomiting appears  in the his-
tories of  thirteen, of forty-seven cases in which the record of, the symptoms
referable to the digestive system is presumed to be complete.  Nausea, with-
out vomiting, is noted in the histories of four cases.   This  proportion of cases
is larger than in the first collection, in which vomiting occurred in nine, of 
172
REPORT ON  CONTINUED FEVER.
fifty-two cases.  In the two collections this symptom occurred in twenty-two,
of ninety-nine cases.   In these enumerations the access, or forming stage of
the disease  is excluded, and, also, the  period of the disease prior to the pa-
tient's coming under observation.   With the exception of one case, it was not
a prominent symptom, and, in the excepted case, it was not very prominent.
In four of the cases in which it occurred the disease proved fatal.   Of the
thirteen cases, eleven were cases of Typhoid, one was a case of Typhus, and
one a case of  Doubtful type.  Its relative occurrence was  therefore greater
in Typhoid than in Typhus.  This was true, also, in the first collection.
   The periods in the progress of the disease, at which the nausea or vomit-
ing occurred,  are as follows:
                                Typhoid.
Case  1.  Vomited yellowish and greenish fluid day before death.
   "    2.  Vomited yellowish fluid on fourth day.
   "    3.  Nausea on the first and fourth days.
   u    4.  Vomited twice fourth day,  and once seventh day.
   "    5.  Vomited once, after drinking freely of tea, on the fourth day.
   "    6.  Vomited once second, ninth, and  tenth days;  nausea eleventh  and
           twelfth  days;  vomited  thirteenth day.   Rather a prominent
           symptom in this case.
   "    7.  Vomited first day.
   "    8.  Vomited fourth and fifth days.
   "    9.  Vomited seventh day, after taking porridge.
   "   10.  Nausea first day.
   "   11.  Vomited second day, after  drinking.
   "   12.  Vomited first, second, third, and fifth days.
   "   13.  Nausea sixth day.
   "   14.  Vomited seventh day.
                                 Typhus.
Case  1.  Vomited fourth day.
   "    2.  Nausea fourth day.
                            Doubtful Type.
Case  1.  Vomited twice during the first six days.
   The days in the foregoing list are dated from the time the patients entered
the hospital, not from the commencement of the disease.
   The facts pertaining to this point show, that, during the febrile career, nau-
sea and vomiting not only are absent in the majority of cases, but  they are
unimportant as  symptoms, occurring at irregular periods, very seldom recur-
ring, or persisting, and possessing no special significance. 
REPORT ON CONTINUED FEVER.
173
  Alvine discharges.  Typhoid.  Diarrhoea,  more  or less in degree, and
duration, was  present in fourteen of the  the  twenty-nine Typhoid, cases.
This result is as near as possible to that developed by the analysis of the hos-
pital Typhoid cases in the first collection, which was nine, of  eighteen cases.
The two results could not approximate more closely without  the division of
a patient into halves!
  The diarrhoea was mild, or slight in degree  in  all but four cases.  This
was the fact in the hospital  Typhoid cases in  the first collection, in  all but
two cases, the relation thus in both collections to each other being as 4 -14,
or 2 - 7, is to 2 - 9.
  It was only present in the early part  of the febrile career in four cases.
This was the fact in the hospital Typhoid cases in the first collection in three
cases, the relation in both collections  thus being as 4 - 14 or 2 >*- 7, is to 3- 9
or 1-3.
  It was only present in the  latter  part of  the career in  two cases, one of
which was fatal.  This was  the fact in  the  hospital Typhoid cases in the
first collection in but one case;  the relation thus being as 2 - 14 or 1 -7, to
1-9.
  It existed moderately through the febrile career in six cases.   This was
the fact in the hospital Typhoid cases in the  first collection in five cases; the
relation thus being as 6-14 or 3-7, is  to 5-9.
   Of the seven fatal Typhoid cases it was  present in three.   In the four
hospital  Typhoid cases in the first collection  which proved fatal, it was pres-
ent in two; the relation thus being as 2 - 4  or 1 - 2, is to 3 - 7.
   Typhus.  Diarrhoea was present  in but three of the ten cases of Typhus*
Of the twelve hospital cases  in the first collection it was present in four; the
relation  thus  being as 3-10, is to 4-12 or  1-3.   In  each of the  three
cases in which it was present,  it was  exceedingly mild  in  degree, and of
short duration.  In one of  these cases it was only present on the day of ad-
mission, four dejections occurring on that day, and  this may possibly have
been the operation of a cathartic taken before entering the hospital.  In
another of the cases it consisted of two daily  dejections on the second and
third days after admission.   In the remaining  case it consisted of two daily
dejections  on the fifth, sixth, and seventh days after admission.
   Each  of these three cases of Typhus  terminated fatally.  Mild  diarrhoea,
therefore, existed in three of the four fatal cases of  Typhus.  Of the two
fatal cases of Typhus in the  first collection, diarrhoea was not present in either.
   The term diarrhoea is used here in the same sense as before, viz., meaning
too frequent, and liquid dejections. 
174
REPORT ON  CONTINUED FEVER.
  It is also to be recollected that these enumerations embrace only the career
of the fever, exclusive of the access, or forming stage.
  As respects this symptom, the two types, Typhus and  Typhoid, exhibit a
striking disparity; for, while in the forty-seven hospital Typhoid cases in
both collections diarrhoea was present in twenty-three, or in the proportion of
about one-half, in the twenty-two hospital cases of Typhus it existed in only
seven, or in the proportion of about one-third.  Moreover, it was universally
very mild, or slight in the cases of  Typhus in which it was present, while
this was not  true of all the cases of  Typhoid  into the histories of which it
entered.   A  greater liability to the  occurrence of diarrhoea, and its greater
prominence as a symptom, are generally recognized as constituting one of the
diagnostic features of  Typhoid considered in contrast with  Typhus, and it
is to be remarked that in the grouping of  the cases for these analyses more
or less importance was attached to the presence or absence of this event.
   Constipation.   With reference to the facts pertaining to the alvine evacu-
ations, it is particularly important to state that, with  a very few exceptions,
probably not  more than three or four instances, no cathartic or laxative medi-
cines were administered in  the cases  under analysis.   The same statement
will apply, nearly, if not quite as fully, to the hospital cases formerly analyzed.
Consequently, the conditions of the bowels,  as respects frequency of the dejec-
tions, and  other symptoms, are  such  as belong to  the disease uninfluenced
by the remedies just mentioned.  Enemas were occasionally employed, but
these not often.  Sometimes it happened  that no dejections occurred  for a
longer period than would perhaps have  been deemed advisable had the
attention been more closely directed  to this point, and pains always taken in
individual cases, while they were in  progress, to ascertain how many days
had passed without an evacuation.  The facts contained in the histories rela-
tive to constipation are not without interest and importance, and will doubt-
less strike the  minds of some of my readers with  surprise.  I will  give a
synopsis of the  histories,  so  far as the dejections are concerned, in  several
cases of  the  Typhoid and  Typhus types, which were characterized by
constipation.
   Typhoid.   Case 1. In this  case the bowels remained quiescent for five
days, and on the sixth day were moved by a simple enema.  They were not
moved for the three following days, when a single dejection occurred sponta-
neously.   On the second  day afterward, three or four dejections took place,
and  the  following  day two; the next day, none, and  the next  day, one,
convalescence being then pronounced.
   Case 2. In this case it is not stated whether the bowels  were moved on 
REPORT ON  CONTINUED FEVER.
175
the day of admission, or not;  but no evacuation occurred subsequently for
six days.  On the eighth day after admission an evacuation occurred spon-
taneously ; the ninth day, no dejection; on the tenth day, two dejections; on
the eleventh and twelfth days, each, one dejection, the patient  now being
convalescent.
   Case 3. In this case the bowels had not  moved  for three days prior to
admission.   They remained quiescent for two days after admission, and mov-
ed spontaneously on the third day, i. e., on the sixth day after the last preced-
ing movement.   On the day following, another dejection occurred, which was
moulded, and perfectly natural in appearance — a phenomenon which is not
likely to fall under the observation of practitioners who are accustomed to
administer cathartics daily,  or every other day,  during the progress of  the
disease!
   Case 4. In  this case diarrhoea existed  on the day of admission, several
evacuations occurring on that day;  afterward, no dejections occurred for two
days, none are noted on the  third day, none occurred on the fourth day, none
are noted on  the fifth day, and none occurred on the sixth day.  On  the
seventh day an evacuation took place spontaneously.   The next day, no de-
jection.  The  next day, one dejection.   The next day, none.  The next day,
one.  The two following days, none.  The next day, two  or three, and at
this time convalescence was established.
   Case  5.  In  this case  one dejection occurred on  the day of admission.
Subsequently no dejection occurred for six days.  On the seventh day there
were two dejections, convalescence being at this time established.
   It will be observed, that  in each of  the foregoing cases, the disease ended
favorably,  and, it  should be added,  that in none of the fatal cases was
constipation present.
   Typhus.  Case 1.  In this case, after the first day in hospital, on which
there was  one dejection, the bowels remained unmoved for four days.   On
the fifth day a stool occurred, the feces being moulded and natural; a single
dejection occurred on each  of  the  succeeding days, convalescence being
pronounced on the following day.
   Case  2.  In this case no evacuation  took place until the fifth day, when
there were  two dejections.  On the two following days there was no dejec-
tion; on the next day none was  noted;  on each of the two following days,
one dejection; on the  next day one, and on  the day following, two, conva-
lescence being established.
   Case 3.  In this case  no  evacuation took  place for the first five days in
hospital.   On the sixth day it is not noted whether the  bowels were moved 
176
REPORT ON  CONTINUED FEVER.
or not.   On  the seventh day there was no  dejection.   On the eighth  day
there was no dejection.   In this case the patient was pronounced convales*
cent, but subsequently dysentery supervened, which proved fatal on the fifty
second day after admission.  This is the only fatal case in which the bowela
were permitted to remain unmoved for several days  in succession.
   I  shall not  deduce from  the foregoing facts the conclusions that cases
of fever are  more likely to terminate favorably in which constipation  exists,
and  that it is injudicious to interfere with this condition even if the bowels
do not move for six, seven, or eight days.  It is by no means claimed  that
the facts are sufficient to authorize these conclusions.   It may, however, be
fairly inferred that constipation is not  generally attended with any unplea*
sant consequences, and does  not appear to affect  unfavorably the course of
the disease.  This inference would  involve, as  a corollary,  that the practice
of administering cathartics and laxatives in Continued Fever is not so neces-
sary, or useful, as is by most practitioners supposed.  AVhether the practice
be pernicious, or the extent to which it is so, must be settled by farther obser-
vations.   As a general maxim in therapeutics, it is certainly true that active
remedies which are uncalled for, and useless, are,  in proportion to their  acti-
vity, hurtful; but I am not prepared to  say that, in my opinion, this maxim
is applicable to the point under consideration.   Cathartics,  or laxatives,  may
be required under certain conditions, when, in general, they may be needless,
and even pernicious.  It would be  out  of place  to discuss this  topic in the
present  connection.  I  will only add,  that  the  practical  rule pursued in
the  treatment  of the cases under analysis was, not to prescribe remedies of
this class so long as, on exploration of  the  abdomen, there  appeared to be
no evidences that the  patient was suffering from  undue  retention of the
excrement.
   Haemorrhage from the Bowels.   This symptom is not noted to have oc*
curred in any case.   In the first collection it was present in two cases,  both
of the Typhoid type.
   Tympanites.   Typhoid.  Tympanites, meteorism, or visible enlargement
of the abdomen from an  accumulation  of gas, is noticed in the  histories of
twenty-two  cases.   The first  analysis  gave, of  eighteen hospital  Typhoid
cases, this symptom in twelve.   The relation in the  two collections, therefore,
isas22-39istol2-18; and, in both collections, the symptom was present
in thirty-four, of forty-seven, cases.   The tympanitic distension was slight in
five cases, moderate in  thirteen, and considerable in four; it would  not be
termed very great in degree in any case.  These results accord with  those
developed by the first analysis. 
REPORT ON  CONTINUED FEVER.
177
   Typhus.  Of the ten cases of  Typhus, tympanites was present in eight.
 In the first collection, of twelve hospital cases, it existed in eight.
   It Avas slight in every case but one, and in the excepted case was consider-
 able.  There was evidently a disparity in  the  degree of tympanites, in the
 cases belonging to the two types; in all the cases, save one, of Typhus, the
 symptom was  less marked than  in all the cases, save five, of Typhoid in
 which it was present.   The first analysis showed  the same disparity.
   As respects  the relative frequency of this symptom in the two types, in
 the first collection, the proportion of instances in which it was present in
 the hospital cases, was found to be exactly equal.  The result, in the present
 collection, is not far from  this, the  proportion  in the  Typhus cases  being
 larger by a small fraction.   If the comparison be made with all the cases in
 the first collection, i. e., including the cases in private practice, with those in
 hospital, the results in both approximate still more closely, the  Typhus cases
 in both having the symptom present in a slight fractional preponderance.
   In the first  Report I have expressed surprise at the fact of tympanites
 being found to be present in an equal  ratio, or nearly so, in the two types.
 The symptom is considered somewhat distinctive  of Typhoid.   It is said to
 be very rare in Typhus.  Entertaining this  impression, I had thought that
 the facts contained in the first collection might  have been affected by some
 peculiar circumstances, and that had the number of cases been much larger,
 the results would  perhaps  have been different.   The similarity in the results
 of  the two analyses, as respects this symptom, is thus worthy of particular
 note.
   It is  not to  be  overlooked that, in so far as my observations  go, tympan-
 ites is less prominent as a symptom in the great majority of cases of Typhus,
 than in those of Typhoid.   In this point of view the symptom furnishes a
 diagnostic feature of importance.
   Examining the cases to ascertain the relation which this symptom sustains
 to diarrhoea, I  find that of the twenty-two cases of  Typhoid in which tym-
 panites was present, diarrhoea co-existed in six, and was  absent in sixteen.
 Diarrhoea  consequently existed without  tympanites  in  several  instances.
 Of the eight cases of Typhus in which tympanites was present, diarrhoea co-
 existed in three, and was absent in five.  The first analysis gave, of the hos-
pital Typhoid  cases, the presence of diarrhoea with tympanites in eight, and
the existence of tympanites without  diarrhoea in four; and of the hospital
 Typhus  cases  the  co-existence of tympanites  and  diarrhoea  in no case, in
other words the absence of diarrhoea in every case in which tympanites was
present.   The results of the two analyses, as  respects this  point, are far from
               N 
178
REPORT ON  CONTINUED FEVER.
 exhibiting uniformity, which goes the more to show that two symptoms,
 tympanites and diarrhoea, have little or no mutual dependence or connection.
   With a view to the  bearing of tympanites on the prognosis, it should not
 be omitted to state the proportion of cases  in which it was present among
 those ending fatally.   Of the severe fatal cases of Typhoid,  it was present in
 six, and in the excepted case the patient died, the second day after admission,
 with apoplectic coma.   It existed in a slight degree  in one case, it was mod-
 erate in three, and considerable in  two cases.   Of the four fatal  Typhus
 cases, it was present in three; being slight  in each.  These results are pre-
 cisely the same as in the first analysis.   They show that the symptom occurs
 in a much larger proportion  of the cases ending  fatally, than of those in
 which recovery takes place.   It is therefore, to a certain extent, a favorable
 indication when tympanites is not present.
   Abdominal tenderness.  More or less tenderness on pressure over the abdo-
 men, was present during a part, or the whole of the febrile career, in twenty-
five of the twenty-nine Typhoid cases, and in five of the ten  cases of Typhus.
 As respects this symptom, thus, a point of contrast is afforded on compari-
 son of the two types, it existing in by far the larger proportion of cases in
 Typhoid.
   In degree it was either slight or moderate in all the Typhoid cases, except-
 ing two in which peritonitis became developed after perforation of the intes-
 tine.   It was slight in all the Typhus cases.  It is evident from the histories
 that the degree of tenderness was less in all the  cases of Typhus in which it
 was present, than in a large proportion of the cases of Typhoid.   This symp-
 tom appears in the histories of the cases in this collection, in a larger ratio, in
 either type, than was developed by the first analysis.  The latter gave it in
 twelve, of eighteen hospital cases of Typhoid, and, in five, of twelve hospital
 eases of Typhus.  There is some room for error in determining the presence
 or absence of this symptom, as there is in all  the subjective phenomena be-
 longing to the history of Continued Fever.   This may possibly account for
 the disparity in the results of the two analyses.   The facts in both collections,
 however,  authorize the deductions, which, for  all  practical  purposes  are
 sufficient, that more or less tenderness  over the abdomen is a  symptom be-
 longing to both types  of fever, but  that it exists much oftener in Typhoid
 than Typhus;  and that it is more or less prominent, as a symptom, in  the
 former, while it is always slight in the  latter.
   The tenderness co-existed with diarrhoea in only eight cases of Typhoid,
 and  in two  cases  of  Typhus.  This  shows the absence  of any  relation
 between these symptoms. 
REPORT ON  CONTINUED FEVER.
179
   It was  associated with  more or less meteorism in a large proportion of
cases, viz., in twenty cases of Typhoid, and in all the cases (5) in which it
was present in Typhus, i. e. in twenty-five of the thirty cases of both types
in which tenderness existed.  It would appear, therefore, that while the ten-
derness is not dependent on the presence of diarrhoea, it does sustain some
connection with the meteoric distension of the abdomen.  This would be the
inference from the analysis of the present collection of cases;  a different con-
clusion, however, was deduced from the results * of the first analysis.  That
analysis gave the co-existence of tympanites in but ten of nineteen Typhoid
cases, and  in four of six  Typhus  cases  in which tenderness was present.
This disparity in the results of the two analyses, and in the deduction based
thereupon, shows the liability to error in numerical investigations from insuf-
ficient data.  Expressed in figures, the relation of the  two collections in this
particular is  as  14-25 to 25-30;  the two symptoms thus co-existing in a
proportion of a  little over one-half in the  first collection, and of more than
two-thirds in the second.   Adding  together the cases in both collections,
tenderness co-existed with tympanites in thirty-nine, of fifty-five  cases.  It
is to be remarked, that  the disparity of the results of  the two analyses with
respect to this point, is, in a measure, explicable by the fact that, in the pre-
sent collection of cases, both  tenderness and tympanites were found to be
present in a larger relative number of cases than in the first collection.  This
would lead us to expect that the instances in which the  two symptoms con-
curred would be more numerous.  In conclusion, as regards the connection
between the symptoms, the inferences from the facts enumerated in the first
Report must be considered correct.
   The situation in which the abdominal tenderness was more marked, or to
 which it was limited, is stated in the histories of all  the cases, save two, in
 which the symptom was present.   Of twenty-four cases of  Typhoid, it was
 limited to, or more marked in the right iliac region in twenty.   It was lim-
 ited to, or especially marked in both iliac  regions in two cases.   Of  the five
 Typhus cases, the tenderness was  limited  to, or more marked in the right
iliac region, in three.
  * On reference to this section of the former Report with a view to comparing the re-
sults, I find a typographical error in the figures, which, until now, had escaped notice.
The error is obvious on comparing the summing up of the cases in which tenderness
was present without tympanites, with the enumerations that  have preceded.  The
reader is requested to correct the error in  the first Report as follows: on page 86, line
7, ten should read nine, and the second ten should read two. 
180
REPORT  ON CONTINUED FEVER.
   Tenderness over the Epigastric region was noted in the histories  of six
 cases of  Typhoid, and in two cases of Typhus.   I have examined  the his-
 tories  of these cases  to  ascertain if,  at  the  time the tenderness over the
 epigastrium was noted, there co-existed any gastric symptoms.  The follow-
 ing are the facts with  reference to this point:  of the six cases of Typhoid, in
four, vomiting appears among the symptoms recorded in connection with the
 epigastric tenderness; in one, nausea, without vomiting, co-existed; and in
 the  remaining case, vomiting existed prior and  subsequent to the tender-
 ness being  observed, but  it  was not noted in conjunction.   Of  the two
 Typhus cases, vomiting is not noted in the histories at  any period of the
 febrile career.  Thirst was present at the same time with tenderness in four,
 of the six  Typhoid cases; in another case it had  existed  the day  but one
 before the existence of tenderness is noted, and in the remaining case  it was
 not present.  In neither of the two cases of Typhus was thirst present.
   Perforation of Intestine.  This event occurred in one case, as was demon-
 strated after death, and was presumed, from the symptoms,  to have occurred
 in another fatal case  in which no autopsy was made.  Both  were  cases of
 the Typhoid type.  It did not  occur in  any of the cases  before analyzed.
 Its numerical relation to the whole number of cases in  both  collections  is,
 therefore, as two to one hundred; and to the whole number of cases of the
 Typhoid type, as two to fifty-nine.
   In the first of the  two cases  mentioned, the perforation occurred on the
 sixteenth day after the admission of the patient.  The fever had  existed for
 several days before the  patient entered  the hospital.   The disease was  of
 about  medium severity, and  at the time of  the  perforation, the  symptoms
 had exhibited improvement, and convalescence was apparently approaching.
 The case was complicated with pneumonitis.
   On  the morning of the day on which the perforation took place, the pulse
 was 108, and moderately developed.  Skin warm and  moist.  She reported
 feeling comfortable.   Cough  diminished.   Considerable tenderness of abdo-
 men;  two  dejections, etc.  At  12, noon, she was attacked with a  severe
 chill, followed by heat and perspiration.   She complained  of  acute pain in
 abdomen.  The pulse, seven hours  afterward, was 132, small,  and  feeble.
 Tenderness of abdomen extreme, and general.  Considerable tympanites.
   On  the following day the symptoms were as follows:   Expression of anxi-
 ety.  Respirations  28, inspiration short and  quick.   Hands cold, and of a
 livid hue.   Pulse inappreciable.  Sordes on  teeth.  Tongue dry and hard.
 One copious dejection.  Abdomen much distended and tympanitic,  and ten-
 der on pressure.  Replies to questions slowly, dozing when  not aroused, with 
REPORT ON  CONTINUED FEVER.
181
eyeballs upturned.   Died in the evening of this day, twenty hours after the
perforation occurred.
  In the case in which perforation is presumed to have occurred, the patient
was a female, fourteen years  of age.   The disease in  this case, was severe,
and complicated with pneumonitis.   The occurrence of perforation was deno-
ted by the development of severe pain in abdomen, great meteorism, extreme
tenderness, prostration, the  pulse rising from 118 to 132, being very small
and feeble, etc.  The  precise  time when the accident was supposed to have
occurred, is not stated.  Death took place in somewhat less than forty-eight
hours afterward.  An autopsy was not permitted in this case.
   Gurgling.  The presence  of this symptom is frequently mentioned, but
pains were not taken to note its presence or absence with sufficient uniformity
to render an analysis with respect to it of much value.

                             SECTION SIXTH.

                    Cutaneous Eruptions.   [Page 87.]
   Typhoid.  The characteristic eruption was present  in twelve, of the twenty-
nine Typhoid cases.  This result differs considerably from that obtained by
the first analysis.  The latter  developed a larger proportion of cases in which
this  symptom was  present, viz., in  twenty-three, of thirty cases;  the  ratio,
thus, being  over two-thirds, while in the present collection it is less than one-
half.  Of the whole  number of cases in both collections, viz., fifty-nine, it was
present in  thirty-five.  I can offer no explanation of the above  disparity.
Careful examinations for the eruption were made in every instance, so that it
is hardly possible that it could have been overlooked, and in all the cases in
which it is not stated to have  been present, the fact of its absence is distinctly
noted in the record  of each day.
   The eruption exhibited the distinctive characters of  that belonging  to the
 Typhoid type of fever, mentioned in the first Report,  in all the cases in which
it was present.
   The rose spots were not abundant save in two cases.  They were confined
to the abdomen and chest in every case but one, in the latter case  extending
over the upper and  lower extremities.
   The period in the disease at which the eruption appeared, dating from the
commencement of the access,  or of  the febrile career, is not accurately deter-
minable  in  many cases, owing to the  histories being defective as  to the du-
ration of illness prior to the patients coming under observation.  The period
after admission at which the eruption was  observed, is generally stated, but 
182
REPORT ON  CONTINUED FEVER.
in nearly every instance, the disease had existed  for a greater or less  length
of time  before the patients entered the hospital.  The facts recorded with
respect to this point, are presented in the following table, which embraces
also the duration of the eruption, dating from the time  of  admission  into
hospital:
ERUPTION IN  TWELVE TYPHOID CASES.
		PERIOD WHEN ERUPTION
	APPEARANCE OF ERUPTION.	WAS MUCH FADED, OB HAD DISAPPEARED.
Case 1.	8th day after entrance.	14th day.
" 2.	5th day do. Had been ill ten days.	12th day.
" 3.	2d day after entrance. Previous duration of illness	
	not noted	6th day.
" 4.	Existed when admitted. Had been ill about five	
	days.	Not noted.
" 5.	5th day after entrance. Previous duration of ill-	
	ness not noted.	10th day.
" 6.	2d day. Previous duration of illness not noted.	6th day.
" 7.	Existed when admitted. Had been ill ten days.	7th day.
" 8.	Existed when admitted. Had been ill fourteen	
	days.	4th day.
" 9.	Existed when admitted. Had been ill ten days	
	and confined to bed four days.	Not noted.
" 10.	Existed when admitted. Had been ill several days, but rode thirty miles the day before, and	
	walked to hospital.	Not noted.
'• 11.	Existed when admitted. Previous duration of ill-	
	ness not noted.	8th day.
" 12.	Existed when admitted. Had been ill several days.	6th day.
  The eruption  in  all  the  cases  faded,  from  day to day, before finally
disappearing.
  Typhus.   The characteristic eruption of Typhus was present in eight, of
the  ten cases of this type.  An eruption was thus present  in a much larger
proportion of the cases than in those of Typhoid.  The result does not pre-
sent so much disparity when  compared with that of the former analysis, as
in the Typhoid  cases.  Of thirteen cases in the first collection, an eruption
existed in all. In the Typhus cases of both collections, viz., twenty-three, it
was present  in  twenty-one.  So far as these observations  go, they show the
occurrence of an eruption in a very large majority of the cases of this type of
Continued Fever. 
REPORT ON  CONTINUED FEVER.
183
  In six of the eight cases, the eruption was copious, and its abundance in
the two remaining cases is not stated.
  In six of the cases the eruption was not limited to the trunk, but extended
over the  upper and lower extremities.   In the  two remaining  cases  the
histories do not state as to this point
  The eruption presented the distinctive characters of Typhus, mentioned in
the first Report, with the following exceptions:   In one case rose spots were
intermingled with the maculse; and  in one case the redness partially disap-
peared on  pressure.   A few vesicles were intermingled with the maculae in
one case.
  The  facts pertaining  to  the first appearance,  and  the  duration  of the
•eruption in the Typhus cases, are presented  in the following table:
ERUPTION IN EIGHT CASES  OF TYPHUS.
	PERIOD WHEN ERUPTION
APPEARANCE OF ERUPTION.	HAD MUCH FADED, OR
	DISAPPEARED.
Case 1. Present when admitted. Had been ill four days,	
but had not kept the bed.	Not stated.
" 2. 8th day.	llth day.
" 3. Present when admitted. Had been ill sk days, ,	
and taken to bed day before admission.	Not stated
" 4. 2d day after admission, and 2d day after taking to	
bed.	5th day.
" 5. 4th day after admission, and 4th day after taking	
to bed.	9th day.
■' 6. Present when admitted. Previons duration of ill-	
ness not stated,	Not stated.
" 7. 2d day after admission, and 2d day after taking to	
bed.	7th day.
" a 3d day after taking to bed	llth day.
   Of the cases of Doubtful type, an eruption appeared in one case only.   The
characters of the eruption in this  case were such as to render it difficult  to
decide whether it resembled most that of Typhus, or Typhoid It appeared
on the seventh day after taking to the bed, and the tenth after illness com-
menced.   The appearances are thus described in the history: " The eruption
 * pretty copious over the chest and abdomen,  and extends, but sparsely, over
the .upper extremities.  It  is not precisely the eruption of either Typhus or
Typhoid,  but approaches nearer  the latter.   The  spots are of a duller red
color, are smaller, and not so  distinctly elevated, or papular.   The redness
disappears on pressure, but not in so marked a degree, as is usually the case 
184
REPORT ON  CONTINUED FEVER.
in Typhoid.  After repeated examinations,  and considerable hesitancy,  I
think the eruption is rather like that of Typhoid, than that of Typhus?
  Afterward, the following record was made: — " The eruption evidently is
of two kinds, the  Typhus and Typhoid.   It  extends over the face."
  On  the next day it is stated  "the eruption to-day  presents more the
appearance of Typhus."
  With respect to the existence of an eruption in the fatal cases, the facts are
as follows: — Of the seven  fatal cases of Typhoid,  in  three an eruption
existed, and in four it was absent.  Of the four fatal  cases of Typhus, in
two, an eruption was present, and in  two  it was absent, the  latter being the
only cases of this type in which   no eruption existed.   These  results  accord
very closely with those developed by the first analysis, limiting the attention
to the Typhoid cases, which is manifestly proper, in so far as the  former col-
lection is concerned, inasmuch as in all the Typhus cases, in that  collection,
an eruption was present.   In the six fatal Typhoid cases among those before
analysed, an eruption was present in precisely one half.
  A petechial eruption was present in one case, a case of the  Typhoid type#
It appeared on the sixth day after admission, and remained for several days.
The ecchymoses  were numerous over the abdomen and chest, being inter-
mingled with a  sparse rose  eruption.  The patient at the same time had
haemorrhage from the gums.   The case ended in recovery.
  Sudamina were not usually sought for,  and the histories are therefore defi-
cient in information respecting this species of eruption.   It is only noted in
the history of a  single case — a case of  Typhoid, concurring with copious
perspiration.  Had sudamina been prominent  in any other  case, it would
hardly have escaped observation.  I feel  sure that this symptom could not
have been present in any of the cases, with the exception just mentioned, save
in so obscure a degree as not to attract attention.

                           SECTION SEVENTH.
Symptoms Referable to the Respiratory Apparatus.    Cough.   Expectora-
  tion,   Pain in Chest.   Pneumonitis.   Aberrations of Respiratory Move-
  ments.  Epistaxis.   Singultus.  [Page 91.]
   Cough.  Typhoid. — The presence of this symptom is noted in the histo-
ries of twenty-two Typhoid cases.  Of the remaining seven cases of this type,
its absence is noted in three, and  nothing  is stated with regard to it in fovr.
   These results are not what would  have been  anticipated  in view of those
contained  in the  former Report.   The first analysis gave, of thirty Typhoid
cases,  the presence of cough in  only ten.   Here is  one of the most striking 
REPORT ON  CONTINUED FEVER.
185
points of disparity developed by the two analyses.   What is the inference ?
Assuming that equal care was taken in observing for this symptom, it would
follow that in the two collections, which it will  be  observed embrace about
an equal  number of cases,  (the  one 30, and the other 29,)  is exhibited a
striking  difference as respects liability to the morbid condition upon which
the cough incident to Continued Fever depends.   It is certain that the disease
does  manifest  a  development,  unusual either  in  degree, or character, of
particular  phenomena, at different periods, and  in different places; and the
occurrence of cough in a proportion of cases so much larger in the second,
than in the first collection, would appear to afford an illustration of variable-
ness as respects this symptom.   The  greater preponderance of the symptom
may have  been owing to circumstances appertaining to the season, or  to the
hospital  at the time  the cases occurred, or it may  denote special  tendencies
inherent in the disease itself at that  time.   I am  unable to  state which of
these explanations is the  correct one.   It is to be considered, however, that,
possibly, the  disparity may not have been so great as appears from the results
of the analyses.   In most of the cases, as will presently be seen, the  cough
was  slight.  The  fact of an occasional act of coughing may have escaped
attention  in  some of the cases first analyzed, and, indeed, it is remarked in
the first  Report, that this may have been  the case.  It is obvious that the
symptom is one which, in many  instances possessing no  prominence,  might
fail to be  observed  unless special pains were taken  to ascertain  whether it
existed, or not;  and the statements of the patients  themselves, for reasons
already given, are not to  be relied upon.  I  can not affirm that the results
are not to  be accepted with the qualification involved in this consideration;
but that the disparity is not in that way fully explicable, is rendered probable
by the fact that the two analyses, as respects this symptom, in the Typhus
cases, will presently be found to develop results  nearly uniform.  In view of
this fact, the  conclusion seems to my own mind  a legitimate one, that, owing
to causes which  I will not undertake  to assign, cough occurred  much more
frequently in the cases upon which this Report is based, than in those before
analyzed.
  The cough, in all  except two cases, was either slight, or moderate in degree.
In the two cases  just referred to, it was so  considerable as to constitute a
prominent symptom.
  Pneumonitis existed in seven cases.   This is evident in three of the seven
cases, by the physical signs, as well as rational symptoms, which are recorded.
In the four remaining cases,  the existence of this complication is denoted by
the symptoms alone, viz., rusty and muco-purulent expectoration, accelerated 
186
REPORT ON  CONTINUED FEVER.
respiration, dilation of the alae nasi, etc.   Physical  exploration was probably
not omitted in any of these cases, but the signs are  not noted in the histories.
The occurrence of pneumonitis is noted in only two of the thirty Typhoid
cases in the first collection.
   In four of the seven cases in which pneumonitis existed, the disease proved
fatal.   In other words,  of the  seven fatal Typhoid cases, three  had this
complication.  Hence, it may reasonably be inferred  that the danger of a fatal
termination is considerably enhanced by this complication.
   The cough was slight in six of the seven cases in which pneumonitis existed.
This is worthy of notice, showing that the absence of  this complication is not
to be predicated on the  fact that cough is not  prominent as a symptom.
   In the two cases ending in recovery, in which pneumonitis existed, conva-
lescence was apparently thereby retarded, and prolonged.
   Pain in the chest is noted in two only of the cases  characterized  by pneu-
monitis.  It is noted in a few  other cases, viz., in five.  In two of these
cases, the seat of the pain was beneath the sternum; in  one, the situation is not
stated; in one, beneath the shoulders, on coughing;  and in one, on both sides.
   As respects Expectoration, save in the cases complicated with pneumoni-
tis, the  histories are deficient in information.  This could not have been
prominent,  as a symptom, with the exceptions  just stated.  Sibilant and
sonorous rales are  noted in the histories of several  cases, but, in general, the
presence or  absence of auscultatory signs were not recorded, except in some
of the cases which were characterized by the occurrence of pneumonitis.
   Typhus.   Of the ten Typhus  cases,  cough was present  in seven.  The
first analysis gave, of thirteen Typhus cases,  the presence of this  symptom
in eleven.   These results do not  exhibit great disparity, and it will  be ob-
served  that, the first collection exhibits a larger proportion of cases in which
this symptom was observed, the reverse of  what  was  developed bv com-
paring, in this respect, the Typhoid cases.
   The cough was  slight in five  of the seven  cases, and was considerable in
the two remaining cases.
   As regards the morbid condition, or  conditions, irrespective of pneumoni-
tis, (which occurred in a small proportion of cases,) on which the cough incident
to Continued Fever depends, we may suppose that it is due to  a slight ca-
tarrhal  affection  of the mucous membrane,  possibly,  in  some  instances,
amounting  to a very mild grade of bronchitis;  or,  what is perhaps more
probable, that it arises from capillary congestion of the mucous membrane
resembling  that which so uniformly affects the skin.  Louis says, with refer-
ence to this symptom in Typhoid fever, that from the acts of coughing being 
REPORT ON  CONTINUED FEVER.
187
commonly slight, and rare in occurrence, he should have frequently failed to
observe it, had he limited himself to taking notes merely of what he himself
saw.  He adds,  that in some instances it  appeared not to be  a  bronchial
cough, but occurred for the  purpose of removing  mucus from the pharynx.
These remarks are applicable  to the cases I have observed.
   In two cases, the presence of pneumonitis is evident, both from the signs
and symptoms recorded; and in one case, the existence of this complication is
rendered probable by the symptoms.   In two of the above cases, the disease
was fatal.  In other words, of the four fatal Typhus cases, two were charac-
terized by the presence of pneumonitis.  In the first collection of Typhus cases,
the  proportionate number of instances in which  this complication  existed,
was larger, the relation in the  two  conditions being as 5 —13 is to 3 — 10.
   Pain in the chest is noted but in one case, in that case situated in the left
side, and beneath the sternum.  Pneumonitis existed in that case.
   Of the cases of Doubtful  type, the histories are defective  as respects cough,
in two.  In  the  remaining seven cases, cough was present in  all save one.
It was  slight, except  in two cases, in which the presence  of pneumonitis is
declared by the symptoms and by physical signs.
   Aberrations of Respiration.  The respirations were generally enumerated
frequently during the progress of  the disease.  In this respect  the  histories
 are more full than in the first collection, in which  it is simply stated  that the
respirations were either increased, or normal.
   Increased Frequency of Respirations.    Typhoid.  Excluding the cases
in which pneumonitis existed, the  respirations were not much  increased in
frequency, save in three cases.   In  these three cases,  respectively, the maxi-
 mum of  frequency was, 40, 32, and 32 per minute; and  the mean 35 1-7,
 32, and 29  per minute.  Inasmuch as  the histories do not contain notes of
 physical  signs, I cannot declare positively that in "these  cases pneumonitis
 may not have been present, although, aside from the respirations, the rational
 indications  of this complication do not appear  to  have existed.  Of the
 remainder of the Typhoid cases, excluding those characterized by the pres-
 ence of pneumonitis, in  ten, the histories of which are pretty complete as
 respects the enumeration of the respiratory acts, the average  number, per
 minute, was not far  from  21^—a moderate  increase of  the healthy mean.
 Of the ten cases furnishing this average, in some, the respirations were not
 at all increased.  The averages in the  cases respectively, are as follows:

           26,          18,          18,          20,          26,
           16,          24,          21,          16,          27. 
188
REPORT ON  CONTINUED  FEVER.
Fractions  are  omitted in this list.   There was considerable  variation  fre-
quently on different days during the career of  the fever.   This is shown by
the following table, which exhibits the successive enumerations in a few cases:
Case 1.	Case 2.	Case 3.	Case 4.	Case 5.
Recovered.	FataL	Recovered.	Recovered.	Recovered
1st day, 24,	16,	32,	20,	26,
2d " 24,	18,	32,	16,	20,
3d " 24,	14,	24,	20,	20,
4th " 30,	16,	20,	20,	22,
5th " 28,	28,	24,	12,	20,
6th " 28,		28,	14,	
7th			14,	
In the cases of  Typhoid which were complicated with pneumonitis, the fre-
quency of the respirations was greater.  In five of these cases, the history of
each of which contains a series of enumerations, the maximum of frequency,
respectively, was as follows: 32, 32, 36, 40, 48.  The average  in the cases,
respectively, was as follows:  241-2,23 15-17, 271-3,32,35 7-12.  The mean,
in these cases, is not  far from  28 1-5, which, it will be observed, is higher
than in the  ten cases in which pneumonitis did  not exist, in the latter being
21-g-.  In four,  of the  above five cases, the disease was fatal.  An  increased
frequency of respirations sufficient  to give the above mean, viz.,  28, is of
importance as an indication of the existence of pneumonitis.   It is more con-
stantly associated with that complication than a  degree of cough  greater than
the average, and, hence, is of more value as a diagnostic symptom.   It should
affect also, to some extent, the prognosis  unfavorably.
   Typhus.   Excluding the cases known to  have  been complicated with
pneumonitis, the respirations became  considerably increased in  frequency in
three.  The maximum of frequency in these cases, respectively, was as follows:
36, 40, 44.   The mean number in the same cases, respectively, is as follows:
27, 31 1-5, 33 1-5.   Of the remaining five cases, including the two compli-
cated with pneumonitis, the respirations were enumerated in but two, and of
these the mean was, in one 27, and in the other, 26 4-7.
   Of the two cases complicated with pneumonitis, the maximum frequency
was, in one  60, and in the other 40.   The mean in  the first of these cases is
but 26 4-5,  in consequence  of  the pneumonitis not becoming developed until
the tenth day of the disease, and the respiration, prior to that date,  not being
much accelerated.   In the other case, the  mean was 34.
   On comparison of the two types, these results show, so far as they go, that 
REPORT ON  CONTINUED FEVER.
189
in Typhus, the increased frequency of the respirations is  greater than in
Typhoid.   This was found to be the fact in the cases before  analyzed.
   It would be highly interesting to determine by a comparison of the cases,
whether a notable increase in the frequency of the respirations only occurs in
connection, either with pneumonitis,  or some other pulmonary affection com-
promising, to a greater or less extent, the vesicular integrity of these organs.
It is certain that when more or less solidification of the lungs takes place in
the cases characterized by pneumonitis, the respirations become accelerated,
and, on examining the daily records, I find that frequently  the development
of the pulmonic  inflammation is  signalized by a sudden increase in the fre-
quency of respirations, the symptoms and signs denoting that complication
appearing in the histories at the same time.  For example, in  one of the
cases of Typhus  in which pneumonitis became developed, the  respirations
numbered, on successive days, 24, 20, 20, 20, 20, 18, 18; and then 32, 36, 60.
Now, in this case, prior to the day on which the respirations numbered 32,
there had been at first slight cough, but  afterward no cough; no dilation of
the alas nasi; no  expectoration.  On the day, however, when the respirations
became increased in number, are noted, cough, dilation of the alee nasi, rusty
expectoration, pain beneath sternum, and pleuritic stitch in  left side; and on
the  day following, dullness on percussion over the inferior part of the left
chest.
   A considerable increase in the number of respirations should  thus lead to
 suspicion of the  development of pneumonitis; but the question  is, may not
 the same acceleration arise irrespective  of pneumonitis, or  other pulmonary
 complications ?   There are but six  cases, as  has been stated, in the present
 collection,  of those of the Typhoid and Typhus type, (three of each,) in
 which the respirations were notably  increased without the evidences of pneu-
 monitis being recorded; and in  these six cases,  inasmuch as the results of
 physical exploration are not embraced in the histories, I am not warranted in
 saying that this, or some other pulmonary complication did not exist, although
 not denoted by the symptoms which are  recorded.  The question, therefore,
 must remain unsettled.
   Among the cases of Doubtful type, there were two which became compli-
 cated with pneumonitis.  Of these  cases, the  maximum in  frequency of the
 respiration, in one, was 60, and in the other, 48.   The mean frequency in the
 former was 42 4-11, and  in the latter 32.
   Diminished Frequency of Respiration.  In two cases, the respirations are
 noted once in each case as low as  12 per minute.  In one of these cases, the
 disease was of the Typhoid type, of a  mild grade, not  complicated with 
190
REPORT ON  CONTINUED FEVER.
pneumonitis, convalescence being established on  the  ninth day after admis-
sion.  There were no unusual cerebral symptoms in this case.  The other
case was of Doubtful type.  In this case, the respirations numbered only 12
the day following an attack approaching  to  apoplectic coma.   Pneumonitis
did not  exist in this case, and convalescence was established on the ninth day
after admission.
   In another case, the respirations, on one occasion, were but 7.  This dimi-
nution in frequency occurred in connection with another modification of the
respiratory movements, viz., spasmodic  inspiration, which  I  shall presently
consider at some length, and give the concurring circumstances in detail.
   Sighing.  A disposition to sigh is noted in two cases, both of the Typhoid
type.   In one, it was observed on the  first day after admission, and  in the
other case, after  the  patient had  been in  hospital for  several days.  In both
cases, the disease was fatal.
   Spasmodic  Inspiration.   The occurrence of an aberration  characterized
by spasmodic  inspiration, in other  words,  the respiration being shortened
and quickened, in several cases, some of which are not contained in this col-
lection, has led  me to regard it as an  important  symptom, significant of a
morbid condition seated at the medulla oblongata, compromising that instinct-
ive faculty pertaining to this portion of the  nervous centre, upon which the
respiratory movements are dependent, and foreboding a fatal termination by
apnoea in some instances when other indications of immediate  death are not
appreciable.  I am therefore desirous of studying  it with some particularity
in the  histories in which it is noted.   I find that this symptom was present
in eleven cases, to wit, in five  of  Typhoid, four of Typhus, and in two  of
Doubtful type.  I will examine the  circumstances connected with it in these
cases severally.
   Typhoid.  Case  1.  In this case the inspiration  became notably spas-
modic (catching) on the sixth day after admission.   Before this, no symp-
toms had  occurred affecting very unfavorably the prognosis.  The nervous
symptoms were  somewhat predominant, consisting of considerable delirium
at night, somnolency at times during the day, and some subsultus.  There
had been moderate diarrhoea, and the febrile movement was not greater than
in the average of cases.
   The following is the record on the fifth  day after admission:
   "Reports much  better.   Says he   slept well.    Face and  hands still
congested.   Conjunctiva  much injected.   Mind  dull.  Indifferent.  Res-
spirations 16,  with dilation of alae  nasi.  Pulse  108, tolerably developed.
Tongue dry and smooth, coated at centre, and moist at sides.  Skin rather 
REPORT ON CONTINUED  FEVER.
191
hot and dry.   Great thirst.  No pain.   Decubitus lateralis et dorsalis.  Dis-
posed to somnolency.   Delirium during night manifested by incoherent talk-
ing and attempting to get out of bed.  Two dejections yesterday, and one
during night."
   This  group of symptoms would  hardly be considered to denote much
danger of a speedily fatal issue.   On the next day the following is the record
made by me: " Reports better.   Delirium during night, as before.  Sleeping
when I approached the bed, and groaning with each  expiration.  Readily
roused.  Protrudes his tongue without difficulty, which is dry on the supe-
rior surface, and cracked.  Relapses into a somnolent state directly after being
roused.  Two dejections yesterday, and one in night, the latter involuntary,
in bed.   Respirations 28, inspiration shortened and quickened.   Occasional
stertor in inspiration.   Dilation of alas nasi.  Slight tracheal rattle.  Slight
epistaxis this morning.  Pulse 120, moderately developed.  Skin warm and
dry.  Swallows without difficulty.  Face  presents deep congestive  redness.
Some muscular tremor of  upper extremities,  and  picking  at  bed clothes
observed this morning, none during examination, nor subsultus.   Abdomen
tender on pressure."
   In the above group of symptoms nothing appears foreshadowing a speedily
fatal issue, save those referable to the pulmonary system.
   Death took place at 11, P. M., of the same day, at which time the follow-
ing record was made:  " This patient continued  to  fail during the day, the
respiration becoming  more labored and difficult,  and each expiration accom-
panied  by a loud groan.   He  experienced some difficulty  of deglutition a
short time before dissolution, but readily swallowed remedies, and nutriment,
up to that time.  The circulation gradually became enfeebled, but was appre-
ciable at the wrist a few moments before death."
   There was no autopsy in this  case.  The patient suddenly died of apnoea,
which was foreshadowed by the symptom under  consideration.
   Case  2.  The inspiration became  spasmodic  on the seventh day after
admission, the patient not having taken to the bed prior to entering the hos-
pital.   The symptoms generally did not denote a severe grade of disease.  On
the day when the aberration of respiration was  noted, the following was the
record: " Reports the same.  Says he did not  sleep well.   Two dejections
yesterday, and two during the night.  Face and upper extremities still  con-
gested.  Pulse,  92, tolerably developed.  Respirations  20, slight dilation  of
alee nasi.  Inspiration shortened and quickened.  Slight tremor of  muscles
of face.  Abdomen tympanitic.  Tenderness  on pressure  over right  iliac
region.  No eruption.  Some cough.  Some appetite.  He is quite thirsty." 
192
REPORT ON  CONTINUED FEVER.
   On the eighth day the following is the record:  " Reports better.   Says he
slept well.   Some cough, dry.   Three dejections yesterday, two in night, and
one this morning.   Skin warm and mellow.   Tongue dry and thinly coated.
Pulse 104, soft.   Respirations  32, with dilation  of ahc nasi, and  inspira-
tion short and quick.  Moderate tympanites.  Indistinct eruption.   Obscure
abdominal tenderness.   Face and hands much congested.  Slight tremor of
muscles of the face when he speaks.   No subsultus."
   On the ninth and  tenth days, the symptom under consideration is not men-
tioned.   On  the  latter date, a slight crepitant rale was discovered, but, in
general, the symptoms denoted nothing unfavorable.   On  the eleventh day,
the record is as  follows:  "Reports about the same.  Says  he slept well.
Had two dejections yesterday, two during night, and one this morning.   As-
pect improved.  Less congestion of face and hands.   Complains  of deafness,
and of being tired of the bed.   Skin warm and mellow.  Tongue moist and
clean.   Pulse 104,  and tolerably developed.  Respirations  24, with some
dilation of the aloe  nasi.  Some cough and expectoration.  Crepitant and
bronchial rales intermingled on the right side, posteriorly, middle  third of
chest."
   On the twelfth day, the  following record was made by me:  "Aspect
improved, and he reports better.  Last evening there occurred a paroxysm
of labored respiration, with some lividity of face, tremulousness of hands, and
dropping of the lower jaw.  A blister was applied to the nucha, and stimu-
lants given more freely.   The paroxysm continued about an hour.   After-
ward, he  became  comfortable, and passed a  good night.   Less congestive
redness  this morning.  Respirations 20.  Inspiration shortened  and quick-
ened.  Tongue moist and thinly coated.  No dejections during  day yester-
day, two in night, and one this  morning.  Pulse 110, tolerably developed.
Skin warm and moist.   Perspired freely this morning, drops of perspiration
on  face.  No delirium,  seems  perfectly rational.   Cough is  troublesome,
expectoration  small,  characters  not observed.   The  right  chest anteriorly
slightly dull.  Sibilant rale over both sides anteriorly.   Posteriorly, flatness
over the left chest, with faint, crepitant rale.
   After  this date  nothing occurred  worthy of note,  and convalescence was
declared on the nineteenth day.
   Case 4.  In this case, perforation of  intestine occurred on the seventeenth
day after admission.  Prior to this event, the career of the disease was marked
by nothing special, save the development of pneumonitis.  The aberration of
respiration under consideration was noted the day after the perforation, death
taking place at evening of the same day.   In this instance the symptom had 
REPORT ON CONTINUED FEVER.
193
no special significance, inasmuch as the other symptoms associated with the
perforation denoted a fatal  issue;  and, in fact, it was only an element of the
moribund state.
   Case 5.   The symptom in this case is noted  in an evening record on the
day the patient was admitted.  She  had  been ill  five days before entering
the hospital.  In the morning record the respirations were 28, the pulse 136.
Moderate  tympanites and tenderness.   No cough, etc.  At  evening, she was
quite somnolent, immediately relapsing into a profound slumber after being
aroused.  The respirations numbered 1.   Inspiration short and quick.  No
dilation.  Reports that she feels better than in the morning.  Has had seve-
ral dejections, (four or five.)  Pulse  144, tolerably developed.   No pain  in
head.   Skin warm and dry.   Some thirst.  Tongue dry and thinly coated.
Abdomen tympanitic.  No tenderness.
   On the following  day,  the  respirations were 24, inspiration short and
quick.  Pulse 140.   Delirious  during night   Considerable tympanites, and
tenderness in iliac regions, etc.
   On the next day, the symptom under consideration  is not noted.  Pulse
136, etc.   Half  an ounce of  brandy, hourly, was administered.  During the
day,  and  at evening, the  pulse  was 116, and all the symptoms denoted
improvement.  Convalescence was established in a few days afterward.
   In this instance, the symptom was  associated with other  symptoms which
rendered  the  prognosis unfavorable,  but, happily,  a change for the better
occurred,  and the patient recovered.
   Typhus.   Case  1.   The  inspiration became notably spasmodic, in this
case, on the fifth day after admission, the patient  not having taken to the
bed prior to entering the  hospital.   The symptoms on the fourth day, as
recorded  by me,  are as follows: " Reports the same.   Aspect bright.   Face
deeply congested.  Mind seems clear, but he was delirious  during the night.
Sordes on teeth.   Tongue  moist,  and thinly coated.   Two  dejections yester-
day.   Complains of thirst.   Skin dry and rather hot.   Pulse 120, soft and
feeble.  Complains of cough, and says the act of coughing  occasions pain in
the belly.   Respirations 24.  Dilation of alae nasi.  Complains if  firm pres-
sure is made over the abdomen.   Slight meteorism.  Eruption very copious,
almost confluent, over the  abdomen,  and  extends  to  the  upper and lower
extremities, even to back of hands."
   The next day as follows:  "Aspect same.  Incoherency during night.
Urinated  in bed.  Tongue coated, and somewhat dry in the centre;  readily
protruded.   One  dejection  this  morning.   Respirations  24.  Inspiration
shortened  and  quickened.     Dilation of alee nasi.    Cough  continues.
            0 
194
REPORT ON  CONTINUED  FEVER.
Congestive  redness diminished.   No deafness apparent.  No epistaxis.  No
abdominal distention,  nor tenderness.   Skin  warm  and  dry.   Pulse 120,
small and feeble.   In this group of symptoms, nothing  certainly denotes
an unusual  gravity of disease, or impending danger,  excepting the modified
respiratory movements.  The  significance attached to the symptom at the
time, is indicated  by the fact that a blister to the nucha  was added to the
treatment.
  The next day it is noted that the respirations were still  catching, number-
ing  36;  pulse 120; no physical signs of consolidation of lungs; delirious
during night, etc.
  The next day  respirations  40,  still catching; delirious  during  night;
pulse 134.
  Next day aspect much worse; inspiration short and catching; expiration
attended  by a groan;  expression vacant;  endeavors  ineffectually to reply to
questions; cannot protrude the tongue;  pulse 146.   Died at  2, P. M.  The
autopsy was limited to the abdomen.
  Case 2.  The inspirations were observed to be slightly spasmodic, in this
case,  on  the sixth day.    Previous to this  time, the  symptoms had not
denoted unusual gravity of disease.  The symptoms associated on the sixth
day, were the  following: "Aspect improved; pulse  120; skin warm and
dry; tongue moist and thinly coated;  two dejections; respirations 32, and
slightly catching."
  On the following day, the patient reported  pretty well.  Aspect about the
same.  Tongue clean, dry, and somewhat fissured.   No dejections.   Respi-
rations 40, inspiration somewhat shortened and quickened.   Pulse 128, small
and  feeble.   Skin  cool and dry.  Deafness continues.   No abdominal ten-
derness.   Talks incoherently.   A blister to the nape of the neck is embraced
in the directions for treatment on this day.
  On  the next day, "Aspect improved.   No manifestations of delirium.
Tongue clean and  somewhat dry.  One dejection.  Abdomen soft, without
tenderness.   Pulse 120.   Respirations 36,  still catching.   Complains of
deafness."
  I recollect being informed, on this day, before I entered  the ward, that the
patient was better, and, in fact, all the symptoms, irrespective of the respira-
tion, gave evidence of improvement.  The respirations, too, were diminished
in frequency.
  Death took place before the  following  morning.   The  details, after the
morning  record just quoted, are not given, nor the hour at which the death
of the patient occurred.  There was no autopsy in this case. 
REPORT ON CONTINUED FEVER.
195
  Case 3.   In the history of this case, it is noted, on the eighth day, that
the inspirations were somewhat shortened;  respirations numbering 28.  He
was delirious during the night.   Disposed  now to somnolency, but readily
roused.  Pulse 112, and well developed.   Eyes somewhat injected.  Con-
siderable congestive redness of  face.  Tongue dry and  hard in centre.
Abdomen moderately meteorized.  Eruption faded.  A blister to nucha was
directed, and sinapisms to the calves of legs.
   The day following, his aspect  was  much improved.  He was perspiring
profusely.   Respirations  28.   Pulse  96, etc.   In two days, convalescence
was established.
    Case 4.   The  inspirations became somewhat spasmodic on the eleventh
day.   The  patient was a candidate for the sisterhood, and was attacked  with
the disease in the hospital,  having  contracted  it, doubtless, by  contagion.
 Prior to the occurrence of this symptom, nothing appeared to denote unusual
 gravity of disease; and  on the  eleventh day, excepting  the respiration, the
 symptoms were not unfavorable.   The following is a transcript of the record
 on this day:  " Passed a comfortable  night.  Less delirium.  Bowels moved
 once yesterday.  She reports better.   Tongue thinly coated, and dry in cen-
 tre.   Sordes  on teeth.   Skin warm and slightly moist   Pulse 120.  Respi-
 rations 24.  Inspirations somewhat shortened and quickened.   No epistaxis.
 She has slight cough.   Abdomen considerably meteorized."
    On the next  day, the record, made  by  me,  reads as  follows: "Last
 evening this case assumed an alarming aspect  The rhythm of the respira-
 tions became affected to a greater extent than in the morning —the inspira-
 tions much shortened  and quickened.  It  was difficult to arouse her.   The
 abdomen  was much meteorized.  A blister  to the neck  was directed; an
 enema, and turpentine fomentations to the abdomen.  This morning there is
 a marked improvement.   Respirations 30, and rhythm quite  normal.   Ab-
 domen moderately meteorized, and soft.  Pulse 100.  Skin warm and moist.
  Easily roused, and appears rational.
    On the day following, the inspiration became again, in some degree, simi
  larly affected. The respirations  numbered 40.  Pulse 120.  Cough became
  a troublesome symptom on  this day, and  physical exploration disclosed the
  occurrence of pneumonitis.   On  the next day, the  symptoms indicated
  improvement.  Pulse  104.   Respirations 40, and rhythm normal.
     Convalescence was shortly established.
     Dovbtful Type.  Case 1. The symptom  under consideration occurred, in
  this case, on the second  day after admission.  In  the morning of the day
  on which it  occurred,  the following record was  made: — " Reports better. 
196
REPORT OS CONTINUED FEVEK.
 Savs he slept well.   Face and hands moderately congested.  Skin warm and;
 dry.   Tongue  dry and coated, dark.  Says  he has some appetite.   Great
 thirst  No dejection.   No  abdominal tenderness.   No eruption.   Pulse
 104,  soft,  tolerably developed.  Says  he has no  cough.  Respirations 16,
 without dilation.   He was delirious during night,  manifested by incoherent
 talking.  Some picking at bed clothes this morning.   He is  quite restless,
 frequently changing his position in bed "
   At six, P. M., of the same  day, the following record was made: — " Copi-
 ous  perspiration.   Hands cold and clammy.   Tongue  dry  and fissured.
 Pulse 140, small, and feeble.   Respiration irregular, catching."
   In the morning record of the succeeding day, which was made by me, it
 is stated:—'"The symptoms in  this  case, last evening, denoted a  striking
 change for the  worse, and the patient  was supposed  to be nearly moribund.
 Stimulants were freely administered, sinapisms applied to the  extremities, a
 blister to the nucha, and snow to  the head.  He began to improve at about
 ten, P. M., and during the night, gradually became more comfortable.
   On the following day he " Reports pretty well.  Says he slept well.  Face
 and upper extremities moderately congested.  Skin warm and moist.  Some
 meteorism.  No abdominal tenderness.   Pulse 68.
   Convalescence was established in a few days.
   Case 2.  In this case the disease was of a severe grade, and complicated
 with  pneumonitis.  On the twelfth day  after admission, the following were
 the symptoms:  — Aspect  the same.   No manifestations of delirium.   Cir-
 cumscribed flush of cheeks.   Skin  moist.   Pulse 108.   Respirations 40r
rhythm normal.  Considerable tympanites.
  On the thirteenth dayr reported pretty well.   Aspect  same.  Pulse  112,
 Skin  perspiring, cool.  Respirations  52.   Inspiration somewhat shortened
and quickened.   Cough diminished.  Two dejections, etc.
  On the fourteenth  day, the respirations were 60, but rhythmical.  Pulse
100,  etc.
  This patient recovered without farther untoward symptoms.
  The foregoing are all the instances in which any reference is  made, in the
histories, to the symptom under consideration.   Had it  occurred in other
cases, it would  not have  been likely to have escaped notice, for I was  spe-
cially interested in observing  it during the time these  cases were collected.
It may, however, have been present in some other cases in the last moments
of life, without  being noted, forming, as it probably does, in many cases, an
element of the mode of dying by apnoea. 
REPORT o:n  CONTINUED fever.
1*97
  I  have given the  circumstances connected with this symptom in detail,
viith a view to exhibit all the facts contained in the  present collection  of
eases bearing upon its  significance and value, as  a symptom, occurring
occasionally during the career ef Continued  Fever.  These  facts appear  to
show that, although sometimes  observed without being  followed by symp-
toms denoting  great gravity and danger, it is generally either a forerunner
©f, or associated with a  morbid condition of the nervous system eventuating
in, or tending to coma, and death  by suspension of that  faculty ©f the ner-
vous system which presides over the respiratory function.  It  is a symptom
of ominous  import, which  may be present,  not only when the associated
symptoms do not give any occasion for alarm, but even when the latter would
signify diminished severity of disease.   The  details that have  been given
seem to establish these conclusions, which invest the symptom with consider-
able importance  in prognosis, and as a means of anticipating an event, to
avert which, therapeutical measures may be seasonably, and  perhaps success-
fully employed.  The significance of this symptom was forcibly impressed on
 my  mind by a case in  private  practice, that came under observation some
 weeks since, of which I did not keep notes.  I was requested to visit a young
 girl, a domestic, who had been  ill several days without medical advice.   I
 found the patient evidently laboring under Continued Fever, the type being,
 at that time, indeterminate. There was high febrile movement — frequent
 pulse, hot skin, etc., but nothing to denote immediate danger, save that  the
 inspirations  were somewhat spasmodic.   In the afternoon the symptoms
 generally, and that just mentioned, remained the same; but I  hesitated to
 believe that the  latter was so ominous  as I  had been  led  to suppose from
 cases before observed.   I encouraged  the suspicion, in my own reflections,
 that I might have overlooked its occurrence in many cases in which no sud-
 den change for the worse  had  followed, and, thus, I resolved not to antici-
 pate any such change.   During the night I was summoned in haste to  this
 patient, and I immediately surmised what I discovered when I reached  the
 house.  Nothing had occurred  during the evening to alarm the family, who
 were, of course not cognizant of the train of reflection I had indulged, but at
 length, the noisy respiration of the patient  attracted  attention.  She could
 with great difficulty be roused, and soon this was  impossible.   Apoplectic
 coma had in fact supervened, and death occurred in  three or four hours after
 the discoverv  was made that she was in a dangerous condition.
   On the pathology or proximate cause of the nervous condition which  this
  jiuptom sometimes foreshadows, some remarks have already been submitted 
198                  REPORT ON  CONTINUED FETER.
in a more appropriate connection, viz., in the section on the symptoms refer-
able to the nervous system, under the head of apoplectic eoma.
   The peculiar modification of the respiration which I have here described
as consisting in a spasmodic, or shortened and quickened inspiration, does not
appear to have excited that  attention which its importance, as a symptom,
claims.   I suppose it  is to this modification that Pro£  Bartlett refers, in
his able  treatise on fever, in speaking of an  irregular and  noisy respiration
which he  distinguishes  as  cerebral.   Disturbance of the  respiration, not
dependent on the condition of the  lungs, is mentioned by Dr. Nathan Smith,
and by Chomel, of France, as a symptom denoting great danger.
   Dilation of the Alae Nasi.   More attention was paid to this symptom in
recording the histories of the cases in the present collection,  than of those
before analyzed.   Its presence was noted in eleven cases of Typhoid, and in
five cases of Typhus.  Its absence was noted in eight cases of Typhoid; in
the remainder of the cases in both  types in which it  is not stated to have
been present nothing  is  said respecting it.   In fifteen of  the sixteen cases in
which it was observed, the respirations were, at the same  time, more or less
increased in frequency.   In the  single case in which the  respirations were
not  accelerated,  the  dilation  was slight,  and is  only noted  to have been
present on one day.   In five of the cases in  which it was observed, the fever
was complicated  with  pneumonitis.   Six of the cases were characterized by
the  occurrence of a quickened  and shortened inspiration.   In other words,
six of nine cases thus characterized, presented this symptom.
   Nine of the cases proved fatal.  In other words the symptom was present
 in nine of eleven fatal cases, and in the two in which it is not  stated to  have
 been present, nothing is recorded  in the histories respecting it.
   These facts suffice to  show that dilation of the alse nasi is to be considered
 almost uniformly a sign of disorder of the respiratory  movements incident to
 affections which, like  pneumonitis, compromise the pulmonary organs, or to
 functional  aberrations dependent on ulterior morbid  conditions.   It is not,
 however, true, on the other hand, that  disorder of the respiratory movements
 is as uniformly accompanied by this  sign; for, in several of the cases  in
 which it was noted that the alse did not dilate, the respirations were accele-
 rated, in some instances constituting a  prominent symptom.   In one case, at
 least in which  the inspirations were quickened and shortened, the alse did
 not  dilate.   In  none of the cases in which pneumonitis complicated, is it
  noted that dilation was not present, nothing being stated with respect to this
  point in the cases in which the presence of this symptom is- not affirmed. 
REPORT ON  CONTINUED FEVER.
199
  Epistaxis.  The occurrence of this symptom is noted in the histories of
nine Typhoid cases.  Of the remaining nineteen cases, nothing is stated rela-
tive to the symptoms in eleven.  It is stated  that epistaxis did not occur in
six;  and in three cases  sputa expectorated were observed to be streaked with
blood, which may have been derived from the posterior nares, but this is not
certain.   This enumeration does not, it will be borne in  mind, embrace the
access, or forming stage of the diseases.  Attention was directed certainly in
most, if not all the cases, to this symptom, and in those, in  the histories of
which nothing  is  stated on the subject it may be presumed to have been
not  present.  It may have occurred, in some instances, prior to the patients
coming  under  observation, and  not be  embraced  in the   records of the
previous  history,  although inquiries were  generally made respecting this
point.
   The proportion  of Typhoid cases in which epistaxis occurred is somewhat
 greater in the  present  collection,  than in  that  previously  analyzed,  the
 numerical relation being as 19 — 29, is to 8 — 30 or 4 — 15.
   The periods  in  the  disease, dating from the time of admission, when the
 epistaxis occurred, were as follows, in the cases respectively: — Case 1, third
 day;  case 2, sixth day (last  day of life); case 3, second day; case 4, first
 day;  case 5, sixth, seventh, and eighth days;  case 6, first and second days;
 case 7, seventh day; case 8, on several days, dates not  given; case 9, third
 day.  This symptom, thus, observes no law of uniformity as respects the time
 of its appearance.
    The hemorrhage was either slight or quite moderate, in all but two cases.
 In one of these cases the epistaxis occurred on the sixth, seventh, and  eighth
 days, and was considerable in degree.  In the other case it occurred on the
 first and second days, and was so profuse that the propriety of plugging the
 nostrils  posteriorly  was  considered,  although not  found  to be  necessary.
 Aside from these two cases, it is not noted that  the epistaxis occurred more
 than once in but  a single case.
    Of the cases of Typhus the occurrence of epistaxis is noted in nom; nor
  were sputa streaked with blood observed in  any  case.  In the first collection
  epistaxis was noted in two of thirteen cases of the  Typhus  type.
    In the nine cases of Doubtful type, epistaxis  occurred on the second and
  fourth  days, in  one case; and on the first and  second days in one case.
  In  three  cases it is  stated  that  this symptom was not observed,  and of
  the five remaining cases the  histories do  not  contain any statements with
  regard to it. 
200
REPORT ON  CONTINUED  FEVER.
   It is perhaps worthy of notice, that none of the cases in which epistaxis
 occurred, proved fatal.  This is the  more interesting  from' the fact that the
 same was true of  the Typhoid cases in  the  first collection.   It would  thus
 seem that this symptom is not  to be considered any evidence of unusual
 gravity in the disease.

                            SECTION EIGHTH.

            Symptoms referable to the circulation.  [Page 99.]
   In most of the  cases the pulse was enumerated once, and sometimes twice
 on each day, during the febrile career.  Occasionally this was omitted, and
 in a few instances  the omission occurred on  three or four consecutive days.
 It is to be presumed, when this was the case, that the pulse presented no
 material variation from what had been previously noted.  In connection with
 the  frequency, other characters belonging to the pulse  are  usually given.
 Whenever any unusual characters were observed, they would undoubtedly be
 embraced in the daily notes.  I will first direct attention to frequency of the
 pulse, irrespective of other qualities, and  since all the facts pertaining to  this
 point may be placed in a tabular form without occupying much space, I will
 again adopt this method, which was pursued in the former Report.  In the
 following tables every thing is  omitted  except the numbers expressing the
 frequency of the pulse per minute at the time of the daily  enumerations.   A
 column will be devoted to each case, and the numbers placed  in consecutive
 order in the same column, to denote the frequency of the pulse on successive
 days during the continuance of the febrile career.   When the enumerations
 were made both at  morning and evening, the numbers  are placed side by
 side, and the letters P. M. placed  before the latter.   Sometimes it happened
 hat the record of  symptoms was made at evening, and not in the morning.
 When this was the case, as respects the pulse, the letters P. M. are placed
 before the numbers.   The numbers without  any prefix, denote enumerations
 made in the morning, or during the forenoon.   The omission to enumerate,
 or to note the frequency of the pulse on some days, is expressed, in the tables,
 by two ciphers.  In two cases of the Typhoid type, and one case of Typhus
 the enumerations are so incomplete that they are omitted.   The tables, there-
fore, which are limited to the cases assigned to these  two types, contain the
  cts pertaining to the frequency of the pulse in twenty-five cases of Typhoid,
and in nine cases of Typhus. 
TABLE EXHIBITING FREQUENCY OF PULSE IN TWENTY-SEVEN TYPHOID CASES.
Case 1.	Case 2.	Case 3.	Case 4.	Case 5.	Case 6.	Case 7.	Case 8.	Case 9.
00	108	96	90	96	90	00	84	88
112	96	92	92	104	86	108	108	92
116	100	84	84	101	100	64	96	83
108	110	89	88	108	92	80	72	90
100	100	80	84	120	100	80	100	90
no	104	72	00	Died by apnoea	96	72	68	90
84	100	76	00	suddenly devel-	101	56	63	80
84	90	*0	Mean frequency.	oped.	92	76	Mean frequency,	88
100	100	80	88 4-5.	Mean frequency,	104	00	85 1-2.	OS
88	112	Mean frequency,		106 2-5.	108	00		88 60
96	112	83 1-9.			108	112		
128 13-2 Died. On the day when	100 96 84				104 100 96 100	p. in. 104 72 63		68 Mean frequency, 82 1-2.
the pulse became	68					'-		
suddenly increas-	76				80	Mean frequency,		
ed to 128, there	Mean frequency,				93 104 88 108 84	80 1-3.		
was copious per-	97 7-8.							
s pi ration and								
great prostration.								
No other notable								
changes. The					76 84 72 96			
next day he vom-								
ited frequently,								
and had several								
dejections. He retained his men-					84			
					Mean frequency,			
tal faculties upto					94 4-13.			
a short time be-								
fore death.								
Mean frequency,								
103 1-0.								
to
© 
I>5
O
to
TABLE EXHIBITING FREQUENCY OF PULSE IN TWENTY-SEVEN TYPHOID CASES.
Case 10.	Case 11.	Case 12.	Case 13.	Case 14.	Case 15.	Unse 16.	Case 17.	Case 18.
		110 p.m. 112	0	120 p.m. 108	128	72	00	104
92	108	78 p. m. 72	100 p.m. 76	84 p in. 72	120p.m.ll2	80 p.m. 88	136 p.m. 144	90 p.m.100
88	128	88 p.m. 72	64 p.m. OI	68 p.m. 68	96	92	140	p.m. 96
76	Died morning of	76 p.m.104	60 p.m. 64	88 p.m. 78	88	92	136 p.m. 116	92
72	fourth day alter	92 p.m. 80	66	84 p.m. 76	Mean frequsney,	76	100	90 p.m.100
80 p.m. 112	admission. Case	84	64	76 p.m. 64	108 7-5-	Mean frequency,	84	96 p.m.106
84 p.m. 88	characterized hy	Mean frequency,	Mean frequency,	76 p.m. 72		83 1-3.	92 p.m. 88	92 p.m. 100
100 p.m. 96	very active and	83 6-11.	69 1-2.	72			81 p.m. 92	100
80	persistent deliri-			64			88 p.m. 84	114
64 p.m.112	um.			100 p.m.118			86	112
84	Mean frequency,			112			Mean frequency,	96
96	118 2-3.			128 p.m.124			98 4-7.	108
108				83 p.m. 80				108 p m.100
104				72 p.m. 76				120
100 p.m. 8S				04				108
100 p.m. 92				Mean frequency,				92
108 pin. 132				79.				00
Pulse extinct.								92
Died alter perfor-								Mean frequency,
ation, which oc-								100 8-11.
curred on the day								
on which at a.m.								
the pulse was								
108, and at p. in.								
132.								
Mean frequency,								
94 2-3.								
 
TABLE EXHIBITING FREQUENCY OF PULSE IN TWENTY-SEVEN TYPHOID CASES.
Case 19.
    130
    120
     92 p.m. 96
    10- p.m.100
     84
     00
     80
     84
Mean frequency,
98 8-9.
Case 20.
Mea
81 3
 72

 00
 00
 00
 00
 104
 108
 104
 80
 76
 80
 84
 76
 96
 72
n frequenc
 13.
Case 21.
    116
    116 p.m.116
    120
    116 p.m.110
    120 p.m.120
    130
    120
    136
    Fatal.
Modcofdyini, by
asthenia.  Pulse
became  extinct
several hours be-
fore death. Mind
seemed  clear.
Mean frequency,
119 3-11.
Case 22.	Case 23.	Case 21.	Case 25.	Case 26.	Case 27.	
128	120	88	100	00	00	
132 p.m.140	120	104	9(1	112p.m.ll0	00	
146	120	102 p m.120	100	108 p.m, 116	00	
00	116	122 p.m.116	90	104	116 p.m. 124	
140	108	112	100	84	88	
136 p.m.112 96	132 p.m.124 121	p.m.140 84	0(1 76	76 70 p.m. 7 6	90 p,m. 80 84 p.m. 90	
p.m 112	124	00	Mean frequency,	84	96	
90 p.m.116 00	120 128 p.m.132	50 42	93 2-3.	Mean frequency, 95 1-5.	Mean frequency, M 3-1.	
00	120 p.m. 120	44				*ti
00	130 p.m. 128	Mean frequency,				o H
112	130 p.m. 135	92 6-13.				
Mean frequency,	138 p.m.114					
121 1-12.	126					O
	140 p.m.108					
	132 p.m.144					o
	128					o
	140					^
	120					
	128					«
	112 112					w a
	124					
	108 118 120					< a
	116					X
	112					
	124					
	116					
	118					
	132					
	Fatal.					
	Perforation sup-					
	posed to have ta-					
	ken place.					
	Mean frequency,					
	123 18-41.					to
						o to
 
TABLE EXHIBITING FREQUENCY OF PULSE IN NINE TYPHUS CASES.
Case 1.	Case 2.	Case 3.	Case 4.	Case 5.	Case 6.	Case 7.	Case 8.	Case 9.
128	108	104	110	92	104	120	120	112
140 p.m. 108	120	104	120 p.m.128	120	120	120	120	120
100 p.m. 110	108	116	110 p.m. 96	120	120	112	120	112
100	100	100	108	120	126	00	124	108
02	100	104	96 p.m. 86	134	128	104	120	112
80	104	108	Mean frequency,	146	120	96	100	120
84	100	104	110.	Fatal.	Fatal.	Mean frequency,	112	100
76	108	88		Mode of dying by	Mode of dying by	110 2-5.	96	120
61	92	80		apncea. Death	apnoea. Death		Mean freq.ucncy,	104
Mean frequency,	108	104		preceded by shor-	preceded by shor-		114.	BH
98 10-11.	104	108		tened and quick-	tened and quick-			Mean fiequency,
	108	140		ened inspiration.	ened inspiration.			109 3-5.
	110	Fatal.		Mean frequency,	Mean frequency,			
	120	Symptoms of		122.	118 2-3.	•		
	116	pneumonitis ap-						
	124	peared at time						
	112	pulse increased,						
	112	from 80 to 104.						
	112	Prior to this,						
	120	symptoms were						
	Fatal.	favorable. Mode						
	Death took place	of dying by ap-						
	some time after	noea.						
	the last enumer-	Mean frequency,						
	ation, with colon-itis. Mean frequency,	105.						
								
	109 3-10.							
 
REPORT ON  CONTINUED FEVER.
205
   On following down the columns of numbers it will be perceived that the
pulse presents, frequently, considerable variations in the same case during the
febrile  career.  These variations, within certain limits, appear to  be due to
fluctuations incident to the  progress of the disease.  A striking increase in
the frequency of the pulse, unless of transient duration, and occasioned by
extraneous influences, usually accompanies  some important event, which will
be likely to affect the issue of the disease.   The events, in the present collec-
tion of cases, observed to be thus signalized, are  the  development of pneu-
monitis, e. g., case No. 3 (Typhus);  the occurrence of perforation of intestine,
e. g., case No. 10 (Typhoid)', of a  condition tending to, or eventuating in
apoplectic  coma, e. g., case No. 5 (Typhus);  a  sudden change  ending in
death by apnoea, e. g., case Nos. 21  and 17 (Typhoid).
   A great increase in the frequency of the pulse is undoubtedly of bad omen
in Continued Fever;  but it  is by no means a fatal sign.  In several of the
cases, it  may be  observed, in which  the  termination was in recovery, the
pulse exhibited very marked accelerations.  It rose, for example, to 140 and
144 in case, No. 17  (Typhoid); to 140 and 146  in case, No. 22 (Typhoid),
and to 140 in case 24 (Typhoid).  The instances in which, among the  cases
ending in recovery, the pulse attained a high maximum were more numerous in
the Typhoid group.  The highest number which the pulse reacBed in the Ty-
phus group, in the cases ending in recovery, was 140, and the highest number
after this was 128.  The reverse of this was true of the first collection of cases.
   The average  mean, however,  in  frequency, is greater in  the cases of
 Typhus than of Typhoid, as the following  comparison shows:
            Average mean in the Typhus cases, 110  5-9.
            Average mean  in the Typhoid cases, 95  15 - 27.
   These results, as respects the disparity disclosed by comparison of the two
types, correspond with those developed  by the first analysis.  The latter gave,
as  the average  mean of the  Typhus  cases,  excluding  those which proved
fatal, 105  4- 9; and of the Typhoid  cases,  95 7-13.   Excluding, in the
present collection, the fatal cases,  and the average mean  of the Typhus  cases-
is 108  1 - 5;  and of the Typhoid cases, 91 6 - 21.  Thus, in both analyses
the average mean frequency of the pulse is considerably higher in the  cases
of  Typhus, than in those of Typhoid. In the present collection, however,
the  average mean  frequency is somewhat higher in  Typhus, and lower in
 Typhoid, than in the cases before analysed.   The average mean frequency is
higher in the cases which  proved fatal, than in  those  ending in recovery.
In the fatal Typhus cases, it is, 113 1  -2; in the fatal  Typhoid cases, it is,
110 1 - 2, the disparity in  the two types being still apparent. 
206
REPORT ON  CONTINUED FEVER.
   The lowest mean exhibited in the tables, is  69 1 -2, case No. 13 (Ty-
phoid).  This  is below the average frequency of  the pulse in  health.  In
this case the patient entered  the hospital on the day after taking to the bed,
and the fourth  day after the commencement of the access.  The diagnosis was
sufficiently clear, although the eruption was not developed.  The disease was of
a very mild grade, convalescence being pronounced on the seventh day after tak-
ing to the bed.   In this case a relapsing febrile attack occurred, and the pulse
then  rose to 128.  I am unable  to say whether the pulse in this patient, in
health, was less frequent than the normal average.  Cases of Continued Fever
presenting  so low a mean in the frequency of the pulse, must be very rare.
   The lowest mean next to that in the case just referred to, is  79, case No.
14 (Typhoid).  In this case the pulse on one day was 128.  The case was
not one  of very mild grade.   It was characterized by notable acceleration of
the  respirations.   Convalescence  was  pronounced  on the  twenty-first day
after taking to the bed.
   As a  general remark, it is undoubtedly true, that the mean  frequency of
the pulse is a pretty good criterion of the severity of grade of the disease,
this being  proportionate to the  degree of acceleration.   The rule, however,
is not without  exceptions.
   A reduction considerably below the normal standard, at or near the period
of convalescence, appears in several cases in the present collection.   In case
No. 9 (Typhoid),  it fell to 60; in case No. 13 (Do.), to 64;  in case No.  14
(Do.), to 64; in case No. 24 (Do.), to 42.   The  same fact was noticed in the
former analysis.   On the other hand, in several  cases, at the time of conva-
lescence, the pulse was more frequent than in health.  The latter fact has
been remarked upon by several observers, but the former  I do not remember
to have  seen noticed by writers.
   It will be noticed, on reference to the tables, that the enumerations of the
pulse often disclose variations in frequency  on the same day.  In some of these
 cases the greater relative frequency was in the morning, and in other cases at
 evening. Other  cases again show, on some days, greater relative frequency in
 the morning, and on other days, at evening.  In  so far as  the pulse  is  an
 index by which to  estimate febrile exacerbations, these variations show  the
 absence of any uniformity or regularity in their recurrence.   It is certain that
 diurnal  exacerbations during the progress of Continued Fever, are not nearly so
 often present as one is  led to suppose from the current literature of the subject.
    As respects the qualities of the pulse, irrespective of frequency, it will suf-
 fice to give a  few  brief statements.   It was usually either moderately or con-
 siderably  developed;  that is, the artery appeared  to have either moderate or 
                      REPORT ON  CONTINUED FEVER.                  207

considerable volume.  Sometimes it was small, and at the same time feeble.
If tolerably developed, the impulse communicated to the touch denoted a
kind of smartness in  the  systolic  contraction, but it was almost invariably
compressible.   It was never hard.   In a few cases it was noted as vibratory,
or thrilling.  If it became very frequent, it was uniformly quite soft or feeble.
To trace the connections of these variations with other symptoms in the dif-
ferent cases, would require not a small degree of labor, which it is not proba-
ble would yield results commensurately valuable.   In general, it may be said,
that in Continued Fever, the  circulation presents a morbid activity, not, how-
ever, involving an increase of power in the motive agencies by which the
circulation is carried on.   The distinction intended to be expressed by these
terms has, theoretically, an important bearing on the subject of therapeutics.
   Congestion of the capillary vessels properly enough belongs in this section,
but the facts pertaining to this subject which the analysis  discloses, have been
 already sufficiently considered in connection with the symptoms referable to the
 general aspect, section third.   The presence of capillary congestion in a large
 majority of the cases of Continued Fever, is evidence that the circulation, al-
 though unduly excited, is carried on less efficiently than in the state of health.

                              SECTION NINTH.
  Symptoms (exclusive of eruptions) referable to the skin.   [Page 107.]
    During  the progress  of Continued Fever, the skin  generally presents a
 series  of changes as respects temperature, dryness, moisture, and  sweating.
 The facts pertaining to the order of succession of these changes in individual
 cases, form an interesting portion of the natural history of  the disease.  In
 the first  Report a few selected cases were given illustrative of  the  diurnal
 succession of this class  of symptoms during the career of the fever.  As it
 will not occupy much space,  I will embrace in the present Report, in a tabu-
 lar form, a succinct statement of the condition of the skin (irrespective of
 eruptions) in twenty-four cases of Typhoid, and in eight cases of  Typhus,
 the histories of which are pretty complete in this particular.  In the  tables
 which follow,  the cases are arranged  in parallel columns, as in those exhibit-
 ing the pulse;  and the  symptoms, which were daily recorded, are arranged
 in each column in the order of their succession, commencing with  the time
 the patients entered the hospital, and ending with the termination of the dis-
 ease either in death, or the  stage of convalescence.  The days on which no
 record of the condition of the skin was made, are represented, as before, by
 two ciphers.  Each  column, thus, contains the  facts  pertaining to  the skin
  which were noted in the history of the case to which the column is devoted. 
TABLE EXHIBITING SYMPTOMS REFERABLE TO THE SKIN IN TWENTY-FOUR TYPHOID CASES.
No. 1, fatal.	No. 2.	No. 3.	No. 4.	No. 5, fatal.	No. 0.	No. 7.	No. 8.
Hot and dry.	Rather hot.	Hot and dry.	Warm and mellow.	Warm and mellow.	Warm and mellow.	00	Warm and dry.
Warm and moist.	Warm and dry.	Perspiring treely.	Do.	Rather hot and dry.	Rather hot and dry.	Dry and burning	Free perspiration in
Do.	Warm and mellow.	Free perspiration in	Warm and moist.	Warm and mellow.	Do.	heat.	night.
Warm and mellow.	Warm and dry.	drops on tace.	Warm and mellow.	"Rather hot and dry.	Warm and dry.	Perspiring freely.	Warm and mellow,
Dry and rather hot.	Do.	Perspiring treely.	Warm and moist.	Warm and dry.	Do.	Warm and moist.	free perspiration
Warm and mellow.	Do.	Warm and moist.		Died 5th day.	Warm and mellow.	Warm and mellow.	in night.
Do.	Warm and mellow.	Do.			Do.	00	Warm and moist.
Do.	Warm and moist.	Do.			00	Warm and mellow.	Warm and mellow.
Do.	Do.	Do.			Warm and mellow	Warm and moist.	
Warm and moist.	Warm and mellow.	Rather hot and dry.			and at p. m. gen-		
V\ arm.	Warm and moist.				tle perspiration.		
Warm and moist,	Warm and mellow.				Rather hot and dry.		
and face covered	Do.				Warm and dry.		
with perspiration					Warm and mellow.		
Warm and moist.					Free perspiration in		
Died. 1 I					in drops on face. Free perspiration. Do. Warm and moist Free perspiration. Do. Warm and mellow. Do. Perspiring. Normal.		
 
TABLE EXHIBITING SYMPTOMS REFERABLE TO  THE SKIN  IN  TWENTY-FOUR TYPHOID CASES.
No. 9.
Warm.
Warm and moist.
Warm and dry.
Warm and moist.
Warm and mellow.
Hot and dry.
Warm and mellow.
Hot and dry.
Warm and mellow.
No. VO, fatal.
Warm and moist.
Hot and dry.
Warm and mellow,
  and at p. in. cool.
Warm  and moist,
  and at p. m.  ra-
  ther hot and dry.
Warm and mellow,
  p. in. warm and
  moist.
Warm and moist.
Warm  and dry, at
  p. m.hot and dry.
Warm and mellow.
Warm, p. m. warm
  and moist.
Warm.
Hot and dry, p. m.
  warm and moist.
Free perspiration at
  night, warm  and
  moist, at p. m.
  hot and dry.
Cool.
Hot and dry.
Warm, at p. m. hot
  and dry.
Warm  and moist.
Cold, livid.
No. 11, fatal.
Ra'.her hot.
Warm and mellow.
Persp'ation in drops
  over face and mo-
  derate over trunk
  and extremities.
Profuse   perspira-
  tion.
Died.
No. 12.
Free perspiration at
  night.
Hot and dry.
Warm and moist.
Warm and mellow.
      Do.
Hot and dry, p. m,
  warm and moist.
Warm and mellow,
  at  p.  m. rather
  hot and dry.
No. 13.
Free perspiration at
  night.
Warm and moist.
Warm and mellow.
       00
Warm and mellow.
      Do.
      Do.
No. 14.
Rather hot and dry,
  ai.  p.  m. warm
  and moist.
Warm and  moist,
  and at p. m.eool.
Warm and mellow.
  ami at p.m. warm
  and moist.
Warm and  moist,
  ami at p. m. do.
Warm and mellow,
  and at p.m. warm
  and moist.
Warm and mellow,
  and at p.m. warm
  and moist.
Warm and moist.
Warm and dry.
Warm and moist.
      Do.
Free perspiration.
Profuse   perspira-
  tion.
Warm and mellow.
Warm and moist.
Warm and mellow.
No.|15.
Hot and dry.
      Do.
Warm and dry.
Warm and mellow.
No. 10.
Warm and mellow.
Warm and dry, and
  nt p.  m. perspir-
  ing.
Warm and dry, and
  free  perspiration
  in night,
Warm and mellow. 
TABLE EXHIBITING SYMPTOMS REFERABLE TO THE SKIN IN TWENTY-FOUR TYPHOID CASES.
No. 17.	No. 1 .	No. 19.	No. 20.	f No. 21, fatal.	No. ,22.	;No. 23, fatal.	No. 24.
00	Warm and moist.	Warm and mellow.	Persp'ation in drops	Warm and mellow.	oo;	Warm and rather	Warm and moist. Do. Perspiring freely.
Warm and moist,	Persp'ation in drops	Warm and dry, and	on face.	Warm and dry.	Warm'and dry, and	dry.?	
and at p.m. warm and dry.	on face, and at	and at p.m. warm	Warm and moist.	Warm and mellow.	at p. m. hot and	Warm and mellow.	
	p. m. warm and	and moist.	Do.	Do. and at p. m.	dry.	Warm and rather	Warm and dry. Do.
Cool and moist, at	moist.	Warm and dry.		warm and dry.	Warm and dry.	dry.l	
p. in. clammy. Warm and moist.	Do-	Warm and mellow.		Warm and dry.	Hot and dry.	Do.	00
	Do.	Do.		Warm and mellow.	Warm and dry.	Rather hot and dry.	00
Warm and mellow. Do. and at p. m.	Perspiring freely. Warm and moist,			Warm. Do. 1	Warm mid mellow. Less heat.	Warm Bnd dry. Do.	Warm and dry. Warm and mellow.
warm and dry.	perspired freely			Died.	Hot and dry.	Do. Do.	
Warm and mellow.	in night.				Warm and mellow.		
Do.	Cool.				at p. m. hot and	Do.	
Warm and moist.	00 00 Warm and mellow.				dry.	Do. Do. Do. Do.	
	Warm and moist,						
	and at p.m. warm					Do.	
	and dry.					Do.	
	Warm and moist.	•				Do.	
	Warm and mellow.					Do.	
	tDo.					Do. Do. Do. Warm and mellow. Do. Warm and dry. Warm. Warm and mellow. Do. Hoi and dry. Warm. Warm and dry. Do. Do. Mellow.	
						Warm and dry.	
 
TABLE EXHIBITING STATE OF THE SKIN IN EIGHT TYPHUS CASES.
	No. 1.	No. 2, Fatal.	No. 3, Fatal.	No. 4	No. 5, Fatal.	No. 6, Fatal.	No 7. ■	:no. s.
	Hot and dry.	00	00	Warm and dry.	00	00	Profuse perspira-	00
	Warm and mellow.	00	00	Do.	Warm and dry.	00	tion.	00
	Warm and rather	00	Warm and dry.		Dry and rather hot.	Warm and day.	00	<!0
	dry.	Warm and mellow.	Warm and moist.		Warm and dry.	Warm and mellow.	Warm and moist.	Hot and dry.
	Warm and mellow.	Dry and rather hot.	Warm and mellow,		Do.	Warm and dry.	Warm and mellow.	Do.
	Do.	Warm and mellow.	perspired freely	Warm and mellow.	Do.	Do.	Do.	Warm and dry.
	Do.	00	in night.	Warm and moist.	Do.	Cool and dry.	Warm and moist.	Do.
	Do.	Warm and dry.	Warm and moist.				Perspiring profuse-	Do.
	Do.	00 Warm and mellow. Warm and moist. Profuse perspira-tion. Perspiring freely, drops on face. Warm and mellow. Died subsequently with secondary dysentery.	Do. Moist. Fiee perspiration. Warm and moist. Do. Do.				ly, drops on face. 00 Perspiring profuse-00 00	Warm and mellow. Warm and slightly moist. Warm and moist. Warm and dry. Mellow. Warm and mellow.
 
212
REPORT ON  CONTINUED FEVER,
   The data contained in the foregoing tables, show that  free perspiration, or
sweating, occurred in fourteen, of the twenty-four cases of Typhoid, and  in
three, of tbe eight cases of Typhus.   In the first collection, this symptom was
present in fourteen, of  twenty-seven cases of Typhoid, and in five, of twelve
cases of Typhus.  The results of the two analyses thus do not greatly differ.
   Of the fourteen cases of Typhoid characterized by sweating, it is noted to
have occurred  but once in the histories of seven; twice in four cases;  three
times in one case; seven times in one case, and  six times in one case.
   Of the three cases of  Typhus  characterized by sweating, it is noted  to
have occurred  once in  the history of one  case, twice in  one case, and  three
times in one case.
   It is  a curious coincidence worthy  of passing  remark, that of the fourteen
Typhoid eases in the first, and of the fourteen  Typhoid  cases in the second
collection, characterized  by sweating, in  precisely  the  same  number, viz.,
seven, this event is noted to have occurred but once in each case.
   The  sweating, in degree, as before, differed at different times, as  also in
duration.  Frequently it was  quite profuse, drops  standing more especially
on the face.  It was observed, as before, also, to occur or commence oftener
at night than during  the day.
   Moisture of the surface  is noted  to have been  present, more or less, as
respects  the number of days, in seventeen cases of Typhoid, and in four cases
of Typhus.  This condition obtained in a larger number of cases in the pre-
sent collection than in  the cases before analyzed.  The number of  times in
which it was noted in  the cases  severally need not  be enumerated.  It will
be seen,  on glancing at the tables, that, of  the cases in which it was present,
it was noted generally several times, alternating sometimes with  free perspir-
ation, and sometimes  with dryness of  the skin.
   The two  Typhoid cases in which profuse perspiration  occurred the great-
est number of  times, (viz., in  one  six, and in the other seven  times), claim
particular notice.  Case No.  6,  in which  it occurred  seven  times, was  of
medium severity, convalescence  being pronounced  on  the nineteenth day
after admission.  The  convalescence was retarded by  the complication  of
pneumonitis.
   Case  No. 18, in which  it occurred six times, was also complicated with
pneumonitis.  In other respects the  disease was not unusually severe, and
convalescence was pronounced on the  sixteenth day.   Thus both cases ended
favorably.
   Directing the attention  now to the  fatal cases, of the seven Typhoid cases
proving fatal, free perspiration occurred in three, and moisture of the surface 
                      REPORT ON CONTINUED FEVER.                  213

 in two.   Of the four cases of Typhus ending fatally, free perspiration occur-
 red  in two, and moisture of  the surface  in  two.   These results accord with
 those developed by the  first analysis,  and confirm  the  conclusion that the
 occurrence of sweating, or moisture, has no special bearing on the prognosis.
   The facts  apparent on  reference to the tables,  confirm another conclusion
 deduced from the results of the analysis, viz., moisture, and free perspiration
 do not, as is frequently imagined, exert a manifest salutary influence on the
 progress or issue of the disease.   On reference to the tables it will be found
 that these conditions of  the skin were observed at different  periods of the
 febrile career, in the large proportion of instances not preceding, by a short
 space of time, the date of convalescence.  Moreover, these  appearances  were
 observed in nearly one half of the cases which  ended fatally.  We are not
 warranted, then, in predicating expectations of speedy convalescence, or recov-
 ery,  upon either of these  symptoms  disconnected from other circumstances;
 nor do these results afford any grounds for supposing that to induce moisture
 or sweating by  therapeutical means will be likely to prove  beneficial.
   The perspiration in Continued Fever has been said to emit a peculiar odor
 characteristic of the disease.  I have directed some attention  to this point,
 but  I could  never satisfy myself of the existence  of  such a symptom.   The
 Sisters at the Hospital, and some of the  Students, have frequently assured
 me that they were sensible of a  distinctive odor  arising  from  the bodies of
 fever patients under my  charge, but I  have always failed to verify, to my
 own satisfaction, this diagnostic.   It would be assuming too much to distrust
 the ability of others to recognize  the disease by the olfactory sense, and the
 probable, as well as the more modest inference is, that the ill  success which
 has attended my efforts, is due to a want of sufficient acuteness to appreciate
 impressions received from this source.
   The temperature of the surface, as estimated by the touch, varied consider-
 ably iii most of the cases  on different clays during the progress of the disease.
 Coolness was seldom observed, but frequently the heat did  not appear to be
 above the normal standard.   In eight only of the  twenty-four Typhoid cases,
 and in two of Typhus the skin on one or more days is noted as hot; and in
five  Typhoid cases, and  one  case of Typhus it is noted as rather hot.   In
 the majority of instances the elevation of temperature thus designated, was
 present in the early part of the disease.  A burning heat  is  noted in only one
 case — a case of the Typhoid type.   The descriptions by  some writers give
 the impression that an acrid heat  (color mordicans) is frequently present in
 both Typhoid and Typhus fever, but more especially in the latter, of which
 it is sometimes mentioned as a characteristic feature.   My observations  do 
214
REPORT ON  CONTINUED FEVER.
not  show it  to be a frequent symptom in cases  of  either type, nor that is
distinctive of either.   On this point the results of the two analyses concur.
   Finally, it will be perceived, on reference to the tables, that a warm and
mellow state of the skin, in other words a normal  condition, obtains, more or
less, during the febrile career, in  a certain  proportion of cases.  It might be
imagined that this would not occur except when the  disease was remarkably
mild, or  only in connection with  other symptoms of a favorable  character.
Such,  however,  does not  appear  to be the fact.  The skin was at times nor-
mal  in cases of severity,  indeed  in  some of those which ended fatally; and
when the symptoms in general did not denote improvement.
   In view of  the foregoing  facts, it does not appear that the skin in  Con-
tinued Fever, so far as it has been considered in this section, affords symp-
toms which possess much special significance or importance: that is to say
we are not warranted in deducing from the different conditions of this struc-
ture, as  respects sweating, moisture, or temperature, any positive inferences
concerning the tendencies and probable issue of the disease, or therapeutical
indications.  A survey of the results  developed by the present and former
analysis seems to lead to this conclusion, which, it is very  probable, does not
accord with the notions  entertained by some  practitioners.   The  investiga-
tion  by means of enumerations, and comparisons of the phenomena in a  series
of recorded cases, not infrequently compels us to abandon, or modify pre-
conceived  ideas based on  speculation,  or imperfect generalizations which
exert more or less  influence upon  the exercise of our art.   So far,  the  effect
of such an investigation is negative in its character, but the advantage is not
less positive than if an important  practical principle had been developed.   To
disprove  an erroneous opinion is  often scarcely less useful  than to discover a
new  truth; for, in the practice of medicine, it  is an object not less to  avoid
acting under false views, than to adopt and apply those which science may
establish.
   Gangrene.   Gangrenous ulceration of the skin  is noted in the histories of
two  cases, one of the Typhoid, and the other of Doubtful type.  In the for-
mer  case it was observed on the  third day after admission, the latter  being
several days after the commencement of the  fever.  The  case terminated
fatally the day after the  gangrene was discovered.   It was  situated on the
left nates.  In the other case it was discovered about the time of convales-
cence,  which was on the eighteenth day after taking  to the bed.  This case
was  severe.  The patient had considerable embonpoint.   The eschar was not
large,  and rapidly headed after convalescence was  established.
   Erysipelas did not occur in any of the cases  in this collection. 
REPORT ON  CONTINUED FEVER.                  215
                            SECTION TENTH.

     Symptoms referable to the Genito-urinary System.   [Page 114.]

  A daily record of the results of careful analyses of the urine during the
progress of Continued Fever, in an extended series  of cases, would form a
valuable contribution  to the natural history of this disease.  Such an accu-
mulation of observations, taken in connection with other classes of symptoms,
would  offer an interesting field for analytical exploration.  The task of col-
lecting the data for an  investigation of this kind, so far as I know, is yet to
be performed.  It is, of course, impossible to foresee the facts and relations
which would be disclosed. They might prove to be both curious and important.
But even if nothing striking or useful should be developed, an end of not a
little consequence would be attained, inasmuch  as it would then be settled,
that, with our present means of pathological research, nothing is to be looked
for in that  direction.  The toil of cultivating the domains of science is best
rewarded, it is true, by the abundance and  richness of  the harvest,  yet  to
determine whence no such reward is to be expected,  will  compensate for not
a little labor by restricting future efforts within the compass of a fruitful soil.
   After these  remarks, I regret to state, with respect to facts pertaining to
the subject of this  section,  that  this  Report will be as meagre as  the  first.
When I began to record  the  cases  embraced  in the present  collection, I
resolved to devote special attention to the urinary secretion.  The difficulties
in the way of prosecuting the undertaking, however, soon led to its abandon-
ment, and, indeed, it was never fully entered upon.   To carry out  the  plan
remains for a future attempt, and  perhaps for those  whose opportunities are
more favorable, or who are more persevering in overcoming obstacles.  The
histories of the cases contain only a few events which were of a character to
attract notice.  They will occupy but a brief space.
   Retention of urine is noted in the histories of several cases, viz., (Typhoid)
in one case no urine was passed for two days, when the catheter was employ-
ed, after which no further trouble arose  from this source.  In another case,
on the third day after admission, a resort to the catheter became  necessary,
and a quart of urine was drawn off.  The difficulty in this case did not recur.
Retention  in a less degree, relieved without the surgical  remedy, is noted in
three cases.   In all these cases symptoms of nervous  disorder were prominent.
The symptom is undoubtedly  due, in most  instances, to the blunted percep-
tions, the patient not experiencing suffering from the accumulation, until the
distension becomes  so great  that  the  power  of  voluntary  evacuation is 
216
REPORT ON  CONTINUED FEVER.
impaired or lost.  The importance of exploring the hypogastric region, and
ascertaining daily if urine has been discharged, is sufficiently obvious.
   Retention is not noted  to have occurred in any  of the cases of Typhus, or
those of Doubtful type.
   In several  instances the  discharge  of urine  took  place in bed, either
involuntarily, or from  indifference.
   Menstruation  occurred  in  one  case during the  progress of the disease, on
the  fifth day after admission, which was several  days  before  convalescence
was established.   The case was one of mild  grade.
   In one case, of the Typhus type, the patient made  complaint of pain in
urinating, about the time convalescence was established.
   In  one  case,  of Doubtful type,  considerable difficulty and  pain  was
experienced in the act of micturition during a portion of the febrile career.
   These are all  the facts  pertaining to the genito-urinary system which the
histories embrace.

                           SECTION ELEVENTH.

Duration of the Disease.   Circumstances attending  Convalescence.  Se-
   quelae.   Mode of Dying.  Fatality.   [Page 115.]
   Duration.   In this, as in the first collection, the histories of several of the
cases are defective  in  data for determining the time when  the patients took
to  their beds, which, according to the  rule  I have pursued, fixes the com-
mencement of the febrile career.  In some cases  the date of the first symp-
toms of the access were not  ascertained.  In these instances there is wanting
the point of departure from which to measure the duration of the disease.
   The period at which convalescence  was  pronounced, was determined by
the ensemble of circumstances.   According to  my observations, it  is not
generally the case that a transition from the febrile career to convalescence
takes  place within the space of twenty-four hours.   The  change is  usually
not sudden.    Occasionally  it is so, but in the  larger  proportion of cases
patients gradually advance  to the point at which  the febrile career  may
be declared  to  have  ended,  and the  stage  of  convalescence entered on.
Nor is it easy to fix  on any arbitrary  circumstances which shall suffice to
mark the  termination of the fever, as  taking  to the bed   is considered
to denote its beginning.   The latter  criterion is confessedly inaccurate,
but any special event which  may be  selected  for the former  end would
be still more open to  objections.  To make the  fact of giving, for the first
time, solid food  as a criterion, after the plan  of Louis, as remarked m the first 
REPORT ON  CONTINUED FEVEK.
217
Report, is to select an event which, of necessity, involves the  pre-determina-
tion of the very point which it is made to indicate.  The event simply denotes
that  at a particular day the patient was considered convalescent.   It is plainly
no evidence in itself of the fact of convalescence, but only of the opinion of
the practitioner that the patient is convalescent.  The patient assuredly may
have the  power to take solid  food, if it be offered, while the disease is pro-
gressing.  Moreover, it may not be considered unobjectionable  by some, to
give solid food prior to  convalescence, and  in  such cases, the rule is  not
applicable.
   There is,  in fact, no alternative but to decide the point, in individual cases,
by a fair and judicious estimate of all the symptoms; in other words, by an
exercise of judgment based on the aggregate of circumstances.   Such being
the  fact,  a  certain  latitude  follows.   Different  practitioners,  it would  be
expected, might differ in the exercise of judgment in  this particular;  and the
same practitioner might differ in applying his judgment in several cases.   In
short, it is by no means practicable in all  cases to define the  precise chrono-
logical limits of Continued fever with mathematical precision.   This consider-
ation, as it seems to me, disposes at once of the subject of critical days — a
subject which has heretofore been much discussed.   The question whether
the disease ended on a critical, or non-critical day, is inapplicable  to a large
proportion of the cases of  fever, inasmuch as the limits of the disease cannot
be determined with exactness.  This want of  precision in fixing  the dura-
tion, is  not attended with any serious  evils.   For all practical purposes,
sufficient accuracy is attainable.
   The following tables will exhibit the facts pertaining to duration in so far
as they are embraced in the histories.  They will present an enumeration of
the  number of days from the commencement of the access, and from the
time of  taking  to the bed to the time of convalescence, in all the cases  that
contain information on  these points.   They will embrace an  enumeration of
the  number of  days after admission into the  hospital, to convalescence, and
with respect to this point  the data are, of course, in all cases available.
   The number  of days from convalescence to discharge, or the last  date of
record, and the whole number of days  in  hospital, will  also  be  included.
With respect to the latter point, however, I should  premise that it is of but
little practical importance, because other  circumstances than those pertaining
to the disease frequently determined the stay of patients in hospital.   Some
were anxious to  get away as  soon  as possible, and  it was an object with
others to remain as long as  possible, for reasons that  were stated  in  the
former Report. 
218                   REPORT ON CONTINUED FEVER.
TABLE  EXHIBITING DURATION IN TEN CASES OF TYPHUS.
	1	2	3	4	5	6	7	8	9	10		
No. of days from tak-ing to bed to convales-cence, -	11			9			14	16	12	18	Total, 80.	Mean, 13 1-3.
No. of days from com-mencement of access to convalescence, -	15			14			14	20	15	21	Total, 99.	Mean, 16 1-2.
No. of days from ad-mission into hospital to convalescence, -	11			8			14		12		Total, 45.	Mean, 11 1-4.
No. of days from con-valescence to discharge,	52			48			10		27		Total, 137	Mean, 34 1-4.
No. of days in hospital,	63			56			24*		39+		Total, 182.	Mean, 45 1-2.
Fatal Cases.												
From taking to bed,					9	9					Total, 18.	Mean, 9.
From commencement of access, - - -			21		11						Total, 32.	Mean, 16.
From admission into hospital, - - -		53	17		9	9					Total, 88.	Mean, 22.
* Sister of Charity connected with Hospital.
| Candidate for Sisterhood connected with Hospital. 
TABLE EXHIBITING DURATION IN TWENTY-NINE TYPHOID CASES.
	1	2	3	4	5	6	7	8	9	10	11 | 12		13	14	15	16	17	18	19	20	21	22	23	24	25	26	27	28	29	
No. of days from taking to bed to convalescence,					10		19						9	7	21		11		16		23				11			8	8	Total, 143. Mean, 13.
No. of days from commencement																														
of access to con-valescence, No. of days from admission to hos-				23	14					19			11	10	21	11	16	13	26	15	23				11				12	Total, 225. Mean,16 1-14
pitid to convales-cence,	11		19	9	5		19	9	6	9			7	6	15	8	6	10	16	10	17		13		11		11	7	8	Total, 232. Mean, 10 6-11
No. of days from																														
convalescence to																														
discharge, or date of lust record,	4			17	10		30	8	7	2			21	21	+	21	19	13	20	31	16		33		32		6	41	70	Total, 425. Mean, 21 1-4.
No. of days in hospital, -	15			26	15		49	17	13				28	27		29	25	23	36	41	33		43		43		17	51	78 f	Total, 609. Mean,32 1-19
Fatal Cases.																														
From taking to bed,		19																						41						41
Fr'm commence-ment of access,												14												41		7				Total, 48. Mean, 24.
From admission to hospital,		•				5					17	4										9		38		2				Total, 49. Mean, 19 1-3.
* Porter in hospital.          f Remained in hospital as domestic.          f Remained a long time after complete recovery. 
220
REPORT ON CONTINUED  FEVER.
   In comparing and commenting  on the  results contained in the foregoing
tables,  I will consider  each division of the enumerations under a distinct
head.
   1. Number of days from taking to the bed to convalescence.  The two
types,  Typhus and  Typhoid, exhibit, in this aspect, the same mean duration
within a fraction — being in the latter, 13, and in the  former, 13 1-3  days.
The fractional excess is in favor of the Typhus tpye.  It is less in either type
than in the first collection of  hospital cases,  in which  the mean number of
days, in  the Typhoid cases, was  20; in the Typhus  cases, 14 4-5.  The
first analysis, it will be seen, gave a marked  disparity, in the two types, as
respects this view of the duration — the number of days being greater in the
Typhoid cases by nearly one-quarter.  Thus, in  comparing  the results of
the two analyses, there  is a difference when  the cases of both types, in the
two collections, are brought  into contrast,  and when the  two types are
contrasted  with each other in both collections.
   The difference in the individual cases, in the duration after taking  to the
bed, is considerable.  The  minimum, in the  Typhoid  cases, is 8, and the
maximum,  23 days; in the  Typhus cases  the variations in  this respect are
less, the minimum being 9, and the maximum, 18 days.
   In the fatal cases the duration from the time of taking to the bed is noted
but in one  Typhoid case, and  in that case was 41 days.  It is noted in two
Typhus cases, in each of which it  was 9 days.
   It is to be considered that the enumerations with respect to the duration
from the time of taking to the bed, do not embrace all the cases in the pre-
sent collection,  as will be observed on looking at the tables.   In some of the
histories information on this point  is not contained.   The number of days is
stated  in thirteen (two fatal) of the  twenty-nine cases of  Typhoid, and in
eight (two  fatal) of the ten cases of Typhus.   The same incompleteness
existed in the tables embraced in the former Report.  In the latter the num-
ber of days is stated in six  of the eighteen hospital cases of  Typhoid, and in
five of the  twelve hospital cases of  Typhus.
   1. Number of days from commencement of the access to  convalescence.
The mean  number of days  in the Typhoid cases, was 16 1-14 days.  In the
Typhus cases, it was 16 1-2 days.  Here, again, the results in the two types
are very nearly equal.
   In the first Report enumerations were not made with respect to this point.
   Of the fatal cases, the mean duration in those of the Typhoid  type, was
24, and in  Typhus, 16.
'   The enumerations of  days under this head,  contained in the  tables, 
REPORT ON  CONTINUED FEVER.
221
embrace seventeen  (three fatal) of the twenty-nine cases  of Typhoid, and
eight (two fatal) of the ten cases of Typhus.
  3. Number of days from admission  into hospital, to convalescence.  In
the Typhoid cases, the mean number of days was 10 6-11.   In the Typhus
cases, it was  11 1-4.   Here the disparity between the two types is not
great.   The Typhus  type, it will  be  observed, exhibits the greater number
of days.
  In the first  Report the mean number of days in the Typhoid cases, was
13 5-14; and in. the  Typhus cases, 11 10-11.
  The cases in the first collection, thus, in both types, had  a longer duration
in this point of view, and as respects the relative duration  of the two types,
the results are the  reverse of each other: in other words,  the duration was
longer in the Typhoid cases in the first, and longer the  Typhus cases in the
second collection.
   In the fatal cases, the mean duration, dating from admission into hospital,
in the Typhoid cases, was 19  1-3, and in the Typhus cases 22; the latter
cases, as well as those which recovered, exhibiting a longer  duration.
   4. Number of days from  the date of convalescence to date of discharge.
In the Typhoid cases, the mean was  21 1-4 clays.   In the Typhus cases, it
was  34 1 2 days.   The  disparity  here was considerable.   In this  point  of
view, the duration, in the two  collections, of both types, presents a striking
contrast.  In the first Report the  mean  duration of the Typhoid cases was
10 5-13, and of the  Typhus cases, 16 3-7.
   This difference is undoubtedly owing, in a great measure, to other circum-
stances than those pertaining to the  condition of the patients consequent on
the disease.   Nearly all the patients in the last  collection of  cases were
foreign emigrants supported by the State Emigrant Fund, which was con-
tinued until they were able to labor.   Support of patients in  this  hospital
from this fund, was not contributed prior to the year in which these cases were
collected.   Moreover, the pecuniary resources of the institution, which, prior
to the past year had  been quite limited, had become larger,  so that patients
who desired to  remain until their health and strength became fully estab-
lished, could  be indulged in this  respect, more  than formerly.   These con-
siderations  account for much, if not  most of the prolonged stay in hospital
after convalescence.   The great disparity between the maximum and  mini-
mum periods of duration after convalescence, in  individual  cases, shows that
the variations were  due to extrinsic causes.  Thus, in the Typhoid  cases we
find  one patient remained  only two  days after the date  of convalescence,
another four days,  and another six  days; while, at the other extreme, one 
222
REPORT ON  CONTINUED FEVER.
 patient  remained forty-four  days,  another seventy  days,  another thirty-
 three, etc.
   The comparisons, as regards  the  whole number of days in hospital, are
 embraced under the  foregoing heads, and  therefore do  not call for distinct
 consideration.
   The duration of the disease  dating from  the time of taking to the bed,
 and from the time of admission into the  hospital, is  less than  in the  cases
 before  analyzed.  This is an  interesting  fact.   How is  it  to be explained ?
 It may be partially, or entirely due to a difference of habitude of this disease,
 in this  particular, at different periods.  That the disease does exhibit varia-
 tions in duration, in different years, is shown by the observations of Dr. Jack-
 son, of Boston.  Dr. Jackson's Report on  Typhoid  Fever, contains a tabular
 exhibition of the  average duration for each year of twelve successive years.
 This table  presents  considerable fluctuations,  the  extremes  being nearly
 eighteen days in one year, and nearly twenty-six days in another.  This is, in
 fact, the best explanation  that can be offered.   It may be supposed  that the
 cases  in  the present collection were better managed, therapeutically,  or
 hygienically, or both, and that the  continuance of the disease was  in that
 way abridged.   There may be some force in this supposition, but it is impos-
 sible to say how much importance is to be attached to it.   The difference in
 mortality was slight in the two collections, and  not in favor of the last collec-
 tion.  Even admitting a  marked improvement in the management of the
 disease to be susceptible of proof, it is not  certain that  the effect would  be a
 notable diminution in the  mean duration.  It  may be  that such an effect
 would follow.  The idea  is certainly not irrational; but,  in  the present state
 of our knowledge, it is hypothetical.
   The average duration of the disease, as developed by the present  analysis,
 dating either from admission into the hospital, the time of taking to  the bed,
 or the commencement of the access, is singularly short, being  less  than  in
 any  collection of cases, the results of the analysis of which have fallen under
 my notice.
   Another point is  important to be  noticed.  The average duration of the
febrile career in cases of  Typhus, has heretofore been  found, by  different
observers, to be so constantly less than in cases  of Typhoid, that this is con-
 sidered to constitute  one of the points of distinction between the two types.
The  results of the  first analysis were  in accordance with this rule.  The pre-
sent  analysis, however, gives  an average  duration nearly equal, the slight
difference telling against the  rule.  This suffices to show that as a law of the
disease it  will not  be found invariably to hold good.  This  fact, however, is 
REPORT ON CONTINUED FEVER.
223
important to be remarked, disparity between  the Typhus cases in  the first
and second collections, as respects duration, is not great;  in other words, the
cases of this type, in both collections, exhibit nearly the same average.  That
the average duration of the Typhoid cases is not greater than that of the
cases of Typhus in the present collection is, thus, owing  to the shorter dura-
tion of the former, not to an extended duration of the latter.  This distinction
should be borne in mind.
   In connection with the above fact, it  may be remarked, that the  disparity
of the results developed by the two analyses with reference, not  only to that
point, but in other particulars, illustrates the value of analyzing the cases col-
lected in different years, separately, so as to bring the results into comparison
with each other.   In this way, the effects due to the eccentricities of the dis-
ease, or to the  influences incident to  different periods of time, are made  to
appear.
   Circumstances  attending  Convalescence.  In  separating  and  arranging
the facts contained in the histories, preliminary to  instituting  the enumera-
tions and comparisons which it  is the object of these reports  to set forth, I
omitted, inadvertently, in the present analysis, to direct particular attention to
the circumstances preceding or connected  with the occurrence of  convales-
cence.   As the first collection of cases were studied carefully with respect to
this point, there does not seem to be an object sufficient to influce a re-exami-
nation of the cases of the present collection to supply the above omission.   I
have, therefore, nothing to add under this head to the conclusions submitted
in the first Report.
   Sequelae.   Aside from the facts which I shall present under the head of
relapses, nothing which would properly  be  classed among the  sequelce of the
disease came under  notice save in one case.   But it  is to be considered that
the patients were  under observation only from the time of their admission,
to their discharge.   After leaving the hospital they were  lost sight of, a large
proportion being immigrants, in transitu to other places.   My opportunities
to study the probable influences of Continued  Fever in the production of other
diseases after a greater or less lapse of time,  and its remote  effects  on the
organism, have been quite limited; nor  have  I taken pains to record the few
facts pertaining to this interesting subject which I might have collected.
   In the sino-le instance just referred to, the  patient left the hospital on the
thirty-third  day after admission, and  resumed  the  occupation of a laborer.
Eighteen days subsequently he was  again admitted with cough and febrile
movement.  He kept the bed for several days after admission, and was after-
ward about  the ward, but remained feeble.   On physical examination of the 
224
REPORT ON  CONTINUED FEVER.
chest a month after the last admission, I found the signs of pulmo-tubereulosis.
This was about the time my service ended, and the history from that date I
have not learned.
   Relapses.   The facts contained in the histories of the cases relating to
relapses, in other words, recurrence of febrile movement, with  more or less
of the symptoms  belonging to the primary career of the fever, several days
after convalescence was apparently established, exhibit a striking  contrast with
the results developed by the first analysis.   In the former Report it is stated
that " in none of the cases  did  relapse occur," and I added, " I have never
witnessed what  might properly be called a relapse after the career of Con-
tinued Fever was  ended."   From my observations up to the time of writing
that Report, I was surprised at the  statements made  by some writers that
patients who had passed through the career of Continued Fever were subject
to relapses. While the cases which form the present collection were in pro-
gress, my attention was frequently called to the  fact that during  convales-
cence, and after patients  had so far  recovered as to sit up, and even walk
about  the ward, they were  attacked with febrile  movement, sometimes pre-
ceded  by a chill,  accompanied  by anorexia, delirium,  etc., these symptoms
continuing for several days, when they again began to  convalesce.  In some
instances  I was  disposed  to attribute this recurrence of fever to imprudence
in diet, exposure to cold, or over exertion, but it  appeared to occur when no
such cause could  be assigned; and as respects the management of convales-
cence, the patients had the benefit of the same precautions and care as those
whose histories were embraced  in  the first collection, and in the  latter this
sequence of the disease  did not occur in a single instance.   Moreover, the
febrile movement, and associated  symptoms, were out of proportion to those
which might  be expected to follow the  imprudences just mentioned.  The
patients, in fact, appeared to pass through  a second febrile career of short
duration.  This relapse of fever occurred in fifteen of the forty-eight cases.
Of these fifteen cases, nine were of the Typhoid type, one was of the Typhus
type, and five were cases of Doubtful type.   I will present a summary of the
recorded  facts in these cases respectively.

                                 Typhoid.

   Case 1. Convalescence was pronounced in this case on the ninth day after
admission. Three days afterward there occurred recurrence of febrile move-
ment, and delirium for two nights.   The last record was made on the seventh
day after the  date of convalescence. 
                     REPORT ON CONTINUED FEVER.                  -'•-<)

  Case 2. The patient was distinctly convalescent on the ninth day after ad-
mission and taking to the bed, and the eleventh day from the date of illness.
•Seven days afterward she had recurrence of febrile movement, tongue became
dry and hard, with anorexia, thirst, etc.  The pulse rose to  128  and 144.
In three clays after the commencement of the relapse of fever, the symptoms
exhibited marked  improvement, and in ten days she was up and about Ui<;
ward.  She left the hospital twenty-seven days after admission.
   Case  3. Convalescent on  the sixth day after admission,  on the seventh
after  taking to bed, and  ten from the commencement  of  access.   Four days
after  date of  convalescence a  relapse  of fever  occurred, skin  hot and dry,
pulse 116, and at  P. M., 128.  The next  day the symptoms exhibited im-
provement, and she was soon again convalescent.   Left hospital twenty-seven
days  after admission.
   Cape 4. Convalescent on the eighth day after admission, and eleventh day
after  attack.   Thirteen days after the date of convalescence it  is  noted that
he had had a slight relapse, but was then doing well.   Left hospital twenty-
nine  days after admission.
   Case 5. Convalescent on the tenth jjay after admission, and thirteenth after
 date  of attack.   Five clays  after date of convalescence, a relapse of fever
 occurred, with anorexia, thirst, pain in  head and limbs, congestion  of face,
 pulse rising to 130.   Continued five or six clays.   Remained  in hospital
 twenty-three  days.
   Case 6. Convalescent on the tenth  clay  after  admission, and fifteenth after
 date  of attack.   Three days after the date  of convalescence, had recurrence
 of febrile movement, epistaxis, etc., without any apparent cause, pulse rising
 to 128.  The relapse  of fever  continued five  or  six days.  Remained  in
 hospital forty-one days.
    Case 1.  Convalescent on  the eleventh  day  after admission, and  date  of
 taking to bed.  Five  days after date of convalescence  attacked with chill,
 pain in head, anorexia, thirst,  dry and hot skin, pulse  104.  The tongue be-
 came dry and hard.  Pulse rose to 130.   Again convalescent  on fifth dr.v
 after second attack.  Remained in  hospital forty-three days.
    Case 8.  Convalescent on 'the seventh day after admission, and eighth after
 date of attack.   He was quite well, and walking ab.-ut the ward, when, eight
 days after the date of convalescence,  he took to the bed, with  chill, pain  in
 head and limbs, anorexia, pulse 116.   Relapse of fever run about five days.
 Remained in hospital fifty-one days.
    Case 9.  Convalescent on  the eighth day after taking to the  bed, ant!
 twelfth after date of attack.   Seven dnys after the date of convalescence, had
                       15 
226
REPORT OS  CONTINUED FEVEK.
return of febrile movement  and kept the bed for ten days.  Remained  in
hospital forty-eight days.

                                 Typhus.
   Case 1.  Convalescent  on  the eleventh day  after admission and taking  to
bed.  Three days after date of convalescence, had return of febrile movement,
which lasted for two days.  Remained in hospital sixty-three days.

                            Doubtful Type.
   Case 1.  Convalescent  on the seventh day after admission.   Five days after
the date of convalescence, attacked with pain in head, and in chest (subster-
nal,) febrile movement, etc.   She kept her bed for ten days, when the symp-
toms again denoted convalescence.  Remained in hospital forty-one days.
   Case 2.  Convalescent  on the ninth day after admission and taking to bed,
and thirteenth after commencement of access.   Five days after date of con-
valescence,  relapse of fever occurred, with epistaxis, and  he was confined  to
the bed eight days.
   Case 3.  Convalescent  on the eleventh day after admission, and sixteenth
from the commencement of  access.  Attacked on day  of convalescence with
chill,  followed by febrile movement, etc.  Relapse  of fever continued five
days.  Remained in hospital thirty-four days.
   Case 4.  Convalescent  on  the  twelfth  day after taking to  the bed, and
thirteenth day after commencement of access.   Four days after date of con-
valescence, relapse of fever occurred, pulse rising to 120.  Four days after-
ward, again convalescent, pulse being, the day before  second  convalescence,
104, and on the day of convalescence, 68.
   Case 5.  Convalescent on  the  eighth clay after admission, the  twelfth day
after taking to bed, and  fourteenth day after commencement  of the access.
Three days after the date of convalescence, relapse of fever occurred, which
continued  about eight days.  During  the  second febrile career the parotid
gland became somewhat swelled, which subsided in a few days, not proceed-
ing to suppuration.
   The occurrence of relapse in nearly one-third of the whole number of cases,
is one of the most interesting of the results of the present investigation.  The
cause, or causes, evidently pertained  to the disease itself, not to extrinsic cir-
cumstances, for the latter, as has been stated, in so far as they were appreci-
able, were  the same as had before existed when in not a single instance was
this sequence noted.   It is  impossible even to conjecture what intrinsic con-
ditions were involved in producing  a special tendency thus incident  to the 
REPORT ON  CONTINUED FEVER.
227
year in which these cases were observed.  The existence of such a tendency
however, is  consistent with the well known  fact that Continued Fever mani-
fests, at different times, and places, certain peculiarities in the predominance
of particular symptoms, the occurrence of complications, and in consecutive
affections.
   Relapses  occurred, it will be perceived, in a  larger proportion  of cases of
 Typhoid, and those of Doubtful type, than of  Typhus.
   Another  point is worthy of notice, viz.,  in  all the cases characterized by
this sequence, the disease finally ended in  recovery.   So far  as these obser-
 vations go,  the occurrence of relapse of fever does not expose the patient to
 new dangers to life.
   The  inquiry  may arise, whether convalescence was not prematurely pro-
 nounced in  those cases in which relapses are stated to have occurred.  Would
 it not have been more correct to have dated  convalescence from the period
 when the so-called relapse of fever terminated?  To do so, would, of course,
 do away with the occurrence of relapses.   This inquiry suggests another fact
 in this  section, viz., the remarkably short average duration in the  cases in the
 present collection.   This fact may seem to show that the career of the fever
 was not really ended in those cases in which convalescence was considered to
 be established, but in which febrile  movement  recurred  after an interval of
 from two to five days.  If the duration of  the disease in these cases was esti-
 mated  from the commencement to the date when convalescence was declared
 a second time,  it would affect considerably the average, and bring it  nearer
 that developed by the first analysis.  According to this view, the peculiarity,
 in the  present collection of cases would consist in the frequent occurrence of
 a kind  of  pseudo-convalescence, or remission of febrile symptoms for several
 days.   But, in  opposition to  this view, it is to be considered, that, in the cases
 referred to, the evidences of convalescence, at the time it was first  pronounced,
 appeared  to  be unequivocal, and, in some  instances, the patients  sat up, and
 even walked about the ward before the relapse of fever became developed.
 Moreover,  if the first were not a true convalescence, it would be expected that
 in the cases characterized by relapse of fever, the duration of the disease, prior
 to the first convalescence, would be in a notable degree less than the average
 period.  I have computed the  mean duration in these cases prior to the first
 convalescence, and find it to be 9  1-15 days.   This is somewhat shorter  than
 the average duration in  all  the cases, which  was  10 6-11  for the Typhoid
 cases,  and°ll 1-4 for the cases of Typhus.  The difference is not sufficiently
 great  to militate much against the propriety of regarding what I have called
 the relapse of  fever, as a recurrent febrile attack, rather than a continuance of 
228
RETORT ON  CONTINUED FEVi-IK.
the primai'y disease.   With respect to this point, however, there may be room
for difference of opinion.
   Note.   Since this Report was completed, my attention has been called to
the views of Dr. Jenner, and some other British writers, on the subject of a
distinct variety or species of fever, distinguished  by the title  of  Relapsing
Fever, characterized by a tendency to relapses, and other peculiarities.   It
may be a question whether the cases in the  present  collection in which
relapses occurred, do not belong  to  a distinct type of Continued  Fever.   I
propose to analyze these cases in order to ascertain if they are marked by any
other distinctive traits than the occurrence of relapses.   For the results of
this analysis, and some remarks on the subject of Relapsing Fever, the reader
is referred to the Supplement to the Reports.
   Mode of Dying.  The modes of  dying, which in this, as  in the first Re-
port, will be considered to be resolvable either into asthenia or  apnoea, are
exhibited in the following tables:

                          Seven Typhoid Cases.
   Case 1.—15th day after  date of first  record.  Asthenia.
     " 2.—5th day after admission.  Apnoea.
     " 3.—17th day after  admission.   (Perforation) Asthenia.
     " 4.—4th day after admission.  Not ascertained.
     " 5.—9th clay after admission.  Asthenia.
     " 6.—38th day after admission.   (Peritonitis) Asthenia.
     " 1.—2d day after admission.   (Apoplectic  coma) Apnoea.

                           Four Typhus Cases.
    Case 1.—53d  day  (consecutive  dysentery) after admission.   Probably
             Asthenia.
      "  2.—17th  day after admission.   (Pneumonitis  set in on 12th day,
             when symptoms augured convalescence.)   Apnoea.
       "  3.—9th clay after admission. Apnoea.
       "  4.—9th day after admission. Apnoea.

    Fatality.   The  number of cases  that proved  fatal, (eleven,) has already
  been  stated, and repeatedly referred to.   The ratio is a fraction over twenty-
  two per centum.  The percentage of fatality is  somewhat greater than in the
  former collection  of cases.  In connection with this point, the remark made
  in the former Report is applicable, viz., the proportion of fatal  cases would
  have been less, had not all cases in which it was supposed there was any 
REPORT ON  CONTINUED FEVER.
229
room for doubt as to the diagnosis, been excluded.   Some cases which were
probably cases of Continued Fever were thus not embraced in the collection
and none of these were fatal cases.   In a few instances, moreover, the histo-
ries were not  recorded, or were found  to be too incomplete to be available
for the analysis.   This also applied only to cases which recovered.
   The ratio of fatality was considerably greater in the cases of Typhus, than
in those of Typhoid, the  proportion being as 4 - 10, or 2 - 5, is to 7 - 29, or
a little less than one-quarter.
   In the whole  number of cases in both collections, the proportion of fatality
is twenty-two per centum.
   Adding together the cases  of  Typhus and Typhoid, respectively, in the
two  collections,  and  the result is, fifty-nine  cases of Typhoid, and  twenty-
three cases of Typhus.  The  ratio of fatality to the whole number of cases
of each tj-pe, thus  added, is  as  follows:  Of the fifty-nine Typhoid cases,
twelve were fatal, i.  e. a fraction over twenty per centum.
   Of the twenty-three cases of Typhus, eight were fatal, i. e. a  fraction less
than thirty-five per  centum.
   These observations, thus, show in the two collections, separately and con-
jointly, a proportion of fatal cases considerably  greater in the Typhus, than
in the Typhoid type of Continued Fever.
   The fatality from Continued Fever at different  times, even when  patients
are placed in  the same situation, and exposed to  similar influences of hygiene,
treatment, etc., has been found to undergo considerable fluctuations.   This  is
shown in  the Report  of Dr.  Jackson,  of Boston, of the cases  of Typhoid
fever received at the Massachusetts  General Hospital, for fourteen consecutive
years.  The variations in fatality  during that period, from year to year, were
between a minimum of a proportion of 1 to 3 1-2, and a maximum of a pro-
portion of 1  to 25 !   Subsequently, at the same hospital, of fifty-five succes-
sive cases received from Nov.  1836, to Nov. 1838,* not a single death occur-
 red!  Louis states that a third of the patients, observed by him, affected
with Typhoid fever, have died.  These facts suffice to illustrate the  striking-
contrasts as respects the rate of mortality that are presented in different years,
contrasts which can only be accounted for by differences in the tendency to
a fatal issue inherent in the disease at different  periods.   This feature in the
history of Continued Fever, is  not only interesting, but one which it is highly
important should be borne in mind when  we would estimate the effect  of
 therapeutical, and other  agencies, by the proportion of fatal cases.
* Hisorv, etc., of Fever, by Prof. Elisha Bartlett. 
230
REPORT  ON CONTINUED  FEVER.
  The deaths that occurred during the period in which the present collection
of cases was made, were by no means equally distributed among the several
months.   Of the eleven Typhoid cases in the month of October, four were
fatal.   Of the eight cases in November, all recovered.   Of the eight cases in
December, three were fatal.   The  fatal  Typhus cases  were as follows:  the
only two cases that  occurred  in  October, and two of five cases in  March.
Two cases which  occurred in December, and one case in April recovered.
  The number of cases, although few, suffice to exemplify a greater tendency
to a fatal result in some of the successive months of the same season  than in
others, a fact already developed by more  extended  observations.

                           SECTION  TWELFTH.
                       Examinations after Death.
  In  the  instances in which examinations after death were practicable,  the
objects were necessarily limited to the disclosure of characteristic lesions, in
order to verify the diagnosis, and to exhibit them in connection with  clinical
instruction at  the  hospital.   Want of leisure, and of proper facilities pre-
cluded complete autopsical investigations  embracing an  inspection of all  the
important organs of the body.   The examinations were generally confined to
the small  intestine, mesenteric glands  and spleen, in some cases extending to
other parts to which  prominent symptoms during the progress of the disease
were referable.
  Examinations, limited as just stated, were made in five of the seven fatal
cases of Typhoid, and in two of the four fatal cases of  Typhus.
  The morbid appearances, so  far as noted  in the histories of the  cases,
respectively, are as follows:
                                Typhoid.
  Case 1. Death on  the fifteenth day  after the date of the first record.
Patient a porter in  hospital, and had been in hospital for some time for
chronic ulcer of the leg.  Mode of dying by asthenia.  Intellect clear a short
time before death.
  Abdomen.   The ilium presented a series of oval excavations  situated in
the Peyerian patches,  the largest, near the coecum, being about an inch and
a half in length, and three-fourths of  an  inch in width.   The mucous  mem-
brane was destroyed  over this, and  several of the excavated spaces above, and
their surfaces appeared to be covered with a very delicate, transparent serous-
like membrane, beneath which could be seen the fibres of the muscular  tissue
of the intestine.   The Peyerian patches removed a few  feet from the  coecum,
were thickened and  softened, not ulcerated.   Several of the solitary glands, 
                      REPORT  ON CONTINUED  FEVER.                 231
situated  in  the  lower portion  of the small intestine, presented the sites of
ulcerations, or excavations, the  surfaces covered with a delicate  membrane.
   Mesenteric glands enlarged.   Peritoneal cavity contained about  a pint of
turbid serum.
   Spleen enlarged and softened.
   No note of other morbid appearances.
   Case 2. Death on the seventeenth day after admission.   Perforation of
intestine.
   No note of the appearances in this case was made until four weeks after
the  examination.   It was omitted throngh inadvertence.  The facts noted
after the interval just mentioned, are the following:  The ilium exhibited the
characteristic lesions of Peyer's patches, the ulceration being, for the most
part, cicatrized.   A perforation in one of the ulcerated spaces was discovered.
The perforation, manifestly, was not  from progressive ulceration through the
coats, but from  rupture, the points at which it existed being cicatrized.
   Mesenteric glands enlarged.
   Spleen enlarged and softened.
   Evidences of peritoneal inflammation existed, viz., effused serum and fibrin.
   Case 3.  Death on the morning of the fourth day after admission.   Had
 been ill about  ten days prior to  admission.   Active  delirium existed before
 admission.   Mode  of dying  not determinable  by the history.   Autopsy
 twelve hours after death.
   Head.   Some subarachnoid effusion, and  about an ounce of serum (esti-
 mated) in arachnoid cavity.   Moderate congestion  of vessels  of brain.   No
 effusion of fibrin, or opacity of arachnoid.
   Abdomen.   The ilium inspected  for the space of  about  three feet above
 :che ccecum.  A large ulcerated patch of Peyer close to the coecum, project-
 ing from two to three lines above the plane of the mucous surface, and pre-
 senting a granular, jagged  appearance.   Above  this point  the  Peyerian
 patches were salient, presenting an ulcerated  surface, but, progressively, less
 and less in ascending the tube.
   Numerous solitary glands projecting and ulcerated.
   Mesenteric glands greatly enlarged — as large as filberts nigh to the coecum.
   Spleen enlarged, but did not appear to be abnormally softened.
   Heart normal.
   Case 4.  Death on the ninth day after admission,  date of  commencement
 of febrile  career  not ascertained.   Mode  of dying  by asthenia, pulse
 becoming extinct several hours before death, and mind apparently clear-
 Complicated with pneumonitis.  Age of the patient  about fifty years. 
REPORT ON  CONTINUED FEVER.
    Head.   Not examined.
    Chest.   Lungs on left  side presented deep engorgement.  In the right
 chest the inferior lobe nou-crepitant, oedematous, pitting on pressure; copious
 sivous exudation  on section, not  spumous.  About  a pint of turbid seiuin
 contained within right chest.  Slight fibrous exudation on pleural surface of
 th.. tolidified lobe.  The remaining lobes crepitant, and not greatly congested.
    Abdomen.   Ilium  presented Peyerian and  solitary glands ulcerated, but
 in process of cicatrization, the surfaces being smooth, not granulated.
    Affection of Peyerian glands gradually diminishing on ascending the tube.
    Mesenteric glands moderately enlarged.
    Spleen of about medium size, and softened.
    Kidneys normal.
    Liver presented no abnormal appearances.
    Case 5.   Death, on  the  second morning after admission, in apoplectic
 cor.-ia.  Had been ill four or five days before admission, but it is not stated
 whether confined to the bed or not.  Age of the patient thirty-eight.
    Head, first examined.
    Considerable congestion  of  vessels  of brain.  Moderate increase of sub-
  ir elmoid effusion.  Aleut an  ounce of serum in arachnoid cavity.
    Chest.  Left lung firmly adherent with  old pleuritic attachments.  Con-
> side.'able engorgement of lungs.
    Heart normal.
    Abdomen.   Ilium  contained  thin  yellowish matter.   Peyer's patches-
 pn >niinent, and mucous tissue softened.
    Mesenteric glands  not  enlarged.   Solitary glands or lower part of ilium
 enlarged, giving  the  appearance of a papular eruption.  Other portions of
 mucous tissue  presenting nothing morbid.
    Spleen enlarged and softened.
    Kidneys enlarged, fiaLby, presenting some degree of granular degeneration.

                                  Typhus.
    Case 1. Death on  the  seventeenth day after admission, and twenty fir at
 after date  of attack.   Symptoms of pneumonitis on the twelfth day after
 admission.   Mode of dying, by apnoea.  Examination sixteen  hours after-
 death.
    Chest.  Inferior lobe in left chest completely solidified.   Pleuritic adhe-
 sions over this lobe.   About half a pint of turbid serum in left pleural cavity.
 Upper lobe free  from disease.   Right lung free from disease.   Hypostatic
 congestion of lower lobe. 
                     REPORT  ON CONTINUED FiVEI*.                 233

  Heart presented no morbid appearances.
  Abdomen.   Ilium inspected for several feet above the ccecum.  A single
Peyerian patch nigh to the ccecum developed so as to be visible, presenting
the shaven beard appearance.   None other discoverable.  The mucous sur-
face through the whole  space inspected, presented  a series  of arborescent
vessels, the direction being transverse as respects the intestine.
  Mesenteric glands not enlarged.
  Spleen about medium  size, and softened.
  Case 2.  Death on the ninth day after admission and date of taking to bed,
and eleventh  day from commencement of access.   Mode  of dying, by apncea.
  Abdomen.   Peyerian patches developed so as to be visible.
  Mesenteric glands very slightly enlarged near the ccecum.
   Spleen not enlarged, nor softened.
   Kidneys, liver, and heart, presented no morbid appearances.
   As the correctness of the diagnosis is an important point, taken ii connec-
tion with the intestinal  appearances  on the two fatal  cases of Typhus in
which examinations were made, I will give a succinct statement of the symp-
toms, in  the  history of each, which have an  especial bearing on this point.
   Case 1.  In this case diarrhoea did  not occur.   Much of the time the abdo-
,men was flaccid, but occasionally slight tympanites.   Slight tenderness existed'
   On the eighth day a faint maculated eruption was  apparent.   It was visi-
ble for three days.   Its characters are not minutely desciibed, but rose spots
and maculae  are sail to have been intermingled.
   Epistaxis did not occur.
   Muttering delirium was a prominent symptom, raid became developed  on
second day after admission.
   Capillary  congestion of the surface was marked.
   Case 2. Diarrhoea was not present in this case, nor tenderness, save that
an  one day  he made complaint when firm pressure  was made  over the
abdomen.   Slight  meteorism  existed at first, but not afterward.
   Delirium was a  nior.iinent symptom, consisting in incoherent muttering,
and efforts to get out of bed.
   The face presented deep congestive redness.
   On the second  day after admission  and  date of taking to bed, a copious
dusky eruption appeared.over  the abdomen  and chest, extending to the upper
and lower extremities.   The eruption was maculated, redness not disappear-
ing on pressuie.  The eruption in this case was very copious, being  almost
confluent over the abdomen, and extended over the upper extremities, even to
ihe back of  the hands. 
 
                SUPPLEMENT
                              TO

REPORTS  ON CONTINUED  FEVER.
SYMPTOMS DISTINCTIVE OF TYPHOID AND TYPHUS FEVER.
    IDENTITY OF THESE TWO TYPES.  DIAGNOSIS, ETC.

  In the preceding investigations, Continued Fever is considered under two
forms, or types, distinguished by the names of Typhus and Typhoid.   It has
been a  leading object in these investigations  to study the symptoms, etc.,
belonging to each of these types, separately, and by comparison as respects
the results developed by analytical examination.  Connected with this noso-
logical subdivision of Continued  Fever are several questions of interest and
importance, the discussion of which would have been out of place in Reports
devoted  to historical facts, but which  invite  supplementary consideration.
These  questions pertain to — 1st. The  propriety of the division into Ty-
phus and  Typhoid fever, and  the  validity  of the distinctive  symptoms
upon which that division  is  based; 2d. The  essential identity or non-iden-
tity of  Typhus  and Typhoid fever, and the relationship^ existing between
the two types; 3d.  The diagnostic traits involved in the discrimination of
Typhus and Typhoid fever from each other, and of Continued Fever from
other affections.
   What views relating  to the foregoing subjects are most consonant with
the results and conclusions set forth in  the two Clinical Reports that have
preceded ?   In  the few  remarks which will  follow, I purpose to confine my-
self, mainly, within the  scope of this inquiry,  not professing to measure the 
236
SUPPLEMENT  TO
range of discussion  by the amplitude of the subjects,  nor undertaking to
collect from available sources all that has an important bearing thereupon.
  A brief sketch of the symptoms distinctive of Typhus and Typhoid fever
which are embraced in the two Reports, will form a proper preliminary to a
consideration of the several points just named.   In order to study the phe-
nomena of  the  two types separately, and comparatively, it  was, of course,
necessary, as a primary step, to make the distinction of type, and arrange the
cases in corresponding groups.  In so doing, it  is obvious that  the  existence
of symptoms distinctive of either type is predetermined, and the results of the
comparison of the two types, in this respect, in a measure forestalled.  The ap-
plication of rules for discriminating between the two.types is thus to be made
in collecting facts which are to test the correctness of these rules.   This was
unavoidable, but it will be found to have had its advantages, showing in how
far  obvious external  distinctive symptoms are  practicably available for the
discrimination.   In classifying cases in order to bring the results of the anal-
ysis of each  type into comparison with those of the other, it  is  evident  that
accuracy of discrimination is indispensable.  Unless cases which are grouped
as Typhus and  Typhoid are correctly collocated, the conclusions cannot fail
to be erroneous.  With reference  to this point, as stated in  the Reports, all
cases in which there appeared any room for  uncertainty respecting the type
to which they belonged, were  classed by themselves under the head of cases
of  Doubtful type.   In this way, it  is presumed, the liability to error on the
score just  mentioned, was obviated.  In making  the discrimination  practi-
cally, those rules were followed which are laid  clown by late  writers, and more
especially in the able and lucid treatise by Prof. Bartlett.
  In proceeding to give, succinctly, the more important of the facts, contained
in the two Reports,  which appear to present traits  distinguishing the two
types from  each other, it will be  convenient to follow an  order of arrange-
ment corresponding with the successive sections in both Reports.

  SUMMARY  OF  SYMPTOMS DISTINCTIVE OF TYPHOID AND  TYPHUS  FEVER.
  Age.  The maximum  and  mean age higher in  Typhus  than in  Typhoid.
  Nutivity.   In Typhoid, patients  foreign immigrants  from different coun-
tries, with a certain  proportion of citizens of  this country.   In  Typhus, for-
eign immigrants except  when the disease is communicated by contagion, and
almost invariably the immigrants  recently from Ireland*

  * It will be borne in mind that this summary embraces the conclusions deduced from
the facts contained in the previous Reports.  "Were it extended so as to embrace con- 
REPORT  ON CONTINUED  FEVER.                 237
  Season.   The  liability to Typhoid  much greater during  the  autumnal
months;  Typhus equally and even more apt to occur during  other portions
of the year.
  Duration  of disease prior  to  admission  into  hospital.   In a  marked
degree shorter in  Typhus than in  Typhoid.
   Symptoms of access.   Diarrhoea present in a certain proportion  of cases
in Typhoid during the access, not in'Typhus.
   General aspect.   Capillary congestion of the face, extending frequently
to the extremities, and more or  less over the body, causing a dull red color,
present in all cases  of Typhus, and in a  large proportion of the  cases of
 Typhoid;  but the congestive redness  greater in Typhus than  in  Typhoid,
and presenting in some cases of the former type a  dusky or dingy hue.
   Nervous System.   Passive delirium, manifested by incoherent talking,
 muttering, attempting to get out of bed, etc., present more constantly in Ty-
 phus; developed earlier in the progress of the febrile career in Typhus; but
 very active, persistent delirium, requiring  forcible  restraint, characteristic of
 Typhoid.
    Cephalalgia, oftener present after  the  fever becomes  established,  an 1
 longer in duration in  Typhoid, (? see  second Report.)
    Vascular injection of conjunctiva oftener present in Typhus, (? see first
 Report.)
    Deafness, present in a proportion of cases larger in  Typhi's.
    Digestive System.  Appetite, or relish of food,  oftener present in Typhus,
 (see second Report.)
    A reddened tongue, occasionally observed in  Typhoid, and not  in Typhus.
    Sordes present in a larger proportion of cases of  Typhus.
     Vomiting, more apt to occur in Typhoid.
    Diarrhoea, present in one-half of the cases of  Typhoid, and in one-third
 of the cases of Typhus; in the  latter type always mild or slight, but  in the
  former  sometimes prominent as a symptom.
    Haemorrhage from the bowels, characteristic of  Typhoid.
     Tympanites, present in about an equal ratio in both types; but in Typhus
  almost  invariably slight, while in Typhoid it is often prominent.
     Tenderness on pressure over the abdomen, an almost constant symptom
  in Typhoid, and less frequently present in Typhus.   In the latter usually
  slio-ht,  and in the former more apt to be marked, or considerable  in degree.
  elusions deduced from facts contained in other analyses, it would not only comprehend
  additional distinctive symptoms, but some of those which it  embraces might require
  qualification.  This note is suggested by what is stated  under the head of nativity. 
238
SUPPLEMENT  TO
  Peritonitis from perforation of intestines, peculiar to  Typhoid.
  Eruption.  An eruption present in a larger proportion of cases of Typhus:
more abundant in Typhus, frequently very copious, and  extending over the
upper extremities, as well as on the trunk; in Typhoid seldom copious, often
only sparely scattered  over  abdomen and  chest, and not present in the
extremities.  The character of the eruption as follows:  In  Typhoid, rose
colored, oval, slightly elevated, redness momentarily disappearing on pressure.
In Typhus, of a  dull red color, smaller in size, not elevated, redness imper-
fectly disappearing on pressure.  These characters preserved in the two types
in the great majority of cases.  Occasionally  slight variations, and some inter-
mingling of the two kinds of eruption.
  Respiratory  System.  Cough more uniformly present in  Typhus (1).
  Pneumonitis more apt to be developed in Typhus  (?).
  Epistaxis extremely  rare  in  Typhus, occurring frequently in Typhoid.
Sputa  detached from  the posterior nares  apt  to be tinged  with blood iu
Typhoid, not  in  Typhus.
   Circulation.   Greater frequency of the pulse in Typhus than in Typhoid.
The average frequency  of the former exceeding an hundred  per minute, in
the latter falling below that number.   Instances of great increase in frequency
occurring oftener in Typhus.
   Skin, exclusive of eruptions and congestive redness, not presenting symp-
toms distinctive of  either type.
   Duration, longer, before  death, or convalescence, in Typhoid, than in
Typhus, this  rule being subject  to variations, owing to  an unusually short
duration of the Typhoid type at some periods.   (See second Report.)
   The foregoing  summary contains several striking  points  of contrast per-
taining to the symptomatology of the two types of Continued Fever, corre-
sponding in the main with facts heretofore contributed by different observers.
In no  important particulars do the results of the preceding analyses directly
conflict with those  which furnished  the  distinguishing traits of Typhus  and
 Typhoid fever as laid  down in the treatise by Bartlett  and  some other  sys-
tematic works.   In  so far as  these results go, they concur in sustaining the
correctness  of this nosological division of Continued Fever, and exemplify the
distinctive symptoms upon which it rests.
   It is, however,  to be borne in mind, that in arranging  the cases for analy-
sis, a certain number were classed  under the head  of Doubtful type;  and
the question arises, why were not the symptoms  distinctive of Typhus  and
 Typhoid applicable to these as well as to  the others ?   This is a question
not to be overlooked, but it will be more appropriately considered in connec-
tion with the  subject of diagnosis, and is, therefore, for the present deferred 
REPORT ON  CONTINUED FEVER.
239
  The lesions found  after death in the two types supply important distinc-
tions.  But aside from these, the propriety of the nosological division seems
sufficiently established; and they will be more especially  involved  in  the
subject next to be considered.

                IDENTITY OF  TYPHUS  AND TYPHOID FEVER.
  It has been, of late years, a mooted  question,  even with those who recog-
nize the propriety of  the nosological division of Continued Fever into  Ty-
phus and Typhoid, whether these two types are essentially identical, or not.
What  relationship  do they sustain  toward each other?   Are  they simply
varieties of one  disease, or are they distinct affections?   These inquiries claim
a few remarks.
   In the summary of distinctive traits which has been presented, facts appear
to show the  existence of  different laws as respects age, season, duration, and
 various symptoms  pertaining to the  several  anatomical systems in which
 these symptoms are  distributed.  These facts concur with  those developed,
 in the same  manner, on a more extended  scale,  by other analyses.  The lat-
 ter, moreover, appear to show additional laws pertaining  to the causation,
 transmission  by contagion, etc., which  it does not fall within my present  plan
 to consider, having restricted  myself,  mainly, to the results of the analytical
 investigation of the limited number of cases  embraced in my  own collections.
   Both Typhus and Typhoid may  be considered, in a measure, eruptive
  fevers, and  in  all  eruptive affections, difference  in the character of the erup-
  tion, provided  it be marked, and constant,  is regarded  as  denoting a differ-
  ence in  the  character of the  disease.   Now, the characters belonging to the
  Typhus  and Typhoid eruptions are by no means identical.   The resem-
  blance is hardly greater than between Scarlatina and Rubeola in this respect.
  As a general rule, also, it would  seem that the eruption  peculiar to either
  type maintains its distinctive characters, but this rule is not invariable.   An
  eruption is occasionally observed presenting a combination of  the characters
  belonging to both types.  Such instances are probably few,  and perhaps  do
  not oftener occur, and  not to  a greater extent than in measles and scarlet
  fever.   In this connection it may be  remarked that the fact of the distinctive
  traits  pertaining  to the  eruption, and  other symptoms, having  been so
  recently pointed out, cannot  be considered  as evidence against the non-iden-
  tity of  Typhus and Typhoid fever, for, with respect to Rubeola and Scarla-
  tina, although  no one now regards them as merely different varieties of  the
  same disease,  it is  but  little more than half a century since they were so
  regarded, and  at  a period not  very remote, small pox was included in  the
  same category. 
240                         SUPPLEMENT  TO

   The lesions found  after death have an important bearing  on the present
subject.   On behalf of  the non-identity  of  the two types, it is  claimed  that
Typhoid fever is characterized by special morbid  changes seated in the aggro-
gated and solitary follicles of the small  intestines, accompanied by enlarge-
ment of the mesenteric glands.   The spleen, also, is  said  to  be generally
enlarged and  softened.   These lesions, more  particularly the intestinal, it u
stated, are peculiar to  Typhoid  fever, being uniformly found after death, in
cases proving  fatal, and not  found in bodies dead with other acute diseases.
In  Typhus, on the other  hand,  these lesions, especially those noted in the
follicles, are declared  to be invariably absent.
   On this subject the preceding  Reports contain the results of a few obser-
vations, upon  which,  as yet, no remarks have been  offered, notice of  them
having been reserved  for this connection.  Of the fatal cases, the bodies were
examined with particular reference to the lesions  deemed to be  characteristic
of Typhoid fever in twelve.  Of  these cases, nine had been classed under the
head of Typhoid, judged by  the symptoms, and three under the head  of
Typhus.
   On reference to the description of  the morbid  appearances in these cases,
severally, it will be seen that in each of the  nine  Typhoid cases  there existed
notable changes in the intestinal  follicles  accompanied  by corresponding
degrees of enlargement of the mesenteric glands.   The follicular lesions con-
sisted either of considerable tumefaction, rendering the patches very prominent
and salient, clue manifestly to a deposit of some morbid material in these parts,
the surfaces being more or less roughened or presenting a granular appear-
ance, in other  words  ulcerated; or there existed  in the sites of the follicular
patches depressed  spaces  which  presented in some instances  an ulcerated
aspect, and  in other instances a smooth  healthy  surface.   The latter appear-
ance seemed  to have resulted from an elimination of the morbid material
producing the appearances first  mentioned, a kind of sloughing, with a cor-
responding  loss of substance, or ulcerated  excavations, which  subsequently
healed.   I have observed, although I have failed to record this fact, the slough-
ing process just referred to, partially completed in some patches, a portion of
the patch being excavated, and the remainder still occupied with  a material
apparently in  the process of separation.
   The changes in the spleen were less constant.   This organ, however, as is
well known, varies considerably in bulk within the limits of health, and alter-
ations in consistence are less appreciable than in other parts of greater normal
firmness of  structure.
   In each of the three Typhus cases, on the other hand, there existed changes 
REPORTS ON  COOTINTTED FEVER,
241
in the follicular patches, accompanied, in two cases, by very slight enlarge-
ment of the mesenteric glands.   The follicular lesions, however, were insignifi-
cant in comparison with those observed in the Typhoid cases.   The patches
were simply developed so as to be visible.   They were slightly hypertrophied,
not projecting several lines above, or depressed below the level of the mucous
surface, as in the Typhoid cases, and in no instance presenting an ulcerated
aspect   The  contrast, indeed, was  scarcely less striking than  if,  in  the
 Typhus cases,  the follicles had remained invisible.
   The united number of observations, thus, which are contained in the pre-
ceding Reports sustain the existence of characteristic lesions of the intestinal
follicles  and mesenteric glands in Typhoid  fever, but they also show that
these parts do  not always continue wholly unaffected in Typhus.   The fatal
cases of the latter type, in which post mortem examinations were made, are
 few in number, but they are sufficient to establish the fact that the intestinal
 follicles  and mesenteric glands may be, to some extent affected in that type,
 provided it be certain that the diagnosis of the cases was correct,  and of this
 fact ample evidence  is adduced from  the histories  in connection with the
 descriptions of the post mortem appearances.
    As before stated, the  present scope of inquiry  does not embrace a collec-
 tion and critical examination of all the available facts bearing on the point
 under consideration which have been contributed  by different writers.  It is
 well known, however, to those  at all  conversant with the literature of the
 subject, that several distinguished observers have testified to the invariable
 absence of the abdominal lesions of  Typhoid fever in numerous cases falling
 under their observation  in which, during life, were presented  the symptoms
 distinctive of  Typhus.  The  most remarkable testimony of this description
  is by Dr. Gerhard, of Philadelphia, to whom, more than any other individual,
  is due the merit of having pointed  out the distinguishing features belonging
  to Typhus, contrasted with Typhoid, derived  from the study of the symp-
  toms  during  life,  as  well as the post mortem  appearances.   In  over fifty
  autopsies he  found no deviation  from the normal condition of the Peyerian
  glands except in a single instance, and in that case the diagnosis* was doubtful.
  =  On the other hand, cases have  been reported in which the follicular glands
  of the intestine have presented  more  or less alteration  in  cases in which,
  during life, the peculiar eruption, and  other symptomatic characters of Ty-
  phus were observed.  The most remarkable testimony of this description is
  by M. H. Landouzy, of France, who affirms, that in an epidemic at the prison

                         * Am. Jour. Med. Sciences, 1837,
                 16 
242
SUPPLEMENT TO
of Rheims, during which one hundred and thirty-eight cases occurred, the
histories  embracing the characteristic  eruption  and other distinctive  fea-
tures of  Typhus, six  autopsies were made, and  the elliptical plates of the
ilium, in all, found to be  either thickened, elevated, or ulcerated*  Prof.
Bartlett,  who advocates the opinion that the two types are radically distinct
affections, admits that the paper of M. Landouzy throws some doubt on the
subject.  Without having seen the original  paper it would  be unfair to offer
criticisms, or to conjecture  sources of error.  The remark, however, may be
admissible, that in accepting results which, in the  present position of the sub-
ject, are  so important in their bearings, it should be understood, in the first
place, that the symptomatology of the cases was deduced from recorded data,
and more especially that the histories of the six fatal cases referred to were
noted at the bed side;  and, in the second place, that the  appearance of the
intestinal lesions were fully described.   In the  absence of that  confidence
arising from personal knowledge of the historian, the above  precautions are
requisite as  a guaranty, on the  one hand, that, in  the epidemic described,
cases of both types  of Continued Fever were not  intermingled  and con-
founded, and, on the other hand, that the follicular intestinal changes were
not within the limits in which, as must be admitted, they may be present in
fatal cases of well marked Typhus.  From the abstract of the paper given
in the treatise by Bartlett, it does not appear whether the account of the epi-
demic is based  on an  analysis of recorded observations, or  not.   By these
remarks I would by no means be  understood to  express the opinion that
observations must necessarily be recorded to merit any confidence, or possess
value.    Such an opinion would be as absurd, as  that all observations which
are  recorded, as a matter of course, are reliable and important.   The idea
intended to be conveyed is, that  every provision  for  accuracy  should  be
required  before  accepting, as  valid, observations which conflict materially
with other well-authenticated  facts, and in the correctness of which highly
important principles are involved.
   The following extract from an article contained in the British and Foreign
Medico-Chirurgical Review, [No. for July, 1851, Am. Edition, page 26,] give9
a fuller account of the facts reported by M. Landouzy, than I have met with
elsewhere.  The article referred to had  not appeared when  the  foregoing
remarks  were  written.  The  reader will doubtless concur  in the opinion
expressed by the reviewer in the closing sentence of the extract:
   " Seventeen cases died, of whom six only were examined, and only two
cases are recorded.   The  first case was indubitably typhus; the mulberry

         * Bartlett's Treatise, from Archives Generate* de Medicine.   1842. 
REPORTS ON CONTINUED FEVER.
243
rash was well marked.  Landouzy says he ' looked in vain for the rose-spots
of  typhoid  fever  which  existed  among  other  patients.'   Nevertheless,
at the  necropsy he  found alteration of  Peyer's  patches.  But after care-
ful examination of  the report, we have great doubt on this head:  The small
intestines were first examined by M. Chabaud and two other physicians, and
pronounced  to  be sound;  then M. Landouzy entering and re-examining it,
detected what he considered evidence of incipient change in Peyer's patches,
with general slight tumefaction of the solitary glands.  But we doubt whether
M. Landouzy has  made out his case; the alterations he  signalizes  are  not
sufficiently defined to bring it within Louis' definition of typhoid fever.*
   Now, since these are the only two  recorded cases, and neither of them is
satisfactory, and since only four other post-mortem examinations were made,
the details of which are not given, and the value of which is, therefore, neces-
sarily shaken by the exception we must  take to the two recorded cases, we do
not think we can do otherwise than consider that the importance of this me-
moir of M.  Landouzy has been very  much overrated, and that the facts
recorded in it cannot be received without the greatest doubt, as evidence on
this pointf   We  feel no hesitation, then, in  putting this  memoir aside, as
being indefinitely precise, and based  on  far narrower details than the writings
on the  other side of  the subject."

   That the intestinal follicles may become affected in some manner, and to
a greater or  less extent, in Typhus, is certain.  But it is, perhaps, a question
yet remaining to be settled definitively,  whether in  Typhoid fever these parts
are not the seat of lesions of a special  character which are never found in
 Typhus.   Putting aside  the  paper of M. Landouzy, I cannot refer to any
observations showing  the existence of lesions corresponding to those presented
in the nine fatal Typhoid cases the histories of which, with the autopsies, are
embraced in my collections, when it was perfectly clear, from the symptom*
noted at  the  bed  side, that the  disease was of the Typhus type.  I do not
affirm that no such observations have been contributed, but only that, if they
exist, I am unable to refer to them, not professing to have bestowed, in  con-
nection with this discussion, sufficient  search to warrant a  positive assertion
that they are not to be found.
   Another question  arises in connection with  the subject of the abdominal
lesions in Continued Fever.  It is this: —Assuming that changes character-
istic of Typhoid fever exist, are  they uniformly present  in cases  of that type?
  * The appearances Landouzy describes are perfectly well known to the German ob-
servers as dependent on a "catarrhal condition" of the intestinal mucous membrane,
which may occur in typhus, as in pneumonia, or any acute disease.  No accurate
observer could confound this with typhoid deposit in and under Peyer's patches.
  t Landouzv himself perceives so many differences between typhus and typhoid fever,
that in sDite of his belief that he had found the anatomical sign of typhoid in typhus,
he wHto  "I findI between the typhus of Rheims, and the typhoid fever, too striking
diffwpiK-es to allow me to regard these two maladies as identical."   He says, however,
that they are analogous, but not identical 
244
SUPPLEMENT TO
 They are, of course, only susceptible of demonstration in cases proving fatal,
 by examinations after death.  Is more or less disease in the follicles  and
 mesenteric glands an essential constituent of  Typhoid Fever?  This ques-
 tion  involves a  correlative  inquiry, viz., are  cases of  Continued  Fever in
 which the follicles are unaffected necessarily cases of Typhus?  These ques-
 tions are important, but the  Reports to which  these remarks are supplement-
 ary, do not contain any facts  bearing  upon them.   Louis, whose researches
 established the significance of these lesions  as the " anatomical characteris-
 tic" of Typhoid fever, evidently formed the conclusion that they constituted
 an essential element of the  disease, before the analysis of the cases in his
 collection was completed, for  he  excludes cases  in which were present the
 important symptoms of the disease, but in which the intestinal lesions were
 absent.   He classes such cases under the  head of "Simulated cases of Ty-
 phoid affection."   In the remarks succeeding the history of one of the cases
 under this caption, he holds the following language:  " This fact presents, as
 we see, the union of almost  all the characteristic symptoms of the Typhoid
 affections.  At  the commencement there was diarrhoea, alternating  with
 drowsiness and delirium; shortly after there  were  pains of  the  abdomen,
 more  or less  decided meteorism, which continued  until death; after these,
 eschars on the sacrum and great trochanters, and return of delirium.  What
 more was wanting to make us certain that the patient was affected with the
 Typhoid disease, and that we  should find, on  opening the corpse, the ellipti-
 cal patches of the small intestine  more or less seriously altered?   Notwith-
 standing this, the  patches  and the corresponding mesenteric glands were
 healthy, and with the exception of a small extent of the mucous  membrane
 of the colon, the whole intestinal canal was natural,  and how, then, can we
 admit that this patient had the Typhoid affection" *
   It is clear from the above quotation, a portion of which I  have italicized,
 that, after proceeding a certain length in his investigations, Louis fixed upon
 the intestinal lesions as a constant element of the disease.  At whatever pe-
riod in his researches this conclusion  was formed, it would necessarily follow
that all  subsequent cases of Typhoid fever proving  fatal would  have the
lesion, since if the  lesion was absent, the disease was  not to be considered
 Typhoid fever!   Plainly, in  prosecuting a series of  autopsical examinations
with a view to settle the point of the constancy of special changes  in a dis-
ease, the  presence  of the disease must have  been  determined, in  order to
avoid a petitio principii, by  other criteria  than the changes  which  are the
objects of search.

     * Louis, on Fever.  Translated by H. I. Bowditch, M. D., voL ii, page 371. 
                     REPORTS ON CONTINUED FEVER.                 245

  If this criticism be just, it follows, that a case exhibiting "an union of
almost all the characteristic symptoms of the Typhoid  affection," and in
which nothing " more was wanting to make us certain that the patient was
affected with the  Typhoid disease" than that the elliptical patches should be
found affected, must be regarded  as neither more nor less  than a case of the
Typhoid affection, as was  pronounced  prior to the autopsy.  Other  cases
detailed by Louis in the same category, as cases of simulated Typhoid affec-
tion, are perhaps to be considered veritable cases of this disease equally with
that to which reference has just been made.  Assuredly, it is by the ensem-
ble of symptoms during life  that the determination of the type of fever is to
be made, not to say that in fatal cases more  or less importance does not
belong  to the lesions, either in confirming or correcting  the diagnosis.  A
post mortem test, it is obvious, is too unseasonable for all  the practical  pur-
poses of diagnosis, and in cases in which recovery takes place, is wholly inap-
plicable.  Were it  generally impossible to decide between the two types of
Continued Fever, during the life of the patient, by distinctive symptoms and
laws, the propriety of even a nosological division could not be sustained, and
the question  of non-identity would be inadmissible.  The intestinal lesions
now regarded by many as characteristic of the Typhoid type, would then be
entitled to be considered to  be merely complications more or less frequently
present  in cases  of Continued Fever.  This  is,  in  fact, the view taken by
some writers, who contend that the distinctive symptoms of the two types are
not valid, or that they cannot be relied  upon for diagnosis.   Persons holding
this view, as  a matter  of course,  regard  the intestinal  lesions as  incidental
events which may, or may not be present; but if  they do not practically
make the distinction between  Typhus  and Typhoid, according to the diag-
nostic  traits deduced from analyses at clinical data, it is plain that they can-
not bring the fact of the absence or presence of these lesions  in individual
cases under their observation to bear on the question of the identity or non-
identity of the two types.  This, then, is the point which I would enunciate:
The determination of  the  question  whether a  particular case of Continued
Fever  be of  the Typhus or  Typhoid type, should not rest exclusively on the
presence or absence of  certain intestinal lesions.  It cannot so  rest, it is evi-
dent, unless the diagnostician, has always the advantage of an autopsy.   But,
irrespective of this, the basis of the division into the two  types is the ante-
mortem history.   Do the two types possess  sufficiently distinctive traits  to
be nosologically separated ?  If so, the distinction is undoubtedly in no small
measure, strengthened  by the fact that certain special lesions are  peculiar
to one of the types.  This  is a point  to  be demonstratively established by 
246
SUPPLEMENT  TO
 examinations after death of cases in which the Typhoid traits were unequivo-
 cally declared  during life. So, also, the question whether the lesions peculiar to
 one of the types are invariably present, is to be settled by repeated examina-
 tions  after death of  casjs in which the distinctive  traits  of that type were
 exhibited during the progress of the disease.  The latter question, as well as
 the former, should thus be fairly and fully met by an appeal to observation.
 It has been seen that, in accordance with this view of the subject, it may
 probably be proved by reference  to  Louis' own  collection of histories, that
 Typhoid fever may exist, and prove fatal without disease of the follicles and
 mesenteric glands.   Other cases have been reported.  Prof. Bartlett refers to
 several, in some of which he appears to think there  may have been room for
 doubt as to the correctness of the diagnosis, and in one striking case in which
 no suspicion on  this score could be entertained, he conjectures that the Ty-
 phoid  lesions  had  existed, all  traces of  which disappeared before death;
 Louis propounds the latter as an  hypothesis which would account for the
 absence of these lesions in the cases supposed by him to be cases of  Typhoid
 fever prior to the autopsies, but he prefers to regard them as cases simulating
 the disease.
   The point under consideration must  be considered, to say the  least, unset-
 tled.   Do cases exhibiting  during life an assemblage of symptoms sufficient
 to render it clear that they are cases of the Typhoid type of Continued Fever,
 in  the event of their  proving fatal, always  present the  lesions which are
 regarded as characteristic of this type ?   A farther collection of facts bearing
 on this inquiry is to be desired.  Should the  inquiry be settled conclusively
 (if it be not already) in the negative, then it remains to ascertain, by aggre-
 gated observations, in what ratio of Typhoid cases these lesions  are present.
   The connection of this point of inquiry with the subdivisions of Continued
 Fever is obvious   If it be  decided  to  call those cases only of  Continued
 Fever  Typhoid, in which these lesions are  present, what shall  be done with
 cases of Continued Fever in which these lesions are absent ? shall all be set
 down as cases of Typhus, whether the distinguishing traits of the latter type
 were present during  life or not ?   The effect  of this would  obviously be to
 impair the significance of the symptomatology of the latter type;  but as the
 point of the departure for the question is believed to be wrong, it is hardly
 worth while to  pursue the topic.
   There is still another question  connected with the intestinal lesions of  Ty-
 phoid fever opening up a subject which it is foreign  to my present design to
 consider at any length, but which calls for a brief passing notice.  What
relations do these lesions  sustain to the disease, i. e. to the Fever ?  Louis 
REPORTS ON  CONTINUED  FEVER,
24?
indicates these relations by the expression " anatomical  characteristic."   By
this expression he evidently means to convey the idea of a peculiar, intrinsic
element of the disease.   He does not regard  Typhoid fever as simply a folli-
cular enteritis, as has been somewhat pertinaciously reiterated  by those  not
conversant with his writings.  A view essentially similar appears to be taken
generally by those who look upon these  lesions as exclusively belonging to
the disease.  If the latter opinion be correct, there must exist some  special
relations between the lesions and the intimate pathological condition consti-
tuting Typhoid fever; but respecting the character of these relations, it is in
vain, with our present pathological knowledge, to inquire.   We  are, however,
not more in the dark here, than with regard to other events in  the history of
the disease, for example the characteristic eruption.  It is difficult to say in
what way, and  to what extent, the  presence of these  lesions  modifies  the
course of the disease.  They expose  the patient to the danger of perforation,
and, if extensive and  severe, they cannot fail  to  add  to the gravity of  the
symptoms.  Diarrhoea and haemorrhage are probably due to  this cause.   It
is reasonable to suppose that the more frequent and greater tenderness  and
meteorism in Typhoid fever are owing to the same cause.  Convalescence,
doubtless, is often retarded by the persisting  morbid condition of the follicles
and mesenteric glands, and, where the lesions are considerable, they may  suf-
fice  to destroy  life when  otherwise  the recuperative energies of the  system
would triumph.
   Finally, facts pertaining to distinctive symptoms and lesions, appear to
favor  the views of  those who hold  to the non-identity of Typhus and  Ty-
phoid fever.  But in arriving at this conclusion a fair allowance  should be
made  for the  points of agreement between the two types not  confining the
attention wholly to  the  points of contrast.  On instituting a comparison in
this point of view, it must be admitted that several important elements are
common to both.   This is sufficiently apparent on reference to the results of
the  analytical investigations of cases of the two types.   But with reference to
this point it is to be remarked that  several important elements are common
to all fevers, and, indeed, not to fevers alone, but other acute affections.  And
this remark is so applicable  to the group of symptoms common to Typhus
and Typhoid, that it  is customary,  both  in  medical writings, and conversa-
tion, to apply the term Typhoid to denote  resemblances occasionally  pre-
sented in various diseases.   Thus we have  Typhoid  pneumonia, remitting
or bilious fever with Typhoid symptoms, etc.   A group of symptoms denot-
ing  a morbid  condition  analogous  to  that  observed  both  in Typhus  and
 Typhoid fever, commonly known as  the Typhoid  stale, as  all practitioners 
248
SUPPLEMENT  TO
we aware, is recognized in affections which no one thinks of regarding as
identical.   Community  in  symptoms which do  not  exclusively belong to
Continued Fever, but are occasionally observed, to a greater or less extent, in
various affections, although doubtless  evidence of relationship between the
two types, cannot  be considered adequate  to establish their identity, so long
as numerous and striking differences point to an opposite conclusion.
   To decide that the  Typhoid and Typhus  forms of Continued Fever are
not identical, is not to  determine the kind and degree of relationship existing
between them.  With respect to the latter topics of inquiry, it is not easy, in
the  present state of knowledge, to arrive at any very precise  ideas.   In all
fevers, as well as various other affections, there is an inappreciable pathologi-
cal condition  underlying the appreciable phenomena which constitute their
natural history.  The latter, for the most  part, are the  objects of  investiga-
tion, the former lies in the terra incognita of science.   Were we able to push
our researches so far as to grasp the prime essential changes in which disease
 Consists, and thence to trace, synthetically, the train of sequences  to which,
with our present means  of investigation, we are mostly  restricted, we might
expect to define with  exactness  the real distinctions  and  affinities  existing
among different  affections.    As  it is, we must judge in  how far diseases
 are kindred, or foreign to  each other, chiefly by inferential  reasoning, based
 on a comparison of phenomena and their laws;  and our conclusions cannot
 be expected to be more than approximations, more or less remote, to the truth.
   That the two types of Continued Fever, Typhus and Typhoid, are closely
 related seems altogether probable.   They are varied forms of  the same
 Iwanch of the family of  Essential Fevers, viz., Continued Fever.  They have
 several important features in common.   They are not always, as will be pre-
 sently seen, readily discriminated.   Their  affiliation and  near resemblances
 fcirnish just criteria for  estimating relationship, without compromising their
 separate individuality.
   Some  questions pertaining  to the  causation of Continued Fever, as yet
 open for  investigation, have an important bearing on this branch of  the sub-
ject.  It is probably the most rational supposition that this, as well  as other
 essential  fevers, always involves,  in its production, the operation of a specific
 morbific  agency.  Now  do Typhus and Typhoid fever require each a dis-
 tinct special  cause, or may the same specific agency produce either disease
 according to the direction or modification it receives irrespective of the intrin-
 sic character of the cause ?  Both types  may be propagated by contagion.
 This seems to be conclusively settled.   Now is  the  contagious miasm fur-
nished by either type capable of giving rise to cases of both types, or ca se 
REPORTS ON CONTINUED  FEVER.
249
only of the same type ?   Another inquiry grows out of that just propounded,
viz., does the occurrence of either type of  the fever exempt the individual
from a recurrence of  both  types, or only of the particular type experienced ?
On the latter point some interesting facts are communicated by Dr. Power,*
of Baltimore, tending to show that the exemption afforded by having the disr
ease, only extends to the  particular type experienced.   The facts are, how-
ever, too few to authorize the induction of a general law.  Observations may
hereafter supply positive answers to these and other questions, the connection
of which with the present topic, and, indeed, with the subject of the identity
or non-identity of the two  forms of fever, must be sufficiently apparent.
   It  is, also, obvious  that in  proportion as, by continued researches, our
knowledge of the natural history of both types becomes more extensive and
complete, it may be expected that the distance between them will  be more
clearly defined.
   In concluding  these remarks on the identity or non-identity of  Typhus
and Typhoid fever, it may be proper  to state that the foregoing views differ
somewhat from those which the  writer has  heretofore  entertained, and  on
several occasions expressed-!   The study and thought  bestowed upon the
subject in connection with the  analyses upon which the preceding Reports
are based, have led to this result.   Without presuming  that any importance
will  be attached  to the fact, it is mentioned simply because  it affords the
opportunity of saying  that,  whether  right  or wrong,  the conclusions are
divested of any bias from preconceived opinions.

                               DIAGNOSIS.
   The subject of the diagnosis relates, first, to the determination of the type,
whether Typhus or Typhoid; and, second, to the discrimination of Continued
Fever irrespective of type.
   Typhus and Typhoid.   The differential  diagnosis, it is obvious, involves
those distinctive traits of either type which enter into its natural history.  In
so far as these are developed by the preceding investigations, they have been
briefly stated under  the head of Summary of the  distinctive symptoms of
 Typhus and Typhoid.  A repetition in this connection is unnecessary.  In
order to decide to which of the two types individual cases are to be assigned,
it is requisite, of course, that the practitioner shall be conversant with the
historical  features  by which each is distinguished from  the other, as well as
competent practically to apply this knowledge by means of correct observa-
tion  and judgment.   Repeated and  extended analyses, by enlarging, and

            * Bartlett's Treatise on Fever.     t Buffalo Medical Journal. 
250
SUPPLEMENT  TO
defining  more  accurately our acquaintance with the symptoms and laws of
each type, will contribute, more and more, to establish the points upon which
the diagnosis is to be based.  This remark admits of a general application.
Just in proportion to the progress made in knowledge of the natural history
of any disease will the means of diagnosis be increased; and our knowledge
of the natural history of any disease is enlarged in proportion  to the impor-
tance of  the results developed by  analytical investigations.   In the majority
of cases  of  Continued Fever falling under observation, it is not difficult to
determine whether the form is  Typhus or Typhoid.  The eruption suffices
to mark  the distinction, when this criterion is available, with  an occasional
exception in which the characters are not well  defined, or those  of both types
are more or less intermingled.  And in cases in which the eruption is absent,
characteristic features will usually be present sufficiently to warrant a decision
as to type.  This is  true as the general rule, but  in some instances, it must
be admitted, the question as to type is doubtful, and  in a few instances the
diagnosis may be quite difficult, and possibly impracticable. It may  occur to
the reader, in  this connection, to inquire, why it  is, if the type be generally
determinable, that in arranging the cases upon which the preceding Reports
are based, so many were  excluded from the  Typhus  and Typhoid groups,
and classed  under the head of Doubtful  type.   Of the one hundred cases,
eighteen  were assigned to this division.  If this be a  just expression of the
result of the effort  to exemplify, in the writer's experience, the  feasibility of
diagnosis, it certainly conflicts with the tenor of the foregoing remarks.  But
it is not a fair inference  that in so  large a proportion of cases the type is
indeterminable.   Inasmuch as a prominent object was a comparison of the
results of the analytical investigations in the two types, the intention was to
exclude any case in which there was the least room for question as to which
type it belonged.  On reviewing the histories of the cases of Doubtful type
since commencing to write on this topic, it is pretty clear, in the majority of
the cases, to which of the two series they belong, and so it was at the time
the classification was made, but the evidence was not deemed complete enough
to satisfy the rigorous rule adopted, and in order to avoid the possibility of a
confusion which might vitiate the results, they were rejected.   A few were
excluded in consequence of the histories being imperfect, on account of the
patients coming under observation late in  the disease.   A few were so mild
as  not to present some of  the prominent traits of either type.  In a very
small number of the cases embraced in the Doubtful series, were the charac-
ters of Typhus and  Typhoid, inclusive of the eruption, so intermingled as to
occasion very considerable difficulty in forming an opinion on  the subject of 
REPORTS ON  CONTINUED FEVER.
251
diagnosis.   In fact, this was  true of but two cases in both collections.  In
nearly all the cases of Doubtful type the eruption was wanting.
   The question has been raised whether the two types of Continued Fever
may not be blended in some cases;  in other words, whether a kind of hybrid
affection is not  occasionally observed, formed by an union of the characters
of Typhus and  Typhoid.   Our acquaintance of the relationship which they
sustain  toward  each other is insufficient to predicate thereon any  positive
opinion with respect to this point.   It  is a question which, with our present
pathological knowledge, must be settled by facts gathered  by observation.
The histories, in the preceding collections, having a bearing upon this question,
are too few, and the facts not sufficiently explicit, to warrant any conclusions.
   Another inquiry suggests itself which  relates  not only to the diagnosis,
but to the  identity or non-identity of  Typhus and Typhoid fever, viz., Is it
not likely that the natural history of Continued Fever is subject to so great
mutations incident to the lapse of years, that a transcript of this history based
upon observations collected at any particular period will  not answer for all
time ?  Is it not probable that the disease has assumed a diversity of phases
within a half century  or more ?  That Continued Fever, as well as other af-
fections, at different periods and places may be characterized by striking diver-
sities, is undoubtedly true.  The analyses upon which the preceding  Reports
are based, embracing collections of cases made, for the most part, in two suc-
cessive years, developed  peculiarities incident to each year.  In the first col-
lection parotitis occurred in several instances, and, in not a single instance in
the second collection.  The Typhoid cases in the second year were distin-
guished by a remarkably short  duration  of the  febrile career, and  by the
frequent occurrence of relapse of fever, the latter not occurring in a single
instance among  the  cases first analyzed.  These are illustrative of variations
that  may be expected to occur from  year to year.   Notwithstanding such
variations,  it may be that, as respects the  greater portion of the important
elements of the natural  history of the disease, there will be found  to be a
striking  uniformity from  year to year, and during a long period of  time, as
well as in different quarters of the world.  It is now more than twenty years
since the analytical  researches upon the Typhoid  affection, by Louis, were
published.  The publication of this remarkable work led to the application
of the same method of investigation by Dr. James Jackson, of Boston, to the
histories of the cases of Continued Fever recorded at the Massachusetts Gen-
eral  Hospital during a period of twelve years.  The results of the analysis
by Dr.  Jackson, were found to correspond, in all material points, with those
enunciated by Louis, showing the  existence of a fever at  Paris and  Boston 
262
SUPPLEMENT  TO
having identical phenomena and laws.   Not mentioning other investigations,
in a small collection of cases occurring at Buffalo, presenting the external dis-
tinguishing traits of  Typhoid fever, has been found, on analysis, a striking
correspondence  in  results with those disclosed at Paris and  Boston; and,
again, the following year by the analysis of another small collection, the same
results are confirmed.   The disease, thus, at different periods, and  at  places
widely separated, maintains a strongly marked individuality.   Its eccentrici-
ties do not compromise a remarkable consistency of character.
   As with Typhoid, so with Typhus, although the latter has not been stud-
ied to the same extent as the former.  Shortly after the publication of Louis'
work, it was ascertained that fever as it prevailed in the British  Islands was
not uniformly of the kind described by that distinguished observer.  Sepa-
rating the cases in which  the characteristic traits of  Typhoid were present,
from those in which  they were absent, the latter were found to exhibit dis-
tinctive traits sufficient to warrant their arrangement in a separate class, to
which has been restricted  the term Typhus.   Dr. Gerhard, of Philadelphia,
was the first to apply, to  any considerable extent, the analytical method of
determining the natural history of the form of Continued Fever just men-
tioned.  He gives the results of an analysis of a  large  number of cases
occurring at Philadelphia in 1836.*
   These results, in so far as the symptomatology of the disease is concerned,
appear to be, in the main,  reproduced wherever, subsequently, the disease has
been studied;  and it has  been seen that they are exemplified in the casual
cases assembled, on two successive years, in the hospital at Buffalo.
   Facts, thus, seem to render it probable that, although the lineaments of
the two forms of Continued Fever may be liable  to variation to a greater or
less extent, the fundamental traits which characterize each, and  upon which
rest their claims to be considered distinct affections, have as much fixedness
as belongs to other diseases.  Indeed, judging from the data as yet available,
both  Typhus and  Typhoid fever are less subject to important changes, from
time  to time, than other forms  of febrile disease,  for examples  Remittent
Fever, Rubeola,  and, especially, Scarlatina.   But with  reference  to this
interesting point of inquiry, multiplied observations and analyses are highly
 desirable.  By this method of appealing to facts, and by  this method only,
can it be demonstrated, on the one hand, what characters of these, as  well as
 other  diseases, are preserved from year to year, and  age to age; and, on the
 other  hand, the nature and extent of the mutations incident to time or place.
    The propriety of resolving  all  cases of Continued  Fever into two forms,
*Am. Jour, of Med. Sciences, vols. 19 and 20. 
REPORTS ON  CONTINUED FEVER.
253
Typhus and Typhoid, and the appropriateness of these terms of designation,
are points not  yet touched upon.   It may be a question whether cases in
which  the distinctive traits of Typhus or  Typhoid are wanting, or at least
not prominent,  should not be considered to form a separate class,  A certain
proportion of the cases of Continued Fever which fall under observation, are
of the kind referred to, and this would  appear to be true of a consecutive
series of cases occurring at particular periods and places, as  in the instance
of epidemics of what has been described by some authors under the name of
inflammatory fever.  It would obviate a difficulty of diagnosis which  must
to some extent  be felt in practice, to include cases in which it is not easy to
recognize distinct  evidences of either the Typhus or Typhoid type under a
distinct head.
   The expression  simple  Continued Fever, which some writers have em-
ployed, might embrace such cases.   Or, another course may be pursued, viz.,
to consider all cases not presenting unequivocal marks of Typhus, as  belong-
ing to a common series, using, instead of the term Typhoid, the phrase  Com-
mon  Continued  Fever.  The  latter is the more simple arrangement, and
would probably answer every practical purpose.
   Objections are frequently made to the terms Typhus and Typhoid.   The
former, Typhus, has long been applied  to denote a form of fever character-
 ized  by ataxic symptoms, and especially stupor, to which the etymology of
the term refers.  The significancy of this  term is in a measure impaired by
 the nosological lines which are now considered  to bound the division.   While
 it is still true that ataxic symptoms, including somnolency, or stupor, are apt to
 be prominent,  and earlier developed  in Typhus, it is also true that these symp-
 toms are not invariably present in a notable degree in that type, while they
 are not infrequently developed in an equal degree in cases of Typhoid.  The
 diagnostic criteria, in short, embrace other  traits than those pertaining  to the
 nervous system.   Still, as most of the cases to which the term Typhus has
 been heretofore applied, would be so considered in the present acceptation of
 that term, there is a propriety in retaining it.
    The term Typhoid is more open to criticism, although it is significant of
 the fact that frequently in cases of the type which it designates are presented
 prominent  symptoms  resembling, and indeed, identical with those observed
 in Typhus.   But  the term is inappropriate, inasmuch  as  this significancy
 only applies to a certain proportion of the cases of the class which  it is em-
 ployed to denote.   Besides, the term has become incorporated in  medical
 literature, and common parlance, to denote Typhus-like symptoms occurring
 in various diseases.  If  all cases  of Continued Fever  not exhibiting the 
254
SUPPLEMENT  TO
 diagnostic traits of Typhus, are  to  be considered as embraced  in  a single
 nosological  group, some  other designation than Typhoid would seem to be
 desirable, and this term might still be used to distinguish certain cases which
 affiliate closely with those of the Typhus type.   The  phrase enteric fever,
 proposed by Prof. Wood, is based in the supposition that all cases  are com-
 plicated with more or less of the  characteristic intestinal lesions.   This, as has
 been seen, cannot be considered established.   The expression Common Con-
 tinued Fever is perhaps as unobjectionable as any that, in the present state
 of our knowledge, could be selected.
   Discrimination of  Continued Fever from other affections.  In sections
 of country in which periodical fevers,are  more or less prevalent, Remittent
 and Continued  Fevers are to be discriminated from each other.   To do this
 is not always easy, and requires,  on  the part of the diagnostician, an accurate
 knowledge of the phenomena distinctive of each disease.  It is probable that
 these affections  have been, to a considerable extent, confounded by practition-
 ers.   This has arisen, doubtless, in part, from not recognizing the character-
 istic traits of each, but, in part also  from the looseness with which the terms
 Typhoid and  Typhus have been  employed.  Cases  in which typhus or
 typhus-like symptoms become developed have been called  cases of Typhus
 or Typhoid fever without inquiring whether other essential  diagnostic crite-
 ria were present or not.  A Typhoid condition  is one  thing, and Typhoid
fever another.   The first  may enter into various diseases.   That is to say,
 the ataxic symptoms which give  rise to those external  characters of which
 the term Typhoid is significant, such as muttering delirium, coma-vigil, sub-
 sultus, prostration,  do not exclusively pertain to Typhoid fever, and, on the
 other hand, are not invariably present in cases of Typhoid fever.  The diag-
 nosis of Typhoid  fever, in fact, is by no means based solely on the symptoms
 which it has been, and is still  customary to characterize as Typhoid symp-
 toms.  Hence, the disadvantage of the  term Typhoid as the title of a parti-
 cular species  of fever.   Uncertainty as to the mode  in which the  term
 Typhoid is applied, has  tended, in no  small measure, to create distrust of
 contributions on subjects connected with  the  disease.   Several interesting
 questions wh.ch have occasioned considerable discussion, of late years, remain
 to be settled by  careful and repeated observations  made in different  portions
 of the country.   One of these  relates  to the geographical boundaries of
 Typhoid fever — is it affected by climate and topography, and, if so, to what
 extent, and  in what manner ?   Another is, what are its relations to Remit-
 ting fever — do the two fevers prevail together at the same time and place —
 do they succeed each other — are they convertible the one into the other — 
REPORTS ON  CONTINUED  FEVER.
255
may the phenomena of each be intermingled in variable proportions, the two
diseases being blended together ?   The topics involved in these inquiries are
exceedingly interesting and  important.   It does not fall within the scope  of
my present  design to inquire what reliable facts bearing upon them have
been contributed;  but it must be admitted  that they open a field in which
there is abundance of room for investigation.
   The differential diagnosis of Remitting and Continued Fever, it is clear,  is
essentially involved  in the collection of observations just stated, and  others
not less interesting and important, for example questions relating to the man-
agement  of  the two fevers.  And  the  differential diagnosis, it  is evident,
involves those points of contrast which are developed by comparing the two
affections as respects the natural history of each.  Here, as in all diseases,
our available means of diagnosis  are  proportionate to the minuteness and
extent of our knowledge of the natural history of the diseases to be discrimi-
nated from each other; and here, as in  all  diseases, the natural history is to
be based on  the  results  of  the analytical investigation of recorded cases.
This method of investigation has been, as yet, inadequately applied  to the
study of Remittent Fever.  Small collections of cases have been analyzed  by
 Dr. Stewardson, Dr. Gerhard, and Dr. Stille, of Philadelphia, and Dr. Swett,
 of New York.  But to determine  the precise relative positions of the phe-
 nomena which  enter into the symptomatology of the disease more extensive
 analyses  are requisite.  It remains to effect for this disease what the labors of
 Louis have accomplished for  Typhoid fever.  When this is done, it  may be
 expected that  not  the  least of its  advantages will consist in the means of
 diagnosis being extended and better defined.
    Without dwelling  on the subject, I will  endeavor to give a  brief synopsis
 of the  more prominent of the diagnostic traits which, with our present know-
 ledge,  appear to be involved in the discrimination of Remittent and Contin-
 ued Fever.   In the great majority of instances in which this discrimination
 is to be practically  made, it will lie between Remitting and Typhoid Fever.
 The following summary, therefore, will embrace the characters distinguishing
 Remittents from  the  Typhoid type of Continued Fever.

 SUMMARY OF CHARACTERS DISTINGUISHING REMITTENT FROM TYPHOID FEVER.
    Access oftener abrupt; prodromic symptoms, if present, less prominent, and
 of short duration.  Disease more uniformly ushered in by a chill; the latter
 more pronounced, more apt to be accompanied by rigor, and to be longer in
 duration, in short, more closely resembling the cold stage of  an intermittent
    The early stage frequently characterized by remissions,  consisting in  a 
256                         SUPPLEMENT  TO
 marked  abatement of the  febrile  movement,  recurring with  more  or less
 observance of the laws of periodicity observed in intermittents, chills some-
 times repeated at the termination of the remissions.
   Quiet, muttering delirium, and coma-vigil, rarely present, and, when pre-
 sent, occurring later in the career of the disease.   The delirium, when  present
 early, generally due to high febrile excitement occurring during the height
 of the exacerbation.  Sopor occasionally observed in the exacerbation, proba-
 bly due  to cerebral congestion.  Deafness very seldom present.   Subsultus,
 carphologia, and great prostration less apt to occur.
   Nausea and vomiting more constant and  prominent symptoms, accompa-
 nied by  tenderness over the epigastrium.   Thirst more urgent.   Absence of
 tenderness in iliac regions, and gurgling and meteorism much less frequently
 developed  in a notable degree.  Peritonitis and intestinal  perforation do not
 occur, nor  haemorrhage from the bowels.   Diarrhoea not occurring as an ele-
 ment of the disease, irrespective of cathartic remedies or other exciting causes,
 Sordes seldom observed.
   Cough,  with sibilant and sonorous  rales, less constant.   Pneumonitis less
 apt to occur as a complication.   Epistaxis not an element of the disease. (?)
   No eruption of rose spots.  Sudamina less frequent  in occurrence.  Yel-
 lowness of conjunctiva and surface of body oftener observed.   Eschars more
 infrequent.   Congestive redness not so uniform or marked.  (?)
   Physiognomy  less characteristic.  A  stupid, besotted  expression, or an
 absence of all expression more rarely observed.
   No predilection for autumnal months;  more apt  to  occur during  the
 heat of summer.
   Dees not evince preference for young subjects.
   Not infectious nor contagious.
   Prevails only in miasmatic regions, or attacks those who have been exposed
 to miasmatic influences.
   Frequently ends in intermittent fever, and  persons having experienced the
disease are subject to  subsequent attacks of intermittents.
   The distinctive traits comprised in the foregoing summary are sufficient to
 denote a form of fever quite different from either type  of Continued Fever.
 They suffice also for practical diagnosis in the great majority of cases,  even
 although the most striking  characteristic of Remittent  Fever which sugges-
ted the name by which  it  is distinguished, to wit,  the remissions, may he
 absent, or have ceased to  recur prior to the  patient coming under observa-
 tion.  That Remittent and  Typhoid Fevers have been confounded, more or
less, by practitioners, may be owing to various causes.   In districts in which 
REPORTS ON  CONTINUED FEVER.
257
periodical fevers are the predominant form of febrile disease, the study of the
characteristic phenomena of Typhoid fever is apt to be neglected, and  this
form of fever is accordingly overlooked.  Moreover, it remains to be deter-
mined whether, and to what  extent, the two fevers are  capable of being
blended, and mutually convertible.
   The traits involved in the differential diagnosis, however, will doubtless be
more accurately determined, and  possibly new points of contrast developed,
when the natural  history of each disease, but  especially of Remittent fever,
shall have been perfected by further analytical researches.
   Continued  Fever is to  be distinguished from inflammations, and local
affections accompanied by febrile movement.  There is  greater liability of
mistaking Continued Fever for diseases seated in particular organs, than the
reverse; but an error of diagnosis, in either way may be committed.   So far
as my knowledge and experience extend, Continued Fever, not recognized as
such, may be considered to be Encephalitis, Pneumonitis, and Enteritis.  I
have heard  of instances in  which Tuberculosis, with tuberculous fever, were
set down  as cases of Continued Fever.   The three affections just named  viz.,
encephalitis, pneumonitis, and enteritis,  may actually be present in connection
with Continued Fever, the  error then  consisting  in regarding  them as pri-
mary, when they are secondary diseases; or the diagnosis  may be predicated
on prominent  symptoms referable to  the head, the chest, or the abdomen,
when  inflammation affecting either of these anatomical divisions, does  not
exist even as a  complication of the fever.
   The discrimination involves several general principles  which are applicable
alike to each of the affections.  First, if the disease be  Continued Fever, in
the majority of cases it will have been preceded by an access of several days'
duration.   This is a feature somewhat characteristic.  Second, the evidences
of fever will probably have been declared prior to the development of  the
local affections, or of the prominent symptoms which lead  to the supposition
of the existence of the local affections.   Third, the local symptoms referable
to the organs supposed to be  the seat of disease,  and which may actually be
affected secondarily, although  they may be prominent, are  yet disproportion-
ate when compared with the  general  symptoms — prostration, disturbance
of intellect, etc.  Fourth, symptoms characteristic of fever, and which do not
belong to the history of the local  affections, may be expected to be  present,
such  as the eruptions, epistaxis, congestive redness, meteorism, abdominal
tenderness, etc.   Fifth, symptoms are  absent which it  would  be expected
should be observed if the local affections were present, or present as primitive
affections.
               17 
258
SUPPLEMENT  TO
   Some of the principles in the foregoing list may be available in cases which
come under observation after the fever has advanced more or less in its career,
and when it is difficult or impossible to obtain an authentic account of the previ-
ous history. The practitioner is  more liable to be deceived in such cases, than
when the disease has been under observation from the beginning.   But even
with this disadvantage, if conversant with the  distinguishing characters of
Continued  Fever, and practically familiar with the local affections named, the
discrimination  should  not often prove  difficult   Without devoting to this
branch of the subject extended  consideration, I will offer a few remarks on
the application of  the above  principles to each affection separately.
   Encephalitis.—Active,  persistent  delirium, preceded  by cephalalgia, in
some instances, and, in  other instances, a state  of profound somnolency, or
coma, may lead the practitioner to think that encephalic inflammation is the
original  disease.   The collections of  cases upon which were based  the pre-
ceding  reports, contained  illustrations of prominent  cerebral symptoms in
both these forms.    Of the  cases thus characterized, in which  post mortem
examinations were made, no evidences of encephalic inflammation were found.
The cerebral  symptoms here referred  to, therefore, however prominent, do
not necessarily denote  that encephalitis  exists even as a complication of  the
fever.   Putting aside the diagnostic evidence to be derived  from the develop-
ment and  early stage  of  the disease, and also  the consideration that acute
encephalitis, in  the adult, except as the result of mechanical injuries, is an
exceedingly rare affection in this climate, the histories of each of these cases
show, on the  one  hand, the presence of characters  distinctive of  Typhoid
 Fever,  and, on the other  hand,  the absence of symptoms  distinctive of En-
 cephalitis.  In the first category are meteorism, tenderness in the iliac regions,
 diarrhoea,  etc.  In the second  are increased sensibility to  light and sounds,
 corrugation of eyebrows, vomiting, constipation, etc.   The former were pres-
 ent when  they should not  have been, had  the disease not been Continued
 Fever;  and the latter were  absent when it should have been otherwise  had
 acute encephalitis existed.   Here, again, it is seen  how diagnosis is based on
 points of  contrast evolved  by  the study of the natural history of diseases'
 Some of the more obvious  and striking symptoms may be common, in cer-
 tain cases, to different affections, while the less conspicuous and minor details
 suffice to  mark the distinction,  and thus obviate errors which would be inev-
 itable without due attention to the latter.   Practical skill in diagnosis, thus, is
 commensurate, not alone with  the tact and sagacity of the practitioner, but
 with the extent of  his acquaintance with the historical features of diseases.
    Pneumonitis.   It is to be presumed  that, in cases in which it is a matter 
REPORTS ON  CONTINUED  FEVER.
259
of doubt whether the disease be Continued  Fever or pneumonitis, the latter
exists as a complication.   To decide whether a pneumonitis be a secondary
or primary affection, may sometimes be attended with real difficulty, arising
from the fact that when primary it is sometimes associated with some of the
more prominent of the symptoms  of Typhoid or Typhus fever, forming
what is called Typhoid  Pneumonia.  We may have the delirium, prostra-
tion, etc., which constitute the Typhoid state, in connection with pneumonitis,
occurring irrespective of  Typhus  or  Typhoid  fever.   It  is to be remarked,
however, that cases of what is called Typhoid Pneumonia are, probably, not
infrequently cases of Typhoid or Typhus fever, with pneumonitis as a com-
 plication.   There is reason  to suppose that the two affections have been con-
 founded, to a greater or less extent, owing to the diagnostic lines not having
 been, until lately, distinctly drawn.   If this remark be true,  Typhoid Pneu-
 monia does not occur so often as  would be inferred from past writings.
   In the differential diagnosis the early history is especially important, for it
 probably is rarely the case that pneumonitis, occurring  as a complication of
 Continued Fever, becomes  developed from the commencement of the febrile
 career.  If the disease has  been observed from the first, therefore, it will  be
 evident that  the local affection is  consecutive to the fever.  Frequently it
 does not occur until late in the progress of the disease.  When this  is the
 case, the inflammation is of a low grade, and would be likely to escape, not
 only detection, but  suspicion,  if physical  exploration were not employed.
 The physical signs,  moreover, are less developed than when the affection  is
 primary, or,  at  least, this remark  is applicable to the special auscultatory
 sign — the crepitant rale.
    To determine the relation  between the gravity of the general symptoms
 and the local affection,;is an important point in the diagnosis, inasmuch as by
 means of physical  exploration  the extent of the  pneumonitis may be accu-
  rately gauged.  A striking disproportion between the general condition and
  the local  inflammation  should  lead to the presumption that the latter is a
  complication  in cases which  come under observation  after the febrile career
  has advanced more or less, and we  have not  the advantage of the previous
  history.   But, in addition  to the evidence derived from these two sources, we
  are to look  for special symptoms characteristic of Continued Fever, and
  which do not enter into the natural history of pneumonitis, such as an erup-
  tion, the  abdominal symptoms, epistaxis, etc.  A sufficient  number  of the
  latter, it may be expected, will be present to determine the diagnosis, even
  when it is required to be  made  late in  the disease, without our being  able
  to  ascertain  whether, or not, the fever  had precedence  of the pneumonitis, 
260         SUPPLEMENT TO  REPORTS ON  CONTINUED FEVER'.

and without reference  to a  disparity between  the  local and the genera!
symptoms.
   Enteritis.   The prominence of diarrheea and other abdominal  symptoms
leads to the error of supposing the disease is enteritis.  Canes  in which this
error is committed are of the  Typhoid type, and follicular enteritis, the char-
acteristic complication of this type, is, of course, present.  The diarrheea and
other abdominal symptoms may have  been  prominent  from  the commence-
ment of the disease, this being true of some cases of  Typhoid fever.  The
diagnostic principle  of the fever  taking precedence of the local affection,
would  then fail in its application.
   The disproportion between the local and general symptoms is a point here
specially applicable.
   The presence of  the  Typhoid condition would not be looked for in con-
nection with  primary enteritis.
   The characteristic traits of  Typhoid fever, viz., eruption, meteorism, epis-
taxis, etc., traits not  belonging  to  the natural history of ordinary enteritis,
possess not less significance than when the differential diagnosis involved the
two affections previously considered.
   The error  of mistaking  Continued  Fever  for local  affections,  is  oftener
committed when children are the subjects of the disease.  The diagnosis of
infantile Continued Fever is less easy  than when  patients are adults.  It is
sometimes difficult, in children, to appreciate some of the distinctive symptoms,
guch as the  state  of the mind, the  degree of abdominal  tenderness, etc.
The rule of the proportion between local and general symptoms  is not the
tame in children as in adults.   The constitutional disturbance is greater from
a less  amount of local  disease in  the former.   Moreover, some of the dis-
tinctive traits of Continued  Fever appear  to be oftener wanting.   This is
probably true with regard to the eruption.  There is reason to suppose that
cases of Continued Fever occurring in childhood  are not unfrequently re-
garded as cases of encephalitis and enteritis.  The more frequent  occurrence
of both  these  affections  in  early life conduces to these errors of diagnosis.
This is a  branch of the subject  possessing not a little  practical importance,
since the  influence of an incorrect discrimination on the treatment  can hardly
fail to be  pernicious.  I shall  content myself, however, with this brief allusion
to it.  An analytical investigation of a collection of cases of  infantile Con-
 tinued Fever is much to be desired, with a view, among other  useful ends, to
 determine in what  manner, and to what extent, the disease is modified by
 circumstances incident to childhood. 
THE
MANAGEMENT  OF  CONTINUED  FEVER.
  So many difficulties stand in the way of determining, by means of nu-
merical analyses, the precise relative value of different measures in the treat-
ment of diseases, that  it is questionable if, by this method  of study, our
knowledge of therapeutics will be much advanced.  The efficacy of different
remedial agencies is  to be estimated, first, by the appreciable  results which
follow directly their employment, and, second, by an apparent influence, either
immediate, or more or less remote, on the severity, duration, and termination
of diseases.   It is, obviously, in the latter point of view, only, that  statis-
tical results  can be, to any considerable extent, available.  Is the  ratio  of
mortality affected  by this or that treatment?   Is the severity, or the dura-
tion of the disease greater, or less, when such and  such  measures  are em-
ployed ?  These are the questions to be proposed  in  the prosecution of this
branch of analytical investigation.   The point of departure for these inqui-
ries, it would seem, should be a knowledge of the severity, duration, and ratio
of  mortality  pertaining to diseases uninfluenced  by remedial  measures.
What would  be the results, in these respects,  of the analysis  of a series  of
cases which were permitted to run their course without any interference from
medical art?  Such results would, doubtless, prove valuable contributions  to
medical science; but our opportunities  for obtaining them, for reasons suffi-
ciently apparent, are limited.   We can only consult  the interests of medical
science, when the means for that end do not conflict with  those humane ob-
jects of our art, which  are paramount in importance.  And, since we are not
justified in withholding therapeutical measures which we have good grounds 
262
MANAGEMENT  OF CONTINUED FEVER.
for thinking  may exert more or less efficiency, we  are, in a great measure,
debarred from studying the laws of disease as respects the points mentioned,
prior to instituting comparisons of results developed by the analyses of cases
treated after different methods.   This is one difficulty.   But, were it sur-
mountable, another, and even greater difficulty springs from  the fact, that
the same diseases exhibit striking diversities,  at different times  and places, in
severity, duration, and mortality, irrespective of measures of treatment.  This
is not less true of Continued Fever than of any other disease.   If, therefore,
we had the advantage of the results of the  analysis of a large collection of
cases in which the disease was allowed to run its course without therapeutical
interference, the laws deduced therefrom could not be taken as  a fixed stand-
ard  by which to measure, by comparison, the relative advantages or disad-
vantages of different plans  of  management.  And, hence, it follows, that
severity, duration, and  fatality are not  reliable  as criteria for testing the
remedial character of therapeutical measures.  The disease may be severe,
prolonged, and unusually fatal, under the most judicious management, and it
may be mild, of a  short career, in  a large proportion  of cases ending in
recovery, when the treatment in nowise contributed thereto.
   Were both these difficulties overcome, others would arise.   The manage-
ment of a disease is  more or less complex.   It comprises various elements.
To isolate these elements severally, and assign to each its proper relative im-
portance, is difficult and often  impracticable.  Statistical  comparisons, to be
complete, must  embrace analyses of successive collections of cases that have
been appropriated, respectively,  to each  important  element which enters into
the  management, whether medicinal  or hygienic.   But the same objections
are  applicable to the collection of observations of this  kind, as to the with-
holding of all remedies in  order to witness the progress of disease  uninflu-
enced by art.  Aside from the intrinsic difficulties  of the undertaking,  moral
considerations conflict with it.
   Finally, assuming that  difficulties  did not  exist, and  numerical analyses
were brought to bear, successfully, upon this branch of investigation, the ut-
 most that could be attained would be to demonstrate that, in the treatment
 of a disease, a certain method, or plan, is preferable in the larger proportion
 of cases.  Therapeutical principles, in other words, would be based on mean
 results, or averages.  Now, it does not follow that  measures which are most
 appropriate  and useful in a series of cases considered  collectively, are the
 most  appropriate and  useful  in  all the individual cases of  the series.  A
 method of treatment  may be  the best, for example, in  seventy-five of one
 hundred cases,  and by no means the best in the  remaining twenty-five per 
MANAGEMENT OF CONTINUED FEVER.
263
cent   Nay, it is only a seeming  paradox to assert that a method of treat-
ment, which, if pursued indiscriminately, would  be instrumental  in saving
more lives than any other method pursued in like manner, might yet, in some
instances, directly conduce to a fatal result.
   I would not be understood to deny that numerical results are of impor-
tance  in  the  stud}' of diseases with reference to their management.   Not-
withstanding the difficulties  that  have  been mentioned,  enumerations and
comparisons with a view to determine the value of remedial agencies, are by
 no means wholly impracticable, nor altogether fruitless.  Statistics showing
 the rate of mortality, for example, under different methods of treatment are
 to be considered in estimating  the relative merits of these methods.   They
 have  a certain positive value; and when this is  not the case, they may pos-
 sess importance in a negative sense.   To illustrate the  force of the  latter
 remark, suppose, in  a series of cases of Continued Fever, in which  the pa-
 tients were kept on  gum-water for diet, the  ratio of mortality was found  to
 be not greater than in other collections  in which more nutritious aliment was
 considered to form an important  element of the management, it would cer-
 tainly be a fair  presumption that the latter  element might be omitted with
 safety as respects the issue of the disease.   To attempt to define the limita-
 tions of the application of the numerical method of study to therapeutics,
  would be to enter on a wide field of discussion entirely foreign to my present
  desio-n.   The foregoing remarks are merely preliminary to saying that, in writ-
  ing a brief essay on the management of Continued Fever, I shall not enunciate
  conclusions based, exclusively, or mainly, on numerical observations.   Aside
  from other considerations, the number of recorded histories that I have collected
  is by far too few to furnish data for comparing the results of different methods
  of treatment.   Nor was this an object  of inquiry while the cases  were  in pro-
  gress.   The treatment pursued in all cases was that which accorded, at  the
  time, with the  opinions and judgment  of the writer, without any reference to
  future analyses.
     What are the general  principles  that should govern  the management of
   Continued Fever, which are most consistent with our present knowledge of
   the  disease, and  the results of experience?  In  expressing views suggested
   by this inquiry, I shall  refer to facts contained  in my recorded observations
   so far as they appear to have any important bearing on the subject, with-
   out descending to tedious details.
     The general principles of management are applicable alike to the Typhus,
   and Typhoid  forms of Continued Fever.  It will suffice  to notice incidentally 
264
MANAGEMENT OF CONTINUED FEVER.
any considerations pertaining specially to either type, without treating of the
subject in its relations to the two types under distinct heads.
  The management of Continued Fever may be considered to embrace, first,
abortive methods, or measures designed to arrest the progress of the disease,
or abridge its duration; second, the  treatment  of the disease irrespective of
abortive  measures,  and  without reference to co-existing or secondary affec-
tions ; third, the remedies required by its complications.

MEASURES DESIGNED TO ARREST THE PROGRESS OF THE DISEASE, OR ABRIDGE
                             ITS  DURATION.
  It has long been  a mooted question, whether Continued Fever, when  fully
formed, can be broken  up  by any plan of  medical treatment.   Various
measures for that end have, from time to time, been proposed, which, after a
short trial, have ceased to be employed.   This fact suffices  to show that no
reliable means for effecting the object  have, as  yet, been discovered; for, if
any of the measures  proposed were uniformly, or in a large proportion of
cases, successful, their efficacy would hardly fail to  prevent  their falling into
disuse.   The question must still be considered an open one.  An opinion on
the subject is, of course, but  conjectural.   Until our ability to control the
course of the disease is demonstrated, we can only judge as to the probability
or possibility of the attainment, by analogy and speculative reasoning.   Both
favor the expectation that  a specific  controlling remedy may, at some future
period, be discovered.   Such a remedy has been found in the case of Inter-
mittent and Remittent Fever, by means of which, these forms of febrile dis-
ease are  rendered amenable to art.   Nor, admitting that all essential  Fevers
involve, as their primary fundamental pathological element humoral changes
due to the action of special poisons, is  it too  much  to  hope that the  time
may come when these changes shall  have been successfully investigated,  their
character and relations to the poisonous agents well understood, and  science
arrive deductively at the knowledge of opposing or counteracting remedies.
Bloodletting, purging with calomel and other cathartics, emetics, vapor baths,
and  cold affusions are among the measures that, in past time, have had, to a
greater or less extent, a transient celebrity in arresting or abridging Continued
Fever.   At first view, it would seem that it must be an easy task to deter-
mine, positively, respecting the efficiency of any plan of  treatment instituted
for these ends.    It is, however, not so easy, but that measures  may  acquire
and  retain, for a time, a fictitious importance.   This arises from the difficulty
of demonstrating whether the febrile career has been arrested  or not, owing
to the fact that the symptoms of  the access, not unfrequently, are observed 
MANAGEMENT OF CONTINUED FEVER.
265
without being followed by the formation and career of fever; and, again, we
meet with instances in which febrile movement is developed, and, continuing
for two or three days, ceases from its  own  limitations, constituting what is
known  as febricula or ephemeral fever.   Now, we are  never  able  to say,
positively, when remedies  appear to  prevent the  development of fever, or
arrest its progress, that the same results would not  have occurred  spontane-
ously, had  no remedies been employed.  This  being the case, it is easy to
conceive that, with the influence of enthusiasm, and the bias of preconception'
the efficacy of  a novel method of treatment may,  at first, appear to be sup-
ported by evidence which longer and more rigorous experience disproves.
   Proposed methods of treating Continued  Fever, with a view to rendering
it abortive, of a more recent date than those which have been mentioned, are
not wanting.  The most  notable  that  have fallen  under my notice are, 1st,
the administration of quinia in large doses.  This  has been advocated parti-
cularly by Prof. Thomas D. Mitchell, formerly connected with the Transylvania
University, Lexington, Ky.  2d, opium  given in large doses is affirmed to be,
in a large proportion of  cases, successful, by Dr. A. G. Henry, of Pekin, 111.,
and others.   3d,  the wet  sheet,  as  employed  by the hydropathists, with a
view to fomentation and diaphoresis.  I have made these  methods  the sub-
jects of a few observations, which are by no means  adequate as tests of their
respective merits, and are,  perhaps, hardly worth reporting.  Few as they are,
however, I will give a brief account of them, as a small contribution toward
a collection of data which shall suffice to settle the importance to be attached
to each of these methods.  Such a collection, so far as I know, is not, as yet
the  property of science.
   In  two  cases, in the first collection, quinia was  prescribed with  a view to
an abortive effect.  In both cases, the fever  was fully formed before the rem-
edy was given.   In one case, twenty-four grains  of quinia were prescribed
in twenty-four hours, on the first day, and twenty grains on each of the two
succeeding days.  It occasioned characteristic buzzing in the ears, but exerted,
no appreciable effect  on the progress of the disease.  The duration  of the
fever in this case, was eighteen days.   In the other case,  the dose given was
three grains every six hours, which was continued for six or seven days.  No
appreciable effect was observed in this case, the duration  being fifteen days.
Both cases were of the Typhoid  type.
   In another case, on the first day of admission into hospital, five grains of
 quinia were given, and repeated  twice,  under the impression that the disease
was Remittent Fever.   No appreciable  effect followed in this case.
   I have  repeatedly prescribed  quinia in doses of two grains every four or 
266
MANAGEMENT OF  CONTINUED FEVER.
six hours from the time patients came under treatment, and continued the
use of the remedy in this way for several days, without observing any appa-
rent influence on the disease.
  In  five cases, of which  I  have presented notes, opium  or  morphia was
given in pretty large doses, in order to try the effect of this as an abortive
remedy.  The histories of  these cases, in so far as concerns the point under
consideration, are  briefly as follows:
   Case 1.   Martin Lyons, Irish, laborer, aged  33, admitted  into hospital
Dec. 13, 1849, on the  sixth  day after taking  to the bed.  The  record of
symptoms on the  day of his admission was not made.   Four grains of opium
were  given  at night.   At the morning visit on  the day following, he was
sleeping profoundly and heavily.  Respiration labored, and  inspiration some-
what spasmodic.   He was readily roused, and replied to questions promptly
and coherently.   Reported feeling finely, and said he had passed a very com-
fortable  night.   Perspired copiously during the  night, and slept soundly,
without muttering.  Surface, at time of  examination, covered with  a cold,
clammy perspiration.   Pulse 130, extremely small and feeble.  Singultus.
   15th. Reports comfortable.  Respiration during night, labored, and inspi-
ration somewhat  spasmodic.  Had  epistaxis last night   Skin warm and
mellow.  Pulse 108, more developed.  Rhythm of respiration now normal.
Has cough and rusty expectoration, with physical signs of pneumonitis affect-
ing right lung inferiorly.   Skin and conjunctiva present moderate yellowness.
    16th. Manifested delirium during night by incoherent talking.  Appears
 now rational.  Reports quite comfortable.  Cough and expectoration continue.
 Epistaxis yesterday twice.   Respirations  28; rhythm normal.  Yellowness
 of skin and conjunctiva diminished.  Pulse 88, tolerably developed.
    17th. Symptoms not materially changed.  Pulse 84.
    19th. Symptoms continue unchanged.   No delirium.  Pulse 96.
    22d. Reports  " finely."  Cough somewhat troublesome.   No febrile move-
 ment.   Appetite improving.
    Parotitis commenced on the 30th, and proceeded to suppuration.  On  the
 19th  of January, he was  able to  sit up.  Discharge  from  parotid  much
 diminished.   Appetite  good.  This is the  date of the last record of the case.
    Remarks.   The remedy was given, in this case after the fever had contin-
 ued  for several  days.  It was followed  by cerebral symptoms of a grave
 character, as denoted by the respiration, great acceleration and feebleness of
 the pulse, and copious perspiration.   On the next day but one after the opium
 was  administered, the course of the  fever appeared to be suspended.   He
 was  laboring under pneumonitis, which, perhaps, was developed prior to the 
MANAGEMENT OF CONTINUED FEVER.
267
administration of the opium.  This complication, and parotitis, which subse-
quently occurred, retarded the  convalescence.   There seems  to be some
ground for suspecting that the remedy exerted an influence over the duration
of the febrile career in this case.
   Case 2.  Katharine Riley,  Irish, domestic, aged" 17, admitted Dec. 18,
1849, on the third day after taking to the bed.  On the 19th, she presented
a dull aspect.   Appeared  drowsy.   Face congested; eyes slightly suffused;
skin  hot and dry.   Moderate  tympanites, and  tenderness in iliac regions.
Pulse 120.  Slight mental aberration at night.  Four grains of opium were
administered.
   20th. Reports not so well.   Says she passed a restless night.   Complains
 of pain " all over."  Face deeply congested.  Aspect  more dull.  Somno-
 lent, but  easily roused.   Pulse 116.  Skin  dry  and warm.   Abdominal
 tenderness continues.
   The career of the fever persisted without any material change, and three
 days after the above date, parotitis, on both sides, commenced, and proceeded
 to suppuration.
    Jan. 9th, she was able to sit up, and rapidly convalesced.
    Remarks.  The result of the remedy, in this instance, appeared to be negative.
    Case 3d.  Michael Donnehea, aged 7, admitted  P.  M., Dec. 21, 1849, on
 the third  day after taking to the bed.
    22d. Complains of  cephalalgia and debility, anorexia,  thirst.   Slight con-
 gestion of the face and upper extremities.   Tongue thickly coated  and
 inclined to dryness.   Two or three  dejections during the night.   Pulse 112,
 small and feeble.  Abdomen full, but not resonant.  Moderate  tenderness in
 rio-ht iliac region.   A sparse eruption over abdomen and chest,  with typhoid
 characters.   Has had no medicine since his admission, or previously.   Opium
 in dose of a grain and a half ivas prescribed.
    23d. Reports quite well.  Perspired profusely last evening.  Tongue clean.
  No febrile movement.   No dejection.  No medicine prescribed.
    Jan. 3d, it is noted that the patient began to sit up after date of the last
  record', an'd appeared convalescent.   Day before yesterday, 1 P. M, Jan. 1st,
  he toolc to the bed, and last night exhibited delirium  by incoherent talking.
  He complains  of headache.   Tongue moist and furred.   Bowels moved last
  nio-ht.   Vomited last night.   Ate porridge and toast for  breakfast this morn-
  ing.  Skin perspiring.  Pulse 108.  No medicine, but restrict the patient to
  farinacious diet.
     No  record  of  the case is  made  after  this date.  The slight relapse was
   possibly occasioned by over indulgence in eating. 
268
MANAGEMENT OF  CONTINUED  FEVER.
   Remarks.   Unless the administration  of the opium was a coincidence
with the spontaneous cessation of the  febrile career, it would seem to have
been successful in arresting, at once, the progress of the disease.  It will be
observed that the grain  and a  half of opium constituted the sole medicinal
treatment of  the case.
   Case 4.  Thomas Toole, Irish, boatman, aged  25, admitted P. M., Oct.
14th, 1850, having been ill five days, but it is not noted how long he had
kept his bed.  15th, he presented the following symptoms:—Considerable
congestive  redness of face and  upper extremities;  cephalalgia; thirst;  some
cough.  Skin hot.  Pulse accelerated.
   16th. Cephalalgia.   Congestive redness continues.   Conjunctiva injected.
Skin warm and dry.  No  dejection for three days.   Pulse 104.   Respira-
tions 24.   Slight tympanites.
   Sulphate of Morphia, gr. ss., at morning, to be repeated at night.
   17th. Reports  better.  Says he slept well.  Was  talkative during night.
No pain  in  head, or elsewhere.  Aspect improved.   Conjunctiva  injected.
Congestive redness of  surface  continues.  Skin warm and moist.  Pulse
104, tolerably developed.  No cough.
   Sulphate of Morphia, gr. 1-4, every four hours.
   18th. Manifested  considerable delirium  during  night, by incoherent talk-
ing, and attempting to get out of bed.  Pulse 116.  Respirations 20, etc.
   The febrile career persisted in this  case; pneumonitis became developed,
and death occurred on the fourteenth day after admission.
   Remarks.   Some amelioration in the symptoms was apparent on the day
following that on which  the grain of morphia was given, but the progress of
the disease was unaffected by the remedy.
   Case 5.  Nora Kinne, Irish,  aged  24, domestic,  admitted on  the evening
of Nov. 5, 1850.  Had been ill since the 1st, and had kept the bed  since
the 3d.
   On the 6th, she presented the following symptoms:—Conjunctiva slightly
injected.    Moderate congestive redness  of the face, and  slight  on upper
extremities.   Occasional cough.   Respirations 25.  Skin hot and dry.  Pulse
116, moderately developed.   Tongue dry, reddened and coated.   Moderate
meteorism.   Slight tenderness in right iliac region.   Opium, grs. iv, given in
the forenoon.
   At 5, P. M., sleeping  soundly.  Skin warm and moist.  Pulse 112.   Re-
spirations 20.
   7th.  Reports better.   Says she slept well during night   Face and hands
slightly congested.  Skin warm and moist  Tongue moist and thinly coated, 
MANAGEMENT OF  CONTINUED  FEVER.
269
reddened at top.  Respirations 20.   Pulse 78.   Tympanites lessened.  No
dejection.   No tenderness.   Anorexia, thirst.  Morphia, gr. ss., at bed time.
  7th. Reports better.  Says she slept well.   No dejection.  Urinates freely.
Face and hands slightly congested.   Skin warm and mellow.  Tongue moist
and  coated.   Slight  tympanites.  Slight  tenderness  in right iliac region.
No eruption.  Pulse 88.   Respirations  20.
  9th. No material change in symptoms.
  10th. Several dejections during night.  Skin  hot  and dry.   Tongue dry
and  reddened.  Pulse 92.   Anorexia;  thirst.  Respirations 20.  No tym-
panites.  Slight tenderness in right iliac region.
  llth. Reports still better.   Says she slept well.  Skin warm and mellow.
Tongue moist and furred.  Pulse 84. Anorexia.  No thirst. Sat up a little.
  12th. Symptoms denote improvement.  Some appetite.
  13th. Improving.
  She continued to improve until the 18th, when relapse of fever commenced.
On the 19th,  the pulse was 108 at A. M., and at P. M., 120.   On the 20th,
it was 128 at  A. M., and at P. M., 144.  On the 21st, the symptoms exhib-
ited decided improvement, the pulse having fallen to  90.   From that date,
she again convalesced, and left hospital on the 2d December.
   Remarks.  There is room for the conjecture that the morphia exerted an
influence on the progress of the fever in  this case.  The striking  improve-
ment in the symptoms on the day succeeding that on which the morphia was
given, favors this supposition.  This improvement was especially manifested
in the pulse.   Convalescence could be pronounced in three or four days after-
ward.  Relapse of fever occurred in  several of the cases observed through the
 winter of 1850-51, as will be perceived on reference to the  second report
   The facts contained in the foregoing cases do not, of course,  authorize any
positive conclusions.   So far as they go, however, they furnish encourage-
 ment for the supposition that opium, in large doses, in some cases,  does pos-
sess more or less power to affect the progress of  Continued Fever.  A series
of  recorded cases, showing the results of this plan of treatment, is certainly
to be desired.  It is to be  remarked that, in each of  the foregoing cases, the
career of the fever had continued for several days before the treatment was
pursued.   It  is, perhaps, reasonable to suppose that the chances for the suc-
 cess of any method of abortive treatment  would be greater the earlier it is
 resorted to.   Nor was the opiate plan of treatment  carried to the full ex-
tent recommended by Dr. Henry and others.  The minimum dose proposed
 with a view to abortive effects was employed; and the  plan was not carried
 out by repeating the measure once, twice, or more, in the same case. 
270               MANAGEMENT  OF CONTINUED FEVER.

   I have resorted  to the wet sheet in five instances, of which I will give a
succinct account.
   Case 1.   An account of this case I  must  give,  from recollection.  The
patient was a private inmate of the hospital, in the  summer of 1850, out of
the period of my service, and the details of the history were not noted.   He
presented sufficient evidences of Continued Fever, having been ill several
days, but had not  taken to the bed  prior to his admission.  On the morning
of the day following that on which he was admitted,  the wet sheet was ap-
plied, and the  body then wrapped in blankets, after the  plan  of packing
practiced  by the  hydropathists.   These were allowed  to remain for four
hours.  Copious diaphoresis followed.   The skin became cool, and he passed
a comfortable night    During the previous night he had exhibited delirium,
and at the morning examination, before  the wet sheet was applied, there ex-
isted  high febrile movement, with somnolency, etc.   On  the next day, he
was  free from  fever; skin cool, pulse not  accelerated, mind perfectly clear,
and, in  short, the  febrile career seemed  at once and completely arrested.   I
was delighted with the apparent success of the measure.  In the afternoon I
received a message that the patient thought to be doing so well in the morn-
ing was dying.   I found  him in apoplectic coma, and death occurred  the
succeeding night.  I ascertained that, feeling so well in the forenoon, he had
essayed to sit up; and had actually dressed himself, and sat up for a time.
He had returned to bed, and fallen into a state of unconsciousness before an
unfavorable change in  the symptoms attracted attention.  The apoplectic co-
ma and fatal termination, it is not improbable, were due to the imprudent act
just skated.   Although they could not,  with propriety, be charged upon the
remedy, the unfortunate issue of the case deterred  me for  some time from
again resorting to it,  notwithstanding  the  immediate apparent  effect was
striking and satisfactory.
   Case  2.   James  Cavernaugh, aged  15, Irish,  admitted Dec. 2d, 1850,
having been attacked the previous day, with pain in head and limbs, chills,
anorexia, thirst, etc.  The symptoms, on his  admission, were as follows:—
Complains of debility.  Lies  quietly in bed.   Aspect bright.  Mind clear.
Anorexia.   Tongue moist and thinly coated.   Not much thirst.  Vomited
to-day.   Tenderness over right iliac region and epigastrium.  No tympan-
ites.  Pulse  accelerated.   Skin hot  and  dry.  Pulv. Doveri, gr. iv, every
four hours.
   3d. Complains  of severe pain  in  head.   Says  he did  not sleep during
night.  Face and hands considerably congested.   Conjunctiva  slightly in-
jected.   Skin hot  and  dry.  Pulse 112, well developed.  Anorexia.  Tongue 
MANAGEMENT OF 'CONTINUED FEVER.
271
moist and coated.  Considerable thirst.   No  dejection.  Tenderness over
epigastrium and right iliac region.   S. morphia, gr. 1-4, at bed time.
   4th. Reports  feeling  very badly.  Complains of pain in head.  Says he
did not sleep during night.  Aspect dull.  Face and  upper extremities pre-
sent considerable  congestive  redness.   Skin hot and  diy.  Pulse  108.
Tongue  moist  and coated.   Anorexia.   Thirst.  Vomited  last evening.
Slight tenderness over abdomen generally.  Moderate  meteorism.   No de-
jection since the commencement of illness.   Says  he  has  no cough.  Slight
epistaxis this morning.
   The wet sheet was applied for two hours, after which,  morphia, gr. 1—4,
and brandy, ^ss., were administered.
   At evening, he reported better than at morning.  Pain in head continues,
 but is lessened.   Skin warm and  moist.  Tongue coated, dry in the center,
 and moist at sides.  Anorexia.  Not much thirst.  No  nausea.  Moderate
 meteorism continues.  One dejection.  Pulse 116.
   5th. Reports better.   Aspect improved.   Skin warm  and dry.   Tongue
 coated and inclined to  dryness.   Anorexia.  Some thirsty.   No  nausea.
 Sonio. tenderness  in epigastrium and right iliac region.   Slight meteorism.
 No eruption.   No dejection.   Slight vomiting.  Pulse 104.
    6 th. Reports much better.   Aspect much improved.  Says he slept well.
 Face much less congested.   Skin warm and mellow.   Pulse 84.  Tongue
 moist and coated.  Anorexia.   No thirst.   No nausea.
    7th. Symptoms improving.  Pulse 76.
    8th. Improving.  Tongue  moist and clean, except at  base.  Some appe-
 tite.  Pulse 84.
    Convalescence continued  until the 18th, when relapse of fever occurred,
 and continued  for three or four days, when  he again  convalesced without any
  untoward symptoms.
    Remarks.   Distinct amelioration of the symptoms followed the application
  of the wet sheet, which  was  resorted to on the third day,  and convalescence
  could be pronounced on  the  eighth day after taking  to the bed.   It may be
  reasonably surmised that the remedy affected the progress of the disease in
  this instance.
     Case 3.  Patrick Cavernaugh, aged 9, brother of James,  (case 2,)  admit-
  ted Nov. 27th, 1850.   He complained of debility at time of admission, but
  was dressed, and  kept about until Dec. 2d, when  he took to the bed.  On
  the 5th of December, he presented  the following symptoms:—Cephalalgia.
  Face flushed, and upper extremities slightly congested.   Skin hot  and dry.
  Pulse 116.  Tongue dry and coated.   Anorexia.   Considerable thirst  No 
272
MANAGEMENT OF  CONTINUED FEVER.
dejection for two or three days.  Moderate meteorism.   Tenderness in right
iliac region.   No eruption.   Slight  cough.  The wet sheet  was applied at
11 A. M., and continued two hours.
   1 P. M.  Reports better.   Less pain in  head.   Face flushed, and perspir-
ing.  Skin warm and moist.   Tongue moist and coated.  No thirst.  Mod-
erate meteorism.   No dejection.  Pulse 124.
   A small dose of morphia was administered after the wet sheet was removed,
and brandy §ss  given twice within four hours.
   5th. Reports better.  Was talkative during night, and frequently got out
of bed.  Replies now to questions  promptly and rationally.  Aspect  im-
proved.  Face slightly flushed.  Skin warm  and  mellow.   Tongue  moist
and thinly coated.  Has  some appetite.  No thirst.   Slight meteorism.   No
dejection.  Vomited  slightly this  A. M.  Pulse 88.   Slight  cough.   No
eruption.
   Gth. Reports  free from  pain, but very weak.   Attempted, frequently, to
get out of  bed during early part of night.
   Directions had  been given  to administer morphia according to circum-
stances, and, by  inadvertency, a  quarter of a grain was  repeated four times
(i. e. one grain,)  within the space of three hours.  At the morning examin-
ation, he appeared partially narcotized, being roused with  some  difficulty.
He slept profoundly the latter part of night.  Face somewhat congested,  and
upper extremities slightly.   Skin warm and mellow. Tongue dry and thinly
coated.   No appetite.  No thirst.   Occasional nausea   No  dejection for five
or  six  days.  Moderate  meteorism.   Slight  abdominal  tenderness.   No
eruption.   Pulse 96.
   6th. Reports comfortable.   Says he slept well.  Slight congestion of face
and upper extremities.  Skin warm and dry.  Tongue rather dry and thinly
coated.  Some  appetite.   Some thirst.   One  dejection.   No meteorism.
Pulse 84.  Disposed to somnolency.
   8th. Aspect  much  improved.  Tongue  moist and  nearly  clean.   One
dejection, moulded, and perfectly healthy in appearance.   Pulse 96.  Skin
warm and mellow.  No delirium.
   This patient convalesced until the 15th, when relapse of fever occurred, the
duration of which is not recorded; but it continued a few days only.
   Remarks.  The history of this case shows a striking amelioration of the
symptoms after  the application of the wet sheet, but not an immediate arrest
of the progress of the disease.   The large quantity of morphia given on the
second night after the wet sheet was applied, is a  point of interest.   It is
difficult, of course, to  say  what influence these  measures exerted, singly or 
MANAGEMENT OF CONTINUED  FiSVER.
273
combined, upon the duration  of the disease; but  it is a fair presumption,
that the short career may have been due to one or both of them.
   Case 4.  Margaret. O'Connor, aged 14, Irish, domestic, admitted March
 12th, 1851.   She had  kept  the bed  for two days prior to her admission.
 The day but one after her entrance, i. e. March 14, she presented the follow-
 ing symptoms:—Cephalalgia.  Cheeks flushed.  Anorexia.  Thirst  Tongue
 thinly coated, and dry in center.  No nausea nor vomiting.  Slight cough.
 Pulse 104.   Skin warm and dry.   No eruption.   Moderate meteorism.  No
 dejection.   No tenderness.
    Wet sheet was applied.
   15th.  Reports much better.  Aspect much improved.  The record states
 as follows:—" She had  the wet sheet at 7 P. M.   Prior to its being applied,
 the skin was hot and dry.  She said she was comfortable during its applica-
 tion.  The surface became cool and moist, and so continued.  She slept well.
 Thirst ceased.  Skin is now cool and moist.   Pulse 72.  Tongue moist and
 thinly coated.  Says she has some appetite, and has taken some  toast and
 tea with relish.  Respiration normal.   No cough."
    It was directed to repeat  the wet sheet if febrile movement returned.   It
 was not called for.  She convalesced from the date of  the preceding record,
 no medicines being administered  until  the 17th, when quinia, grs. ii, three
 times daily, was directed.  No relapse of fever occurred in this case.
    Remarks.  With the post hoc reasoning, the remedy, in this instance, was
 directly and  completely successful.
    Case 5.   This was a case of fever occurring, in private practice, in a child
 four years of age.   The case is interesting from  the intensity of the febrile
 movement,  and from  the fact that  the wet  sheet  constituted  the chief
 treatment.
    The patient  came under my care March 10th, A. M.  The day previous,
 she fell asleep after dinner, and on awakening, complained of feeling very ill,
 and took to the bed.   She had not appeared well for several days previously,
 but, on the morning of the  day of the attack, was as bright as usual.  Du-
 ring  the night after the attack, she vomited  several times;  the surface was
 hot°; she was very restless, and talked incoherently.  On the morning of the
 10th, just  before I saw  her, she had a slight convulsive tremor, without en-
 tire loss of consciousness, lasting but  for a moment or two.   The pulse was
 greatly accelerated, and the skin very hot.
    I directed simply the  ext. Hyos., in solution,  grs. ii, every four hours.
    At noon, high febrile movement  continued;  skin intensely hot; pulse
 ranging  from  °170  to  180;  disposed  to  somnolency; inooherency.   The
              18 
274
MANAGEMENT OF  CONTINUED  FEVEK.
bowels had moved the day previous.   Under the impiession that the disease
would prove to be scarlatina, the chlorinated soda in solution was prescribed,
but occasioning vomiting, it was omitted after the second dose.
   At evening, the symptoms presenting no change, the wet sheet was applied.
The immediate effect was soothing, and the pulse fell to 160.   Late at night,
the rhythm of the respiration became somewhat affected,  the inspiration be-
ing shortened and quickened, and  the expiration prolonged.  Dr. Winne
visited in consultation;  and it  was agreed  to envelop the body in a sheet
wetted with mustard water, and, afterward, to repeat the wet sheet as before,
ice being applied to the head.   The sheet wetted with mustard water was
applied  for an hour, and followed  by the  simple wet  sheet, which was con-
tinued for about four hours. The patient wa3 soothed, but  the pulse remained
the same.  No remedies were given, except the hyosciamus.
   llth. At 6 A. M., patient had  slept quietly for several hours.   Respira-
tions  40, rhythm normal.   Pulse 160.  Less  delirium.  Asked frequently
for cold water.
   The ext Hyos. was continued, and  the face, neck and  arms frequently
sponged with cool water.   At noon, a  solution of sulphate of morphia  and
tartrate of antimony and potassa,  of each  gr.  1-32, every three hours, was
substituted  for the hyosciamus.  No vomiting since the chlorinated soda was
suspended.   No dejection until an enema was administered in the afternoon,
which was followed by a tolerably free evacuation.  Abdomen not meteor-
ized nor tender.   Pulse 160.
   12th. Passed  a comfortable  night.   Slept   quietly much  of  the time.
Pulse, at A. M., 150.  Skin less hot, mellow.  No vomiting.  No dejection.
Slight meteorism.  No food had  been given since the attack prior to  this
morning, when she took a little milk and essence of beef.  She relished the
latter, and  it was continued through  the day.  She had a little wine and
wine whey.   At  evening,  she took a  little bread  and milk which she had
asked for.  Pulse, at  evening, 140.  Skin mellow.  Respirations  30.  No
dejection.  Slight epistaxis.  Slight mental aberration.
   The treatment, on this  dayT consisted of  the morphia and antimony, of
each gr. 1-32, every fonr hours.
   14th. Night before last  was  passed  quite  comfortably.   Yesterday morn-
ing, aspect  improved.  Took a little  egg-nog  and a little bread  and milk
with  relish.  Pulse ranged from 130 to  140. Bowels  moved  slightly by
enema.   No  medicine until evening, when the ext. hyos. gr. i ss, every  four
hours, was  prescribed.  To-day, aspect still more improved.  Pulse  130,
and at  noon, 120.   Syrup of rheubarb  and  magnesia  was prescriled im
repeated  doses, until it produced a laxative operation. 
MANAGEMENT  OF CONTINUED FEVER.
275
  From this date the little patient rapidly convalesced without farther treat-
ment.  On  the 17th,  medical attendance was discontinued,  and  she  has
remained perfectly well up to the present time, Jan. 1852.
  It will be understood that the foregoing report of cases in which quinia,
opium, and  the wet sheet were employed, contains the sum of my  observa-
tions, up to  this time, relating to these methods.   The cases are not selected
for illustration, but are all that I have collected bearing on the present subject
As already  remarked, they are too few for purposes of induction.  So far as
they go, however, they afford  evidence,  in the  first place, of the  safety of
making trial of these methods.   This is a point of primary  importance.
With the  present uncertainty attending the employment of any measures to
cut  short, or abridge the duration of  Continued Fever, we should be hardly
justified in resorting to those which, if not successful, would be likely to impair
the chances of passing through  the disease with safety.  In this respect  the
three methods of treatment just mentioned compare favorably with others that
have formerly been in repute, viz: copious bloodletting, emetics, and cathartics.
   But the facts contained in the histories of the cases in which opium and
the wet  sheet were employed, although  insufficient to authorize inductions
respecting the positive influences due to them, yet tend  to support the pre-
sumption that they do possess more or less power to ameliorate the symptoms,
 and to affect both the duration and severity of the disease.   At all events,
 they are of a character to render it interesting to prosecute farther observa-
 tions, in order to collect a larger series of data for investigation.
   It is by  no means improbable that various methods of treatment may be
 found to exert  more or less control over the intensity and  persistence of the
 morbid conditions upon which Continued Fever depends.   This is the  fact
 with respect to periodical fevers.   In  the latter form of fever, arsenic, strych-
 nia, prussiate of iron, salacine, etc. are found to have each a specific influence,
 tKe' quinia  being superior to any.  So, in Continued Fever, it should be, not
only an  object  of inquiry to ascertain  a single plan  of abortive treatment
which may be, to a greater or less extent, successful, but to discover different
methods; and, finally, by comparisons, to ascertain their relative value, and
the circumstances upon which  the efficiency of each depends.   Should Sci-
ence, at length, succeed in  acquiring a  special  remedy, adequate to the ob-
jects of art in the management of this disease, as  quinia is in the treatment
of periodical fevers, it will  certainly be not more extraordinary than that the
latter should  have been discovered;  nor, prior to  this discovery, were there
stronger reasons for anticipating it than now exist with reference to prospective
success in seeking for the means of controlling Continued Fever. 
 276               MANAGEMENT OF  CONTINUED FEVER.

   A single  remark  suggests itself, in conclusion, respecting  measures that
 have heretofore been considered successful in arresting or abridging  the ca-
 reer of Continued Fever.  Allusion has been made to the factitious import-
 tance attached, for a transient period, to different  methods of treatment for
 these ends.   It is to be considered, on the other hand, that  the demonstra-
 tion of this fact with regard to any measure naturally leads  to a disparage-
 ment of the value which it may actually possess.  If a remedy fails to fulfill
 the sanguine expectations which had been raised, it becomes as much under-
 valued as it had been over estimated, and, hence, falls into unmerited neglect,
 Possibly this remark may be applicable to some of the methods of treatment
 formerly supposed  to be successful in controlling  the course of Continued
 Fever.  The extent however to which some of these methods have been em-
 ployed forbids such  a supposition.  For examples, bloodletting, emetics, and
 cathartics, it is probable, have been in vogue sufficiently to establish their inef-
 ficacy as abortive remedies.  It may, perhaps, be doubted whether this is true
 of cold affusions  as recommended  by Dr. Currie, about a half century ago.
 The striking success which appeared to attend this measure, and  which gave
 it, for a short time, such celebrity, it would seem, could hardly have rested on
 a basis wholly suppositious.   May not disappointment at not finding it so
 uniformly or completely successful as had been anticipated,  have caused it«
 value to be  unduly depreciated, and too  soon abandoned ?  Having no facfc
 to contribute bearing on this question, I shall content myself with  merely
 propounding it.

 TREATMENT  IRRESPECTIVE OF ABORTIVE MEASURES,  AND WITHOUT  REFER-
            ENCE TO  CO-EXISTING OR SECONDARY AFFECTIONS.

   What are the leading principles  that  should  govern the management of
 Continued  Fever, exclusive  of measures  designed to arrest its career or
 abridge its duration, and  aside from remedies addressed  to  local affections,
 with which  the disease may become complicated ?   Several considerations
 may be mentioned which have an important bearing on this  inquiry.
   First.  The disease, if not arrested, or abridged, by therapeutical inter-
 ference, has  its intrinsic limitations.   It runs a certain course, ending in recov-
 ery, after the lapse of one, two, or  three weeks, provided  the issue  be not
 fatal.
   Second.   The intimate pathological conditions  upon which the disease is
 dependent, or, in  other words, its proximate cause,  in the present state of sci-
ence, cannot be explained.  The nature of the special agents inducing the 
MANAGEMENT  OF CONTINUED FEVER,
277
disease is unknown, and, consequently, their mode of action within the organ-
ism, as well as the immediate changes produced thereby, are not understood.
We have not, therefore, the point of departure from which to advance de-
ductively toward a rational plan of cure.
   Third.   In the majority of instances, the tendency of the disease is to end
favorably.   If we study the histories of a series of fatal cases, we find  that
the unfavorable issue is generally owing to causes not belonging intrinsically
to  the  disease — for examples, various complications  like pneumonitis;  or
what may be distinguished as  accidents, like haemorrhage, intestinal perfora-
tion, apoplectic coma; or external circumstances, such as the absence of hy-
gienic advantages;  or diminished power of resistance from enfeebled health,
etc., etc.   All these are  not, properly, elements of the disease, some being
incidental  to it, and others wholly  adventitious.   Divested of every thing
collateral,  or superadded,  affecting its  progress in an  unfavorable manner,
there is  reason to believe that  the termination  in recovery might  almost  be
considered to be a law of the  disease.
    Now, from  these  considerations, it  appears to be a legitimate deduction
 that  the  management of Continued  Fever per se, under the qualifications
embraced  in this division of the  subject, does  not  claim  efficient medicinal
 interference.  This conclusion accords  with the views entertained by many of
 the most judicious practitioners and the soundest writers of the present time.
 Apart from means  instituted  to  cut short the disease,  and to prevent or  re-
 lieve complications, the plan of treatment most consistent with what  knowl-
 edge we at present possess, is  the expectant, as it is called.  The mere fact of
 the existence of Continued  Fever does not involve any special therapeutical
 indications.  Cases may occur in which little or no active  interference is
 called for.  It is probable that, of a collection of cases permitted to run  their
 course,  under favorable hygienic conditions, without  medicinal treatment, a
 good proportion would end in recovery.  This remark is not based altogether
 ^conjecture.  For example, Hildebrand says of Typhus:  « The experience
 of all ages proves that, like all other contagious fevers, it is frequently cured
 of itself, that is, by the mere action of the vital powers, unassisted by any of
 the resources of our art.  The simple state of the disease is, in fact, always
 dissipated in this manner; and  it would be a lamentable circumstance,  espe-
 cially for  the poor, if this assertion were not correct"  The same  author,
 after citincr his own case in  which, after an emetic and  bleeding, he  took  no-
 thing butlemonade and barley water  during the whole course of the d.sease,
 continues • -1 have repeatedly seen patients who were affected with a simple
 ordinary typhus, get perfectly well by taking  nothing but lemonade."   He 
278
MANAGEMENT OF CONTINUED FEVER.
adds, " For this mode of treatment I am indebted to the views of a  great
physician, the Baron De Stork, who has treated the same disease successfully
by the simple employment of wine whey."  In several of the cases which I
have observed, the medicinal treatment has been  virtually nugatory, consist-
ing only of slightly palliative remedies,  or placebos.   As an instance, in ono
of the cases contained in the first collection, the patient, who had been under
homoeopathic management for the first ten days, and then abandoned by the
attending practitioner as a hopeless case, my treatment, aside from diet, and
other measures of hygiene, consisted  solely of the sulphate of quinia,  gr. 1,
every four hours, the career of the disease running to twenty-eight days, and
then ending  favorably.   This was a case in private practice, and the  chief
reason for prescribing the small doses  of quinia was,.that I might not, in the
event of an unfavorable  issue, be exposed to the charge of having given no
remedies!
  That Continued Fever may often do well without medicinal interference,
is a fact important to be  borne in mind; but it does by no means follow that
the rule of management of the  disease is to be based  thereon.  In saying
that the treatment should be expectant,  it is not  intended to assert  that the
practitioner  is to be merely a spectator of  the phenomena of the disease,
waiting for convalescence without any effort to render therapeutical aid.
   The  point to  be enforced in view of the considerations that have been
presented is, that the presence of the  disease does not, as a matter of course,
furnish the occasion for active remedies.  We are not to resort to efficient
medication simply because a patient  is affected with Continued Fever, nor
are perturbatory or powerful measures always required.   On the other hand,
it may be that little or no medicinal treatment is called for.  The therapeu-
tical indications, in other words, are not indissolubly associated with the ex-
istence of fever, but are derived from  the various  circumstances, incidental
and accidental, which may be connected with the disease in individual cases.
To watch, in every direction, for  the development  of these  indications, to
appreciate their character and importance, and to meet  them, as they arise,
by appropriate measures, are, in  general terms, the objects of the expectant
method of management.
   Let us now proceed to inquire respecting some of the particular indications
for treatment during the progress of Continued Fever.   They may be divid-
ed into special and general.   The special indications will relate, for the most
part,  to the symptoms and  events, respectively, which enter into the natural
history of the disease.   The most convenient arrangement will be to  notice
them under the same anatomical divisions employed in the analyses upon 
MANAGEMENT  OF CONTINUED FEVER.
279
which the preceding Reports were based.   Following this plan, the indica-
tions pertaining  to the nervous system  are first in order.  The symptoms
which claim attention with reference to treatment  under this head are, ceph-
alalgia, somnolency, insomnia, and delirium.
   The pain in the head which accompanies the access and early part of the
febrile career, is  sometimes acute, and may be the chief source of  suffering.
It is to be borne in mind that, in  a greater  or less degree, it is an element of
the disease, and  that, after a few days, it usually ceases to be the subject of
complaint.  It does not necessarily denote inflammation, or even a tendency
thereto, although it may be intense.   A different opinion was held by prac-
titioners heretofore, and even  now obtains to a considerable extent.  In con-
nection with delirium it has been  supposed  to denote encephalitis, or a liabil-
ity to  this  complication, which, in fact,  occurs  as  rarely as  it was formerly
regarded frequent.   The treatment, then, which this symptom  may call for,
is not to relieve or avert inflammation, as was laid down, for example, in the
treatise by Dr. Southward Smith, an able work that did much toward giving
direction to the practical notions  of  physicians in this country, which wer«
 formed twenty years ago.  The author just named advocated  prompt and
copious bloodletting for that end.  It is questionable how  far the cephalalgia
is due to active congestion, or any disorder of the circulation.  The propriety
of bloodletting, theoretically, is involved in  this question.  The  power of thi-
 remedy to affect pain or other cerebral symptoms must be mainly by dimin-
 ishing the quantity of blood determined  to.the brain, directly, by the amount
abstracted from the mass, or, indirectly, by lessening  the  force  and rapidity
 of the circulation.   The circumstances which indicate the  remedy, therefore,
 are those showing the dependence  of the  symptoms which we wish to re-
 lieve upon  repletion of the vessels of the encephalon, or upon conditions of
 the vascular system which depletion will be likely to remove.   The subject
of bloodletting, in general, in Continued  Fever, will be more properly noticed
 presently, in another connection.  Of the efficacy of this remedy in relieving
 intense cephalalgia, I cannot speak from results witnessed in cases the histories
 of which I have preserved.   I have resorted to it for this or any other pur
 pose in two only of the one hundred analyzed; but in  a large  proportion of
 the cases collected, pain in the head had ceased to be a prominent symptom
 before the patients came under  my care*  I have  the  same confession to
  * In  a few of the cases bloodletting had been practiced before the patients came
under my observation.  This will account for an apparent discrepancy between  tL*
statement and some facts mentioned in the preceding Reports. 
280
MANAGEMENT OF CONTINUED FEVER.
make respecting topical depletion by cupping  or leeches.  Evaporating lo-
tions applied to the forehead, and over the whole head, afford comfort; and
in order  to  facilitate their application, as well  as to promote, in  itself, cool-
ness of the surface, cutting the hair close to  the  scalp, whenever  circum-
stances render it proper, is a measure of some consequence.   The latter is a
standing direction for all  fever  patients admitted  into  hospital during my
term of service.   The  ice  cap, in some  cases  in which  the cephalalgia was
intense, I have found useful.   Cold affusions, limited to the head, pouring
water for several  minutes from some height  from a pitcher or jug, the head
being held  over a basin, is an appropriate means of procuring the benefits of
refrigeration.  I cannot speak of its advantages from trial, never having em-
ployed it.   It is said to be strikingly efficient,  and with  regard to its imme-
diate effects an error of observation would not  be  very likely to occur.  An
opiate, in tolerably large doses, for example a quarter of a grain of morphia,
has seemed to me to be serviceable in relieving this symptom, when not in-
tense, and unaccompanied by evidences of marked determination of blood to
the head.  I have never observed any unpleasant effects to follow the use of
this remedy in the early period of febrile career when cephalalgia is  present.
   This symptom by no means gives rise to a special indication for treatment
in all  cases.  If moderate or slight  in  degree,  with the prospect that it will
gradually abate  as the disease  progresses, and in  a few days cease, minor
palliative remedies will be sufficient.
   Somnolency, in other words  a semi-conscious  condition from which the
patient is readily, but  only momentarily roused, need  not deter us from pre-
scribing  opiate or  anodyne remedies, but, on  the  contrary, they appear to
produce  a good  effect  by substituting for this  condition more complete and
refreshing sleep.  The results of my analyses show that the state of somno-
lency,  which is somewhat characteristic of Continued Fever, more especially
the Typhus type, does not denote a tendency to stupor or eoma which would
contra indicate narcotic medicines.  The latter symptoms, which denote great
danger, are of infrequent  occurrence, and belong properly among the events
complicating the disease.
   Vigilance, or insomnia, is a symptom  claiming  attention  in  the manage-
ment.   Is it not probable  that the enfeebled  condition of the brain indncing
the delirium and  mental  hebetude incident to the  progress of Continued
Fever may be due, in some measure, to the deficiency of sleep ?  It  k to be
borne  in mind that somnolency  is not sleep, and, hence, that patients may be
in a dozing state the greater part of the time, and still experience the evils of
insomnia.  To endeavor to procure sleep is an important indication, and for 
                   MANAGEMENT OF  CONTINUED FEVER.               281
this end opiates seem to me to be valuable remedies  throughout the disease.
Opium, in substance or tincture,  Dover's powder, or morphia  may  be pre-
scribed.   I have been accustomed to employ the last article mentioned oftener
than the others.   In a large proportion of the cases upon which my second
Report was based, generally in doses of a  quarter of a grain every four or six
hours, it was given during the greater part of the febrile career.  In several
cases this constituted the chief, and in  some instances almost the sole treat-
ment.  It has never occasioned any appreciable ill effects; and with reference
to this and other indications, I am disposed to think that an anodyne  influ-
ence maintained by some form of opiate  is of considerable  utility in the
management of Continued Fever.
   Delirium, if slight, or even moderate, does not furnish special therapeutical
indications.   It is  an element of the disease, and, if it does not exceed the
degree in which it is present in the larger proportion of cases, is not of much
importance.   When it is prominent as a symptom, and especially when it is
predominant, or active, it, of course, claims attention.  Opiates, in decided
doses will be found useful.  I have in several instances observed, after com-
plete sleep effected by anodyne remedies,  the mind become more clear, and if
delirium recurred, it was lessened  in degree.  But, so far as my experience
goes, the  remedy  upon which most reliance  is to be placed for restraining the
delirium of Continued Fever, is the  Tartrate of Antimony and Potassa, given
in connection with anodynes.   It is seldom  that this remedy will fail to  palli-
ate this symptom,  and generally the effect  is striking.  Small  doses usually
suffice.  My course is, to direct a sixteenth  or eighth of a grain to be  given
hourly, or half hourly, until the patient becomes quiet, unless distinct nausea
or vomiting  occurs, when it is to be  suspended.  The desired quietude will
frequently be obtained without its being  carried to an extent to disturb the
stomach.   Anodynes may at the same time be given with  intervals of four
or six  hours  as when the object is to procure sleep.  The manifestations of
delirium calling for treatment take place  especially at night, and, hence, the
tartar  emetic is seldom required during the  day time, but it may be repeated
nightly if required.
   So satisfactory  has been the employment of antimony with reference to
this symptom, that, excepting  in those  instances in which  the delirium was
remarkably active and persistent, a more  efficient remedy seems to me hard-
ly attainable, or even desirable.   In the instances  in which  delirium is  a
predominant feature, I have no remedies to suggest more likely to be  bene-
ficial than opiates and antimony.   There is reason  to think  that when the 
282
MANAGEMENT OF CONTINUED FEVER.
disease is thus  characterized, it will almost inevitably prove fatal in spite of
any measures of treatment.
   The indications pertaining to the Digestive System will  relate, mainly, to
nausea and vomiting, diarrhoea, haemorrhage from the bowels, constipatiow
tympanites, and abdominal tenderness.
   Nausea  and vomiting,  seldom present in a  degree to require special
treatment, very rarely  occur after the access, or early part  of the febrile
career.   When they claim any attention, restrictions as respects  the quantity
and quality of what is ingested will  usually suffice;  and, if  further measures
are necessary, those are appropriate which are employed to  relieve gastric
irritation  developed irrespective of fever, or in connection  with  other affec-
tions.  These measures are a sinapism or  blister to epigastrum; morphia;
kreosote;  hydrocyanic acid, etc.
   Diarrhoea, is a  symptom embraced among the distinctive traits of the
 Typhoid type,  which will sometimes call for special remedies.  So far as my
experience goes, it  is seldom difficult to regulate the  evacuations by simple
measures.   An anodyne and astringent enema, repeated according to circum-
stances, usually suffices; and if morphia, or some form of  opiate, is admin-
istered with  reference to other objects, agreeably to the plan I have pursued
in the majority of cases, it is seldom that the diarrhoea will require additional
treatment.  The presence of diarrhoea furnishes an indication, in addition to
those already noticed, for the employment of some form of opiate.   I  have
had no experience with the nitrate of silver which has been recommended to
be given by the mouth, and by injection, to relieve the diarrhoea occurring in
 Typhoid fever.   The  spirits of turpentine also, which has been advised for
the same  end, I have prescribed  too little to form an opinion of its efficacy
from  the  results of  my  own observations.   Merely looseness of the evacua-
tions, without undue frequency, does not call for  special treatment.
   In the  two instances among the one hundred  cases upon which the pre-
ceding Reports were based, characterized  by the occurrence of  haemorrhage
from the  bowels, the administration, by the mouth, of  opium and the acetate
of lead in one  case, and, by enema, of the tincture of opium and tannic acid
in the other case, proved at once  successful.  This symptom, which is some-
what distinctive of the Typhoid type is probably due to ulceration of Peyer's
patches, conjoined with a condition of the blood itself, favoring  its transuda-
tion.   The importance of pursuing measures to  arrest the haemorrhage as
speedily as possible, cannot be doubted.   This is apparent  from the prostra-
tion attending  its occurrence.  Having once occurred in the progress  of a 
MANAGEMENT  OF  CONTINUED FEVER.
283
case, the impropriety of administering cathartics, or laxatives subsequently
is obvious.
   Constipation not  infrequently exists in Continued  Fever, oftener in the
 Typhus, than in the  Typhoid type, but occasionally in the latter; that is to
 say, the  bowels will  remain  quiescent for several successive days if cathar-
 tics or laxatives are not given, and, especially if opiates  enter  into the
 management.
   The question here suggests itself, what are the indications in the manage-
 ment of the disease which pertain to cathartics ?   Most writers on this subject
 enjoin the employment of remedies of this class sufficiently to procure one
 or more dejections daily; and the majority of practitioners, probably, make
 this an object of treatment.  My own observations lead me to hold a different
 view.   The  results of  the investigation of the histories that I have collected
 show, first,  that  diarrhoea frequently follows the operation  of a cathartic;
 second, that  the proportion  of cases characterized  by diarrhoea is greatest
 among those in which  cathartics were employed; third, in one case, haemor-
 rhage from  the bowels followed the operation  of  doses of castor oil, occur-
 ring  only in  this connection,  and no cathartics being given  in  that case
 with these exceptions; and, fourth, no appreciable evils resulted from omit-
 ting all  remedies of this class in a large proportion of the cases, a dejection not
 occurring, in  several instances, for periods varying from three to eight days.
    These facts appear, to my mind, to  render more than doubtful the propriety
 of resorting to cathartics in  Continued Fever, save for some special  objects.
    Looking  at the subject rationally, it is to be considered, first, that cathar-
 tics are not indicated, more than other remedies, by the mere fact of fever
 being  present.  We have no adequate evidence that patients  pass through
 the disease  more safely and pleasantly, other things being equal, when^cathar-
 tics  enter into the  management, than when they do not.  Second, it is a
 principle of general application in therapeutics, not to be lost sight of here,
 more than in other affections,  that remedies  of more or less potency, if not
 indicated, will be likely  to prove hurtful.  If not efficient for good, they will
 probably be  productive of harm in proportion to their activity.  They cannot
 be expected to be neutral in their consequences.  Third, it is not difficult to
 conceive from the  modus  operandi of cathartic  remedies,  how  they  may
  prove  injurious.  Their local  action on  the  alimentary canal involves more
  or less irritation,  and  this, when the  follicular patches are diseased, ulcerated,
  in the  TyphoidtyVe,  (a conditionnot incompatible with constipation,) cannot
  but be prejudicial.  Under these circumstances the only way in which  they
  can be  considered  appropriate in their local effects  is to  suppose  that  by 
284
MANAGEMENT  OF CONTINUED  FEVER,
effecting the discharge of the morbid contents of the  intestinal canal, they
remove causes of irritation, which, by remaining, would do greater harm than
is occasioned by the action of the cathartic.   Admitting that the direct effects
of the latter are bad, it may be said that it is indirectly useful by causing the
discharge of what would occasion effects much worse.  This is doubtless the
reasoning often adopted; but the premises are  assumed, not proved.  In-
deed, in so far as the facts presented in the preceding Reports furnish evidence
relating to the  matter, it is adverse to the hypothesis just stated.   Other
reasons which may be assigned such as,' to correct the secretions,'' to excite the
action of  the liver,' etc.,  are too gratuitously speculative to deserve attention,
more particularly so long as the results of experience appear to be  adverse to
the utility of cathartics.
   The remote, or general effects of this class  of  remedies is to diminish the
vital forces, to conduce to prostration.   In other words they are debilitating
in their tendencjr, and, hence, it is reasonable to  suppose  that they may be
productive of harm rather than good.  Although this phraseology is  some-
what indefinite, owing to the want of precision in our knowledge of the re-
mote effects of cathartics, as well as various other remedies, on the organism,
it conveys ideas which are practically  appreciable, and  with which all practi-
tioners are sufficiently familiar.  For the reasons, therefore, which I have thus
endeavored briefly to set forth, I think purgatives are not useful in the man-
agement  of  Continued  Fever except there  arise  some special indications for
their use.  Constipation alone may  furnish  an  indication.   If the bowels
do not move spontaneously after several days, even if  no evils are apparent,
it may be the part of prudence to effect a movement.   But for this, so far as
my  experience  goes,  active cathartics are not requisite.  Remedies distin-
guished as laxatives will suffice, and even these, simple injections will usually
render unnecessary.   The latter are always to  be  preferred when practicable
or adequate.  If remedies are  given by the  mouth, the mildest, and most
grateful are  preferable, such as Seidlitz powders, Congress-water, Magnesia,
etc., provided there  are no special  reasons for  moving the bowels except to
obviate costiveness.
   By omitting  cathartic or laxative measures, unless they appear  to be spe-
cially called for, the evacuations which take place spontaneously will  sometimes
preserve an appearance of health, a fact which perhaps will hardly seem  credi-
ble to those who are  accustomed  to move  the bowels by medicinal  means
daily, or every other day throughout  the progress of the disease.   This fact
is noted in the histories of  several of  the cases which I have observed.
   Tympanites or meteorism, may furnish an indication for cathartics.   This 
MANAGEMENT OF  CONTINUED FEVER.
285
symptom is a source of distress, and, by impeding respiration, etc., may add
to the  danger of a fatal issue.  It therefore claims attention.   Enemas are
sometimes useful; but if these are ineffectual, a cathartic should be tried, more
especially if the bowels are constipated.   Mechanical compression by means
of a bandage, and  friction with stimulating embrocations appear to be ser-
viceable.   Cloths dipped in heated spirits of turpentine have seemed to be a
useful  application.   I have given, in several instances, powdered charcoal
with a view to its property of absorbing gases, and  I have imagined that it
produced some effect in that way.
   Abdominal tenderness, is peculiar to Typhoid cases, and is seldom so great
as to  occasion  suffering except upon pressure, or movements of the body.
 Fomentations, or a light cataplasm, would be appropriate, but the cases must
 be rare in which  this symptom requires special treatment, excluding, for the
 present, those in which peritonitis exists as a complication.
   It is rarely  that important indications appertain  to symptoms referable to
 the Pulmonary System, excluding, for the present, cases in which the disease
 becomes complicated  with pneumonitis.  More or less cough belongs to the
 natural  history of Continued Fever, but it is seldom sufficiently prominent
 or troublesome, to need remedies.   When  it is otherwise, provided opiate?
 do  not  enter into the  management, small doses of  morphia dissolved in
 mucilage, or syrup, are appropriate.
    Epistaxis, which also belongs to the natural history of the disease, in the
 great majority of  instances is slight, not requiring  to be  restrained, but per-
 haps  being a salutary fluxion.  Occasionally, however, it is copious, and may
 proceed to an alarming degree.  The usual methods of arresting hemorrhage
  from  the nostrils,  are then to be resorted to, viz: the application of cold, and,
  in some cases, plugging the anterior and posterior nares.  Of the one hundred
  cases upon which the  preceding  Reports were based, in but one case was
  the loss of blood  so great  as  to occasion apprehensions of danger.    The
  haemorrhage was  arrested in this case without resorting to plugging.
    The indications pertaining to the circulation relate  chiefly to bloodletting.
  Respecting bloodletting in  Continued Fever,  my recorded observations are,
  with a very few exceptions, confined to cases in the treatment of which it did
  not enter   That  I have omitted to avail myself of facilities to study, to some
  extent  the effects of this  therapeutical  measure, has been not wholly owing
  to a reluctance to employ a remedy of doubtful  applicability, but, in  some
  measure, to the fact that a large proportion of the cases, the histories of which
  I  have preserved, did  not  come  under  observation until  the disease had 
286
MANAGEMENT  OF CONTINUED FEVER.
advanced so far that bloodletting would have  been deemed inadmissible by
those who advocate its propriety.
   If  Continued Fever offers  indications for bloodletting,  it is  evident that
they are now of a  character different from those  which have heretofore
led to its employment in this  disease.  The objects for which this  measure
was formerly practiced, (aside from the effort to cut short the disease,) were to
relieve and to prevent local inflammations.  Its supposed utility was based
either on the dogma that fever was always symptomatic of  local inflammation
somewhere, after the doctrine of Broussais, or on the belief that inflammations
of internal organs were very liable to occur  as complications, and that, in the
latter cases, they constitute the chief source of danger.   The doctrine held by
Dr. Southward Smith, for example, was, that the only element of fever over
which art can exert any control, is the tendency  to local inflammations,  and
hence, bleeding was regarded by him as (to use a common metaphor) the sheet
anchor of the treatment. These pathological notions are now well nigh obsolete.
Few will be found, at the present time, to contend  that there is no such  dis-
ease as  essential  fever; and it may be  considered equally settled that local
inflammatory complications, calling  for active treatment,  are of infrequent
occurrence.  These facts by no means suffice to disprove the utility of blood-
letting, but they show, assuming its usefulness, that the reasons why it is so,
are other than those which have heretofore  been considered satisfactory.
   In seeking to form a just estimate of the value of this, as of  every other
remedy, the question of course arises, what are the accumulated results of ex-
perience ?  This question properly precedes an inquiry concerning the rational
indications which the remedy is to fulfill.   The difficulties, already alluded
to, of testing by experimental observations, different methods of treatment,
are applicable to bloodletting, as well  as other therapeutical measures.   It
cannot be said that the positive  influence exerted by the. employment of  this
remedy on the average fatality, or duration of Continued Fever has been  set-
tled by numerical facts.  It may, indeed, be doubted if statistics have demon-
strated, or are capable of demonstrating that it possesses any power to shorten
the career of the disease, or to lessen the liability to  death, all other  things
being equal.   It must, however, be admitted that experience renders highly
probable, if it has not established an important  negative conclusion,  viz, that
bloodletting does by no means  always increase the duration,  or fatality of
Continued Fever.   This is a legitimate deduction from the employment of
the remedy in successive series of cases, in which the average of fatality  and
duration is small or moderate.  Not to mention other statistics bearing on  this
point, those contained in  the  treatise by Dr. Southward Smith,  before 
MANAGEMENT  OF CONTINUED FEVER.
287
referred to, suffice for this deduction.  These statistics are based on cases, in a
large proportion of which bloodletting was practiced, it being regarded as the
most important therapeutical measure in the management of the disease,  and
the results, during several years, do not exhibit a large  proportion of deaths.
   Now, while a low rate of mortality, on the one hand, and, on the other hand,
a high rate, may not afford much evidence either for, or against the effect of
bloodletting, owing to the  great variations of the disease at different times
and places, in the relative fatality, and  for other reasons, a small proportion
of deaths in a series of cases into the treatment of which the measure en-
tered, certainly affords a strong presumption that the effect was not in a great
degree prejudicial.
   Were we to inquire concerning the views which have been entertained by
practical men, and professedly based on impressions derived from individual
experience, we  should  find discrepancy  of opinion.  It would require  con-
siderable research to determine on which side recorded testimony of this kind
 preponderates.   Unanimity of opinion by no means  obtains among  practi-
 tioners of the present time.   Confidence in the remedy and its employment
 have, doubtless, declined within  the few past years, but the  subject  is  an
 open one for discussion and investigation.   Common consent, or the united
 voice  of the profession, does not fix a precise estimate of  the value  of the
 remedy, more than do the rigorous  analyses  of facts.
    With our present knowledge, it would appear to be as unphilosophical and
 irrational to commit the judgment in behalf of repudiation of bloodletting in
 all cases of  Continued Fever, as  to  advocate its  employment  in every case.
 The conclusion most consistent with facts, and which best reconciles the con-
 flicting results of  experience, is, that the remedy may, or may not be appro-
 priate—that it  is useful  in some cases, and probably hurtful in other cases.
 Its propriety and  usefulness, it is reasonable  to suppose, depend not only on
 the circumstances appertaining to individual cases, but on characters of the
 disease peculiar to certain times and places; and, hence, observations showing
 at one time, or place, its utility, and at another time  or place its evils, may
 bo equally  correct.   The  importance of studying the  traits  of Continued
 Fever as of various diseases, of different seasons  and situations, in order to
 adapt'the treatment to the varying  characters which it may assume, applies
 to  other  therapeutical  measures, as  well as the particular remedy  under
 consideration.   The value of this precept emphatically enunciated by Syden-
 ham, the experience of practical observers since   the day  of that illustrious
 physician has abundantly confirmed.
    In view of the general conclusion, with respect to bloodletting, just stated, 
288
MANAGEMENT OF CONTINUED FEVER.
it remains to inquire what are the indications derived  from symptoms which
should lead us  to resort to the remedy in individual cases of Continued
Fever?   Let it be borne in mind that we are not to bleed simply because the
patient has Continued Fever; we do not  bleed for the disease per se.  We
do not bleed to extinguish the disease, or because it is proved that by this
remedy its duration is shortened.  Nor do we bleed because Continued Fever
necessarily involves  local inflammation, or tends thereto.  What do we im-
mediately effect by bloodletting?  We lessen the mass of blood, and thereby
diminish the motive power carrying on the  circulation.  Now the quantity
of blood may be in morbid excess in fever, and the momentum may be un-
duly exaggerated.   Here, then, are objects to be fulfilled by detracting blood,
viz: to reduce the excess in quantity of the circulating fluid, and to abate the
excess of energy in the action of the forces  carrying on the  circulation.  If
this be the  correct rationale of the supposed beneficial operation of bloodlet-
ting, the special indications, it is plain, relate to the condition of the vascular
system, as respects repletion, and of the circulation as respects power.   Full-
ness of the  vessels, a pulse denoting, not activity, but power, i. e. in volume
well developed, and  resisting compression — these symptoms, associated with
the other elements of a high grade of febrile movement, are those by which
the employment of this measure is to be governed.
   To settle upon the conditions under which bloodletting  may be practiced,
is one point, but another point, manifestly of importance, is, to determine the
extent to which it may be carried with prudence and advantage.  The lim-
itations of the remedy, in the abstract, are defined with more difficulty than
the indications for its employment.   In  resorting to this, as to any potent
therepeutical measure, the harm that it is capable of doing, is to be taken into
account, as well as the good that it is desired to effect by it.  The chief point
of consideration in this  aspect is, that  since we  do not expect to arrest or
abridge the continuance of the disease, it would be obviously injudicious to
bleed to an  extent to compromise the ability of the patient to hold out through
the febrile career.  It were better to forego the relief it may afford to some
of the contingent symptoms, than to incur that hazard.   To adapt the remedy
to the circumstances of particular cases, keeping within proper conservative
bounds, is a matter that cannot be embraced  in routine rules, but must be left
wholly to the judgment  and tact of the practitioner.
   To  conclude these few desultory hints on the subject of bloodletting in
Continued Fever, I should  say, judging from my own  observations, that the
indications  for  this remedy are rarely  present.  I can readily understand,
however, that in a series of cases of a different description it may be otherwise. 
MANAGEMENT OF CONTINUED FEVER,
289
wise.   A large proportion of the cases I have observed were among  newly
arrived immigrants, reduced by the deprivations incident to a tedious voyage
across the  Atlantic, and suffering from the depressing moral  influences of
sickness  in a hospital in a strange land.  Moreover, the greater number, as
already remarked, were  admitted after more or less  continuance of the dis-
ease,  and the rational indications for bleeding are very rarely present save at
an  early period.   Patients  attacked in vigorous health, and especially if
laboring under an overplus of blood, and  an unduly energetic circulation,
other things being equal,  are those who would be expected to present indi-
cations for bloodletting.    A larger proportion of this class of patients would
be likely to be found in  a  series  of cases in a healthy rural district, than
among the poor population of a  city.   Hence,  I have had occasion to
remark that practitioners in  the country are apt to be stronger advocates of
bloodletting than those  residing in cities.
   Finally, the indications for bloodletting  are less frequently present in the
 Typhus, than in the  Typhoid type.   This accords with the distinctive char-
acters of the former.   In the Typhus form of the disease the vital powers are
more prostrated;  the circulation seldom exhibits morbid  increase of power,
and  the importance of conservative  precautions is greater than in Typhoid.
   The special indications  pertaining to the skin, relate, first, to increased
'heat, and  dryness.   These symptoms  are  usually present, more  or less, in
Continued Fever.  They  denote a condition of  the skin unfavorable for the
exercise of its functions, and it  is reasonable to suppose that thus, indirectly,
they  may prejudice  the welfare of  the patient, aside from compromising his
comfort  The direct effect of an increased disengagement of caloric, moreover,
it is not improbable,  may  contribute  to some of the evils of the febrile state.
   The most effective, and, in fact, the only refrigerating  measures that pos-
sess much  potency, are  external applications, and these are cold  water and
cool air.   Ablutions  with  cold  water are usually very grateful  to the sensa-
tions of patients affected  with  fever,  and abate, frequently in  a striking
manner, the increased heat and dryness.   The simplicity of the remedy
causes it to be too lightly esteemed  by attendants, and sometimes,  perhaps,
by physicians.  It is really an  important part of the treatment of a large
proportion of fever cases.  The  face,  body, and extremities, may be  sponged,
in succession, several times during the day, or as often as the  heat  and  dry-
ness  return.    A faithful, judicious nurse may occupy a considerable portion
of the time with these ablutions, to  the advantage of the patient   Should
■cold  water occasion  uncomfortable sensations  (which will  rarely, if ever, be
the case) tepid, or even warm water will secure, by evaporation, part of the
             19 
290
MANAGEMENT OF CONTINUED FEVER.
refrigerating effect.   The  evaporation will be more rapid if spirit be added
to the water.   Cologne, or other perfumed spirits may be employed for this
purpose, as a matter of taste, or elegance.  The ablutions (with water) should
extend  to  the  mouth and teeth.   The appearance, comfort, and, in some
degree,  the welfare  of the patient are promoted by removing the deposits on
the teeth and lips (sordes), and cleansing the tongue  and mouth, so far as
practicable, from the vitiated secretions.
   Cold water taken into  the  stomach  exerts  a refrigerating effect on  the
skin, and the system at large.  Patients should be allowed  to drink freely,
the only restraint required being not to  take  at a single draught sufficient to
distend  the stomach  and occasion distress  or vomiting.   The refrigerat-
ing effect of cool air is important.  This is one of the useful ends of  free
ventilation.  To secure  this end the patient  should be lightly covered,  and
ventilation beneath  the bed clothes attended  to.
   The  skin being endowed with  important  excretory functions, the suppo-
sition that  a morbid material may be eliminated through  this channel, pro-
vided the humoral  pathology of fever be adopted, is certainly not irrational.
The notion that fevers sometimes arrive  at a favorable termination by means
of a critical cutaneous excretion, has for a very long period been entertained,
and is  still in vogue with  the profession, and especially with the  public.
Upon this idea is based the indication for measures designed to induce dia-
phoresis in  Continued  Fever.  Is this a valid indication ?  So  far as  the
results developed by my analyses  bear upon this question, they do not  fur-
nish evidence for the affirmative.   These results show that increased perspir-
ation, or sweating, although occasionally coincident with a favorable change,
is oftener not immediately followed by  convalescence, or a distinct ameliora-
tion of  symptoms.  This being the case, the chances are unfavorable to an
expectation of benefit from diaphoresis, were it practicable  to induce it at
will, unless it be more beneficial when it results from remedial measures than
when it occurs  spontaneously, which is not a very probable supposition.  The
most  rational inference from the facts  just  mentioned is,  that when sweat-
ing directly precedes or concurs with convalescence, or marked improvement,
it denotes either a coincidence of phenomena having no connection of cause
and effect, or that the sweating is one of the  results of the favorable changes
in the progress of the  disease  due to other  causes.   In the latter view the
occurrence of sweating  is a sign or token, instead  of a means, but since it
occurs as often without, as with an amelioration of symptoms, it has little or
no significance  in this aspect, unless, at the same time, other symptoms denote
improvement, or herald convalescence.   Reasoning in this way there seems 
MANAGEMENT OF CONTINUED FEVBR.
291
little encouragement to  endeavor to excite  the excretory function of the skin
in the management of Continued Fever.  Experience, however, may lead to
a  different conclusion, but  I  have no facts to  offer bearing  on  this  point,
except the few observations already presented  on the use of the wet  sheet,
the effect of which is mainly to promote diaphoresis.
   The Genito  Urinary System cannot be said, with our present knowledge,
to furnish  special indications for treatment, excepting attention to the blad-
der to obviate  over accumulation of urine.  The  latter point is not  to be
overlooked in the management of the disease.  The blunted perceptions of
the patient may prevent, not  only due attention on his part  to the evacua-
tion  of  the  bladder, but  the  consciousness of  suffering  from  distension.
Hence, it is important  to ascertain daily the quantity of urine passed, and to
explore the hypogastric region whenever there is reason to suspect  retention.
The kidneys, as well as the skin, form an  important excretory outlet, which
may  possibly be concerned in the elimination of matter upon  which the  con-
tinuance of the  disease  more or less depends.   The secretion of urine in
 Continued Fever is generally  scanty, and some  observers  have noticed,
shortly before,  or at the time of convalescence,  the quantity to become more
abundant, and  to contain an increased proportion of lithic acid, or the  lith-
ates.   It does  not,  however, appear  to have  occurred  to practitioners to
endeavor to effect, by the use of diuretics, ends similar to those which are
intended to be fulfilled by diaphoresis.  All that is to be said on this point
must, of course, be wholly conjecture.    A collection of facts showing the re-
 sults of  experience is desirable, and the  study of the changes which the urine
 undergoes in Continued  Fever would perhaps tend to encourage the trial of
 remedies designed to affect the  quantity and composition of this secretion.
   The indications which I shall  distinguish as general, either relate  to the
 management of the  disease without exclusive reference to any particular class
of symptoms, or are deduced from the ensemble of symptoms.  The general
indications embrace, first, sanitary conditions.  The hygienic treatment of
 Continued Fever is of prime importance.   If  compelled  to elect  between it
 and the employment of medicinal measures, in the majority of cases it would
 probably be the better policy to relinquish the  latter.   Remedies, be  they
 ever  so efficient  and judicious, cannot compensate  for the absence of favor-
 able  sanitary conditions.  This  follows  as  an  inference from considerations
 already  presented.   Inasmuch as we do not claim to exercise any direct con-
 trol,  by  means of medical  art, over  the morbid  processes constituting  the
 febrile state, and, consequently, do not  address our remedies to the disease
per se, the reliance for  recovery must be mainly  upon the self-adjustipg 
292
MANAGEMENT  OF CONTINUED FEVER.
power of  the organism — a  truth  applicable to other affections than Con-
tinued Fever.  It could hardly be otherwise, than that circumstances most
conducive to the welfare of the economy in a state of  health, in other words
sanitary conditions, are  of  the first importance with reference to restoration.
  The more important points belonging to the  hygienic management per-
tain to temperature, ventilation, cleanliness,  and  attention to the  various
wants of the patient.  Sufficient space to receive an abundance of wholesome
air  for respiration, etc., is a sanitary condition second to none other.   In pri-
vate practice, whenever  practicable, a spacious apartment  is to  be selected.
Frequently, through ignorance on this subject, patients are found occupying
bedrooms too contracted to permit a proper supply of  pure atmosphere.  In
hospitals the proportion of the area of the wards to the number of inmates
should not fall below the limits which health requires.  At least five hundred
cubic feet  should be allowed for each patient.   These points, which are, of
course, of more or less  importance in the management of all diseases, claim
as much attention in cases of fever as of any other affection.
  The sick apartment, or ward, is to be kept at  a comfortable temperature,
care being especially taken to guard  against an excess of heat.
  Free ventilation  is highly important.   Adequate provisions for this end,
especially  in hospitals,  demand attention.  But,  in addition to these, the
doors and windows should be thrown open, in suitable weather, several times
daily, to secure a more complete renewal of the atmosphere.
  Cleanliness requires  ablutions of the body, and frequent changes of the
bed clothes and body linen.  Whenever circumstances permit, it is an excel-
lent plan  to have two beds provided, and  to transfer the patient daily from
the one to the other.  The change is in this way  more complete, and effected
with the least inconvenience,  fatigue, and risk.
  Attention to the wants, even where they are  not expressed, is  requisite.
The condition of the mind is such that it becomes necessary to take pains to
ascertain  necessities, and  sometimes  to judge  of  their  existence without
reference to information given  by the  patient.  Drink, for example, is to be
given at the discretion of the attendant without reference to any spontaneous
expression of thirst, or, sometimes, without regard  to the response to  the
inquiry whether it be desired or  not.    Efforts at  appropriate times  to
evacuate the bladder and bowels, are  to be suggested and  encouraged, etc.
  The co-operation of an intelligent, judicious nurse,  is in no disease more
indispensable to successful management than in  Continued  Fever.   This is
the more  essential in proportion to the peculiar degree of importance  belong-
ing to the measures which, of necessity, must be left  in  some measure to
their discretion as well  as fidelity;  and, in many cases of Continued Fever, 
MANAGEMENT OF CONTINUED FEVER.
293
upon measures of that class, viz., hygienic regulations, diet, etc., the success
of treatment mainly depends.  Not a few patients with this disease are lost
through the incompetency, carelessness, or perverseness of those upon whom
the physician is obliged to rely for carrying out the plan of management
whioh he directs.
   The second of the general indications is to sustain the powers of the system
through the febrile career.   This language is somewhat indefinite, owing to
want of precision in our knowledge of the intimate nature of the forces by
which the organism resists, and recovers from  disease.  Its practical signifi-
cance is,  however, sufficiently plain.   In importance, sustaining measures
rank next to those belonging  to hygiene.  The disease has its intrinsic  limi-
tations.   It  runs a circumscribed career; and the great  object of manage-
ment, in most cases, is to assist in bringing its course to a favorable termina-
tion. The self-adjusting, restorative energies of the system, accomplish the
work.  To economize, sustain, and develop these energies, placing  the patient
under circumstances most favorable for their operation, is the chief duty of
the physician.
   Continued Fever may end fatally, not from the occurrence of lesions incom-
patible with  recovery, but simply because the powers of the system fail before
the disease reaches the termination of its career.  If  the patient  can be sus-
tained for a sufficient period,  he is safe.   It is not uncommon for active agen-
cies to be required to obviate an immediate and strong tendency  to death —
 the issue  appears to  hang upon a thread—yet, the  sustaining measures
 prove efficient, the crisis is passed, and in  a short time the  patient  passes
from a state  involving the greatest possible danger into convalescence.   These
 facts exemplify the importance of the general indication under consideration.
   The  sustaining measures comprise stimulants, tonic remedies,  and nutri-
ment.   These,  almost  invariably, are indicated  in  combination.   I will,
 however, offer a few remarks on each under a distinct head.
    Stimulants.   The pathological views which recognized local inflammation
 as the proximate cause of fever, or an almost constant element of the disease,
led practitioners to employ stimulants with great caution.   They were admin-
istered only when the danger from exhaustion was imminent.   Apprehension
of commencing their use too soon (which was deemed fraught with danger)
occasioned frequently delay until the patient was about  to succumb, when little
hope remained of benefit from  a change of treatment   Great  timidity  in
prescribing this class of remedies  even now exists, more or less, partly because
it  is not easy in medical practice to escape  from the  influences of tradition
and of habit, and, in part, because the pathological views just referred to are
still  in  vogue to a considerable extent. 
294
MANAGEMENT OF CONTINUED FEVER.
  My observations have been  sufficient to convince me that, of the great
majority of cases of Continued  Fever, stimulants may with advantage enter
into the management;  and that they often form a highly important part of
the treatment.  They may be prescribed  whenever the  symptoms indicate
the propriety of sustaining measures in general.   Feebleness, compressibility,
and great frequency of the  pulse, diminished impulse  and sounds of the
heart, coolness of the  external surface  and copious perspiration, muscular
debility, and low delirium — these are the more prominent of the symptoms
which point to the importance of supporting the powers  of the system.   In
proportion to the degree of weakness as  denoted  by these symptoms will be
the urgency of the indication, and the extent  to which sustaining measures
are to be carried.
   The stimulants which  may be  employed, in  conjunction with  tonics  and
nutriment, are those of  the diffusible class, wine and spirits, and other excit-
ants  such as camphor and ammonia.  The diffusible, or alcoholic class is
most uniformly applicable, and the others  may be superadded if it be desired
to render the measures still more efficient.  Spirits have appeared  to me to
be preferable to wine, and brandy has been  the article I have generally
employed.
   The period in the progress of the  disease when stimulants  are called for,
will, of  course,  vary considerably in different cases.  They may  in some
instances be demanded almost from  the  commencement.  Generally speak-
ing, they will be useful  after the first week.  So, also, as respects the amount
to be prescribed, there  is no uniformity, and consequently no  routine rules
can be laid down.   This, as well as the  time when it is advisable to enter on
the use of stimulants, is to be  determined by the circumstances proper to
individual cases.  The  quantity which  I  have  been accustomed to give in
the average of  cases, at  a time, is about half  an ounce,  or a table spoonful.
This dose may be  repeated with intervals varying from  half an hour to six
hours, according to the evidences of the need of  stimulants, and their effects.
To produce a stimulant action upon  the digestive organs the brandy should
not be too much diluted.  An  equal quantity of water is sufficient.
   With proper care and attention, I feel  assured that fears lest the patient
should receive injury by commencing  too soon  the use of stimulants, are
groundless.  When there is  room for doubt as  to their  propriety, they may
be given at first cautiously, allowing  sufficient interval to watch  their effect.
 The remedy can be suspended before any considerable harm  is done should
 it be found to be inappropriate.  There is much more risk involved in defer-
 ring the use of stimulants too long.   Just in proportion to their usefulness is,
 of course, the injury to the patient the  longer they are withheld.  The  time 
MANAGEMENT OF  CONTINUED FEVER.
295
that is lost cannot be regained.  It is therefore far better to commence too
•early than to incur any needless delay;  and if the indication be not perfectly
clear it is more judicious to test the question by a cautious trial than to wait for
farther evidences of exhaustion. Judging from my own observations, if com-
menced when the indication is  a matter of question, and given with due mod-
eration, they will seldom be discontinued.  It is easier to maintain strength,
than to restore it; and this, as  it seems to me should be the end of sustain-
ing measures.  Agreeably to this view it is preferable to anticipate the period
when the  powers of the system evince marked prostration, than to lose any
time afterward.
   Fear of employing stimulants in  fever, is based on their usual effect in
health.   Their action, however, is quite different when they are indicated to
sustain the vital powers.   They do not then, in fact, act as stimulants.  They
do  not, even  when  given largely,  disturb  the intellect,  occasioning  any
of the  phenomena of intoxication; and the influence on the circulation  is
such that  their operation may be ealled sedative.   I have in several instances
observed  the  pulse, when its frequency was  greatly increased, numbering
from 130  to 140, fall rapidly while the  patient was taking half  an ounce of
brandy hourly, or half-hourly.   An illustration of  this strikingly sedative
effect on the pulse has fallen under my notice within a few days of the time
I am penning these remarks.   A pulse much increased in frequency, in fact,
furnishes a speeial indication for stimulants.
   Aside  from the  circulation, which  should  improve under  the beneficial
operation  of stimulants, the  evidences of its good  effects  consist in  better
warmth and mellowness of the surface, lessened delirium, refreshing sleep,
moisture  of the tongue, ete.   If a more favorable condition does not speedily
follow, it is by no means to be inferred that the remedy is uncalled for, and
should  he discontinued, so  long as there  is no aggravation  of symptoms
denoting unpleasant consequences.
   As respects other excitant  remedies, my experience is mostly limited  to
 the two articles  mentioned, viz., camphor and ammonia.   Camphor is  sup-
 posed by some  observers to  be especially suited to cases characterized by
ataxic symptoms, such as  muttering  delirium, insomnia, subsultus.  The im-
 pression derived from some  trial of it under these circumstances is, that its
value has  been overrated.  It has not appeared to me to fulfill the expectations
formed from the recommendations of others.
   The carbonate of ammonia  is specially suited to cases in which it is desired
fc> produce  an effect on  the circulation.   These and  other remedies of an
 analogous character cannot be considered substitutes for diffusible stimulants,
bait ihey  doubtless are more or less valuable as adjuvants. 
296
MANAGEMENT OF CONTINUED FEVER.
  If the views which I have submitted on the  subject of stimulants differ
from those entertained by many, if not most practitioners, it is not necessary
to inform the reader that they are neither original, nor entitled to the char-
acter of singularity.  In advocating the importance of this class of remedies
in the treatment of Fever, I do but contribute my humble testimony to  that
of several distinguished writers, among whom the names of Drs. Graves and
Stokes, of Dublin, are particularly to be mentioned.
   Tonics.  The indication to sustain the powers of the system would seem to
call for remedies distinguished as tonics.  That they are useful in the treat-
ment of Continued Fever, is altogether probable.   Their utility, however, is
limited  by the fact  that their tonic influence is cumulative: an appreciable
effect requires an aggregate of doses extended over a considerable period.
They are not sufficiently prompt in their action to be of great service in fever.
They are better suited to chronic maladies.
   The tonic remedies best adapted are the bitter infusions and quinia, espe-
cially the latter, which I  have frequently prescribed m  cases of fever, but I
am not  prepared to say how much importance is to be attached to it  I  can-
not conceive of tonics doing harm, whenever sustaining measures are appro-
priate, except  possibly by offending the stomach, and, thus, counteracting the
end to which, to be useful they must be subservient, vizT the ingestion  and
assimilation of nourishment
   Nutriment.  The powers of the system  cannot be effectually sustained
without the assimilation of aliment.  If we would fulfill the general indica-
tion tinder present consideration, then, nutriment must be received, digested,
and appropriated by the economy.  Are the assimilatory processes suspended
in Continued  Fever ?  Observations warrant an answer to this question in
the negative.   Nutriment, given in this  disease, may be retained, without
being followed by diarrheea, the evacuations even  being  in  some  instances
natural in appearance.  Under these circumstances it must be digested  andi
appropriated.   I have witnessed a marked development of strength during
the continuance of the febrile career.   A patient who came under my charge
after fever had existed for several days, and who had  taken nothing but rice
water, presented evidences of great prostration;  but under an improved sys-
tem of  dietetics, although  the duration of the disease was long, there was a
decided gain  in muscular strength, as well as  in  other particulars, notwith-
standing the febrile career persisted.   If the powers of the system may thus
be  developed  during the continuance of fever, they can be preserved,, or, iis
in other words, sustained  by means of nutrition.  Upon these facts the im-
portance  of nutriment in the management  of Continued Fever  is based.
Relatively, this class of sustaining measures ia the most  important.   It is 
MANAGEMENT  OF CONTINUED FEVER.
297
mainly with reference to promoting the digestion and appropriation of nutri-
ment that stimulants and tonics are useful.  Except as  subsidiary to assim-
ilation, the good effects of the latter can only be transient, for it is alone
through the addition of fresh alimentary supplies that the organism acquires
renewed energy and strength.  The idea of local inflammation as the proxi-
mate cause, or a constant element of Continued Fever,  which has rendered
practitioners  distrustful of stimulants, has also prevented the importance of
alimentation from being appreciated.  With the attention fixed on inflamma-
tion, the antiphlogistic regimen was thought to be indispensable.   But when
it is considered that a great source of danger in fever cases is in  the liability
that the powers of  life will  give way before the limited career of the disease
is reached, and  that a leading indication in the treatment is the one under
consideration, viz., to sustain the  system, it must be apparent that the only
rational ground for doubt is whether  the  condition of fever is incompatible
with the digestion and assimilation of food.
  In the management of the disease, my practice is uniformly, after the lapse
of  a few days, at farthest the first week, to commence the administration of
highly nutritious aliment.   The forms of nourishment which I have thus far
selected, are the essence of beef, and what is known commonly in this part of
the country as milk porridge, consisting of milk scalded, with the addition
of a little  wheat flour.   By the essence of beef is meant the pure  juice of the
meat, extracted by  putting lean portions in a vessel (usually a stone or glass
bottle) which is placed  in boiling water, no water being added to the meat.
The fluid  thus obtained  is quite different from what passes under the name
of beef tea, which is merely warm water flavored with osmazome, having very
slight nutritious properties.   Occasionally I have given, in  addition to the
two articles just mentioned, strong chicken soup.
  I direct these forms of diet to be administered systematically,  without ref-
erence to  the appetite or wishes of the patient, generally in alternation, small
quantities being given at a time,  at short  intervals.  The quantity of nutri-
ment to be taken in a given time  is, of course, to be  regulated somewhat by
the urgency of the  indication for sustaining measures.  It should correspond
generally  with the  amount of stimulants, both being conjoined for the same
end.  The systematic administration  of nutriment is also to be  commenced
at the period in the progress of the disease when  stimulants are called for,
both being simultaneously entered upon.   Explicit specifications as to quan-
tity, and  intervals, are to be made in individual cases by the  practitioner,
especially in private practice, but routine rules  cannot  be laid down  which
will apply indiscriminately to all  instances.   In the average of cases I  have
been accustomed to direct from  half an ounce, to  an ounce, of  the essence 
298
MANAGEMENT  OF CONTINUED  FEVER.
of beef, hourly, and  the milk porridge in somewhat larger  doses, making
up the quantity, if, for any reasons, they are not given regularly at so short
intervals.   I state this as an  approximation to a  general rule of diet  as
respects quantity.
  The articles of diet mentioned are selected in consequence of their contain-
ing nutritious principles in a concentrated form, and of a digestible charac-
ter, being, at the same time, easily prepared, and administered.
  They are sometimes taken by patients without reluctance, and occasionally
are apparently acceptable to the  palate.   Oftener, however, they are unde-
sired, and frequently considerable disinclination is  manifested.   The  latter
may proceed, in a measure, from  the indisposition to make any effort, or to
be  disturbed, which belongs to the disease, rather than from  a repugnance
occasioned by  the idea of food;  but, in  some instances, the antipathy is
apparently not less than to doses of medicine.
  As  already stated, the course I have  pursued  is to have the nutriment
administered, not only irrespective of any expressions of desire by the patient,
but without reference to his appetite, and even when taken with disgust.   If
the sense of hunger, the appetite,  and  the taste are competent  to govern the
ingestion  of  food  in a state of health, this is not true of  Continued Fever.
The proper exercise of these functions involves normal mental  perceptions.
In health, the mind feels certain impressions, derived from within the organ-
ism, by which the desire for food, or hunger, expresses the demand of the sys-
tem for fresh supplies.   The mind, in health, experiences pleasure  from  the
ingestion  of aliment,  in  other words from the indulgence of appetite, and is
eapable of discriminating  appropriate  kinds  of food by the  sense of taste.
All this is changed in fever.  The mental perceptions then fail to respond to
the wants of the system;  the mind lacks sufficient healthful activity for appe-
tite or taste.  The system, nevertheless, needs the addition of  new  materials
for calorification and nutrition, and the power of assimilation, although impair-
ed, is not wholly lost.   The indication for nutriment, in short,  exists, but the
criteria pertaining to the consciousness of the patient  by which  this indication
may be  measured in health,  are perverted or suspended by  the disease,
so that it becomes necessary to fulfill the indication without  consulting the
mental functions, viz., hunger, appetite  or taste, which were doubtless designed
to secure an adequate supply of proper aliment in health.
   This, briefly, is the  reasoning which leads to the propriety of administering
nutriment in Continued Fever.  But  facts bearing on the  subject, have more
force than reasoning.  The dietetic plan which has been described, I have
pursued sufficiently to test, at  least, its freedom from danger, or unpleasant
consequences.   I  have not observed any apparent injury  from it in a single 
MANAGEMENT OF CONTINUED FEVER.
299
instance, and I am persuaded  that it not only tends to diminish the liability
to a fatal termination by asthenia, but that the patient passes through the
disease with less expenditure of vital strength, and recovers more rapidly and
completely after convalescence is established.
   The foregoing views relating to nutriment are by no means novel, although
there is reason to think that  they have been adopted by practitioners to a
hmited  extent only.   Dr. Graves, of Dublin, who dwells emphatically on this
point in the management of fever, remarks, that if he has had more success
than others in the treatment of the  disease, it is owing, in a great degree, to
the adoption of the advice of a country physician of great shrewdness, who
advised him  never to let his patients die of starvation!*   That patients may
literally die of starvation when the disease is protracted, and the diet restricted
to toast or rice water, does not seem to me improbable; and that the gravity
of the  disease — the prostration, delirium  and other ataxic symptoms, etc.,
 are often due, in no inconsiderable degree, to innutrition co-operating with
 the essential morbid condition in fever, I am fully convinced.
   In conclusion, of the two types of Continued  Fever,  Typhus and Typhoid,
 in the former, as a general remark,  measures designed to sustain the system
 are required  more uniformly,  oftener with urgency, and at an earlier period
 in the progress of the disease.
    Treatment of Complications.  I shall notice only the more important of the
 complications which have occurred in the cases that have come under my own
 observation, viz., Pneumonitis, Peritonitis, Parotiditis and Apoplectic Coma.
    Pneumonitis.   It is obvious that in treating any inflammatory complica-
 tion, the practitioner is not to have reference exclusively to the local affection.
 A consideration to be borne in mind is, that if  the inflammatory affection be
 subdued, the patient has, nevertheless, to pass through the febrile career.  It
 is also to be considered that  there is less energy in the restorative processes,
 when fever is present, than if the local affection existed alone.  Therapeutical
 measures which  might be appropriate were  fever not present, if they com-
 promise the ability of  the organism  to withstand and surmount the febrile
 disease, may be highly  improper.   In  all cases, remedies are to be employed
 under the restrictions imposed by clue  attention to the existence of Continued
 Fever, irrespective of the application.   In the treatment of pneumonitis, as
 a primary affection, what is commonly known  as the antiphlogistic plan of
 treatment is generally pursued, comprising general and topical bloodletting,
 antimony,  mercurials,  counter-irritation,  and low diet.    Now, in deciding
 whether the same method of treatment be admissible,  or the extent to which
* System of Clinical Medicine, by Graves & Gerhard, Am. Ed. 
300
MANAGEMENT OF CONTINUED FEVER.
it is to be pursued in the treatment of pneumonitis occurring as a complica-
tion of fever, we are to take into  account the probable  effect  not  alone on
the pulmonary affection, but upon the condition of the patient with respect
to the fever.  Will it be likely to affect unfavorably the progress of the latter
disease ?  To what  extent  may it be safely  and judiciously carried with
reference, on the one  hand, to the  fever, and, on the  other  hand, to the
inflammation ?  The practical bearing of these questions is sufficiently appa-
rent.  If, for example, bloodletting  be the particular remedy proposed  to be
employed, its propriety, or the extent to which it is to be carried, will depend
upon whether its  usefulness in abating the severity of the pneumonitis be
overbalanced by  its diminishing  the power  of the system  to sustain the
duration of  the febrile career.   This  conservative principle  is applicable to
the trealment of any, and all  the complications of fever, as well as the par-
ticular affection under present consideration.   According to it proper weight
in all  instances, will doubtless  lead  to  quite different  modes of  practice,
in individual cases,  but, in general, the result will be, that the measures
suited  to primitive pneumonitis  will by no means be uniformly indicated in
the management of this affection occurring as a complication  in Continued
Fever, and,  when admissible, it will be to a more or less limited extent.
   It is hardly necessary to say,  that various  circumstances are to be  taken
into account in the treatment of pneumonitis superadded to fever, not  less than
when this affection is primary; such as the previous constitution of the patient;
the extent to which the lungs are involved; the activity of the symptoms, etc.
   Aside from these, there are certain features somewhat  distinctive of the
affection occurring as a complication of fever.   The cases must be extremely
rare in which the  lungs become inflamed  at  the commencement, or during
the early part of the febrile career.   So  far as my observations go,  pneu-
monitis  is  not  developed  until  the fever  has  advanced  to the period
when the antiphlogistic measures that have been mentioned,  are always to
be employed with caution, lest the ability of the patient to bear up under
the febrile disease be impaired.  It is obvious that the later, in the progress
of the disease, this complication occurs,  the  more is circumspection, in the
employment of these therapeutical  measures, called  for.   An activity of
treatment which  might be judicious  if the pneumonitis were developed  at
the onset of the fever, would be  improper  at a subsequent  period,  other
things being equal.
   Again, the inflammation of the lungs, developed during  the progress of
Continued  Fever, seldom has that intensity  or activity which  belongs  to
acute pneumonitis as a primary affection.   The rational symptoms are less
prominent, and even the characteristic physical sign, the crepitant rale,  is less 
MANAGEMENT OF CONTINUED FEVER.
301
constant and marked.  The affection is more frequently latent.  When devel-
late in the disease, and especially in the  Typhus  type, (in which it oftener
occurs,) it seems in a measure to come from the hypostatic congestion which
is due to an enfeebled  circulation and a morbid condition of the blood.   The
inflammatory  action, under  these  circumstances,  is  of  a very  low grade.
This has been sometimes distinguished as pseudo-pneumonitis.
   In view of  the  foregoing  facts and considerations, it would  appear  to be
a rational conclusion, that pneumonitis complicating Continued Fever rarely
calls for active treatment.    General bloodletting  is  by no means advisable
as the rule, but may perhaps be  occasionally admissible.    Topical bleeding
is perhaps proper in a larger proportion  of cases.    Autimonials are  to be
employed  with more circumspection than when the affection  is primary.
The propriety of  counter-irritation by means of blisters  is doubtful.  Sina-
pisms, dry cupping, stimulating liniments, and the like, should  constitute the
revulsive measures.   The appropriateness of mercury is questionable.   The
reader has doubtless observed that I  have made no  allusion to this remedy
 heretofore in connection with the treatment of fever.  It was  formerly very
 generally employed, and is still in vogue, to some extent,  in the management
 of this disease.   I believe, however, it may be  said,  that, by the most
 judicious practitioners  at  the present time, it  is not considered necessary, or
 useful, in the treatment of fever uncomplicated by local inflammation.  The
 antiplastic effect attributed  to mercury would hardly seem indicated in a
 disease which modern researches have  shown to involve, as a constant ele-
 ment, diminution in the fibrinous constituent  of the blood.   An increase of
 this constituent obtains in inflammations, and, hence, a rational indication for
 the supposed antiplastic operation of  mercury.   Cases of fever  complicated
 with local  inflammations  have been found to present an increase, instead of
 a diminution of fibrin, and  the  inquiry  therefore may arise, if,  under these
 circumstances, mercurials are not rationally indicated.   I am not prepared
 to answer this question.   My observations furnish  no facts bearing  on the
 apparent results of  the mecurial treatment of Continued Fever with, or with-
 out pneumonitis  or any inflammatory complication.   With  respect  to the
  o-eneral views submitted on  the subject of the treatment  of the complication
  under consideration, I should remark that, so far as my experience goes, it
  has appeared to be in confirmation of their correctness.
    In conclusion,  a practical  point not to be overlooked is, that  the occurrence
  of pneumonitis, or any secondary inflammation, does not of necessity conflict
  with  the indication to sustain the powers of the system  through the course
  of the fever.   Stimulants,  nutritious  aliment, and  tonics are  not  to be
  deferred, or laid aside in consequence of the development of an inflammatory 
302
MANAGEMENT  OF CONTINUED FEVER.
complication, provided they are called for by the symptoms  or condition of
the patient, irrespective of the local affection.   On the contrary, the co-ex-
istence of  local inflammation may render a supporting plan of treatment
more important, in order to increase the ability of the organism  to  carry on
the processes of restoration.
   Peritonitis.   The remarks on  the treatment of Pneumonitis will, in gen-
eral, apply to Peritonitis, or any local inflammation complicating Continued
Fever.  To dwell upon  this affection would therefore be to recapitulate much
that has been  already said.    Peritonitis may result from intestinal perfora-
tion, or it may arise independently of that accident.  It cannot, however, be
of frequent occurence without a special tendency forming a characteristic of
the disease at certain times or places.
   Peritonitis from perforation, which is peculiar to the Typhoid type, almost
of necessity occurs late in the febrile career, or during convalescence.  The
active measures of treatment  generally deemed admissible in primary peri-
tonitis are  out of the  question.   The plan which  is rationally indicated, and,
which has the sanction of experience, being, if I mistake not, the only plan
that has proved successful, consists in the exhibition of opiates in as large
doses as can be  borne without  narcotism, repeated at proper intervals for
several days, the bowels being allowed to remain  unmoved.   The object of
this plan is to arrest the peristaltic movements, and favor the  adhesion of the
peritoneal  surfaces surrounding the perforation.  Recovery depends upon this
object being effected.   The  chances  of  success  are, however,  exceedingly
small.   The merit of first pointing out and exemplifying the advantages of
treating cases  of perforation  with large  doses  of opium, belongs  to Dr.
Graves, of Dublin.
   Peritonitis, without perforation, is a less serious form of \ this complication,
and claims the same measures proper to this affection, with all the restrictions
applicable  to the  treatment of any local inflammation occurring in connec-
tion with Continued Fever.   This general remark comprises all that need be
said under this head.
   Parotiditis.   This  complication, as the results of the preceding analyses
have shown, involves a special tendency peculiar to the  disease at  certain
times or places.   The affection occurs at different stages of the disease, and,
sometimes, as a sequel, during convalescence.
   In none of the cases characterized  by inflammation of the Parotid that I
have observed, could it be regarded  in  the light of a critical event, and, so
far from relieving the  condition of the patient, he was exposed thereby to a
new source of suffering and danger.   The inflammation, in  the cases  that
have fallen under my observation, was decidedly phlegmonous in its character, 
MANAGEMENT OF CONTINUED FEVER.
303
suppuration occurring after  the lapse of several days.  Active treatment,
with  a view to prevent the formation of pus, as a general remark, is  not
judicious, owing to the little prospect of effecting  the object, and the risk of
compromising the powers of the system.   As  the formation  and discharge
of pus will be likely to continue for some time, proving a source of exhaus-
tion, the indication for sustaining measures  is  increased by the presence of
this complication.  A few leeches, in some instances, at first, might tend to
diminish  the intensity of the inflammation.   I did not, however, resort to
this measure  in any of the cases  that have  fallen under my observation.
Warm  fomentations, and cataplasms to the  inflamed part, opiates to relieve
pain, opening the abscess so soon as fluctuation is discovered, and, afterward,
a liberal  administration of stimulants, tonics and nutriment, constituted the
measures addressed to this complication.
   Apoplectic Coma.  Coma, developed  more or less  suddenly, is an event
liable to occur during the career of Continued Fever.  Could this complica-
tion  be prevented, or relieved  by appropriate treatment, the fatality of the
 disease would be diminished, inasmuch as in a certain proportion of cases a
fatal  termination is due to this event.  In the Second Clinical Report I have
called attention to symptoms referable to the  respiration which precede and
accompany apoplectic coma,  by means of which the occurrence of this com-
plication may be anticipated, showing, also, that the seat of the affection is at
the medulla oblongata, life being destroyed by apnoea arising from suspension
of the functions pertaining to that portion of the nervous system, which pre-
 side over the  respiratory acts.   The pathological condition upon which apo-
 plectic coma occurring in fever depends, is a subject open for discussion, and
 farther investigation.  It would be out of place to consider this subject  in
 the present connection, but the treatment must have  some reference to the
 pathological views which are entertained.  I have submitted the opinion that
 the complication is due to effusion within the  arachnoid cavity*   If this be
 the correct explanation, the probability of success from any  therapeutical
 measures, after sufficient effusion has taken place to induce a state of coma,
 is slight   The suspension of the functions of  the medulla is due to the me-
 chanical pressure from the presence of fluid.   To relieve the condition of the
 patient, the resorption of this effused fluid, or a portion of it, is to be effected.
 The  chances are against the attainment of this end soon enough to rescue the
 patient from apnoea.  The measures which suggest themselves,  and to which
 I have thus far resorted, are a blister to the nucha, revulsives to the extremities,
  * See remarks on effusion within the arachnoid cavity, by the author, in the April Ho.
of the Buffalo Medical Journal. 1850. 
304
MANAGEMENT  OF CONTINUED FEVER,
and cold applications to the head, other measures being continued or adopted
according to the symptoms.
   Although an exceedingly dangerous complication, apoplectic coma  is not
necessarily fatal.   An instance affording a striking  illustration of recovery
under the most discouraging symptoms, is given  in the First  Clinical Re-
port: case of McDonald, see section devoted to symptoms referable to the
nervous system.  (Page  45.)
   Treatment of Convalescence.   I do not propose to consider  the details of
the management  of Convalescence.  Every physician is familiar with the
precautions to be observed during the period which intervenes between the
expiration of the  febrile career, and the recovery of the usual health and
strength.   In this interval, the system is peculiarly susceptible to injury from
over exertion of the powers of  body or mind, and imprudences of any kind.
The common idea that relapse of  fever arises from error of management, is
questionable.  The singular contrast exhibited in the reports of the two pre-
ceding  analyses with respect to this  sequel, tends to disprove this idea.
The recurrence of a brief febrile  career would  seem to  arise from  some
intrinsic tendency peculiar to the disease at certain seasons.
   There is one point, pertaining to diet, respecting which the views  com-
monly entertained appear to me to be faulty.  I refer to the  apprehensions
frequently, if not generally felt by  practitioners, in allowing  a  nutritious ani-
mal diet early in convalescence.   These apprehensions, which I am persuaded
are imaginary, have probably arisen, from the habit of associating Inflamma-
tion with Fever.  The susceptibility to disorder, or consecutive diseases, is prob-
ably owing to the enfeebled condition of the organism after passing through
the febrile career.  It is an object, therefore, in the management of convales-
cence, to effect a return  of the accustomed constitutional vigor  as speedily as
practicable.   The means for this end are, aliment of the most digestible and
nutritious kind, tonics, stimulants, and hygienic measures, of which one  of the
most useful is early gestation in the open air.  I have pursued  this course in
a sufficient number of cases to feel satisfied from experience that it is not only
unattended by danger, but is conducive to the well being of the patient   I
have never witnessed any unpleasant results from the effort to re-establish the
strength of the patient by resorting at once to an animal diet, etc.
   A great advantage of the sustaining  plan of treatment during the febrile
career pertains to  convalescence.   The patient emerges from the disease with
the powers of the constitution less enfeebled, the liability to sequelae is dimin-
ished, and the recovery is more rapid and complete, other things being equal,
in proportion to the pains taken  to preserve, up to the  date of convalescence,
undue reduction of strength* 
        THIRD  CLINICAL  REPORT
                            ON

CONTINUED    FEVER:
                     BASED  ON AN

       ANALYSIS OF  SIXTY-FOUR CASES.
  Since the preparation of my Second Report on Continued Fever, in the
summer of 1851, which is contained in the seventh volume of the Buffalo
Medical Journal, another six months' service as attending physician to the
Buffalo Hospital of the Sisters of Charity, has transpired. The hospital
records during this period, viz., from October, 1851, to April, 1852, embrace
a larger number of fever cases than  have heretofore been treated, in the
same length of time, since the institution was established.  This, probably,.
was partly in  consequence of the hospital accommodations having been
increased in 1851, so that it is now capable  of receiving a considerably
larger number  of patients than hitherto; and, in part, because the sick sup-
ported  by the  emigrant fund have been more uniformly sent to this institu-
tion than formerly.   The number of cases, the histories  of which were
recorded during my last term of service, is sixty-four, making with the num-
ber previously  analysed, one hundred and sixty-four.  The labor of the two
analyses, so far as my own mind is concerned, instead of rendering the sub-
ject tiresome or disagreeable, has served to enhance an interest therein, so that
is difficult to  forego the gratification of subjecting this new collection of
recorded data to  similar methods of interrogation, in order to compare the
           20 
306
REPORT ON  CONTINUED FEVER.
results with those  contained  in the  former Reports.   The  majority of the
readers of the Buffalo Medical Journal, however, may not sympathize with
this feeling, and I could  hardly  expect that  their patience would  endure
another series  of articles on this subject so extended as those  which have pre-
ceded.  In fact, conscious that the announcement of a Third Clinical Report
on Continued Fever may be likely to give rise to impatience, if  not disgust,
at the prospect of a repetition of all the dry, tedious details of another inves-
tigation, I am desirous to make haste in giving an assurance that such is not
my present intention.  I design only to  examine the cases with  reference to
points possessing peculiar interest  or importance.  In this Report I shall not
aim to enumerate and compare all the events,  or symptoms, that have been
recorded,  with a view to their relations, respectively, to each  other, and to
the natural history of the  disease; but my object will  be to study the facts
only in  so far  as  they relate to  questions which  are  more or less  unsettled,
and in  which every  medical  reader  is  supposed to feel  an interest.  The
identity or non-identity of the two types of Continued Fever, Typhus and
Typhoid; the circumstances involved in  the  distinctive diagnosis, and the
treatment of the disease, will form  the most prominent of the points to which
attention will be directed;  and I shall content myself with stating the results
relating to these points as briefly as possible, indulging in very few comments.
By pursuing this course, I  shall hope to make the following Report not alto-
gether uninteresting to those who have honored the previous Reports by a
careful perusal, and, at the same time, render it acceptable to those who have
become subscribers to the Journal with the commencement of  the present
volume, as well as to some, (if not many) who, from a want of fondness for
the minutiae of statistical researches, may have been in  the habit of leaving
unread the articles that I have heretofore contributed on the subject.  Should
I fail in attaining these ends, at all  events the  space occupied  by the pre-
sent Report will be  comparatively small, so that, in  consideration of good
intentions, even  the captious reader will  perhaps  vouchsafe his indulgence.
   Of the sixty-four cases upon which the present Report is based, fourteen
were of the Typhoid type; forty two were cases of Typhus, and in eight the
•diagnosis is not  positive.   The latter, therefore, are to be included under the
head of cases of Doubtful type.   In  this collection the cases of Typhus pre-
ponderate considerably over those of  Typhoid.   The reverse of this was true
in  both previous collections.  This  variation  does not necessarily indicate
that the  Typhus form of Continued Fever was more prevalent during the
past season, but it  is in part owing to a greater number of emigrants  having
heen sent to the hospital, and, as will  be seen, it is partly due to the fact that 
REPORT ON CONTINUED  FEVER.                 307
more cases were developed within the hospital limits than heretofore.  Add-
ing  the Typhus and Typhoid cases respectfully in the three Reports, and
the result is as follows:
           Number of Typhoid cases,     -    -     -     61
           Number of Typhus cases,   -     -     -     -  65
   The preponderance of the Typhus cases in this collection thus renders the
aggregate  of  cases of each  type  nearly  equal.  Of the fourteen  cases of
 Typhoid Fever five were  fatal.   Five  of  the forty-three cases of the
 Typhus type  ended fatally.   All of the eight cases of Doubtful type recov-
ered.  As respects mortality, this collection compares favorably with the
cases treated in previous years.   The consideration of this fact will come up
in an appropriate place hereafter.
   It will be most convenient to distribute the facts to be presented in this
Report in the same sectional divisions  that  have  previously been adopted.
Reference can then be readily made to  any particular topic in  the  three
 Reports.   This plan will be pursued, but the limited scope of the present
 Report will involve the omission of more or less of the topics enumerated in
 the headings  of the several sections.
   I shall make no reference to the cases of Doubtful type, in the twelve
 succeeding sections, but devote some attention to them afterward.

                             SECTION FIRST. '

 Age, Sex, Nativity, Season.   Constitution, and previous health.  Period of
    Residence  in this Country.  Duration of Disease before coming under
    Observation.
    Age.   Typhus.   The average age in thirty-five cases is a fraction under
 26, or, to be precise, 25, 32-35 years.   In this  group of cases are included
 five in which the  ages respectively were but 10, 9, 10, 15, 13.   Excluding
 these cases, and the mean age is 28 1-3 years.  This group embraces among
 the oldest patients the following ages:— 58,  46, 45, 43, 40, 37.
    The average age in the five fatal cases is 28 2-5.
    Typhoid.   In the fourteen cases of this type the average age is a fraction
 over 25  years.  The youngest patient was 20 years, and this was the age
 precisely in  six of the cases.  The oldest patient was 50  years; the next
 oldest, 34; the next, 27; and the next, 24.
    The average age in the five fatal cases is 28' 3-5.
    In these  enumerations  we find, as  in the  previous Reports, that the
  Typhus type exhibits the  maximum of age, and the highest mean.  We 
308                  REPORT ON CONTINUED FEVER.

find, also, that the average age in the fatal cases of both types is higher than
in those ending in recovery.
   Sex.   Typhus.  Males, 26; Females, 16.
         Typhoid.  Males, 10; Females, 4.
   Nativity.  Typhus.   Thirty-six were  from Ireland;  two were Germans;
two were English, and one, French.   In one case the nativity is  not noted.
Of the five patients not from Ireland all, save one, were either immigrants
lately arrived in  this country, or the  disease was developed  in the hospital.
The excepted case was  that of  the Frenchman, who had  been in America
three months, and  in Buffalo six days.  Whether he had been  brought in
contact with the disease prior to being attacked, or  not, is not stated.
   Typhoid.  Six were  Irish, and eight were Germans.
   Season.  Typhus.  The cases were distributed among the several months
as follows: — October, none;  November, four; December,  nine;  January,
eleven;  February, ten; March, eight.
   Typhoid.  The cases occurred as follows: — October,  two;  November,
one;  December, four;  January, three; February, two;  Marfch, two.
   Constitution and previous health.   Typhus.  In twenty-one cases it is
noted that the patients,  up to the time of  being attacked with fever, were in
good  health.  In fifteen  cases the facts with respect to this point are not
noted.  In six cases the histories show the previous health not to have been
good.  In one of these  cases the patient had been  poorly, without  any defi-
nite  ailment, during  the  passage  across the Atlantic, being attacked with
fever shortly after his arrival.  In the five remaining cases the patients were
attacked in hospital, having been admitted for other affections, as follows:—
acne,  one; varioloid, one;  chronic conjunctivitis, two, and in one case  the
patient had shortly before passed through  the career of Typhoid fever.
   Typhoid.  In  six cases the facts with respect to this point were not noted.
Of the remaining eight cases, the previous  health was good  in six.  In  one
case the disease, as stated by his attending physician, was preceded by Inter-
mittent fever, and in the other case, the patient had  had cough and more or
less diarrhoea for seven weeks before  being attacked with fever;  these symp-
toms being probably due to tuberculosis of the lungs.
   Period of residence in this country.  Typhus.  In nine cases the patients
were attacked within the hospital.   In the remaining thirty-three cases, the
patients had resided in this country as follows: —For a period not exceeding
one week, (six days,) one  case; not exceeding  two weeks, seven  cases;  do.
three  weeks, six cases; do. four  weeks, two  cases; do.five weeks, five cases;
do. six weeks, one case;  do. seven weeks, one case;  do. eight  weeks, one case. 
REPORT ON  CONTINUED  FEVER.
309
For periods longer than eight weeks, nine cases, viz.,  five months,  eight
months, three  months, seven  months, ten months, eight years, three years,
four months, two and a half years.
  Five of this  group of patients were members of the same family, and
came over in  the same  ship.   Three  other patients were also related, and
crossed the Atlantic together.                                 .
   Typhoid.   The shortest  period of time any of the patients had been  in
this country was seventeen days.  This was the period in one case.  In one
case the  period was nineteen  days.   In one case the period did  not exceed
three weeks, and in one  case it did not exceed four weeks.   In one case the
patient was attacked with the diseas:  in the hospital.   The periods longer
than  four weeks were respectively as follows: — fourteen weeks, five months,
six weeks, six months, eight months, one and a half years.
   Duration of disease before coming under observation.   From the enume-
ations under this head in the last Report, it appeared that patients are more
apt to enter the hospital so soon as they, are obliged to take to  the bed when
the type of the.disease is Typhus; and also that the average duration  of the
 disease, dating from the time of taking to the bed, before entering hospital,
 is shorter in cases of Typhus, than of  Typhoid.  An  examination of the
 cases in  this collection with reference to these points develops the  same
 results.   Excluding cases in which the patients were attacked in the hospital,
 the duration prior to admission is noted in twenty-four cases of Typhus, and
 in  ten cases of  Typhoid.   Of  the twenty-four cases of  Typhus, in six the
 patients did not take to the  bed until they entered the hospital.   This was
 true  of only one of the ten cases of Typhoid.
    The mean  duration of the disease, from the time of taking  to the bed to
 the  time of coming under observation, in the cases  of  Typhus  exclusive of
 those who  did  not take to the bed prior to entering  the hospital, in the
 Typhus cases is 5 10-17 days; in  the Typhoid cases 7  7-9 days.

                             SECTION SECOND.

 Access.   Circumstances supposed to have been concerned in the production
    of the disease.
    Access.  In cases of fever received at  different stages of the febrile c ireer,
 it  is frequently difficult to obtain precise, reliable information  respecting  the
 previous history.  Owing  to this  difficulty, the duration of the access, (the
 only point that I shall  consider under this head, in the  present Report) was
 determined in a portion only of the cases, although  more pains were taken 
310
REPORT ON CONTINUED  FEVER.
to obtain this information than  heretofore.  It will  be borne in  mind  that
the data determining  the duration of the access, as stated in the previous
Reports, are the first prodromic symptoms, and, the time of taking to the
bed.   The latter circumstance is selected, as, on the whole, the  best criterion
(although by no means perfect) for marking the end of the access, and the
beginning of  the  febrile career.  These  data  are noted in  the  histories  of
eighteen cases of Typhus, and  ten  cases of Typhoid.  A comparison of the
two types develops the following results: — Of the eighteen cases of Typhus,
the attack was  sudden  in  seven;  that is to  say, in these  seven cases the
patients took to their beds on the  first day on which any symptoms of dis-
ease were  present.    The longest  duration  of  the  access in the  Typhus
group, was  seven days.  The mean  duration  in the cases  of  this type  is
4  4-11 days.
   Of the ten cases of Typhoid, the attack was  sudden in but one case.   The
longest duration was ten days.   The  mean duration is 5 3-8 days.
   These results, thus, exhibit a larger proportion of cases of the Typhus type
in which the disease occurs abruptly, without any access; a higher maximum
of duration in cases of Typhoid, and  a shorter average duration* in cases  of
Typhus.
   Circumstances supposed to have been concerned in the production of the
disease.  In a large proportion of cases the  patients, as has  been seen, were
immigrants but lately arrived in this country.    In  these cases, and, indeed,
as a general remark, in all excepting  the patients who  were already inmates
of the  hos pital when attacked, it would be difficult to obtain reliable infor-
mation concerning circumstances which, directly  or indirectly, might be more
or less involved  in the causation of the disease.    The histories, therefore, con-
tain very few facts of importance except in the cases which were under obser-
vation before fever became developed.   I shall  direct attention, with reference

   * In  the Second Report, after giving the  duration of the access in ten cases of Typhoid,
and six cases of Typhus, I have remarked, " The foregoing results do not afford any con-
firmation of the law, deduced from extensive observations, that the Typhis type of Con-
tinued Fever oftener commences with a sudden attack, or is ushered  in by an access of
shorter duration than Typhoid."   An examination of the figures shows that this state-
ment is not altogether correct, and I regret to be obliged to conclude that it must have
been written without due attention.   If the  reader will turn  to the second Section  of
the Second Report, and take the trouble to compare  the cases of the two types with
respect to this point, he will find that the duration in the Typhoid cases is a fraction
longer than  in  the cases of Typhus, the ratio being as  3 6-7 days is to 3.  In the pro-
portion of the cases of sudden attack, liowever, the law of the disease was reversed, i. e.
the instances were more numerous in the Typhoid group, the ratio being as 3-10 is to 1-6. 
REPORT ON  CONTINUED FEVER.
311
to the subjects belonging  under this head, to the latter cases only, and the
chief point of interest will  be the enquiry in how far do they exemplify the
operation of  Contagion.
   Eleven of the patients affected with the Typhus type, were attacked with the
disease in the hospital.  I will give briefly the facts, so far as they relate to the
present subject, which are  contained  in the histories of  these cases severally.
   Case I. — This patient  had been employed as a  domestic in the  hospital
for twelve months.   She had been accustomed  to be frequently in the ward
in which fever patients were received, making the beds of these, as well  as
other patients,  etc.   The case was the fifteenth that occurred in the order of
time.   She was attacked Jan. 3d.  She was well  up  to the date of the attack.
The case was the first that proved fatal.
   Case II. — This patient was  admitted  in December with acne.  He was
in the general ward with fever patients until the 18th of December, when he
 left the hospital.  Jan. 26th he entered with  fever.  Strictly speaking, he
 was thus not attacked in the hospital, but had been  in hospital shortly before
 being attacked.  He was  a German, and  had been in this country a year.
 This case ended  fatally.
   Case III. — This patient entered with varioloid, the disease not being-
 declared prior  to his admission.   He remained in the general ward a couple
 of days, until the character of the disease was manifested, and was then trans-
 ferred  to a  separate apartment.  The varioloid was very mild, the eruption
 being quite  small.   He was an Englishman, and had arrived in this country
 but a few days before  his  admission.  Twenty-two  days after the date of his
 admission, having, in the  mean time convalesced from the varioloid, he took
 to the bed presenting  the eruption and other symptoms of Typhus.
    Case IV.__This patient had been in the hospital three months in the
 capacity of  porter.   Had  been accustomed, occasionally, to sit up with fever
 patients  at  night.   He was attacked February 1st, having  been, up to  that
 time, in good  health.  This was the twenty-ninth case  in chronological order.
    qase v.__This patient had been in the hospital three months for chronic
 conjunctivitis.   She was  in the surgical ward, and it is not stated whether
 she had been in the  habit of visiting the female ward in which fever cases
 were received, or not.   She had been in this country sixteen months.
    Case VI. — This  patient had  been in hospital a  year with chronic con-
 junctivitis.  It is not stated how long he had been in this country, nor how
 frequently he had been in the general ward in which fever cases were received.
  Surgical patients, however, frequently passed through, and visited this ward..
  This was the  thirty-seventh case. 
312                  REPORT ON CONTINUED FEVER,

   Case VII. — This patient had been in hospital  between three and four
months, as a boarder, being in good health.  It is stated that he had not slept
in the general ward, but he was probably frequently in this ward.  It is not
stated how long he had  been in this country.  This was the thirty-fourth case.
   Case VIII.—This patient entered hospital about three weeks before being
attacked.   He was in good health when admitted.   He was a German, and
had  been in this  country about six months.   He  was attacked in March,
making the thirty-seventh case.
   Case IX. — This patient had been employed as a cook  for  ten months.
She  had been in the ward in which were fever  patients a few times, remain
ing each time but a few minutes.   This was the thirty-eighth case.
   Case X. — This patient had been a surgical patient with chronic ophthal-
mia  for ten months.  It is stated that he had not been in contact with fever
patients.  Attacked in March.
   Case XL — This patient entered with Typhoid fever presenting the char-
acteristic  eruption, etc., and was convalescent on the twenty-third day after
taking to bed, and the sixteenth after the date of  admission.  He was attacked
with Typhus on the twenty-sixth day after the date of convalescence from
 Typhoid, presenting the characteristic eruption, etc., of the former type.  He
was convalescent  from  Typhus on the seventeenth day after taking to the
bed.  He died about  three weeks after my time  of  service  expired, with
tuberculosis of lungs.   Some account of the autopsical appearances will be
given in the section devoted to that subject.
   In addition to these cases, one of the Sisters of Charity connected with the
institution was attacked with Typhus in January, and died on  the tenth day
of the disease.  Notes of this case not having been taken, it is not included
in the collection for analysis.  This Sister was one  of two who were added
during the past year, to the institution; so that, up to the date of this Report,
five of twelve Sisters have had fever.  A fact especially bearing  on the ques-
tion of contagion is, that to the Sister who died  with the disease was assigned
 the  care  of fever patients, and she was  the  only  Sister brought  into close
 proximity to fever cases, except those who had already had the disease.   Vp
 to the present date, in fact, every  Sister to whom  has been  assigned, during
 the terms of my  service, the duty of nursing fever cases at this institution
 has suffered an attack.*
   The accommodations at this hospital have, as yet, not enabled the entire
 separation of fever cases from patients affected with other diseases.  Heretofore
   *  In some of the  cases of Doubtful type, the disease was developed in the  hospital.
 See section fourteenth. 
                     REPORT  ON CONTINUED  FEVER.                  313

no instance (with a single exception mentioned in the second Report) has
occurred in which fever  has  apparently originated in  the  institution, save
in those who have been brought  into close and continued contact with the
disease  by nursing the sick.   Assuming that  in  most, if not all the cases
which have just been enumerated, the disease  was due to contagion, there are
several circumstances accounting for its diffusion in this way during the past
winter.   The number  of Typhus cases admitted was considerably greater
than  in  any previous year.   The  number of patients with various diseases
was also greater, and hence the general wards  appropriated to fever and other
diseases, were more crowded.  The winter, moreover, was unusually  severe,
and, on this account, ventilation was less practicable.
   The two latter circumstances, it may be said, are adequate to account for the
generation of the special  cause of fever irrespective of contagion.  It is prob-
ably true that from concentrated animal exhalations may be evolved a miasm
capable  of developing Typhus.   Had  these cases occurred in immigrants
lately arrived, the supposition might be entertained  that the special cause of
the disease was imbibed prior to entering the hospital; but it will be observed
that, with  a single exception, all the patients had  been in this country for a
considerable period of time.   The latter explanation is consequently hardly
 admissible.  The former, however, it must be considered, has sufficient force
 to affect somewhat the conclusiveness of the  evidence which the cases afford
 of contagion;  and the argument of the non-contagionist  is in some  degree
favored by the fact, that in some of the cases originating within the hospital,
 the patients were not brought into close or frequent contact with the disease.
 Notwithstanding these considerations it seems most rational to attribute the
 origin of the disease, in these instances, to contagion.
   In none of the cases of the Typhoid type did the disease originate in the
 hospital.  The only instance  admitting the supposition of a contagious influ-
 ence was  in the case of a female, the wife of a patient who  died with this
 type of fever.   She was not an inmate of the hospital during the illness of
 her husband, but was with him daily more or or  less.  Three days after his
 death she was  admitted with fever which proved to be  Typhoid.   In  this
 case  it may be suspected that  the disease was  communicated, but it is per-
 haps quite as reasonable to  suppose that the special cause was received  by
 both persons from the same source, and that  the  circumstances connected
 with the attendance of the wife on her husband, were only indirectly involved
 in the development of the disease*  ___________________________^^^^
   • A son was also admitted with  Typhoid  about the time  my term of service ended,
 making three cases of the same type in this family. 
314
REPORT ON  CONTINUED FEVER.
  Assuming the instances in which fever originated in the hospital  to be
explained on the supposition of contagion, it is to be observed that they were
cases  of the Typhus, not the  Typhoid  type.  This  shows,  not only the
greater contagiousness of  Typhus, but that its offspring is the same form of
fever — a fact of importance in its bearing on the question  of the identity or
non-identity of these  two types.   But the facts given in  No.  11 of these
cases is especially interesting with, reference to this question.   In that instance
the patient entered with Typhoid fever, and in about three weeks after con-
valescence, was attacked with Typhus, presenting, successively, the distinctive
characters of both forms of fever, including those pertaining to the eruption.
This is a striking case, which cannot but be considered to sustain the doctrine
of the non-identity of Typhus and Typhoid.

                             SECTION THIRD.
  Symptoms referable to the general aspect and expression  of countenances.
  I do not  propose  to enumerate the  symptoms belonging to this section.
The results would show the existence of more or less capillary congestion of
the face  as a constant element of both types, and a marked  degree of this
congestion as a distinguishing feature of Typhus.  They  would also show
that a circumscribed flush  of the cheeks pretty uniformly attends cases of
either type complicated with pneumonitis, and the absence of this symptom
in eases in which pneumonitis did not exist.
   I have given sufficient examination to the histories with  reference to these
points to be warranted in  the general statements just made.

                            SECTION  FOURTH.
        Symptoms referable to the nervous system.   Mind.   Coma.
   Mind.  More or less manifestations of delirium, consisting  in  incoherent
talking, or efforts to  get  out of bed, were noted in thirty  of the forty-two
cases of  Typhus; and in  nine of the fourteen cases of Typhoid.
   It is by no means probable that the patients who exhibited  no manifesta-
tions of delirium were entirely free from  mental aberration.   It is very rarely
the case that  the faculties of the mind remain wholly unaffected during the
career of Continued Fever.   It is possible that had  these cases been more
constantly and completely under observation than is practicable in a hospital,
even with  the greatest attention, some evidences of delirium might have been
discovered.  The presence  of this  symptom was noted in all instances in 
REPORT ON  CONTINUED FEVER.
315
which any manifestations were apparent at the daily visits, or had  attracted
the attention of the attendants in the intervals between the times of making
the daily records.   Inquiries were always carefully made with respect to this
point, and it is uniformly noted either than delirious manifestations were, or
were not apparent.
   It will  be observed that the  proportion of cases  in which this  symptom
existed, is larger in the Typhus group; the exemption  from delirium in this
group being in  the ratio of about twenty-eight per cent, while it is about
thirty-five per cent, in the Typhoid cases.   The disparity between the two
types, in this particular, is less striking than in the former collections.
   The difference was greater as respects the  stage of the disease  at which
the manifestations of delirium occurred.   In no case of Typhoid  did they
occur until the febrile career had  continued for several days,  while they
were frequently observed  in the  cases of Typhus  early in  the disease, and
sometimes almost at  the very commencement.
   In nearly all  the cases in  which there were  no manifestations of delirium,
the disease was mild, as shown by the symptoms and the shortness of the
career.   This was  true of every instance in the Typhoid group, and in all
but three instances of the cases of  Typhus.   In every fatal case,  save one,
 delirium occurred.   In the excepted case, which was of the Typhus type, the
 patient died with apoplectic coma.
    The decree of delirium was variable in the different cases, and also at dif-
 ferent periods in  the same cases.  It was always more prominent at night,
and frequently was only manifested at that time.
    None of the cases in this  collection were characterized by very active, per-
 sistent delirium, requiring restraint, of which a few instances are given in the
 former Reports.
    Coma.  The comatose state  became suddenly developed, proving  fatal, in
four cases,  two  of  Typhus,  and two of Typhoid.   In two  other  (Typhus)
 cases there  occurred a close approach to  coma, and in several instances  a
 lesser degree of approximation thereto.   I shall have occasion to refer to these
 cases in the section devoted to  the Respiratory System, and I will therefore
 defer the details until I take them up in that connection.

                              SECTION  FIFTH.

 Symptoms referable to the digestive system.  Alvine dejections, Tympanites,
    Tenderness of abdomen.
    Of the forty two cases of Typhus, more or less constipation was  present in 
316
REPORT ON  CONTINUED FEVER.
twenty-seven; and  diarrhoea was absent in all  but ten cases.  In  each of
these ten cases the diarrhoea was mild, and of short duration, in several
instances lasting but a single day.
   Of the fourteen cases of Typhoid,  diarrhoea, more or less in duration and
degree, existed in thirteen;  the single remaining  case was characterized by
constipation.   The diarrhoea was  generally mild, and easily restrained by an
opiate administered by the mouth, or by injection.   In some instances it con-
tinued more or less throughout the febrile career, and in other cases it was
of short duration.
   The proportion of Typhus cases characterized by diarrhoea is not far from
that developed by the previous analyses; but  the proportion of cases of Ty-
phoid in which this symptom was present is considerably larger than in the
former collections.  I can assign no reason for the  latter fact.  It  renders the
contrast between the two types, as respects this symptom, more striking than
appears in the former Reports.
   Tympanites.   The following enumerations, relate, first, to  the absence of
this symptom during all the time the cases were under observation: that is,
by the statement of its absence is meant that it was never  at any time pre-
sent.   Second, they relate to the  degree of  tympanites  as expressed by the
terms slight,  moderate, and  considerable.  Here, also, it is meant that these
respective degrees were present once,  or oftener, while the cases were under
observation.   Frequently  in the  cases in which  moderate or considerable
tympanites existed, it continued for a short period, perhaps  for a single day
only; and in  some instances  in which  it existed  in a slight degree, it was
absent the greater part of the time.  The results  then, it  is to be borne in
mind, have no relation to the habitual condition of  the abdomen as respects
this symptom while the disease was in progress;  but only the proportion of
cases in which tympanites, in different degrees, was present at any time, and
for ever so short a period during  the  febrile  career.  It is obvious that, with
this explanation, the enumerations do not cover an important point of com-
parison, viz.,  the proportionate duration of  the  symptom.   Thus, two cases
may be on equal ground in the fact that moderate meteorism existed in both;
but in one case  the moderate meteorism may have continued  during the
whole course of the disease, and  in the other  case it may have existed but a
very short period, perhaps being noted only on one day.  It would be diffi-
cult to institute a  comparison of  the  two types as  respects the  duration, as
well as presence or absence  and the degree of tympanites, without occupying
considerable space.  It will perhaps suffice to say, in general terms, that the
individual cases in the Typhoid group presented this symptom, in its different 
REPORT ON CONTINUED  FEVER.
317
degrees, much more frequently during the progress of the disease than the
cases  of Typhus.  In  a large proportion  of the latter  group of cases, in
fact, this symptom was of very short duration, often being observed only once
or twice.   In this point of view the two groups of cases exhibited a contrast
more striking than is apparent in the following enumerations:
   Of the forty-two cases of  Typhus, tympanites was absent  in twelve, and
present in  thirty cases.
   It was slight in ten cases; moderate in fourteen cases, and considerable in
six cases.
   Of the  fourteen cases of  Typhoid, tympanites was absent in  one case,
and present in thirteen cases.
   It was slight in two cases; moderate in five cases, and considerable in six cases.
   These results differ from those developed  by the former analyses, in the
larger proportion of instances in which tympanites was present in the Typhoid
cases.   It  is curious to observe how nearly as respects the proportion of cases
in which the  symptom was present in the Typhus cases, the results of the
former analyses are repeated.   Adding together the cases of  Typhus in the
two previous  collections and  tympanites was present in the ratio of 16-22.
In the present collection  it was present in 15 - 21!  This similarity is strik-
ing.  But in the Typhoid cases the same conformity does not exist, for while
 in the cases which enter into the  two previous collections the symptom was
 present  in but thirty-four of forty-seven,  the present  analysis  gives it in
 thirteen offourteen cases.  I can assign no reason for this disparity.
   It will be remarked that the proportion of instances in which the tympan-
 ites was considerable and moderate, is  much larger in the Typhoid cases.
 This accords with the results of the former analyses.
    Tenderness of abdomen.   The remarks made with reference to the dura-
 tion of tympanites will  measurably apply t® the present symptom.   The enu-
meration of the cases in which tenderness was present, embraces all in which
 it was noted  at  any time, even on a single record, during the career of the
 disease; and, on the other hand, in the cases in which it was not noted, it was
 never present at the times of the daily examinations.  So in  those cases in
 which  it was considerable, it is not to be understood that it was  uniformly
 present in that degree, but that it was so on one day, or more.   With respect
 to the continuance of this symptom, the same is true as with tympanites, viz.,
 it was  more frequently or uniformly present during the  progress of  the dis-
 ease in the cases of  Typhoid, than in those of Typhus, its greater duration
 constituting quite as  distinguishing  a trait of the former type, as  that of
 tympanites. 
318
REPORT ON  CONTINUED FEVER.
   Of the forty-two  cases of Typhus, abdominal tenderness was absent in
twenty-seven, and present in fifteen.
   It was slight in degree in nine cases; moderate in five cases, and consider-
able in a single case.
   Of the fourteen cases of Typhoid, abdominal tenderness was absent in not
a single case.
   It was slight in three;  moderate in five, and considerable in six cases.
   These results  accord with those developed  by the  previous  analyses in
showing a greater frequency of tenderness in cases of Typhoid, and  its pre-
sence in a more marked  degree in cases of that type.   They differ, however,
from  the  results  contained in the former Reports in exemplifying the dis-
tinctive traits of the Typhoid type in a more striking manner.   In  the pre-
sent collection of cases, tenderness was in  no instance absent in the Typhoid
group, while in the former collections it existed in a large proportion of cases,
but was not uniformly present.  In this collection the tenderness was oftener
considerable in degree in the  Typhoid group.   And in the Typhus group,
in this collection, tenderness was absent in a larger proportion of cases than
in the two former collections.  Thus,  a comparison of the results of different
analyses with respect  to this, as well as other points, is interesting as showing
sometimes  considerable numerical  fluctuations, but  nevertheless concurring
to establish  by their  uniformity certain laws of the disease, and principles of
diagnosis.  The results of the former analyses authorized  us to consider the
more frequent occurrence of abdominal tenderness, and the greater prominence
of this  symptom, as  characterizing the Typhoid type  of  Continued Fever.
The foregoing  results differ from  those previously developed, in furnishing
more striking proof of the correctness of this distinction!
   In  this collection of cases, as heretofore, the abdominal tenderness was fre-
quently confined to the right  or left iliac  regions,  more  especially to the for-
mer, and when more extensive  it was especially marked in these situations.
This was true of the  cases  of either type,  but particularly those of the
Typhoid group.
   Haemorrhage from the bowels did  not  occur in any instance, save that in
one fatal case of  Typhoid, shortly before death,  the dejections were some-
what bloody.
   Slight bleeding  from the gums occurred in one case,  which was of the
Typhus type.   This case did  not prove fatal.
   Parotitis occurred  in but a single case, which was of the Typhoid type
It became developed about  the time of convalescence.   The right gland was
alone affected.  The affection proceeded to  suppuration, and  the  patient 
REPORT ON  CONTINUED FEVER.
319
recovered.   The case presenting this complication, or, rather, in this instance
sequel, was admitted in March,  being one of the latest of the recorded cases.
   Perforation of intestine did not occur in any of the cases in this collection,
nor peritonitis irrespective of this accident.

                             SECTION SIXTH.

                           Cutaneous  eruptions.
   Typhus.  Of the forty-two cases of this type, the characteristic maculated
eruption was present in thirty-six, and absent in the remaining six.
   The eruption was quite abundant in twenty-seven cases.
   It was more or less copious on the limbs, as well as body, in twenty-seven
cases.
   A few macula; were observed on the face in one instance.
   In seven cases, intermingled with the maculae, were more  or less of the
rose-colored papulae characteristic of Typhoid:  in other words, the eruption
exhibited mixed  characters.  Inasmuch as considerable  interest and impor-
tance belong to the  eruption  in its relations to diagnosis, and the question of
the  identity or non-identity of the two types,  I will give a brief statement of
 the  facts pertaining to this symptom in the cases just referred to.
   Case I.— The patient presented on her admission, the sixth day after tak-
ing  to the bed, an eruption, extending over the body and limbs, consisting in
 part of spots, rose-colored, somewhat  elevated, the redness disappearing on
pressure;  and in part of others which were small, dusky, the redness not dis-
appearing on  pressure.   It is subsequently noted  that the greater part of the
 eruption was  of the latter description.  The eruption continued,  gradually
fading, for fifteen days after the date of admission.
   Case II. — The patient presented, on admission, the fifth day after taking
 to the bed, an eruption, the greater part of which consisted of rose spots, large,
 elevated, and  disappearing on pressure, the remainder small and dusky.   The
 eruption extended over the body and limbs,  and continued until the day of
 death, this being a fatal case.
   Case III.__At the time of taking to bed, this patient presented an erup-
tion with  mixed  characters.  It was  copious, extending over the  body and
limbs.   It continued to present mixed characters so long as observed, remain-
ing  visible up to the day before convalescence,
   Case IV.— On the fourth  day after taking  to the  bed, a few rose spots
were visible,  elevated, and disappearing on  pressure.  The day following, a
 a copious eruption  appeared over the body and limbs, being  in part rose 
320                 REPORT ON CONTINUED FEVER.

colored, etc., but the greater part having the typhus characters.  The erup-
tion gradually faded, but was visible up to convalescence.
   Case V. —On the second day after taking to the bed, an eruption appeared
over the body and limbs, dusky, not disappearing on pressure.  On the fourth
day it was noted that the eruption presented mixed characters, and this was
observed for the three following days.
   Case VI. — An eruption appeared  in this case on the day on which the
patient took to the bed,  over the abdomen and chest, copious, and presenting
the characters of Typhus and Typhoid intermingled.   It  continued to be
thus mixed, and disappeared two days  before the date of convalescence.
   Case VII.— On the second day after taking to the bed an eruption made
its appearance, copious, dusky, not elevated, and the redness not  readily dis-
appearing on pressure.   Subsequently a few rose spots with the Typhoid char-
acters became developed, and were intermingled.   The eruption continued
visible for ten days, gradually fading.
   I have no doubt respecting the correctness of regarding the foregoing cases
as belonging to the Typhus group.  In all instances in which there seemed
any room for doubt as to the 'diagnosis in this  collection, as heretofore, the
cases  were rejected, and  placed under the head of Doubtful type.  The dis-
tribution was made after carefully surveying all  the symptoms  and events
belonging to the history.  These cases, thus,  presented  the  Typhus eruption
with  more or less of the Typhoid eruption superadded.  The history of the
eruption, aside from  the sensible characters, points to Typhus.  It appeared
earlier in the disease than the Typhoid eruption, it continued longer, it was
more copious, and extended over the limbs as well  as the chest and abdomen.
I shall revert to this subject presently.
   In  nineteen cases, the time of the first appearance of the eruption, reckoned
from  the  date of taking to the bed, was accurately determined.   This wa«
not practicable in a larger number of  cases, in  consequence of patients fre-
quently not entering the hospital until  after the eruption had appeared.  Of
these thirteen cases, in four, the eruption appeared on the very day of taking
to the bed; in ten, it appeared on the second day;  in two, on the third day;
in one case on the fourth day; in one, on  the sixth, and in one, on the eighth
day.  In the two cases last mentioned, the patients took to the bed as soon
as they were attacked.
   The average period elapsing from the time of taking to the bed to the first
appearance of the eruption, according to the foregoing data, is about two and
a half days.
   The duration of the eruption was noted in fourteen cases.   The  number 
REPORT ON  CONTINUED FEVER.
321
of days in  the cases respectively are as follows: —17, 16, 10, 7, 9, 8, 12,
11, 14, 15,  16, 7, 7, 10.
   The average duration will, thus, be between eleven and twelve days.
   The eruption uniformly, after a few days, commenced  to fade, and  grad-
ually became less distinct from day to day  until its disappearance.
   Typhoid.  Of the fourteen cases of this type, the  characteristic eruption
was  present, in a greater or less degree, in every  case.
   The eruption was abundant in but a single case, the rose spots  in all the
cases, with this exception, being not numerous, and in some instances quite
small.   The smallest number of rose spots counted in any case was three.  So
small a number as this  occurred in but a single instance.   The next smallest
number was four.  In  only two cases, were so few as this observed.  In the
remainder of the cases,  exclusive of the case in which the quantity was copi-
ous, the number ranged from a dozen to fifty.  The number varied at different
periods of the febrile career.
   In not a single instance  is it  noted that the eruption extended  to the
extremities, being confined, in all, to the chest and abdomen.
   In no instance among the cases in  this  group did the eruption present
mixed characters.  The traits distinguishing the  Typhoid type  were uni-
formly preserved.
   The time of the first appearance of the  eruption, reckoning from the com-
mencement of the febrile career, or the date of taking to the bed,  was ascer-
tained  in six cases.   The number of days in these cases successively,  are as
follows: — 2, 6, 7, 3, 12, 11.   This gives  an average of a fraction  less than
seven days.
   The duration was noted in seven cases, and was, in  the cases, individually,
as follows:  —10, 4, 7, 13,3,6, 11.
   The average is found to be seven days.   The  foregoing results differ from
those  developed by the previous analyses  chiefly in the uniform presence of
the  eruption in the cases of the  Typhoid  group.  In the two collections of
cases before analyzed, it was nresent not invariably, but in a large  proportion
of the cases of this type.  On reference to  the first and second Reports it will
be found that  in the Typhus group the eruption existed in the larger num-
ber  of instances.  The  reverse is true of the present collection, but this is not
owing to the proportionate number of cases of Typhus in which the eruption
was absent  being greater, but to the constancy of the eruption in the cases
of Typhoid.   Why such a contrast should exist it is impossible to say.
   On comparing the time of appearance, and the duration of the eruption in
the two types, we find  very striking points of distinction in the earlier period
             21 
322
REPORT ON  CONTINUED FEVER.
at which it is observed  in  Typhus, its abundance in a larger proportion of
cases, extending very frequently over the extremeties, its mixed  character in
a few instances, and its longer duration.   There are important  points to be
considered, in discriminating the two types, in addition to the striking differ-
ences in the sensible characters of  the eruption, viz., that  in Typhus being
maculated, small, orbicular,  dusky, and the redness not readily disappearing
on  pressure;  in  Typhoid,  papular, larger, oval,  rose red,  and  the  redness
disappearing momentarily on pressure.
   The mixed character of the eruption in a small  proportion of the cases of
Typhus, is a  point of interest and importance.  In  discriminating between
the two types  considerable stress is properly to  be laid on the sensible appear-
ances of the eruption, and, hence, when the two eruptions  are intermingled,
difficulty as to the diagnosis might be expected  to arise from this circumstance.
My observations thus far lead to the conclusion that this intermingling occurs
in cases of Typhus only.  It  is desirable to settle  by more numerous obser-
vations, whether cases of the Typhus type are alone liable to  this variation
from the general rule of each type preserving with distinctness its  peculiar
eruption.   Should this law be established, such variations  would, of course,
occasion no practical difficulty whatever.   The presence of a  well  marked
Typhus eruption would  denote the type of the disease whether more or  less
" rose spots"  are intermingled or  not.   Were the eruption frequently to
exhibit mixed characters, the fact  might be  considered justly to  militate
against the doctrine of the non-identity of the two  types.  Instanced in which
this peculiarity is observed, are, however, few in  number, as shown by their
small proportion in this,  and the preceding collections.
   One of the distinguishing  features of the Typhus eruption is not always
very strongly  marked.   I allude  to the  non-disappearance  of the redness on
pressure.   In several of the cases in the present collection it is noted  that the
redness did not  readily  disappear on  pressure.   Frequently the redness  can
be made to disappear on firm  pressure, and in this particular different spots
present at the same time, in the  same case, will be found  to differ.  Refer-
ence was made to this fact in a single  case in the  second Report.   It  will
also occasionally be observed that some  rose spots in the Typhoid eruption
disappear but partially on pressure.   This was noted in one case mentioned
in the first Report.
   V petechial eruption occurred  in  but a  single case in this collection.   The
petechia? were few in  number, confined to the abdomen  and chest, appearing
late in the febrile career.  The case  ended in  recovery, and was not one of
unusual severity. 
                     REPORT ON  CONTINUED  FEVER.                  323
  Miliary vesicles, or sudamina,  were observed in four cases, all of the Ty-
phus  type.   They were  not  carefully sought for  in every case,  and may
therefore  have existed  in  some instances, in  small  numbers, and escaped
notice.  In the cases in the histories of which their presence  is  noted, they
were abundant.
                           BECTION SEVENTH.
Symptoms referable to the Respiratory Apparatus.  Pneumonitis.   Epis-
  taxis.   Aberrations of respiratory movements.
  Pneumonitis.   The data are insufficient for determining the precise num-
ber of cases in which pneumonitis existed.   This arises from the histories not
uniformly embracing records of physical signs.  The presence of this com-
plication is rendered positive by the evidence of physical explorations in ten
cases, seven of which were of  the Typhus, and  three of the  Typhoid type.
It undoubtedly existed in a greater number of instances.   In  all  the cases in
which it is certain that  pneumonitis existed, the respirations were increased
in frequency, the cheeks generally presented a circumscribed flush, and there
was some dilation of the alse  nasi.  These symptoms are more distinctive
than cough and expectoration.   It is superfluous to say that physical explor-
ation furnishes demonstrative evidence either for, or against the existence of
this complication, and that this cannot be  claimed for any, or all the symp-
toms referable to the respiratory system.
  I regret that  my observations in the cases forming  this collection only
authorize these few remarks.   My apology is, that my daily duties rendered
it extremely difficult, and almost impossible  to determine and record the
physical signs daily while the cases were under observation.
  Epistaxis.   Of the forty-four cases of Typhus, epistaxis occurred in five^
and its non-occurrence is noted in all the remainder.  In the  five instance in
which this symptom was present, the  periods of its occurrence were as fol-
lows:__1. On the eighth  and ninth clays of the febrile career, and  in this
case slight haemorrhage from the gums occurred.  2. Fourth day.   3. Day
before taking to bed.   4. Several  times  before admission.  5. Fifth day.
It was slioht in all but one instance, in that case being considerable, but not
profuse.
  Excluding one case of Typhoid in which nothing is said  respecting  this
symptom, of the remaining thirteen cases its presence is noted  in the histories
of four, and its absence in  the remaining nine.  The periods of its occurrence
were as' follows: — 1. Twice during the access.   2.  Eighth and ninth days.
3. Second day.  4.  Ninth day.   In none  of the cases was it profuse. 
324
REPORT  ON CONTINUED FEVER.
   These results correspond very  nearly with those developed  by the first
analysis.  They show the presence of the symptom in a larger ratio of cases
in Typhoid than in Typhus, sustaining the correctness of regarding this fact
as one of the points distinguishing the two types from each other.
   Aberrations  of respiration.  Under this head I  shall  direct attention only
to the occurrence of spasmodic inspiration.  In the second Report I gave a
brief account of the circumstances connected with this  aberration in several
cases, which appeared to invest it with considerable importance as a symptom
accompanying  and forerunning the  development of sudden coma,  or  an
approach to the comatose state.   Special attention was directed to this  symp-
tom  in observing the cases entering into the present collection.   It occurred
in several  instances, and I will proceed  to give  briefly an  account of  the
circumstances in the cases respectively.
   Typhus.  Case  I. — The symptom occurred on the seventh day after tak-
ing to the bed.  The record of symptoms on the  sixth clay is as follows: —
" Reports better. Aspect the same.   Passed a quiet night.  No  pain.  Mind
dull.  No subsultus.  Pulse 128.  Capillary congestion considerable.  Res-
piration 32.  Slight cough.  Surface warm and dry.   Tongue coated and
dry.   Slight sordes about teeth.  Anorexia.  Thirst.  One dejection.   Erup-
tion  continues.   Slight meteorism.  No abdominal tenderness."
   On the seventh  day,  at A. M.,  the  record is  as  follows: — " Reports  the
same.  Passed  the  night quietly, manifesting  no delirium.  No pain.  No
subsultus.   Mind quite dull.   Eyes  suffused.  Tongue moderately coated
and  dry.   No  nausea.  Anorexia.  Thirst. Three or  four dejections dur-
ing the  past twenty-four hours.   Pulse 128.  Capillary  congestion consider-
able.  Respirations 28.  Eruption continues.  Considerable meteorism.  No
abdominal tenderness."
   " P. M.  Pulse 128.   Spasmodic inspiration.  Treatment —T. opii, grs. xx.
Blister to nucha.  Brandy §i. hourly."
   Eighth day.   " The difficulty of respiration  increased during the evening
until the inspiration became loud  and highly spasmodic.  During the night
she gradually improved.  She  is easily  aroused this morning, but  in  the
evening with difficulty.   She reports  feeling well.   No pain.  Eyes less suf-
fused.   Speaks more distinctly.  Surface perspiring.  Aloe nasi dilate mod-
erately.   No subsultus.   Tongue  dry and  coated.   Sordes about the teeth.
Two  or  three  dejections  during the last  twenty-four  hours.   Pulse 120.
Moderate capillary congestion.  Respirations 36.  Occasional cough without
expectoration.   Eruption continues.    Some meteorism.  No abdominal ten-
derness.   Treatment —  Brandy ^i. hourly." 
REPORT  ON CONTINUED FEVER.
325
  After this date she continued to improve daily, and six days afterward was
distinctly convalescent.
  Case II. — This was one of the gravest of the cases ending  in  recovery.
The aberration under consideration occurred  at night on the twelfth day of
the febrile  career.   The symptoms on the morning of this day were noted as
follows: — " Reports no better.   Delirious during the first part of the night,
but slept quietly during the latter part.  No pain.  Mind quite dull.   No
deafness.   Slight  subsultus.   No tinnitus.  No dilation of alse nasi.  Eyes
slightly suffused.  Remains on her back in a somnolent state, but is easily
aroused.  Anorexia.   Thirst.   No nausea,  nor vomiting.    No  epistaxis.
Takes brandy and nutriment readily.   Pulse 128.   Moderate capillary con-
gestion.  Eruption continues over body and limbs.   Considerable meteorism.
Abdomen  tender on pressure.  Skin warm and dry.   Treatment — Brandy
"fss. every  half hour, with carb. ammonia grs. iii."
   Thirteenth day.  " At nine last evening the respiration became disturbed,
the inspiration being short and  quick.  A blister 4x4, was  applied to the
nucha.   This morning the respirations are frequent, but the rhythm is nor-
mal.   Somewhat  delirious during the first part of the night, but slept occa-
sionally during  the latter part.   Moderate capillary congestion.  Eruption
continues.   Meteorism  slight.  Abdominal tenderness  continues.  Frequent
cough, without expectoration.   Mind dull.  Slight  deafness.   Marked sub-
 sultus.  Quite  restless, constantly moving her hands  and throwing off the
bed clothes.   Tongue moist and coated.  No sordes.   Respirations 24.  No
 epistaxis.  Pulse  144.   No dejection  for several days."
   From this date she slowly improved, and was convalescent on the twenty-
 fifth day.
   Case III.__The inspiration  became spasmodic on  the seventh day.  Up
 to that time there were no symptoms denoting  unusual  gravity of disease-
 On the fifth day the record is  as follows: — " Reports the same.  Passed
 the  night quietly.  No pain.   No subsultus, nor tinnitus.  Eyes suffused.
 Sliohtly deaf.  Mind somewhat dull.   Tongue  coated  and  dry.   Sordes
 abo^ut the teeth.  No nausea.   No dejection.  Pulse  114.  Moderate capil-
 lary congestion.   Respirations  34.   No cough.   Eruption  slightly faded.
 Meteorism moderate.   No abdominal tenderness."
    Seventh  day.   " Passed  a very restless night, talking  incoherently, and
 frequently attempting to get out of bed.   He did not, however, appear to be
 in an alarming situation until about  5 o'clock, A. M,  when he became dull,
 and the  inspiration spasmodic.   Stimulants were given  freely, sinapisms
 applied to different parts of the  body, and a  blister over the occiput.  At 7, 
323
REPORT ON CONTINUED FEVER.
his appearance denoted some improvement.   The respiration was still dis-
tended, and the inspiration, except when he was aroused, slightly spasmodic.
The respirations were also irregular, an interval occurring  after about  every
sixth respiratory act.  He reports better.   Says he has no pain.  Mutters.
Considerably deaf.  Eyes suffused.   No subsultus.  Tongue dry and coated.
Sordes about  the teeth.   Tongue  readily protruded.   No  nausea.   One
dejection during last twenty-four hours.  Pulse 130.  Respirations 6 or 7.
Surface warm and moist."
   Died at evening.
   At the autopsy, in this case, the larynx was carefully examined to ascertain
if oedema, or any mechanical obstruction existed.   None whatever was found,
and the  antero-posterior diameter of the glottis  appeared to be unusually
large.
   Case IV. — Spasmodic inspiration and coma occurred in this case, on the
sixth day of the febrile career, and  death on the following  morning.  Up to
the evening of the  day on which the  above symptoms became developed,
there were  no circumstances  in the history of the case denoting immediate
danger.  The disease, in fact, appeared to be unusually mild.'  The follow-
ing is the morning  record on the sixth day: — " Reports better.   Slept con-
siderably.  Aspect  improved.  Somewhat  deaf.  Mind not dull.  No sub-
sultus.  Nausea and vomiting frequently.   Tongue covered with a thick
yellow coating.  Some  sordes.  Herpetic eruption on  lips.   One  dejection.
Respirations  16, and rhythm normal.   Slight cough.  Moderate capillary
congestion.   No suffusion of eyes.   No epistaxis.  Skin mellow.   No pers-
piration.   No meteorism.  Slight abdominal tenderness. Somnolent.  Pulse
96 and well developed."
   Evening.   " Has spasmodic inspiration  and cannot be aroused.   Pulse
feeble and frequent."
   Seventh day.   " Died at 4, A. M."
   Typhoid.   Case I. — Disorder of  the  rhythm  of respiration was  first
noticed in  this case on the thirteenth day of the  febrile career.  Up to  that
time the symptoms denoted  a mild  grade  of disease.   The following is the
record on the morning of the thirteenth day: — " Aspect the  same.  Passed
the night quietly, without delirium.   Says  that he has pain in the umbilical
region, but it is not sufficient to keep  him  awake.   No subsultus.  Tongue
dry and thickly  coated.   Sordes on teeth.   Pulse 108.   Slight capillary con-
gestion.  Respirations 26, rhythm normal.  Slight cough,  without expectora-
tion.   Nineteen rose spots.  Moderate meteorism  and abdominal  tenderness."
   On the fourteenth day the record is as follows: — " Yesterday morning 
REPORT ON  CONTINUED  FEVER.
327
this patient was observed by the Sister nursing him, to catch his inspiration-
in taking drink.  In the afternoon Mr. Smith, the resident student, observed
that the inspirations were  slightly spasmodic.   A blister  was immediately
applied to the nucha.   This morning the respirations are 16, the inspirations
slightly spasmodic.  He can with great difficulty be roused.  Up to the pre-
sent time he has been able to swallow without much difficulty, and  he can
now be made to swallow but with considerable difficulty.  He began to grow
dull last evening but was easily aroused.  The pulse was then 114 and well
developed.   He was found this morning apparently moribund.  Pulse 132,
feeble."
   Died  at 1, P. M.
   Case II. — In this case a sudden change for the worse, eventuating speed-
 ily in coma, with  spasmodic  inspiration, took  place on the seventh day of
 the febrile  career.  There were evidences  of pneumonitis on both  sides in
 this case, but, aside from this, the symptoms did not denote great gravity of
 disease.    On  the sixteenth day the record was as follows: — " Not dull.
 deafness much diminished.  Eyes not suffused.  Tongue dry, and moder-
 ately coated.  No sordes.  One dejection in past twenty-four hours.  Pulse
 lio'. Respirations 42, rhythm natural.  Frequent cough, with slight expec-
 toration.  Crepitant rale on both sides posteriorily."
    Seventeenth day.   "Last  evening she  became suddenly worse;  restless,
  groaning  frequently;  perfectly rational, not somnolent, declared she should
  not live°till morning.  About an hour afterward the pulse was 122, full;
  moderate  capillary congestion; appeared  quite  comfortable; no change  of
  rhythm of respiration; talked rationally.   This was at 8* o'clock, P. M.  At
  10 o'clock she was comatose;  respirations 23,  and the inspiration spasmodic.
  Surface warm and perspiring.  Deglutition  difficult.  The nucha was scari-
  fied  and strong aqua ammonia applied, after  which she became considerably
  aroused.   In  about  half  an hour afterward, she relapsed into the  comatose
  state, and died at 3, A. M, of the following morning.
     In the autopsy of this case the  larynx was carefully examined, but  no
  appearances of oedema were present.
     These were all the instances  in which this aberration of respiration was
  present in a marked degree.   In several other cases there was some approach
  to a spasmodic inspiration.  Having been led by the observations of the pre-
  vious year to regard this symptom as a precursor of coma, the cases were
  closely watched with reference to its occurrence, and whenever it was observed
  in ever so slight a degree, a blister was directly applied over the nape of the
  neck  This measure appeared in several instances to determine the return of 
328
REPORT ON  CONTINUED  FEVER.
normal rhythm, and prevent the development of the comatose state.   That it
exerted any such influence, however, is of course only a matter of conjecture.
   The circumstances connected with this symptom  in the cases in which it
was observed in the present collection, and in the cases upon which the second
Report was based, certainly seem to invest it with considerable  importance.
In the last Report I ventured  to indulge a hypothesis respecting the'patho-
logical condition  upon which  it depends.  I  am  not, however, prepared at
this time, more than when that Report was written, to offer any positive proof
of the correctness of the hypothesis,

                            SECTION EIGHTH.
                  Symptoms referable  to the circulation.
  In  stating facts referable to the circulation, I shall give simply results, with-
out the details presented in the two previous Reports.
  The pulse was  enumerated once, and sometimes  twice daily in all the cases,
during the progress of the febrile career.   From these data I have calculated
the mean frequency in the cases individually; and  from these, in round num-
bers, i. e. disregarding fractions, the following averages are obtained:
   Typhus.   The average mean frequency of the  pulse in the Typhus cases
is a fraction over 107.
  Excluding the fatal  cases, and  the mean frequency in the remainder is a
fraction  over 104.
  The mean frequency  in the five fatal cases is a fraction over 126.
   Typhoid.   The average mean frequencv in the Typhoid cases, collectively,
is 99.
  Excluding the fatal cases, and the mean frequency in the remainder is  93.
  The mean frequency  in the five fatal cases is 110.
  These results concur with those developed by the previous analyses, show-
ing in the Typhus group a higher average of frequency of the pulse, in the
cases collectively, in the fatal cases, and in those ending in recovery.   It will
be  perceived, also, on  reference to the  corresponding  sections  in the two
former Reports, that the results, irrespective of this  comparison  of  the two
types,  are not very discordant.
  The greatest degree of frequency of the pulse observed during the febrile
career, and the highest mean in any individual case, in this, as well as in  the
preceding collections, are found in the Typhus group.   The greatest degree
of frequency observed in any case not proving fatal, was 156.  So great fre-
quency was noted in hut one case.   The next highest in frequency, was 148.
The next, 144.  In several cases the pulse reached 140. 
REPORT ON  CONTINUED  FEVER.
329
   The greatest frequency noted in any of the fatal cases, was 160.
   The maximum of the mean frequency in any of the Typhus cases ending
in recovery, was 124, and in the cases ending fatally, 148.  The lowest mean
in any of the cases ending in recovery was 86, and in the fatal cases 106.
   In the Typhoid group, on the other hand, the greatest degree of frequency
observed in any of the non-fatal cases was 132.   So great frequency as this
occurred in but a single case, and it diminished at  the evening of the same
day to  100.   The  next highest was 128, and the next 116.  In the fatal
cases the highest point reached was 138.  The maximum of the mean fre-
quency in  any of the  Typhoid cases not proving fatal, was 103, in the fata*
cases 117.  The lowest  mean in  the  non-fatal cases was  80, in the fatal
cases 100.
   All these results  show a  marked difference between the two types in the
amount of influence exerted by the disease on the circulation.
   In this collection, as heretofore, the cases of  either type exhibited striking
diversities  in  the  frequency of the pulse, and striking fluctuations in this
respect were often observed in different periods of the febrile career in the
same case.
   A fact which is mentioned  in the former Reports was in a  few  instances
noted in this  collection of  cases, viz., a diminution of the frequency of the
pulse below the average of  health, occurring about the time of convalescence*
In one case it fell to 54; in another to 56, and in two cases to 68.  All these
cases were of the Typhus type.
    Capillary congestion, evidenced by redness of the surface, disappearing on
pressure, and returning more or less quickly after the pressure was removed,
is noted in the histories of all the cases save two (one of  Typhus and one
 Typhoid) and in these excepted cases nothing is stated relative to this point.
 This congestive redness was always more marked on the  face than  in any
 other part, and sometimes confined to that situation.
   A point of disparity between the two types  relates to the degree in which
this symptom was present.   The congestion, as a general rule, was greater in
 Typhus, frequently giving  a dusky or dingy hue to the countenance.
   Arranging the variations in  three grades distinguished, respectively,  as
 considerable,  moderate and slight,  and  comparing  the cases of Typhus and
 Typhoid,  as regards the number of instances exemplifying  each grade, and
 the results are as follows: —
   Offorty-one cases of Typhus, in fifteen the capillary congestion was con-
siderable; in twenty-five it was moderate, and  in one case only was it slight. 
330                  REPORT  ON CONTINUED  FEVER.

   Of thirteen cases of Typhoid, in but one case was it considerable; in nine
cases it was moderate, and in three slight.

                             SECTION NINTH.

         Symptoms (exclusive of eruptions) referable to the Skin.
   Having given in the Second  Report the symptoms relating to temperature,
dryness,  moisture and sweating, as noted in a considerable number of cases,
individually, on successive days during the  progress of the disease, I  shall
dispense, in the present Report, with these details.   Were I to prepare  simi-
lar tables (the data for which  are before  me) so far as I can  judge from a
general survey of the facts, the results would be materially the same.  There
would be nothing gained  by such a repetition.  I propose in this section to
study the cases with reference  to  a  single subject, which  is  one  of interest,
and  importance.   I refer to the  occurrence  of perspiration in the course of
Continued Fever, its influence on  the progress and  issue of the disease, and
its significance as a prognostic.  The results  disclosed by the former analyses
led to conclusions  at variance with ideas which are frequently,  if  not gener-
ally entertained by medical practitioners.  These conclusions were, " that we
are not warranted in predicating expectations of speedy convalescence, or of
recovery, upon either of these symptoms (moisture and free perspiration) dis-
connected from other circumstances, nor do these results afford any grounds
for supposing that to induce moisture or sweating by therapeutical means,
will  be likely to prove beneficial."  Now, do the facts contained in the pre-
sent collection of cases sustain  these conclusions ?  In the former analyses it
was found that moisture and sweating " were observed at different periods of
the febrile career,  in a large proportion of instances not preceding by a  short
space of time the  date of  convalescence.  Moreover, these appearance  were
observed in nearly one-half of the cases which ended fatally."   These were
the considerations upon which were based the conclusions just stated.   Let
us see if, on examination  of the  cases in this collection, facts are found  to
correspond  with those heretofore developed.
   It will suffice to interrogate  the histories respecting the presence of  sensi-
ble perspiration without taking pains to state whether it consisted  in moisture,
or in free sweating.
   Excluding fatal cases, of the thirty-seven  remaining in the Typhus group,
in twenty-eight, moisture of the  surface or sweating more  or less profuse,
occurred either once,  or several times, during the course of the disease,  while
the patients were  under observation. 
REPORT ON CONTINUED FEVER.
331
  Of the nine cases of Typhoid, excluding the fatal cases, the same was true
of five.
  Of the twenty-eight cases of Typhus characterized by perspiration, it took
place at, or near the date of convalescence in eleven; and at other periods of
the  disease, not being speedily followed by a  favorable termination of the
febrile career, in seventeen.
   Of the five cases of Typhoid characterized  by perspiration, it  took place
at, or near the date of convalescence in not  a single instance, in all the cases
not being speedily followed  by a favorable  termination of the  febrile career.
   According to these results, then, the occurrence of moisture or sweating in
the course of Continued Fever, considered abstractedly, cannot  be considered
an indication that convalescence is  near at hand.  The balance of probabil-
ities, in fact, is  against such an anticipation.
   Directing attention now to the fatal cases, of the five cases of Typhus end-
ing  fatally, perspiration occurred toward the  close of life in two, and at periods
in the disease more or less remote from the  close, in three.
   Of the five fatal cases of  Typhoid, perspiration occurred toward  the close
of life in three, and  at other periods in two.   Thus, in one half  the cases of
 either type ending fatally, perspiration took place irrespective of its occurrence
 at, or near the  time of death.
   The foreo-oing  results, it will be perceived on reference to the  former Re-
 ports, accord, in  a striking  manner, with those developed by the previous
 analyses.  The views therefore, as set forth  in the quotation from the Second
 Report, respecting the importance to be attached to the occurrence of pers-
 piration in the progress of Continued  Fever,  and to the efforts to produce
 this symptom by therapeutical means, are  sustained,  provided the reasoning
 therein involved be legitimate.
   Another mode of interrogating the facts contained  in the cases respecting
 the influence of perspiration on the progress of the disease, is to examine the
 symptoms immediately preceding, and  following its occurrence.    It may be
 supposed  that  perspiration  generally  accompanies  an  abatement of  the
 severity of the disease,  although it does not in the majority of instances her-
 ald convalescence.   We will  direct a little attention  to this point  And in
 order to determine the condition of the patients prior, and subsequent to the
 occurrence  of  perspiration, it will  probably answer to ascertain  the relative
 frequency of the pulse at these times.   The pulse may be considered a ther-
 mometer  of the  grade of severity  of the disease sufficiently for the present
 object.   I will give the enumerations of the  pulse, in several cases, on the day
 previous to the occurrence of perspiration,  the day on which the perspiration 
332
REPORT ON  CONTINUED FEVER.
was noted, and the subsequent day.  In the following table the instances  in
which perspiration occurred at periods of  the disease more or less remote
from  the date of  convalescence, will of course only be selected.   In  some
cases  perspiration continued for several days in succession, or was frequently
repeated.  These cases will be rejected.   Fatal cases are also excluded:
Pulse day before Perspiration.			Day of Perspiration.		Subsequent day.
No. 1.	Typhus,	120.	120 A.M.	116 P.M.	100.
No. 2.	u	108.	104.		104.
No. 3.	it	132.	124.		118.
No. 4.	«	108.	100.		88.
No. 5.	«	128.	128.		120.
No. 6.	((	156.	134.		128.
No. 7.	a	110.	120.		104.
No. 8.	u	106.	124.		136.
No. 9.	a	90.	100.		108.
No. 10.	u	111.	108.		98.
No. 11.	u	not noted.	120.		120.
No. 12.	tt	120.	112.		120.
No. 13.	it	112.	138.		112.
No. 14.	u	not noted, day of admission.	100.		96.
No. 15.	u	132.	*126 and 116.		118.
No. 16.	Typhoid, 132.		100.		100.
* Perspired two consecutive days.
  The results displayed in the foregoing table, obtained  after the preceding
portion of this section was written, are interesting, and, I confess, to me un-
expected.   In this  point of view, perspiration appears either to occasion, or
signify, an improvement, in  so far as the pulse is a criterion of the  latter.
Finding no grounds, numerically, for the  opinion that this symptom is gen-
erally the precursor of convalescence, it was natural to presume that it would
be found  to possess small  importance  as a means, or a sign of improvement.
It would  appear, however, that in a very large proportion of instances, it is
followed by more or less diminution in the grade of severity of the disease.
This being the case,  the views which have  been  expressed respecting the
probable  inutility of diaphoretics may require to  be modified, since it  is
manifestly a  legitimate  object  of  therapeutics to  endeavor to abate the 
REPORT ON  CONTINUED FEVER.
333
intensity of  disease when we are unable either to  arrest it,  or abridge its
duration.
   In several of the cases  ending in recovery in this collection, moisture, or
sweating  more  or less copious, occurred several times during the febrile
career.   It may be worth  while to inquire respecting the gravity of the dis-
ease in  the cases thus characterized.  With reference to this  inquiry, I will
throw into a tabular form  the facts contained  in the histories  of these cases,
relating to—first, the number of days on  which  either moisture or free
sweating  occurred; second, the  mean  frequency of the pulse during  the
febrile career;  third, the duration of the disease from the  time of  taking to
bed to convalescence, and fourth,  the number of days the patients were under
observation.
Cases.	No. of days on which moisture or sweating was noted.	Mean frequency of Pulse.	Duration of Disease.	Number of days un-der observation.
1. Typhus.	5.	112.	13 days.	9.
2. "	5.	107.	12 "	12.
3. "	7.	108.	13 «	13.
4. "	4.	100.	12 "	12.
5. "	5.	94.	14 «	11.
6. Typhoid.	8.	89.	16 "	16.
1.	5,	80.	16 "	16.
8. "	3.	80.	23 "	16.
  The results exhibited in the foregoing table show a grade of severity, as
exhibited by the pulse and duration, somewhat  less than the average in all
the cases characterized by the more or less frequent recurrence of perspira-
tion, with a single exception, viz., the first case in which the mean frequency
of the pulse was 112.   The inference, therefore, from the cases now analyzed,
would be that, other things being equal, the repeated occurrence of perspira-
tion is generally associated with  mildness of the  disease.   This inference,
however, is by no means to be adopted as a law of Continued Fever, for, in
the first place, the data are too few  for such a deduction, and, in the second
place, it  is to  be considered that perspiration was  repeated in several of  the
small number of  cases in this collection which proved fatal.   The facts with
respect to the latter point are  as follows: —Of  the ten fatal cases of both
types, perspiration occurred  more than  once  in four.  In  one case  it was
noted on five days; in one, three days; and  in two cases, two days. 
334
REPORT ON  CONTINUED  FEVER.
                            SECTION TENTH.
            Symptoms referable to the Genito-urinary System.
  Notwithstanding the views expressed in the Second Report, of the impor-
tance of recording examinations of the urine in cases of Continued Fever, the
histories that, in the mean time, I have collected, contain very little relating
to this subject.   The few observations that were made, I will give as noted
in the cases respectively.
                                Typhus.
  No. 1. On the  third day the  urine was  acid, with a slight phosphatic
deposit, and the sp.  gr., 1.016.
  No. 2. On the first day the sp. gr. was 1.023, and there was a slight trace
of albumen.
  No. 3. On the second day, the urine contained a small quantity of albu-
men.   It deposited  on cooling the urate of ammonia.   On the  twelfth day,
sp. gr., 1.023.
  No. 4. On the second day, sp. gr. 1.026.   There was a considerable depo-
sit of the urate of  ammonia, and a trace of  albumen.   On the fourth day,
sp. gr. 1.014, and a small quantity of albumen.
  No. 5. On the tenth day tne sp. gr. was 1.026; it deposited urate  of am-
monia, and exhibited a trace of  albumen.
  No. 6. On the fourteenth clay, sp. gr. 1.0-5, and a trace of albumen.
  No. 7. On the sixth day, deposited urate of ammonia.   No other change.
  No. 8. On the sixth da}-, sp. gr. 1.022, a small deposit of urate of  ammo-
nia, and a  trace of albumen.   On  the twenty-first day (three days before
convalescence) sp. gr. 1.023, and normal.
  No. 9. On the sixth day, sp. gr. 1.014, and a small quantity of albumen.
                               Typhoid.
  No. 10.  On the  ninth  day, sp. gr. 1.026,  deposite of urate of ammonia.
Twelfth day (four days  before  convalescence) deposited urate of ammonia.
Day after convalescence, sp. gr., 1.019.
  These isolated observations are of course insufficient for analytical examina-
tion.  They show that urate of  ammonia is apt to be deposited  at different
periods of the febrile career, and that the urine frequently contains a smal'
quantity of albumen.  If a conjecture were to be indulged respecting the lat-
ter,  it might be attributed  to a certain degree of congestion, which it is prob-
able exists internally, as well as upon the surface  of the body, and from which
the kidneys would not be  likely to be exempt. 
                     REPORT ON CONTINUED FEVER.                  335

  The facts relating to the specific gravity have little or no value, inasmuch
as the quantity of the secretion was not ascertained.

                           SECTION ELEVENTH.
      Duration of the disease.   Sequelae.  Mode of dying.   Fatality.
   Duration.   In order  better to  compare  the two types with respect to
duration, I will examine the facts pertaining to each type under a separate
head, giving, in this Report, results without details.  The duration from two
points of view only will  be considered, viz., from the date of taking  to the
bed, and from the time of admission into hospital, to the day of convalescence,
or to  the day of death.
   The duration of the access has already been considered in another section.
It would be useless  to determine  the duration in  the  cases not fatal  to the
time of discharge from  hospital, as this was too  often  affected  by circum-
stances  entirely foreign to the disease.
   Typhus.  The data for determining the duration from the date of  taking
to the bed, to the day on which convalescence was pronounced, are contained
in the histories of thirty four cases.  The mean duration  is fifteen 8-17 days.
The maximum of duration, in this point of view, was twenty-six days.  The
minimum duration was nine days.
   The  duration from the time of admission into hospital to the day of con-
valescence is ascertained in twenty-five cases*   The mean duration is eleven
9-25 days.  The maximum duration, in this point of view, was twenty days,
and the minimum duration, six.
   Typhoid.  The data for determining the duration from the time of taking
to the bed to  the day of convalescence, are contained in the histories of six
cases.  The mean duration is eighteen 1-3  days.   The maximum duration
was twenty-three days.   The minimum duration, eleven  days.
   The  duration from the time of admission  into hospital to the day of con-
valescence, is  determinable  in  seven cases.   The  mean  duration is thirteen
days.   The maximum duration was sixteen  days.   The minimum duration,
nine clays.
   These results approximate closely to those developed by the first analysis,
differing, as did the latter, from those afforded by the second.
   They show a shorter mean duration in Typhus, dating both from the time
of taking to the bed, and admission into hospital.
* The remainder of the patients were inmates of the hospital when attacked. 
336
REPORT ON CONTINUED FEVER.
   The cases of Typhoid approximated, individually, nearer the mean dura-
 tion than those of Typhus, the  latter type affording the greater  maximum,
 as well as minimum duration.
   Directing attention, now, to the duration of the fatal cases, the following
 are the results:
   Typhus.   Mean duration from date of taking to bed, to fatal termination,
 twelve 3-5 days.   From time of admission into hospital to fatal termination,
 seven days.
   Maximum duration, from'taking  to  heel, eighteen  days; minimum, nine
 days.
   Maximum duration, from  admission  into hospital, nine days;  minimum,
five days.
   Typhoid.  Mean duration, from date of taking to bed to fatal termination,
 twenty-one 1- 5 days.   From time of admission into hospital, to fatal termi-
 nation, fourteen 4 — 5 days.
   Maximum duration, from  taking  to  bed, twenty-seven days;  minimum,
 thirteen days.
   Maximum duration, from admission into hospital, twenty days;  minimum,
 twelve days.
   Sequelae.   A large proportion of the patients remained in hospital but a
 short period after convalescence.  My observations relative to  sequelae, there-
 fore, not extending over much space of time, are few.  I will give all the
 facts which appear in the histories.

                                Typhus.
   Case 1.  Mild diarrhoea occurred during convalescence.
   Case 2.  Sloughing, on the nates, superficial,  and to a  limited extent,
 occurred about the time of convalescence.
   Case 3.  Several furunculi appeared  shortly after convalescence.
   Case 4.  Ecthyma occurred shortly after convalescence.
   Case 5.  In this case the patient became convalescent, and sat up on tha
twenty-third  day after  the date  of the  attack.   On that afternoon he was
attacked with a severe  chill which lasted  an  hour, during  which the pulse
could not be felt at the wrist.  Five  or six months prior to being attacked
with Typhus, he had  had  Intermittent fever.   The pulse became very
frequent when reaction took place, numbering 148.   Several dejections occur-
red,  and muttering delirium.  The next  day he had  another chill in  the
afternoon, and on the following morning perspired freely.  Death occurred 
REPORT ON  CONTINUED FEVER.                  337
on the succeeding day.   The record of the symptoms after the relapse occur-
red is rather imperfect.
   Case 6.   This case was followed by tuberculous deposit in the lungs and
spleen, and death in about two months after convalescence.  The patient had
had Typhoid fever a short time before being  attacked with Typhus, the lat-
ter disease being developed while he remained in hospital after convalescing
from Typhoid.

                                Typhoid.
   Case 1.   Twenty-two days after the date of convalescence, the patient was
attacked with Dysentery, which proved fatal.
    Case 2.   Parotitis occurred at about  the  time of convalescence.  Refer-
 ence has  already been made to this case in the section relating to the digest-
 ive system.
   Relapses.   Case No. 5,  (Typhus) in the foregoing list, might  perhaps
 with propriety be considered a  case  of  relapse  of fever.   Aside from this
 case, relapse occcurred but in a single instance.   In this  respect the present
 collection as well as the first, presents a striking contrast to the second.   In
 the single instance referred to, the  patient was seized with headache, pain in
 the limbs, and febrile movement, seven days after the date of convalescence,
 having, in the mean time, been  able to sit up a little.   On the fourth day
 after the second attack, free perspiration occurred, which was renewed for
 several successive nights, and the patient was again shortly convalescent

                       Mode of dying.   Typhus  cases.
    1. Ninth day after taking to bed, by asthenia.
    2. Eleventh do., and fifth after admission,  by asthenia, preceded by apnoea.
    3. Twelfth do., and seventh after admission, by apncea, apoplectic coma.
    4.  Eighteenth do., and ninth after admission,  by asthenia.
    5.  Thirteenth do., and seventh  do., by apncea, apoplectic comai

                               Typhoid cases.
    1. Fifteenth day after  taking  to bed, and  twelfth after  admission,  by
 apnoea, apoplectic coma.
    2. Twenty-seventh do., and twentieth do., by  asthenia.
    3. Thirteenth do., and twelfth do., by apnoea.
    4. Twenty-fifth clay do., and twelfth do., by asthenia.
    5. Twenty-sixth day do., by  apncea.
    Fatality.  The number of cases that proved  fatal has already been stated,
              22 
338
REPORT ON  CONTINUED  FEVER.
 \iz.,five of the cases of each type, i. e. ten in the whole number of cases ana-
 lyzed, viz. sixty-four.  In this enumeration the instances of death occurring
 subsequent to the career of fever are not included.  Death took place in one
 case from dysentery supervening on Typhus; another from relapse  of fever;
 and a third from tuberculosis.   Since in each of these instances the patients
 had convalesced, and the issue was not due to  the fever except so far  as it
 may have predisposed  to the consecutive affections, or diminished the power
 of resistance inherent in the organism, it would hardly be proper to consider
 these as cases of fever ending fatally.
    As already stated, one case of Typhus which,  the history not having been
 recorded, is not included in the collection, ended fatally.   I refer to the death
 of the Sister of Charity mentioned in the Second Section.  In determining
 the rate of mortality this should  be included, which makes eleven of the six-
 ty-five cases,  proving fatal.  This gives nearly a ratio of one death  to every
 six cases, or 17 per centum.
    This rate of mortality is less than in the two collections of cases previously
 analyzed.   For reasons assigned in the last Report,  it would be unfair to
 infer from this difference the superiority of the management of the cases in
 this collection.  The treatment, as  will be seen in the section devoted to that
 subject, was not altogether the same  as heretofore, but  the fluctuations in
 fatality at different times and places are so  great  as almost to preclude any
 positive deductions as to the success of any  particular plan of management in
 any  collection of cases.  Negative conclusions,  however,  may be  adopted
 with less reserve, in view of a large proportion of recoveries.  In other words,
 the treatment under these circumstances, it may  fairly be claimed, could not
 have been highly pernicious.
    A striking  point  pertains  to the dates  of  the fatal  cases.  Up to Jan. 3d
 not a single death from Continued Fever had occurred.   More than half of
 my six months' service  had  then expired, and I had  then treated fourteen
 cases of Typhus, seven  cases of Typhoid, and three cases of doubtful type, in
 all twenty-four cases.   The dates of admission of the fatal cases, respectively,
 were  as follows:  Typhus.—Jan. 3; Jan. 15; Jan. 15;  Jan. 26; March 5.
 Typhoid—Jan.  19; Jan. 26; Jan. 29; Feb. 18; March 11.   Thus, it is
 perceived, four of the five  recorded  Typhus cases, and three  of  the five
 Typhoid cases proving fatal, were admitted in the month of January.  If, now,
 the reader will turn to  Section First, he will find  that during the month of
 January eleven cases of  Typhus, and three of Typhoid were admitted, making
fourteen cases; so  that one-half of the cases received during this month
 proved fatal—an enormous proportion compared with the ratio of deaths to 
REPORT ON CONTINUED FEVER.
339
recoveries in any other month.  It would hardly seem probable that this
was owing merely to coincidence, and, if not, there  must have existed during
that month, for reasons utterly inexplicable, an unusual tendency, in cases of
fever, to a fatal result  Striking differences in this respect, in different years,
and at different places, are abundantly established.   It is only circumscribing
within narrower limits a similar fact, to show that a greater liability of death
obtains during one of a series of months, in the same situation, and under the
same kind of management.
   The two previous analyses developed a  larger ratio of fatality in the Ty-
phus, than in the Typhoid cases.   The reverse of  this is true of  the present
collection.   The proportion of deaths was  considerably greater in the Ty-
phoid group, being as 5—14 is  to  6—42.   This disparity shows that, for
reasons unknown, there existed a stronger tendency to a fatal  result  in  the
Typhoid cases.  Compared with the previous collections, the ratio of fatality,
in the cases of the latter type, is much greater than  heretofore, being  nearly
36 per cent.;  while, on the other hand, the ratio of fatality in the Typhus
cases is as strikingly less, being a fraction below 14 per cent.

                            SECTION TWELFTH.
                        Examinations  after  death,
   I shall restrict myself, in this Section, to the appearances  presented in the
intestinal canal, more  especially the small  intestine.  The appearances in the
latter  situation are interesting in  consequence  of their  bearing  on  the
question of the identity or non-identity of  Typhus and Typhoid fever.   My
reasons for taking this  limited view of the post  mortem  examinations  are,.
first, it is with reference to the question just stated  that the contribution of
facts is, in a special manner, desirable; and, second, for the reasons given in
the previous Reports,  the dissections did not generally embrace  an inspection
of all the important parts of the body.  Intestinal lesions were always sought
for with care, and  the appearances recorded, but  in most of  the  cases the
condition of some organs was not ascertained, and, except with reference to
some special point  of interest  like that relating to the lesions stated  to  be
characteristic of the Typhoid type, an autopsy is  unsatisfactory  which does
not embrace all the facts, negative as well  as  positive, which the scalpel can
disclose.  I have already had occasion to refer to two instances of  death by
sudden coma,  with spasmodic  Inspiration, (Section Seventh,)  in which the
larynx was inspected in order to ascertain whether oedema, or  other morbid
conditions existed in that  part.    Any other facts  noted, aside  rom  the 
340
REPORT  ON CONTINUED  FEVER.
intestinal  appearances, which shall  appear to have any particular interest,
will be mentioned; otherwise, for the sake of brevity, they will  be omitted.
  Of the five fatal cases of Typhus, examinations were made in four instances;
and of the five fatal cases of Typhoid, examinations were made also in four.
In addition to these I have had an opportunity  of inspecting the intestinal
canal and  other parts of a patient who has died since  the expiration of my
term of service, the appearances taken in connection with the history of the
case being peculiarly interesting.  In another case, not embraced among the
cases of death from  fever, in which the  patient, after sitting up, suffered a
relapse which proved  fatal, a  post mortem  examination was made.  The
appearances in this case, which was of the Typhus type, may also be included.
  I will give a succinct statement of the results of  these examinations of the
cases respectively.

                                Typhus.
   Case 1.  Death by asthenia, on the llth day.  Several of the Peyerian
patches developed so as to be visible, with black  points, presenting the
shaven heard  appearance.  No enlargement of the mesenteric  glands.  A
patch of  arborescent  redness in the ileum just  above the coecum.   Large
intestine free from disease.
   Case 2.  Death by apncea, on the  12th day.  A few Peyerian patches
developed so as to be visible.   No enlargement of mesenteric glands.
   Case 3.  Death on the 18th day, by asthenia.  Deep capilliform redness
of mucous membrane lining the lower part of the ileum.  A single Peyer-
ian patch  near the coecum,  and solitary glands developed so as to be visible.
No enlargement of mesenteric glands.
   Case 4.  Death, bg apncea, on the l?>th day.   Several Peyerian patches
developed so as to be visible.   Mesenteric glands  slightly enlarged, the largest
being of  the  size of a small pea.   Two small Tricocephali found in the
coecum.                         \
   Case 5.  Death on third day after relapse of fever, the patient having
convalesced from  Typhus.  An  account of this case is given in Section
Eleventh.   So far as the post mortem appearances are concerned, it  has as
much value as any of the Typhus cases.
  The Peyerian  patches presented the  shaven beard appearance,  being
developed so as to be visible.   Some of the solitary glands also developed.
  Mesenteric glands somewhat enlarged.
  Several small ulcerations  in coecum. 
REPORT  ON CONTINUED FEVER.
341
                               Typhoid.
   Case 1.  Death,  by apoplectic  Coma, on the  15th day.  The Peyerian
patches greatly developed, projecting two or three lines above the level of the
surrounding mucous membrane.  This enlargement was most marked in the
patches nearest the coecum, and it progressively diminished on ascending the
tube.   The patches did not present any sloughing, except, to a limited extent,
in the patch nearest the coecum.   The mesenteric  glands  much enlarged,
some  as large  as filberts.
   Case 2.  Death,  by asthenia, on  the 21th day.  Peyerian patches much
diseased, those nearest the coecum presenting deep excavations exposing the
fibres of the muscular tunic.   On ascending the tube, in some of the patches
partial sloughing of  the glands and morbid deposit had occurred, while  in
those still  higher in the tube the morbid deposit remained, i. e. the patches
were  salient, and not ulcerate!.
   Mesenteric glands moderately enlarged.
   Case 3.  Death,  by  asthenia,  on  the  25th day.  Peyerian pat hes ex-
tensively ulcerated, a large proportion  presenting excavations, the morbid
deposit and the glandular follicles having sloughed away.
   Mesenteric  glands much diseased.
   Three tricoeephali in the coecum.
   Case 4.  Death  on  about the  2Qth day, by apncea.  Peyerian patches
 developed, and those nearest the coecum presenting excavations.  The soli-
 tary glands enlarged.   Mesenteric glands enlarged.
   Case 5.  Death fifty-three days after  convalescence from Typhus, the
patient having previously had Typhoid, being attacked while at the hospital
 with  the former type shortly after convalescence from the  latter.  To this
 very  interesting case I  have already had occasion to advert, (Section Sixth.)
 The  patient entered the hospital with Typhoid  fever, Dec. 27th.  He had
 then been confined  to the bed seven days.   He was convalescent Jan. llth,
 (sixteen days.)   On February 7th he took to the bed with  Typhus, and was
 convalescent from the latter on the 23d of February, (seventeen days.)  Death
 occurred  on the 15th of April, fifty-three days after the date of convalescence
 from  Typhus, and  ninety-six days from the date of convalescence from Ty-
 phoid.  He presented successively the characteristic symptoms of each type
 of Continued Fever, including the eruptions.   The following  post mortem
 appearances  were observed: The lungs contained numerous disseminated
 tibercles, and some masses of about the size of filberts.   The  tuberculous
 deposit was most abundant in the right lung.  There were no excavations. 
342                  REPORT ON CONTINUED  FEVER.
  The surface of the spleen was studded  with tubercles of pretty uniform
size, about as large as small  shot.  Being reserved, in order that its external
appearance might be copied, it was not examined internally.
  The peritoneal surface over the liver presented a space of about the size of
the palm  of the  hand,  which was  thickly covered with a granular deposit,
apparently of tubercle.
  The small intestine presented near the  coecum an oval space presumed to
be the site of a Peyerian  patch, of a slate color, without any black points,
not depressed,  nor salient.   The dark color caused  the  patch  to be well
defined, contrasting  with  the pale  color of the surrounding mucous  mem-
brane.   The  mucous membrane  over this patch was somewhat  softened.
Upward the same discoloration was  observed  in several patches,  but  less in
degree.  Numerous small oval excavations  existed in these patches, extend-
ing below the mucous coat, not presenting a granulated or ulcerated aspect,
but apparently covered with a delicate, serous-like membrane.   Several simi-
lar depressions,  also, existed  in the mucous membrane in the neighborhood
of the Peyerian patches.   Some twenty or more of these excavations were
counted, being  less numerous and more  superficial in proportion  to  the
distance from the coecum.
  The  mesenteric glands were  enlarged, some being as large  as a small
«ized bean.
  The appearances in the foregoing  case (No. 5) are interesting  from  the
fact that they were  the remnants of the characteristic  lesions of Typhoid
ninety-six days after convalescence  from  that type of fever,  the  patient
having, in the mean time, passed through Typhus.
  In the two former Reports the appearances  found after death were sub-
mitted  without  comment.  The  few remarks  which I  shall offer  on the
subject now, will be based on the results of  the examinations in fatal cases
contained in all the three collections.  My remarks, as already stated, will be
limited to the appearances found in the small intestine.   What are the con-
clusions to be drawn from these data as  respects the appearances which dis-
tinguish the two types from each other?   It  is  chiefly with reference  to this
inquiry that I propose to review the facts which I have recorded.
   The  three Reports contain  an account of the appearances of the small
intestine in  twenty-two  cases.  Of  these twenty-two  cases, thirteen were of
the  Typhoid type, eight  were of the Typhus type, and in one case the
patient had  lately passed through both types.  In each of these cases the diag-
nosis was made during life, and based on evidence deemed unequivocal.   In
nearly all the cases  the distinctive symptoms embraced the peculiarities of 
REPORT ON  CONTINUED  FEVER.
343
the eruption.  There can be no  room for doubt that in every instance tta
ante mortem history, exclusive of the p>ost mortem appearances, fully war-
ranted the determination of type.   I am  particular to make this statement,
for it is obvious, when we are  prosecuting investigations in order to ascertain
what lesions distinguish either type from the other, it is necessary to settle
positively on the diagnosis in  individual  cases, irrespective of the lesions of
which we are in search.  In  other  words,  with  reference  to the  question
which has just been propounded, the post mortem appearances  should not
enter into the diagnosis.   On this point the reader is referred to some remarks
contained in the supplement to the two  first Reports, under the heading  of
the " Identity of Typhus and Typhoid fever."
   What are the morbid appearances that have been found in the Typhus
cases ?  In each of the seven examinations in cases of this type, the Peyerian
patches have been somewhat changed, the alteration consisting apparently of
a slight degree of hypertrophy, causing  their development  so as to  render
them visible.  In some instances the patches have been studded with black
points, giving rise to what has been called the shaven beard  appearance.
Occasionally the solitary glands  have exhibited the same kind  of  develop-
ment, and the glandular bodies of the mesentery have been slightly enlarged.
In no case  of the  Typhus type have the appearances exceeded those just
described, but more or less of these appearances have been uniformly observed.
Both these facts are important to be borne in  mind.  These results prove
sufficiently the incorrectness of the statement that the Peyerian patches and
mesenteric glands are entirely unaffected in Typhus.   So far as these results
go,  they  show, on  the  contrary, that the Peyerian  follicles  are uniformly
affected, but they contain proof only of  a certain amount of morbid change,
consisting, judged by the gross appearances, simply  of  a slight degree  of
abnormal development or hypertrophy.
   On the other hand, what are the morbid appearances in the Typhoid cases ?
In each of  the instances of this type the Peyerian  patches exhibited  a nota-
ble degree of alteration, the change not consisting in merely a  slight develop-
ment, but in great enlargement, causing  the patches to  project several lines
above the  level of the surrounding mucous membrane, or in  excavations
involving more or less destruction of the mucous coat and follicles, the sur-
face of these excavations sometimes having a granular, ulcerated aspect, and
in other instances covered by a thi n, transparent serous-like tissue.   Generally,
the  solitary  glands were  also the seat  of similar excavations,  or  of great
enlargement.  The mesenteric glands, also, were invariably increased in size
to a much greater extent than in the Typhoid cases, in some instances being 
844
REPORT ON CONTINUED  FEVER.
quite large.   To be more precise with respect to the Typhoid type, in three
of the thirteen cases the Peyerian patches were notably enlarged, without
excavations, and  in  the remaining  ten  cases the latter, with more  or less
enlargement, existed.
   These appearances show, in the Typhoid cases, a morbid deposit  in the
Peyerian patches taking place early in the disease in considerable abundance,
and  in the  Typhus cases simply a tumefaction.   They show, at a more
advanced stage of the Typhoid type, a sloughing of the enlarged glands with
the morbid deposit and the mucous covering, leaving ulcerated excavations
extending to the muscular tunic, sometimes  leading  to rupture and perfora-
tion ; and, at a later stage, more or less advance toward cicatrization and fill-
ing up of these excavations; while, in the Typhus cases, in no  instance were
these processes of ulceration and sloughing apparent.
   Although, therefore,  the Peyerian patches are not wholly  unaffected  in
Typhus, the changes, when compared with those that obtain in Typhoid, are
quite insignificant.   The contrast,  as remarked  in another place, is scarcely
less striking than if the  follicles in  Typhus had remained invisible.  The dif-
ference in the appearances  is  as great  as that, for example, which exists,  on
the external surface of  the body, between the efflorescence of measles, and
the pustular eruption of small pox.  The force of the difference in its bear-
ing on the question of the  identity or non-identity of the two  types, cannot
be considered to be much impaired by the fact that the  Peyerian patches are
frequently, if not generally changed in a slight degree in Typhus.
   It seems to me more important to dwell on these points with some empha-
sis, because an idea appears to be very generally entertained that if the Pey-
erian patches are found to be affected in ever so slight degree in Typhus, its
non-identity with Typhoid is disproved.  But this conclusion assuredly does
not follow, if it be true that the affection of these parts in Typhoid  is quite
different in character,  as well as degree, from that  in  Typhus.  Moreover,
observers are likely to be confused, and distrustful in verifying the differential
diagnosis by the intestinal appearances, in consequence  of the erroneous
idea just mentioned.
   As respects the intestinal lesions of Typhoid fever, several points of inte-
rest remain to be studied.   The nature  of  the typhous  material, or  deposit,
does  not  appear to  have been ascertained.   It has been compared to the
tuberculous deposit, and it appears to pass through changes somewhat analo-
gous to the evacuation  of tuberculous material into the  bronchial tubes.
   The Peyerian  patches are frequently destroyed by the sloughing  process.
Are they afterward reproduced ?   What is  the condition of  these parts at a 
                      REPORT  ON CONTINUED  FEVER.                 345
period considerably remote  from the time of convalescence, after the pro-
cesses  of restoration are completed ?   Do  the  Peyerian patches invariably
present the notable degree of alteration found in my examinations  in Ty-
phoid, and,  in what proportion of  cases,  are they wholly unaffected  in
Typhus?  These, and  other inquiries which suggest themselves in this con-
nection, afford interesting fields of research.
   A point of interest, in conclusion, relates to the history of the eruption in
the cases in which examinations were made after death.  Directing attention
to the cases entering into the present collection, an eruption existed in two of
the four cases of  Typhus, and in all the four  cases of Typhoid.  In one of
the Typhus  cases the eruption had mixed characters, i. e., a combination of
the Typhus and Typhoid eruption.  In one of the Typhoid cases, only four
" rose spots" were counted, and in another case  only five.  The two last men-
tioned cases show that the intestinal  lesions bear no relation of proportion to
the abundance of the eruption.

                          SECTION THIRTEENTH.

                                Treatment.
   The cases in this collection were treated with greater simplicity, but, in
some  respects,  more efficiently than  those heretofore analyzed.   The first
object in the management, of course, was  to direct those measures which, in
the  opinion  of the reporter,  would  most conduce to the welfare  of the
patients, and afford the best chance  of recovery.  It  is quite superfluous to
add, that this object must ever be paramount to every other in the minds of
conscientious practitioners.   Objects, however,  of  a  scientific character, may
properly, and in fact should, whenever practicable, be superadded — objects
relating to self improvement, and the collection of facts by which, it is to be
hoped, science  may be enriched, and the resources of our art enlarged.   In
the latter point of view, two ideas were prominent in my mind  during the
time the  cases were in progress.   One of these ideas was  to prescribe medi-
cinal remedies  only when clear and definite therapeutical indications were
recognized, adopting, as heretofore, the expectant method.   Another idea
was to meet the indications which appeared to present themselves, directly
and efficiently,  employing for this end the fewest and simplest means ade-
quate  thereto.   These ideas, it may be said, so far from possessing any nov-
elty, are  those  upon which a rational  practice is usually based.  Without
stopping to engage in any discussion  on  this topic, I will merely remark, that
reflection and observation, as it seems to  me,  must convince us that every 
346
REPORT ON  CONTINUED  FEVER.
one is open to more or less self-deception on this score.   So difficult is it to
repress  the tendency to resort to therapeutical  interference, that  there are
few, if any, acute affections concerning which it  is not still  a desideratum to
know what would be the consequence of permitting them to run their course
uninfluenced by medication.  All must admit the importance of this knowl-
edge as a point of departure for rational principles of  management.  I have
no reluctance to confess a desire to observe the progress of Continued Fever
divested of all extrinsic influences save those which, considering my views of
what was due to the interests of the patient, I should not be justified in with-
holding.  The same  tendency which stands  in  the way of refraining from
all medication, even wdien it might be better for  the patient, as well as more
conducive to scientific knowledge, also leads to the multiplication of different
remedies for the attainment of a common end.   The unfavorable effect of
the latter upon medical observations  is two fold.   It is obviously difficult to
assign to each remedy  its  proportionate degree of  efficacy when several are
employed conjunctively.  This is one evil.  Another  is, that in distributing
our expectations of benefit among  a variety of means, we  are apt to attach
undue importance to some, or to their collective  operation,  and  thus employ
too sparingly those which are the most efficient, and upon which it were bet-
ter that the main reliance should  be placed.   Having aimed to have  these
considerations exert, practically, their full effect, the treatment of these cases,
as already remarked, was  even  more simple than  that pursued during the
two previous years; and I shall be better  able to submit a summary of the
facts pertaining  to this, certainly not the least interesting or important part
of the history.   In endeavoring to give the  reader an  account of the kind
and amount of medication practiced, the most convenient method will  be to
consider the  different  remedies employed, under  separate heads.   I will,
therefore, examine the records of the cases with reference  to the  extent to
which different articles of the materia medica  were prescribed.
  In two cases, both of the Typhus type, no medicinal remedies whatever,
were  prescribed.  The  disease  passed  through its career favorably, sanitary
measures being alone directed.   In all  other instances some remedies were
employed.
  Laxatives.  Laxatives  were prescribed in several  cases in which no
dejection had taken place  for several successive days.  In no  instance was
an active cathartic administered.  The laxative measures consisted either of
castor oil taken by the mouth in the dose  of half an ounce, or in simple ene-
mas.  The oil was prescribed, I find, in ten cases.  Nine of these ten cases
were of the Typhus  type.  In every case but one, oil was given once only 
REPORT ON  CONTINUED  FEVER.                 347
during the course of the disease.  In the case furnishing the single excep-
tion  to this  statement, the oil was  repeated on the  following day.  It was
given in nearly every instance  early in  the disease,  usually at the time the
patients entered the hospital.
   A single enema was prescribed in three cases, all of the Typhus type.
   In one case in which castor oil was given, and in one of the cases in which
an enema was resorted  to, the dejections which followed were so frequent as
to call for remedies to  restrain  them, which, in both instances, at once  suc-
ceeded.  The same was true of another case in which the patient had taken
some cathartic just before entering the hospital.
   In two instances (Typhus) no medicinal remedy was prescribed in addi-
tion  to a single dose of oil; and in  one case a  simple enema constituted the
sole  treatment.
   Anodynes.   Anodynes were employed in a few cases to restrain diarrhoea,
and  the undue operation of laxative remedies.  The tincture of opium was
used for this end, taken either by the mouth, or by enema.   It was prescribed
in five cases of Typhus, and in eight cases of Typhoid.  The proportion of
the  instances  in the latter  type, it will be perceived, is very considerably
largest.  In all these  cases  it  was employed to a very limited extent, and
frequently only once during the course of the  disease.
   In treating  cases of fever, heretofore, I had been accustomed, very gene-
rally, to prescribe opium, or morphia, with a view to relieve mental aberration,
and  promote sleep.  I have supposed that an anodyne influence was salutary
even when  vigilance or delirium were  not prominent  symptoms.  In  this
collection of cases, however,  I  resorted  to  remedies of  this class, except to
restrain  too frequent dejections, in  but a very few  instances.  Morphia was
prescribed in only two cases of  Typhus, and in one of  these it was given to
allay cough.  In one case of  Typhoid, Dover's powder  entered  into the
treatment.
   My  sense of the necessity of Anodynes, save for the object first stated, was
lessened  by the observation  of cases in which they were omitted.   Had  it
been otherwise, they would have been given more frequently.
   Astringents.   I gave the  tannic acid in one case of Typhoid in which
diarrhoea called  for restraining measures.   This was the  only instance in
which  any remedies of the astringent class  were employed.
   Sedatives.  The only articles employed  which will  fall under this  class
are tartarized antimony and potassa, and camphor.  The former was pre-
scribed in  three  cases of  Typhus, and in  one case of Typhoid.   In the
Typhus  cases it was given to relieve delirium, in doses of gr. 1-16.  In the 
348
REPORT ON CONTINUED FEVER.
Typhoid case it was given with reference to pneumonitis which existed as a
complication.  In one of the Typhus cases the antimony constituted the sole
medicinal treatment.
   Camphor was given in three cases of Typhus for ataxic symptoms, and
in no case of Typhoid.
   Ammonia.  The carbonate of ammonia was given whenever there was a
marked failure in the forces carrying on the circulation.   It was prescribed in
all the cases ending fatally by asthenia.   It entered into the treatment of six
cases of Typhus, and four cases of Typhoid.
   Quinia.   Quinia was prescribed in doses  of three grains, three times daily,
and continued for several days in four  cases of Typhus.  In each of these
cases it was given from the commencement of  the  febrile career.  It was
given in one case of Typhoid.
   Huxanis tincture was prescribed in one case.
   Spirit us  ether nitrosus.   This remedy was given in two instances, once
for some difficulty in urination, and in the other  case the indication doos not
appear in the history.
    Vesication.   Blisters to  the nape of  the  neck were resorted  to whenever
spasmodic inspiration was observed, or a tendency to coma.  It entered into
the treatment of all cases which ended  fatally by apnoea.  The employment
of blisters was  limited to the  above  indication, save that in one  case they
were applied behind the ears  for external otitis.   They were applied to the
neck in nine cases of Typhus, and in four cases  of  Typhoid.
   Sinapisms and stimulating liniments. These  were occasionally employed
in cases complicated  with  pneumonitis, and  when  coma existed, or  was
threatened.
   Diffusible stimulus.  The only form of diffusible stimulus employed, save
in one or two instances, was brandy.    This remedy entered into the man-
 agement of the  great majority of the cases of both types.  It was omitted in
 but five cases of  Typhus, and two of  Typhoid.  In these cases the disease
 was mild.   Two of them were those which received  no medicinal treatment.
 In  one the treatment consisted only of a single enema, and  in another of
 antimony in doses of a sixteenth of a  grain.
    In several of the  Typhus cases (in all nine)  brandy constituted the sole
 remedial agent  employed.
    The mode of administration, in all save  two  cases  in which milk  punch
 and egg nog were given, was with cold or warm water, from  two to  three
 parts of the  latter,  and, occasionally, the addition  of sugar.  The quantity
 given at a dose was generally half an  ounce, or a tablespoonful.   In some 
REPORT ON  CONTINUED FEVER.
349
instances this quantity was increased to an ounce.  The dose was repeated
at intervals varying from half an  hour to four hours.   The shortness of the
intervals corresponded with the apparent urgency of the indications, and the
apparent effect.  The frequency with which the doses were repeated varied
very considerably in individual cases, and at different  periods of the febrile
career in the same case.  I commenced its use, in a large proportion of the
cases,  early in the disease, frequently at the time the patients first came
under observation, and  it was  usually continued pretty steadily throughout
the disease.
   Prostration, coolness of  the surface, feebleness, and, more  especially, nota-
ble frequency of the pulse were regarded as indicating its free administration.
But it was given in many cases in which these symptoms were  not particu-
larly prominent,  the object being  to forestall  their occurrence by sustaining
the vital forces.
   I have thus given a brief statement of the medicinal treatment.  The die-
tetical and sanitary management was deemed not  less important than that
pertaining to  the exhibition of remedies.  In every instance nutriment was
systematically administered; the  forms being the same as heretofore, viz.,
essence of beef and  milk porridge.  These articles of nourishment were given
at short intervals during  the  course of the disease, without waiting for an
expression of,  or consulting the wishes of the patients, and sometimes against
their inclinations.  Attention to  cleanliness, ablutions, and  ventilation, were
attended to so far as circumstances permitted.   Owing to the hospital  being
 more crowded than hitherto, the  sanitary conditions were  perhaps somewhat
less favorable than during the previous years.  The larger number of patients
 also rendered  it more difficult  to bestow always the same vigilant attention.
   I  have not mentioned  any efforts  to cut short the disease.  The  only
 measures  resorted to for  this  end was the wet  sheet, which was applied in
 two cases of the Typhoid type.  In one of these cases it was applied on the
 third day after admission, and  the fifth of the febrile career.   The fever con-
tinued, convalescence being pronounced on the nineteenth day.
   In  the  other case it was resorted to on the second day after admission, and
the fifth of the febrile career.  The progress of the  disease was unaffected,
 the patient  being convalescent on the sixteenth day.  In this case a relapse
 of fever occurred a  few days after the date of convalescence.
   It is  at once  obvious that  in  presenting the foregoing summary of the
 treatment pursued in this collection of  cases, the object is not to furnish any
 proof of the effects, either immediate or remote, apparently due to each  of the
 different measures in  the cases  individually.   In order to form  any estimate 
350
REPORT ON  CONTINUED  FEVER.
 of these results it would be necessary to consider the details of the treatment
 in each case, together with the symptoms from day to day during the course
 of the disease.   In other words, the histories of all the cases should be given
 at length.   The enumerations that have been given only afford a coup d'oeil
 of the treatment which the cases received collectively, the remedies employed
 being so few, that, without occupying much space, it has been practicable to
 present a statement of facts which it is presumed will  be rather more satis-
 factory than mere general statements.
   The  reader  will perceive that the  medicinal remedy  upon which most
 dependence was  placed  was brandy.  In  this,  with the administration of
 nutriment, consisted most of whatever efficiency belongs to the management.
 The other remedies, for the most part, were secondary in importance;  and it
 is more than probable that the treatment  might have been more \miformly
 restricted to the use of diffusible stimulus without affecting materially the
 results.   That  is to say, some of the remedies which were  prescribed in  a
 small proportion of cases,  did  not possess  enough potency for much impor-
 tance to be attached to them.
  What conclusions are to  be drawn from  the  management of these  cases?
 I am half disposed to leave this question wholly with the reader.  I shall
 devote to it but a very few remarks.  We  are  to regard this collection of
 cases as exemplifying, therapeutically, the treatment of Typhus and  Typhoid
 fever mainly by stimulants and nourishment.  The rate of mortality certainly
 was not large.   It is probably below the average of cases of the same descrip-
 tion  under analogous circumstances, irrespective of remedies, or under  differ-
 ent plans of management.   I am not disposed, however, to deduce from this
 fact any inferences as to the positive merits of the mode of treatment.  It is
 well known that these forms of fever exhibit at different times and  places
 widely different tendencies  to a fatal result.  Statistics  may be referred to,
 showing a small rate of mortality, in which stimulants and a nutritious diet
 did not form a  prominent feature of management.  All  that can be claimed
 in behalf of the treatment on the ground of  the small fatality is, that it did
 not exert an unfavorable  effect.  In making this admission I would not be
 understood to  mean that I attach only a negative value  to the  measures
pursued.  I  cannot but entertain the conviction that these measures did exert
more or less  real efficacy.  If I had  thought otherwise, I should  assuredly
have withheld them to a  greater or less extent   Attaching to them consid-
 erable importance, I could not conscientiously deprive  the patients of the
advantage which I supposed was to be therefrom derived.  This is, however, 
REPORT ON  CONTINUED FEVER.
351
an opinion, which is quite another thing  than a truth demonstratively or
logically established.
  The  probable influence on the rate of mortality in a collection of cases is,
however, not the only, nor the most reliable source of information respecting
the  efficacy of remedies.  We estimate their influence, in  the formation of
our opinions by experience, by studying their immediate effects in individual
cases.   This kind of observation has led me to attach considerable importance
to the employment of diffusible stimulants, in conjunction with alimentation,
in cases of fever.  I cannot, as it seems to me, be deceived in the fact that the
symptoms are frequently improved thereby, and that the condition of patients
frequently deteriorates wdien these measures are withheld.  I have in several
instances in this, as in the collection of cases before recorded, observed the pulse
to fall in frequency, the mind  become more clear, etc., after stimulants, with
nutriment, have  been administered, or the quantity been increased, when it
was hardly conceivable that this connection of events was one of coincidence
merely.  I have sometimes withheld  these measures, or diminished  their
use, for a short time, in order to watch the result, and found  their usefulness
 apparently verified in that way.   In one  of  the Typhus cases in this collec-
tion, presenting the  greatest  degree of gravity, the pulse  being nearly or
 quite 140 per  minute for several successive days, I was led to try this exper-
 iment under the suspicion that the great acceleration of the pulse might pos-
 sibly be due, in  a measure, to over stimulation.  In that instance, after the
 discontinuance of an ounce of brandy every half  hour, for a few hours, the
 pulse rose from 140 to 150 and  again fell to  140 on resuming the stimulus
 in the doses previously given.  The  patient finally recovered.  It was fre-
 quently remarked  that the pulse was more frequent, and other symptoms
 more unfavorable  in the morning, when, owing to  the greater difficulty of
 administering  stimulants and nutriment with the same regularity during the
 night as during the day time, these measures had been less efficiently carried
 out;  and I cannot but think  that the happy issue of some cases was due to
 the 'vigilance with which the patients were watched  at night as well  as day,
 the quantity of stimulus being  graduated carefully  by the immediate effect
 on the pulse and other symptoms.
   With  respect to  the  uniformity with which  these sustaining  measures
 should be pursued in cases of fever, and, in  this point  of view, the degree of
 importance which belongs to them, my impressions are not so definite.  I
 am by no means prepared to assert that they could not have been dispensed
 with in some cases, or  employed less freely, without compromising the safety
 and welfare of the patients.   Continued observations relative to these, and 
352
REPORT ON  CONTINUED  FEVER.
other points in therapeutics, are desirable.   A combination of negative deduc-
tions from the analyses of different collections of cases, may, in the end, settle
the principles which should govern the treatment of Continued Fever more
positively than comports with our present knowledge of the subject


                          section Fourteenth.

                        Cases of Doubtful Type.

   In the foregoing Sections I have made no reference to the facts contained
in the histories of the cases in which the type of the disease was not deter-
mined.   I have thought it preferable in concluding  this  Report to devote to
the cases of doubtful type a distinct  Section.  They will require but a brief
consideration.  I shall examine them only with reference  to the subject of
diagnosis.   It is in this point of view chiefly that they possess interest.  The
question naturally arises—' Is it true that the type of a certain portion of the
cases in each collection is indeterminate?'   If it be difficult or impossible to
assio-n to 8-64 or -J of the cases falling under our observation their  proper
situation in either the Typhus or Typhoid groups, does not, it may be asked,
this fact militate against the doctrine that  Continued Fever is resolvable into
these two forms ?  I propose  to  analyze the cases  of doubtful type, in this
collection, with reference  to these inquiries.  Let  us see what are the facts
pertaining to the distinctive diagnosis in the  cases severally.   Confining  the
examination to the points which distinguish the two types from  each other,
it will not occupy much space to present a summary of  the history of each
case.  This I will proceed to do, appending to  each case a few remarks, and
afterward  offering some general conclusions.
   Case I.   Thomas  Daily,  aged 11 years, Irish,  recently arrived in this
country.  Entered hospital in the month of November.   The  attack was
abrupt,  having no period of access.
   There were no manifestations of delirium.
   The  bowels were at first constipated, no dejection occurring for three suc-
cessive days; afterward the bowels were loose, but diarrhoea was not a prom-
inent symptom.
   There was moderate meteorism, and considerable abdominal tenderness.
   No eruption.
   No epistaxis.
   The maximum of the frequency of the pulse was  144;  the mean frequency
a fraction over 115. 
REPORT  ON CONTINUED FEVER.
353
  Capillary congestion was  moderate.   The duration of the febrile  career
was about twelve days.
  Remarks.  From the foregoing assemblage of symptoms the type  of the
disease is presumed to have been Typhoid.   This  opinion is mainly predi-
cated on the abdominal symptoms, which, although not present from the first,
nor prominent at any time, were yet sufficiently marked.  The abruptness
of attack is unusual, but with respect to this, as well as other points, it is not
improbable that a collection of cases of the disease occurring in young sub-
jects would show some variation from the laws obtaining in cases of adults.
   Case II. — Mary Daily, sister of No. 1, aged  about eight years.   Admit-
ted in November.  Attack abrupt, took at once to  the bed.  No manifesta-
tions of delirium.   Deafness was marked.
   Mild diarrhoea from the first, or, rather, looseness of the bowels.
   Meteorism and tenderness are not mentioned.
   Maximum of frequency of pulse, 152; mean frequency, 107.
   Moderate capillary congestion during the early part of the career.
   Epistaxis occurred on the third day.
   Duration, fourteen days.
   Remarks.  There can  scarcely be  a question respecting the type in this
 case.  It was doubtless Typhoid.   The evidence is stronger than in case No.
 1, and this being so, the  fact of the relationship of the patients adds to the
 evidence in the first case.  The history is defective in  not  containing state-
 ments relative to tympanites and tenderness.   This was the reason, chiefly, of
 the case being excluded from the  Typhoid group.
   Case III.—Henry Nigelab, German, aged 40.  Admitted in December.
 Been in America two years, and in Buffalo five weeks.
   Attack was abrupt.
   Delirium occurred on the third day, consisting in  incoherent talking, and
 efforts to get out of bed.  Eyes suffused.  Bowels  constipated, two dejec-
 tions only occurring  in the space of eight days.  No abdominal tenderness,
 nor tympanites.
   An indistinct eruption noted on one day.
   Maximum of pulse, 128; mean frequency,  107.
   Moderate capillary congestion.  Epistaxis (moderate) on the fourth day.
   Duration, eight days.
   Remarks.   The type of the  disease was  unquestionably Typhus.   Ine
 absence of abdominal tenderness and meteorism, the constipation, the sudden
 attack, the age of the patient, the early delirium,  the mean frequency of the
 pulse, constitute conclusive proof of the correctness of this opinion; and had
             23 
354
REPORT ON CONTINUED FEVER.
the details  of the history been studied as fully at the preliminary examina-
tion, when  the distribution of the cases were made, as now, the case would
have been included in the Typhus group.
   Case IV.—Aaron Young, English, aged  23.   Admitted January.  Been
in this country but five days, and stated  that there was fever on board the
vessel in which he came over.  He entered January llth, with cough, debil-
ity, and febrile movement.   He  kept the bed several  days, when  he began
to sit up, and was supposed  to be convalescing from an attack of ephemeral
fever.  The chest was not explored at  that time, but subsequently  the exist-
ence of tuberculosis was  determined.   He  was  probably laboring under
incipient phthisis when he entered.
   On the 16th of February, (thirty-six days after date of admission) he was
attacked with symptoms of fever.
   He took  to the bed after an access of two clays duration.
   Delirium was manifested on the third  day, consisting of incoherency and
efforts to get out of bed.
   The bowels were rather loose, i. e. on some days two dejections occurred
during the  twenty-four hours.
   There was moderate tympanites, but no abdominal tenderness.
   On the second day after taking to the  bed a copious eruption  appeared,
consisting of maculae, dusky, not  disappearing on pressure, intermingled with
which were rose spots.
   Capillary congestion moderate.
   Maximum  of pulse, 108;  mean frequency, 95.
   Slight epistaxis  on the fourth  day.
   Duration, thirteen days.
   Remarks.   The looseness of bowels, together with  the mixed eruption led
to the rejection of this case, but that it was a case of  Typhus hardly admits
of doubt.   This is shown by the abrupt attack, the  short duration, the ab-
sence of abdominal tenderness, the early manifestations of delirium, the early
appearance of the eruption, its copiousness, extending  to extremities as well
as over the body, and the probability of the disease having been contracted
by contagion in the hospital ward.
   Case V. — John Jany, Irish, aged 22.   Admitted in February.
   Been in  this country ten days.
   Duration of access not determined.
   No manifestations of delirium.
   One dejection daily during the career of the disease, save that on one day
there were  two. 
                     REPORT ON  CONTINUED  FEVER.                 355

  No tympanites, nor abdominal tenderness.
  On the fourth day there was no  eruption.  On the fifth, sixth, and seventh
days the daily record of symptoms was not made.   On the ninth day there
were three rose spots which remained for several days.
  The maximum of pulse was 90; mean frequency, a fraction over 75.
  Moderate capillary congestion.
  Duration of febrile career, fourteen days.
  Remarks.  The interruption  in the daily records, and consequent imper-
 fection of the history, was the chief reason for  excluding this case.  It was a
 case of Typhoid without doubt,  of a very mild grade.
  Case VI. — John Welch, aged 25, admitted in March.
  Been in this country five years.
  Entered on the sixth day after taking to the bed.
   Access of eight days duration.
  Slight manifestations of delirium, consisting only in incoherency at night
  Mild diarrhoea during the whole of the febrile career.
  Moderate meteorism and slight  abdominal tenderness.
   Presented at the time of his admission an eruption which is described as
 dusky, not elevated, and  the redness  not disappearing on  pressure.  The
 same characters are recorded the following day.  On the next day it is simply
 noted that the eruption remains.   On the next  day several rose  spots were
 observed, disappearing on pressure.
  Maximum of pulse, 120; mean frequency, a fraction over 104.
  Moderate capillary congestion.
   Epistaxis occurred early in the  disease.
   Duration, eighteen days.
   Remarks.  The variation in  the characters of the eruption in this  case
 renders  the diagnosis doubtful.  The  patient, it will be perceived, did not
 enter until the sixth day, so that the time of the development of the erup-
 tion, and the character which it  at first exhibited are not ascertained.  Aside
 from the eruption, the symptoms  clearly point to Typhoid.   The long dura-
 tion of  the access, and the  duration of the  febrile career;  the abdominal
 symptoms, absence of delirium, and the occurrence of  epistaxis,  would ren-
 der the discrimination sufficiently  easy, were it not for the mixed characters
 of the eruption.
   This, it will be observed, is the first of the cases of Doubtful type in which
 the facts pertaining to the history really occasion much hesitation as to the
 diagnosis.
    Case VII. — Charles Madden, Irish, aged 27, admitted in March.  He 
356
REPORT ON  CONTINUED  FEVER.
 entered hospital  three weeks before  being attacked with  fever, with  some
 trifling ailment which was not closely investigated.   He was  able  to be up
 and about until attacked with fever.
   It is not stated whether he had recently arrived in this country.
   Access of four days duration.
   Slight manifestations of delirium on the second night after  taking to bed.
   Diarrhoea, the dejections being frequent, occurred on the second and third
 days,  but did not  afterward continue.  Previously there  was constipation.
 No meteorism, nor abdominal tenderness.
   An eruption appeared  on  the second day consisting of three or four rose
 spots.  The next day there was a copious eruption, dusky, not' disappearing
 on pressure, and, intermingled, a few rose spots.
   Maximum of pulse, 114; mean frequency, 96.
   Moderate capillary congestion.
   Duration of disease, thirteen days.
   Remarks.  The  rose spots, and the diarrhoea, give rise  to some doubt as
 to the diagnosis  in this case.   Aside from these, the evidence of Typhus
 predominates.  The absence  of tympanites and tenderness over the abdo-
 men ;  the early development of delirium; the  appearance of the  eruption
 early in the disease and  its  copiousness; the short duration  of the disease
 and the probability of its having been contracted in the hospital, are in favor
 of the Typhus type.
   Case VIII. — George  Gaylord, aged 25, English, admitted in January.
   Been in America ten months, and in Buffalo eight.
   A brother of this patient  entered December  12th, with Typhus, and  his
 case is included in the Typhus group.
   Admitted on the fifth day  after taking to the  bed.
   Duration of access, three days.
   Slight incoherency from the time of admission.
   Bowels constipated until the eighteenth day, when they were slightly loose.
   Slight tympanites noted on one day only.
   No abdominal tenderness.
   Eruption abundant, presenting mixed  characters.  It is thus described:
 " Eruption copious  over the body and extremities, mostly consisting of mac-
 ulae, not disappearing on firm pressure, rather dusky.  Intermingled with
 these a sparse eruption of rose spots, larger in  size, elevated, and the redness
 readily disappearing on pressure."
   The eruption was present when admitted, and had been already observed
for two days, making its first  appearance as early as the third day. 
REPORT ON  CONTINUED  FEVER.
357
   Maximum of pulse, 124; mean frequency, a fraction over 111.
   Moderate capillary congestion.
   Slight epistaxis on the fourth day.
   Duration of the disease twenty-three days.
   Convalescence was retarded by pneumonitis.
   Remarks.  There is but little room for doubt  in this case as  to the type.
What doubt exists is occasioned  by the  mixed characters  of the eruption.
Admitting that the eruption does present  occasionally characters  more or less
mixed, without necessarily compromising  the claims of such cases to be con-
sidered either  Typhus  or  Typhoid,  I should have  been warranted, as it
appears to me, in including this  case in the former group.   The early devel-
opment of the eruption, its copiousness and  extent; the short  duration of
the access;  the mean frequency of the  pulse, and  the fact that a brother,
shortly before, with whom  he  had been associated, was admitted  with clearly
marked Typhus,  render  the diagnosis almost, if not quite positive.

   It is sufficiently apparent from  the circumstances relating  to the histories
of these cases, that the type of the disease, generally, was not very doubtful.
In fact there were but two cases (Nos. 6 and 7,) in which much uncertainty
could be considered to rest upon  the  diagnosis.  That these few cases were
included in the class of Doubtful type, does not, therefore, show that difficulty
in practically discriminating between the two types, which the reader, without
these details, might naturally have been led to infer.  Their exclusion from the
Typhus and Typhoid groups, was owing  to the care not to include in either
group a single case in which  the  type was in  the least degree  doubtful, it
being deemed far better to be over cautious  in this respect, than to run any
risk  of error.  So far as  my observations  go, the principles of  diagnosis
briefly presented  in the Supplement to the Second Report, admit of a ready
and positive application in all  but a very small proportion of instances.  The
fact must be considered  to have considerable significance in connection with
the question as to the identity of Typhus, and Typhoid fever.  At the same
time, the fact is not to be overlooked that we do find, in a certain proportion
of cases, a combination,  to a greater or less extent, of  the symptoms distinct-
ive of either type.  The latter fact applies to the eruption, as well as other
events belonging to the  natural  history of the two forms of fever.   In view
of this fact, it'may seem, in the minds of some, to be a rational conclusion
that the two forms of Continued Fever are not so distinct but that they may
be blended, developing  a kind of  hybrid  disease, which cannot  properly be
considered to be either  Typhus or Typhoid.  This  certainly opens a very 
358
REPORT ON  CONTINUED FEVER.
interesting point of inquiry.  It cannot, however, be  prosecuted, with any
expectation of coming to a satisfactory conclusion, by means of speculative
reasoning, and my observations relative to the subject do not afford  data
adequate to any logical deductions.

   Note.  It is proper to state that the histories of the cases upon which the
foregoing Report is based, were, for the most part, not recorded by my own
hand, but by Mr. J. Lewis Smith, resident medical student at the hospital,
for whose faithful  services  I desire  to express my obligations.   The records
were made under my daily direction and supervision. 
    MORBID APPEARANCES AFTER DEATH,

                     (exclusive of intestinal lesions,)

DISTINCTIVE OF THE TYPHOID AND TYPHUS  TYPES OF
                     CONTINUED  FEVER.
  The investigations upon which were based  my clinical Reports on Con-
tinued Fever relate  chiefly to events belonging to the living history of the
disease, that is to say, to the symptoms and circumstances developed during
the continuance of life.  In the fatal cases, inquiries concerning  the morbid
effects impressed upon the organism, were generally prosecuted  but  to a
limited extent, attention frequently being  directed only to  the  presence or
absence of the intestinal lesions regarded  as characteristic  of the Typhoid
type.   It is  needless to say that the appearances after death form an impor-
tant  portion of the  natural history of any disease;  and with reference to
these, as well as  the phenomena manifested during  life, it  is important to
examine all  the organs of the body, noting the absence, as well  as presence
of morbid  changes.   The post mortem history, like that pertaining to the
phenomena of life, is to be based on analyses of recorded  observations, suf-
ficient in  number, and made at different periods and places.  Studied in this
way, the  morbid anatomy of Continued Fever offers a field for inquiry, as
yet by no means exhausted.  The researches of Louis embrace an account
of the appearances in a pretty large number of cases  of Typhoid fever; and
within the past few  years, facts have been contributed by various observers
relative to the changes distinguishing  this  from the Typhus type.   A point
of absorbing interest, however, has been the presence of intestinal lesions in
Typhoid, and their absence, or relative insignificance  in Typhus.  Attention 
360
MORBID appearances  after death.
appears to have been in a great degree engrossed by these lesions, to the
exclusion of a more extended  comparison of the two types embracing the
appearances found in other organs.
  Dr. William Jenner, Prof, of pathological anatomy in University College,
London, has  lately contributed some  observations on this subject which are
highly interesting  and valuable.  They are  contained in a series of articles
communicated for the Monthly Journal of Medical Science, thus entitled: —
" On Typhoid and Typhus fevers — an attempt to determine the question of
their identity or non-identity, by an analysis of  the  symptoms,  and  of the
appearances found after death in sixty-six fatal  cases of Continued  Fever,
observed at the London fever hospital from Jan., 1847, to Feb., 1849."  It will
be perceived by the foregoing title that the articles  embrace an analysis of
the symptoms, as well as post  mortem appearances.  The course pursued by
Dr. J. was to select only fatal cases, and to determine the type by the presence
or absence of  the intestinal  typhoid lesions.  Having in this way arranged
them  into  two groups, he then  proceeded to analyze the symptoms  and
appearances after death in both groups, and  compare the results.  The arti-
cles by Dr. Jenner have  fallen under my notice  since my third  Report was
written.  The data for comparison  of the morbid appearances  in the  two
types (typhus and typhoid) are fuller and more complete than, so far as  I
know,  have been contributed by any other observer; and  in order to supply
a manifest deficiency in the analyses which I have  made, I  shall take the
liberty of  appropriating, for the benefit of those  who have honored my Re-
ports with  a perusal, a summary of the results  of his investigations.  The
synopsis which follows is copied from the Journal  already mentioned, and is
given  as it is there presented by  the author.   The intestinal lesions are
excluded.   The propriety of this is apparent when it is considered that  upon
the presence or absence of these lesions the post mortem diagnosis was based.
Moreover, as  respects  these lesions, the fatal cases  in my collections  were
studied with  considerable care.

Synopsis of morbid appearances distinctive  of Typhus and Typhoid fever,
                 based on an analysis of sixty-six cases.

   " Cadaveric rigidity,  ceased much more  quickly in subjects dead  from
typhus than from typhoid fever."
   " Discoloration of the walls of the abdomen and of the skin covering the
larger veins, was much more frequently present  in those dead from  typhus
than typhoid fever." 
MORBID APPEARANCES AFTER  DEATH.
361
  Emaciation had made greater progress in the typhoid than in the typhus
subjects."
  " 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."
  " 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
only of the fifteen cases; the cerebral 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  point
were made.  The vessels of the pia  mater were congested in nearly  half, 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 sesosity found within the cranial
cavity was decidedly  greater after typhus than typhoid fever."
   " Pharynx.   After typhoid fever, this organ was found ulcerated in one-
third of  the cases.  After typhus fever, ulceration of the pharynx was  not
detected in a single case."
   " Larynx.   Ulceration of the larynx was found in one of fifteen subjects
dead from typhoid fever; in one of  twenty-six from typhus fever."
   "(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."
   "Stomach.   In none of the fifteen cases examined after death from typhoid
fever was the mucous  membrane of the stomach softened throughout  the
whole extent; in no case did softening  of the  cardial 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 cut de sac, that they
were perforated by the slightest violence.
   "Small Intestines  and Mesenteric Glands.   The  presence or absence of
lesion of these  organs was the  ground on which the cases of typhoid and 
362
MORBID APPEARANCES AFTER  DEATH.
typhus  fever here analyzed were  divided  from  each other,—consequently
they were invariably diseased in the one, and sound in the other."
  "Large Intestines.   After  death from typhoid fever, the mucous mem-
brane 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 de-
pendent on the entero-mesenteric disease, it may here be excluded from con-
sideration."
  "Spleen.   This organ was enlarged in  all  the cases of  typhoid fever—
softened in  one-third  of the cases only.   Before the age  of 50, it was as
large after typhus as typhoid fever;  after that age, it was decidedly smaller
in the former than in the latter aftection.  After the age of 50, it was as soft
in typhus as in typhoid fever;  before that age it was frequently softened."
  "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."
  "Liver, Pacreas, 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."
  "Pericardium.  This cavity  contained a small amount of yellowish trans-
parent serosity in all the  cases of typhoid fever examined.  The contained
serosity was  red, from transudation of a solution of hsematosin,  in  five of
thirty-one  cases  of typhus fever,  in which the  pericardium was  examined
before the termination of the fever*
   "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."
   "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 congestion of the
most depending part of the lung."
   liPleura.  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 not  much less  in amount were found
* There is evidently a mistake in the last sentence. 
MORBID APPEARANCES AFTER  DEATH.
363
in two only of thirty-six cases of typhus fever—i. e. one-sixteenth, or in the
proportion of  55 per cent."
   The foregoing is copied from the Monthly Journal of Medical Science for
April, 1850.
   Dr. J. adds, after the foregoing parallel of pathological appearances, as fol-
lows : " The particulars here briefly recapitulated, and still more those fully
detailed in the foregoing papers, appear to me to prove indisputably that the
symptoms, course,  duration, anatomico-pathological lesions, and the tendency
to cadaveric changes, are different in typhoid fever from what they are in
typhus fever." 
RELAPSING   FEVER.
  In the distribution  of cases for analytical investigation hitherto, I have
practically assumed  that they were either of the Typhus or Typhoid type.
Are all the varieties or species  of  Continued Fever embraced in these two
forms of the disease ?  This is an interesting and  important  question which
perhaps cannot, in the present state of knowledge, be answered positively.
  The  distinctive nosological features  of  Typhus and Typhoid fever have
been but recently established, and it would not be surprising if further inves-
tigation should lead to other subdivisions of continued fever, showing that
we have been accustomed to include in one or both of these forms, affections
which should be considered distinct.
  The  opinion has been advanced by some British writers that already there
are sufficient grounds for such a subdivision.   A form of fever observed at
different  epochs in Edinburg and London  is  described as possessing, in
common, characters differing  from those of Typhus and  Typhoid fever
sufficiently to constitute it a distinct affection, which has been named, Relaps-
ing fever.   The following extract from  an able article  in the British and
Foreign Medico- Chirurgical Review,  No. for July, 1851, furnishes a brief
historical notice of the occurrence at different times and  places of the kind
of fever which has received this title:
  * " In the early part of 1843, a febrile disease appeared in  Edinburgh and
Leith, so different in its course, in its  symptoms, and  in the amount of  its
mortality, from any Continued Fever which had been recently observed there,
that  it  was at once and unhesitatingly declared to be a peculiar and new  dis-
ease.   It was soon known that the same disease  had appeared in Glasgow a

  * We omit the various authorities to which the writer refers.  For these the reader
may consult the Review. 
RELAPSING  FEVER.
365
month or two prior to its outbreak in Edinburgh; it was more or less preva-
lent also in Dundee and in other large towns in Scotland, whether it appeared
in London or in other English towns is doubtful; at any rate it was not de-
scribed.  It was observed with great accuracy, and recorded in the periodi-
cals of the time, by Craigie, Alison, Arnott, Henderson, Halliday, Douglas,
Jackson, and Mackenzie; and it was made the subject of two special and ex-
cellent treatises by Cormack and Wardell.
   " Ii was soon discovered, however, that although this fever had not been
seen in Edinburgh for  many years, it was not altogether a new disease.   Dr.
Christison expressed an opinion that it was similar to  the fever  witnessed by
him in 1817 - 18, and recorded  by Welsh, in his well-known work, and by
himself in the ' Library of Practical Medicine.'  That this opinion is correct,
 and that the Edinburgh epidemic of 1817 -18, was in great measure made
 up of this disease, no one can doubt, who will attentively collate the descrip-
 tions of Welsh and Christison, with those furnished by the observers of the
 attack in 1843.  But not  only in Edinburgh was  evidence  of its former
 existence  brought forward.  It  was observed that it had  evidently formed
 part of the Irish  fever of 1817-18-19, which had  been so minutely
 recorded by Barker and Cheyne.  It  appeared also that this fever had been
 prevalent in Ireland for many years.   Epidemics in 1739  and  1741 were
 described in unequivocal  terms  by Rutty; and other epidemics  during the
 eighteenth century, and those in Dublin in 1806 and  1826, presented, among
 other forms of fever, the peculiar and unmistakable  features of the disease
 in question.
    "The fever thus distinguished  and elaborately described by the Scotch
  observers in 1843, became again epidemic in Glasgow, Edinburgh, and other
  towns in  Scotland,  in  1847.   It did not by any means prevail so extensively,
  and  there was a simultaneous  occurrence of other species of fever; among
  which, however,  the eyes of Steele, Paterson, Orr, and others, trained by the
  epidemic of 1843, had no difficulty in singling out this peculiar form.   In
  1847 it was also epidemic in  London; and having come under the observa-
  tion  of Dr. Jenner, has  been very  carefully described.  Before this time, in
  1846, and  in previous years, sporadic cases had been witnessed in the me-
  tropolis; and since 1817 a case has  every now and  then presented itself at
  the London Fever Hospital, and at other institutions.
    «Instructed by the  experience of these observers, it is also easy to perceive
  that this disease is not confined  to these islands.   It appears, although imper-
  fectly described  and confounded with other forms, in the  pages of the cele-
  brated treatise of Hildenbrand;  and  in  the  epidemic, in 1847, in  Upper 
366
RELAPSING FEVER.
Silesia, which we intend  presently to describe, it evidently formed in some
places the great  bulk of the cases.   Yet it must be said, that although its
characters are so striking that the most superficial observer could not over-
look them, the German systematic writers have made no allusion  to it  as a
separate disease; and even those who  observed  it have failed to draw  that
obvious inference to which the Scotch physicians unanimously came, viz., that
it is a disease altogether distinct from ordinary Continued Fever.
  " We are not aware that any perfectly satisfactory evidence is to be found
in French writers of the existence of this fever in France; it has, in fact,  con-
sidering the elaborate  descriptions of the Scotch physicians, been somewhat
singularly overlooked in that country, as in Germany.   In America it is not,
I believe, known, or at  any rate it has not been  described.   There is reason
from Dr. Bell to believe, that it is known in Persia."
   The subject of Relapsing fever has, as  yet, received little or no attention
in this  country.  At the time of writing my second report, I confess I was
only aware of the fact that this name had been employed to designate a form
of  continued fever.  I  was not  acquainted with the distinctive  characters
attributed to it
   In reference to that  Report the reader will perceive that  among the forty-
eight cases analyzed, were several (fifteen) which were characterized by the
occurrence of a relapse  of fever, after convalescence appeared to be distinctly
declared.*   The occurrence of this second febrile career in  so large a propor-
tion of that collection of cases, was the more surprising from the fact that
nothing of the kind had been observed in the cases previously analyzed, and
I can now add that the same is true, as a general remark,  of the cases upon
the analysis of which my Third Clinical Report is based.   The article in the
British and Foreign Medico-Chirurgical Review, from which  the above ex-
tract was taken, appeared about the time I had completed my second report.
After reading that article the inquiry naturally arose whether the  cases of
fever characterized by the occurrence of  relapses in the collection I had  just
analyzed, might not be cases of Relapsing fever.  With  reference  to this
inquiry I now propose, as I  then promised, to  subject them to  a  separate
analysis, with a view to ascertain if, in other points than  the occurrence of
relapses, they differ from Typhoid and  Typhus fever, and, if, at the  same
 time, they exhibit  traits which are said to distinguish Relapsing fever.   Be-
 fore entering on this analysis, however, inasmuch as it will probably not be
an act of injustice  to our readers to presume that many, if  not most  of  them
"See page 224 et seq. 
RELAPSING FEVER.
367
are but little acquainted with the subject, I will premise some account of the
diagnostic  points which  are said to distinguish this  form of fever.  In so
doing I shall avail myself, without giving more particular credit, of the article
in the British and Foreign Medico-Chirurgical Review already referred to,
and a paper by Dr. William Jenner, on the " identity or non-identity of the
specific cause of Typhoid, Typhus and Relapsing fever," contained in the
Medico-Chirurgical Transactions, published by the Royal Medical and Chi-
rurgical Society of London."   [Second series vol. 15, 1850.]
   Evidences of a form of fever supposed to be identical with Relapsing fever,
have heretofore received different names, such as the " short fever;" the "five
day fever;" the " seven day fever;"  " bilious  remittent fever;"  " remittent
icteric fever;" " mild yellow fever," etc.
   The disease is stated to affect  all ages, and both sexes  in  about an equal
ratio.
   The access  does not present any very distinctive features.  The  attack is
 oftener abrupt than in Typhoid  fever, and the  muscular and articular pains
 are apt to  be severe.
    Delirium, and other head symptoms are represented to be oftener absent,
 and, when present, less in degree than in the other forms of continued fever.
   The absence of the abdominal  symptoms which are so generally present, in a
 greater or less degree, in Typhoid fever, is an important point distinguishing
 Relapsing fever.  Diarrhoea, with notable meteorism, and tenderness in the
 iliac regions, do not belong to the latter.   It is, however,  characterized by
 certain symptoms pertaining to  the digestive system rarely found in  Typhoid,
 viz: nausea  and vomiting, which are frequently prominent symptoms, and
 tenderness over the epigastrium. The matter vomited is stated to be " bright
 grass green," and  sometimes like coffee grounds, approximating to  the black
 vomit of yellow fever.
    The eruptions characteristic of Typhus and Typhoid, are not found in Re-
 lapsing fever.   Sudamina  and occasionally petechias have been  observed.
 An eruption consisting of " small spots, round, purple, unaltered by pressure"
  has been described  by some observers as  an element of the affection. These
  spots are stated to be extremely like flea  bites, and  it does  not appear to be
  fully ascertained that they were not, in fact, flea bites.  The chest symptoms,
  i. e. cough and bronchial rales, so generally present in  Typhoid fever, are said
  to be  lei commonly present in this disease.  Epistaxis, so frequently ob-
  served in Typhoid fever, sometimes occurs.   The pulse, seldom falling below
  100, in more than  half the cases  is 120, and in a considerable number the
  frequency is still greater. 
368
RELAPSING FEVER.
   Profuse sweating is stated to occur pretty uniformly, preceding the apparent
 convalescence, and  also when the relapse of fever is about to terminate.   An-
 other distinguishing feature referable to the skin, is more or less yellowness,
 occurring on the fourth or fifth day.   In severe  cases the jaundice is often a
 prominent symptom.  The most distinctive event, however, is that indicated
 by the title of the disease, to wit: the occurrence of relapses.   The first febrile
 career continues for a period rarely less than four, nor more than ten days, and
 then ends, generally after profuse sweating, which is considered to be critical,
 leaving the patient free from febrile movement, and apparently convalescent.
 After an interval varying in duration from five to eight days, another attack
 occurs, generally abruptly, and frequently preceded by a chill.   The recurring
 febrile movement is equally or more severe than the first.  It continues from
 four to five days, and  then terminates usually after profuse sweating.   Usu-
 ally after a single  relapse, the patient becomes permanently convalescent.
 A second, third,  and even a greater number of  relapses, however, have been
 observed to occur.
   The  disease  is seldom  fatal.  Patients almost uniformly recover,  unless
 some complication takes place, such as pleurisy,  pneumonitis or dysentery.
   The  most distinctive characters derived from  autopsical examinations, are
 the absence of the intestinal lesions belonging to Typhoid fever. The peyerian
 glands are unaffected.   The spleen is generally enlarged and softened.
  It may be communicated  by contagion, and Dr. Jenner, in  the  article
 already referred to, has collected observations tending to show that Relapsing
 fever cannot be  derived  from patients  laboring under the  other forms of
 Continued Fever, but that it alone produces the special miasm for its propaga-
 tion.   How far the facts  contributed by him  go to  establish this important
 point, it does not fall within my present purpose to inquire.
  This form of fever does not secure immunity from the  other forms; nor
 from subsequent attacks of the same form.
  These are, briefly, the more prominent of the traits distinctive, of Relapsing
 fever which  are  mentioned by the  two writers to whom I am indebted for
 the foregoing summary.   They appear to have been deduced from an exam-
 ination of reports of epidemics, supposed to be of this  character, by various
 authors.   If they are  sufficient to render probable the position  that the
 disease  to which they relate  is a peculiar form  of  fever, distinct from the
 Typhus and Typhoid forms, it is certainly desirable that collections of cases
should be subjected to careful numerical analyses.   The question can only
be definitively settled by the results of such analyses.
  So far as I know, we have no account of a form of fever prevailing in this 
RELAPSING FEVER.
369
country, analogous to the relapsing fever as just described.  Were the cases
characterized by relapse, among those observed by me during the winter of
1850-51, cases of Relapsing fever?   With a view to arrive  at the answer
to this question, and, if the  conclusion  be  in  the  affirmative, to furnish a
small contribution toward the natural history of that form of fever, I will now
proceed to analyze the cases referred to.

Analysis of Fifteen Cases of  Continued Fever, characterized by Relapses.
   In my Second Clinical Report I have stated that fifteen of the forty-eight
 cases upon the analysis of which that Report was based, were characterized
 by the occurrence of relapses.  Of  these fifteen cases nine were included
 among those of Typhoid fever; one was considered a case of Typhus, and five
 were among the cases  of Doubtful  type.   Upon a fresh examination of the
 cases I find that one case in the Typhoid group was rejected from the list in
 consequence of the first convalescence occurring about the  time the patient
 was admitted into the hospital.  I am satisfied that this case may be included
 in the category.  The  single case of Typhus characterized by a  relapse, was
 undoubtedly a  case of that  type, the characteristic eruption  being well
 marked.  The apparent convalescence  in this case occurred on the  eleventh
 day, and  the  relapse of fever was of two days duration, after an interval of
 only  three days.   These  facts show that this could not have been a case of
  Relapsing fever, and I shall accordingly now exclude it.  The whole number
  of cases, therefore, will remain the same as stated in the Second Report, viz:
  fifteen; and  of these fifteen cases ten were distributed  among  those of
  Typhoid fever, and the remaining five among the cases of Doubtful type.
     Of the fifteen cases, eleven were males,  and four were females.
     The age of the youngest patient was nine years; of the  oldest, thirty-five
  years.   The average age was a fraction over twenty years.
     All the  patients were from Ireland.   Six had recently arrived in  this
  country—i. e. within the space of five weeks.   Six had lived in this country
  several months—i. e.  between six and sixteen months.  One had resided in
  this country four, and one five  years.  In one case the period of residence
  is not stated.
     Two of the cases were admitted in  the month of October; four  during
  the  month of November; eight in December; one in January, and none in
  February and March, my term of service  ending with the latter month.
     Access.  The duration of the access was not ascertained in seven cases.
  Of the remaining eight cases, the attack was sudden  in four; there was an
               24 
G FEVER.
access of a single day in one case, and of two days in two cases.  The dura-
tion of the access here, as heretofore, is measured by the period elapsing from
the commencement of illness, to the time of taking to bed.
   Of thirteen  cases in  the histories of which the presence or absence of a
chill, or of chills  is noted, the access was  ushered  in  by one or more in
twelve.   The chill was followed by perspiration in seven, and  was not thus
followed in three cases.
   Pain in the head, back and limbs was complained  of during the access, or
at the onset of the disease in nine cases; in the head alone  in three cases; in
the head and limbs in one case, and in the back only in one case.
   Of thirteen cases in which the presence or absence of vomiting during the
access, or at the commencement, was  noted, it  existed in eight, and was
absent in five.
   Diarrhoea is not noted  to  have been present during  the access, or at the
commencement, in a single instance.
   Three of the patients stated that they had previously had  an attack of
Continued Fever.
   Two of the patients were sons of the patient affected  with Typhus fever,
in which an imperfect relapse occurred, this case being that already referred
to which was  included among the  cases characterized by  relapse in the
Second  Report.
   General Aspect.  Passive capillary congestion  of the face was noted in
all cases but one, and in the excepted instance the congestion was active, in
other words the face was flushed.   The passive congestion was  considerable
 in three cases, moderate in  eight cases, and slight in three cases.
   The eyes were more or less injected  in five cases;  in one case there was
no injection; and with respect to the  remaining cases nothing is stated rela-
tive  to this point.
  'Yellowness of the conjunctiva existed in two cases.  These were the only two
cases in which this symptom was noted out of the forty-eight cases composing
the  collection upon the analysis of  which the Second  Report was based.
   Nervous System.  Of fourteen cases there  were  no manifestations of delir-
ium in five, and more or less delirium existed in nine.   The manifestations of
delirium consisted in incoherency only, in one ease.  In the remaining eight
cases there were efforts to get out of bed.   In several instances, however, the
delirium was of very brief  duration.  In three cases it was manifested only
on a sino-le night.   In not a single case was  this  sympton at all prominent.
   Deafness is noted but in  two cases.
   Digestive System.   In ten cases there was nothing like diarrhoea.  Of the 
RELAPSING FEVER.
371
remaining five cases the evidences of diarrhoea consisted in one case of too
frequent dejections for the  first  three days, the patient having taken a dose
of salts  the night before  entering the  hospital; in one case the dejections
were too frequent on the fifth, sixth and seventh days; in two cases this was
the fact  on a single  day only.   In but one case was diarrhoea a symptom of
any prominence.   These results are  remarkable when it is considered that
ten of the  cases were embraced in the  Typhoid, and  none in  the Typhus
group.   More or less meteorism existed in nine, and  this symptom was absent
in six cases.   The meteorism was moderate in four, and slight in four cases.
In one case only  was it considerable.
   More or less  abdominal  tenderness  was present in all but three cases.
There was tenderness in the right iliac region in ten cases.   In all of  these
ten cases the degree of tenderness  was slight, and in several instances it was
present only for a short period, in some but  for a  single day.   Tenderness
over  the epigastrium  existed  in six cases.   By reference to  the  Second
Clinical Report it will be seen that of the forty-eight cases upon the analysis
of which that Report was  based, epigastric tenderness was  noted in six in-
stances.  Thus all the cases in which it was present in that collection were
characterized by  relapses!   The tenderness was universal over the abdomen
in one case.
   Vomiting is noted to have occurred  in but three cases ; this is exclusive
of the access or commencement of  the disease, to  which reference, as to this
symptom, has been already made.
   Eruption.   Each of the fifteen  cases  was unattended by  an eruption.
This result is certainly remarkable.   Recollecting that ten of the cases were
included in  the   cases of Typhoid  fever  upon  the  analysis of which my
Second Clinical Report was  based,  it is  interesting  to refer to the facts con-
tained in the section of that Report devoted to eruptions.   It is there stated
as follows: " The characteristic eruption was present in twelve of the twenty-
nine  Typhoid cases.   This  result  differs  from that  obtained  by  the first
analysis.   The latter developed a  larger proportion of cases in  which this
symptom was present,  viz.:  in  twenty-three, of thirty  cases; the ratio, thus,
beino- two-thirds, while in the present collection it  is less than  one-half.  I
can offer no explanation of the above disparity."
   If  we were to deduct from  the twenty-nine Typhoid cases in the second
collection, the ten cases characterized by relapses,  in which there  was no
eruption, the ratio of the cases  in which the eruption was present would be
nearly the same as in the  first collection — the disparity with respect to this
symptom would  disappear;  or, in  another point  of view, of the seventeen 
372
RELAPSING FEVER.
 cases in the second collection in which no eruption existed, ten may be sus-
 pected  to have been cases of Relapsing fever.   The disparity in comparing
 the  second  with the third analysis, as respects the eruption, will be found to
 be even more striking.
    Respiratory Apparatus.   Epistaxis was  noted  in six cases.   Pneumon-
 itis existed  in three cases.  In  two cases, spasmodic  inspiration occurred
 Aside from  these facts, there was nothing worthy of note referable to the
 respiratory system.
    Circulation.   The average mean frequency of the  pulse was a fraction
 over 75.  The highest mean in any  case was 108;  the lowest, 69.
   As respects the average  mean frequency, it was considerably less in these
 cases than in the  Typhoid cases in either collection; and the disparity is still
 greater when compared with the cases of Typhus.
   Skin.   Sweating  occurred in  ten of twelve cases, the histories of which
 contain  information on this point.  The sweating was profuse in eight cases.
 It was noted but once in nine cases, and three times in  the remaining case.
   In each of the cases in which sweating occurred, it took place at a period
 more or less remote from the date of  the first or second convalescence.
   Moisture of the surface, i. e., a  degree of perspiration less than sweating,
 was noticed in twelve of fourteen cases.  It occurred on one day in six cases,
 twice in two cases, and on several days in four cases.
   Both sweating and moisture, thus, were  present  in a large proportion of
 cases; but, it  is  a point to be noticed, that  they did not occur as critical
 events.
   Duration.   The average duration  of the febrile career, from the time of
 takino- to the bed  to  the date of the first apparent convalescence,  was about
 nine days.  The longest period was twelve days, and the shortest six days.
   The average duration of the interval between the date of  the first appar-
 ent convalescence, and the recurrence of fever, was precisely five days.   The
 longest interval was eight days; the shortest three days.
   The average duration of the second febrile  career was six days.   In  one
 case,  it  is noted that the relapse  of fever lasted  only two  days.  Exclusive
of this case, the shortest period was four days, and the longest ten days.
   Mortality.   All the cases  terminated in recovery.
   Sequelae.   Nothing coming under this head worthy of note is contained
in the histories. 
RELAPSING FEVER.
373
                          Concluding Remarks.
   On reviewing the  results  developed by the foregoing analysis, and com-
paring them with  the distinctive traits of Relapsing fever, as presented in
the account preliminary to the analysis, the correspondence is certainly strik-
ing.  The access was abrupt in one-half the cases  in which this point was
ascertained, and unusually short in duration  in the remainder.   In 5-14 of
the cases, there were no  evidences  of delirium; and in all the cases, this,
together with other head symptoms, was slight.
   In 10-15 of  the  cases  there was entire absence of diarrhoea, and  in one
case only was this symptom  in any degree prominent or persistent.   Vomit-
ing was not a  prominent  feature, being present  at the access or commence-
ment in but 8-13, and afterward in  but three  instances.  Iliac tenderness
was very slight in every case,  and in six  cases tenderness over the epigas-
trium, which is extremely rare in  Typhoid and  Typhus fever, was marked.
Meteorism was considerable  in  but a  single instance, and  absent in  several
cases.   The abdominal symptoms, thus, were absent or slight in a remarka-
ble degree, unless the cases were of the Typhus  type, and it is to be  borne
in mind that none  of the cases were considered to be of that  type.  The
chest symptoms, and the circulation offer nothing worthy of particular note,
except that the frequency of the pulse was considerably less than is stated to
belonp- to the history of Relapsing fever.  Sweating and moisture occurred in
a very large proportion of the cases, in this respect presenting a  contrast
with the  average occurrence of  these symptoms in Typhus and  Typhoid
fever;  but differing from other observations  with respect  to Relapsing fever
in the fact that these symptoms did not occur at the time  of the temporary
or permanent  convalescence.  Mild jaundice, a very rare  event in  Typhus
or Typhoid fever, was present in two of the fifteen cases.  But the most
striking of all the  points of correspondence relate, first, to eruptions, and, sec-
ond, to  the relapses.   In none of the cases was there an eruption,  a fact
which  would certainly be very remarkable with respect to the same number
of cases of the Typhus or Typhoid type occurring successively.   The circum-
stances pertaining to the relapses, viz., the duration of the first febrile career,
of the interval, and of the second febrile attack, accord  with the previous
description of these events  as  they are stated to occur in Relapsing fever.
Finally, the absence  of a fatal tendency is exemplified by the  fact that all
the cases ended in recovery.
    In view of these facts  the conclusion seems unavoidable that  the cases of 
374
RELAPSING FEVER.
 fever characterized by relapses, among those which came under my observa-
 tion in 1850—51,  presented  the  distinctive traits attributed to Relapsing
fever sufficiently marked to entitle them to be ranked in the class of cases
 which have been described by different observers as a peculiar form of Con-
 tinued Fever.  This conclusion does not necessarily involve the position that
 the traits distinguishing the cases  authorize their separation  as  cases of an
 affection entirely distinct from Typhus or Typhoid fever.  It of course fol-
 lows either that this position is correct, or that the Typhoid or Typhus forms
 of Continued Fever occasionally exhibit, as peculiar modifications, the symp-
 toms which  are considered  the diagnostic features of Relapsing fever by
 those who regard  the  latter as a  separate form of the disease.   I  am not
 prepared to discuss the relative merits of these inferences. 
 TRANSPORTATION AND DOFUSION

           BT CONTAGION, OF

     TYPHOID  FEVER:  ■


EXEMPLIFIED IN ITS OCCURRENCE AT NORTH BOSTON,
           ERIE CO., N. Y. 
 
THE  TRANSPORTATION AND  DIFFUSION

                     BY CONTAGION, OF

           TYPHOID  FEVER.
  The contagiousness of Typhoid fever is not yet settled satisfactorily to all
minds.  While  few, if any,  at  the  present time, entertain doubts as to
Typhus being communicable  from one person to another, the opinion is still
held by some that this is not  true of the Typhoid type of Continued Fever.
The weight of authority is doubtless against the latter opinion, but so long
as it obtains with a respectable  minority, the subject remains open for discussion,
and the accumulation of evidence on either side continues to be a desidera-
tum.  Of seventeen essays recently submitted to the French academy of
medicine for a prize to be adjudged for the researches shedding most light
on the subject, in  thirteen  the affirmative of the question was maintained,
but four of the candidates contended in behalf of * the non-existence  of con-
tagion.  This is cited simply to show the want of unanimity in the medical
profession on this  point.   To refer to an  illustration nearer home, in an
American publication designed for the use of medical students, issued but a
few months ago, non-contagiousness is included among the traits distinguish-
ing Typhoid from Typhus fever.  Under these circumstances an apology is
not needed for inviting the attention of the medical reader to facts which  ap-
pear to bear with remarkable cogency on this mooted question.  In this remark
I have reference to the occurrence of a series of cases of Typhoid fever at a
place known as North Boston, county of Erie, N. Y., in the autumn of 1843,
a report of which was communicated by the writer for the American Journal
of the Medical Sciences, No. for July, 1845.   Having, since  that report was

         * British and Foreign Medico-Chirurgical Review, January, 1852. 
378
TRANSPORTATION  AND DIFFUSION
written, been, practically, more conversant with the Typhoid  and Typhus
forms of Continued Fever than previously, I am prepared to speak with still
greater confidence of the correctness of the diagnosis in the cases referred to.
Additional  facts, moreover, relating to the prevalence of the disease, have
come to my knowledge, which strengthen considerably the evidence of con-
tagion.   These  considerations have  made me desirous of reproducing an
account of the circumstances connected with these cases, rendering it more
complete, and, at the same time, divesting it of details which are unimportant
so far as concerns their bearing on the question of contagion;  and inasmuch
as the subject is one falling within the scope  of the  preceding observations
relating to Continued Fever, there seems to be no impropriety in devoting to
it a few pages of the present work.
   The proof of contagion in the propagation  of fever is obtained mainly in
two ways.   It is afforded, in the first place, by the production of the  disease
in public hospitals into which patients affected with fever are received, among
the other inmates, and those brought into contact with the disease by their
attendance on the  sick.   If under these circumstances a much larger number
of individuals contract the disease than would be  expected  from the degree
of its prevalence out of these institutions, and especially if this is found'to
occur not at a single time or place only, but at various periods, and in differ-
ent situations, we are bound  to acknowledge a principle of communicability"
In this way the contagiousness of Continued Fever has been already abund-
antly established.  The evidence of contagion, however, thus obtained, ap-
plies, for the most part, to Continued Fever as a whole, not to the particular
forms or types of the disease; for, usually, at public charities,  patients labor-
ing under Typhus and Typhoid fever, are received simultaneously. Moreover,
until lately, these two forms  or types have  not been  carefully discriminated
from each other;  and this remark holds true, to a considerable  extent, with
respect to the present time.  Without such a discrimination, it is evident that,
be the proof of contagion ever so strong, it may be contended that the con-
tagious miasm is developed by those affected with Typhus, exclusive of the
cases of Typhoid fever.
  Hospital observations that have related to cases of Typhoid, to the  exclu-
sion of Typhus fever, have frequently appeared to favor the  opinion that the
former is not propagated by contagion, for these observations do by no means
always furnish evidence of the communicability of the disease.  For example,
Dr. James Jackson, of Boston, after many years service as attending physician
at the Massachusetts  General Hospital, states that no facts have ever fallen
under his cognizance which appeared to involve the operation of contagion, 
OF TYPHOID FEVER.
379
and numerous  cases  of Typhoid fever were  admitted into  that institu-
tion every year*  A similar statement was formerly made by Louis; and an
abundance of negative testimony of this kind might be cited.  When, on the
other hand, it is considered how strikingly marked is the fact of contagion in
many instances in which cases of Typhus alone, or of the two types conjointly,
have been  congregated together, we can understand  how the conclusion may
seem to be based on experience that the Typhus form is alone communica-
ble ; and when occasionally instances occurred conflicting with this conclusion,
it might appear more rational to suspect inattention  or error of diagnosis,  on
the part of the observer, in the discrimination of Typhus from Typhoid, than
to attribute a contagious property to the latter.   Such a suspicion may always
be advanced to throw some doubt on the observations, made in  public institu-
tions, which are adduced to prove the contagiousness of Typhoid fever; and,
hence, it is difficult to settle the question beyond cavil by hospital experience.
   The second mode by which the proof of contagion may be developed, is
free from these difficulties, and furnishes evidence far more satisfactory and
conclusive.  This is the production of fever and its diffusion among different
members of a family or a community into which a  patient affected with the
disease had been transported.   In addition to other grounds of superiority
   hich this kind  of evidence has over that afforded by hospitals, we can with
greater certainty isolate the type of the fever which furnishes  the  miasm of
contagion.   We can  determine  positively whether  the transported  patient
was affected with Typhus, or Typhoid fever, and  that the individuals who
were subsequently affected had been brought into contact with  this case only-
The importance which belongs to these points must be at once apparent.
   Were it proposed to devise a series of experiments the most unobjection-
able and complete, in order to test the communicability of a particular form
of disease, no better plan could be adopted than to  introduce a case or cases
of the disease into districts where it was  not at the time prevailing,  and to
procure free exposure on the part of some of  those residing in the district.
 The experiment would be more satisfactory if  the  disease  thus introduced
 was not indigenous in that locality, and had never, or at least not for many
 years  before, been known to occur.   To render the experiment as perfect as
possible by divesting it of any moral influence, it should be made without the
knowledge of those  who were to be the  subjects.  In  other words,  the
* I have quoted this statement by Dr. J., from  memory, and have not the work in
hich it is given at hand to refer to.   From a reference to it in another work since the
,ove was in type, I suspect I have given the statement too unqualifiedly. 
380
TRANSPORTATION  AND DIFFUSION
character of the disease should be unknown, and the persons coming in con-
tact with it should be wholly unconscious of any exposure to contagion.  Now,
if under all these circumstances, a large proportion of those of the inhabitants
of the district who had been brought into contact with the disease, are attacked
■imultaneously, or in quick succession, and thus, a new and hitherto unknown
affection is suddenly developed, which spreads rapidly over a limited circuit,
affecting those only  who had been in habits of intercourse with the imported
case or with the persons who were subsequently attacked, others residing in
the  same  district, but not brought into contact with  the disease, uniformly
escaping—what would be  the logical deduction from the  facts ?  In the
absence of all evidence of epidemic  or endemic agencies, contagion offers the
only adequate explanation.  The laws of probabilities would not authorize the
supposition that the events depended on mere coincidence.  Stronger proof of
communicability certainly could not be  obtained  by  any other process of
investigation.  To undertake such an experiment would neither be practicable
nor justifiable.  The same combination of circumstances, however, not involv-
ing  premeditation or design, will be found in the history which I shall pro-
ceed to give of the development and diffusion of Typhoid fever at North
Boston in  1843.
  The place called  North Boston is situated  about  eighteen miles from this
city, and twelve miles from the lake shore, at a considerable elevation above
the  level  of the lake.  The situation, at the time mentioned, was  in every
respect salubrious.   There were no paludal  grounds  in the neighborhood.
Neither Intermittent fever,  nor any disease had prevailed for several  years.
The medical gentlemen  residing in the  vicinity united in affirming that  it
was as healthful  a  locality as any in the county.   Not only was  Typhoid
fever an  unknown disease in that particular situation, but in no part of this
county was  it known to have occurred up to that time.  The fever then, and
previously indigenous in  this part of the country, was mild remittent, or what
was more commonly called bilious fever.  It is indeed possible that cases of
 Typhoid  fever may have occurred from time to time without being recognized
as such; but it is undoubtedly true  that Continued Fever was not the usual
form of fever met with in medical practice.  In this respect a marked change
has  taken place during  the past eight or ten years.  Remittent or  bilious
fevers have diminished in  the frequency of  their  occurrence,  and cases  of
 Typhoid fever have become proportionably more common.  This statement,
I believe, accords with the experience of practitioners generally in this neigh-
borhood.   At the time the cases of fever of which I  am to  give an account
were in progress at North Boston, it was a novel disease to the physicians 
OF TYPHOID FEVER.
381
who were called in attendance, and this was  a source of embarrassment in
endeavoring to arrive at the explanation of their occurrence.
  The settlement at North Boston, in 1843, was quite small, consisting only
of nine families, all  being within an area an  hundred rods in diameter, but
the few houses in which the disease occurred were closely grouped together,
the house farthest  removed  from the tavern being only ten rods  distant.
Forty-three persons made up the entire community.
   On the 21st of  September a  young man from Warwick, Massachusetts,
being on a journey westward, took  lodgings at the tavern, kept  by a man
named Fuller.  He had been ill for several days, and had kept on his jour-
ney until he felt unable to proceed farther.   He  remained at the tavern, and
died on the 19th of October.   Dr. Timothy T. Lockwood, now a practitioner
in this city, but at that time residing a few miles from North Boston, attended
the young man to  within nine days of his death.   He was then superseded
by a Thomsonian practitioner, who was discharged after a few days trial, and
was  succeeded  by  Dr.  Allen, a  partner of  Dr.  Lockwood.   Diarrhoea, and,
toward the latter part of the disease, low muttering delirium  were promi-
nent symptoms in  this case.   Drs.  Lockwood and Allen, who saw more or
less of the cases which subsequently occurred,  state unqualifiedly  that the
 disease was the same.   The patient was undoubtedly laboring under  Typhoid
 fever.   He had but a few days before left a part of the country (Massachu-
 setts) where this disease is the prevailing form of fever.  The clergyman of
 the  town in which he resided, Rev. Preserved Smith, in a letter written
 shortly afterward, in reply to my inquiries, stated that during the November
 following his departure, (while the subsequent cases  were in progress at
 North Boston,) there were a few cases of a mild, slow fever in the town of
 Warwick,  although not in  the immediate section of the town in which
 the young man resided.   The form of fever referred to  by Mr.  Smith was
 the common autumnal fever of New  England; in other words, Typhoid fever.
    Between October 19th, and December 7th, twenty-eight of the forty-three
 persons comprising the little community at North Boston were attacked with
 fever, and in ten instances the disease proved fatal.
    The first patient attacked was a son of Fuller, the innkeeper, aged sixteen
 years.  He was attacked on the 14th of October, twenty-three days after the
 arrival  of the stranger.  About the same  time, or a few days afterward, a
 daughter of  Fuller, aged fifteen, was seized; another daughter was  taken on
 the ° 6th of October, and another, aged three years, about the same date.  A
 son  acred eioht years, was attacked on the  19th of October.   Two other cases
 occurred in this family, both proving fatal, the dates of the attack not being 
382
TRANSPORTATION AND DIFFU8I0N
ascertained.  Seven cases (exclusive of the stranger) occurred in this family,
and three deaths.  These, and the cases occurring in the other families, were
seen professionally by Drs. Lockwood and Allen, Dr. Camp, since deceased,
Dr. Charles H. Baker, and others.
  Evi Fuller, aged 21, a son of the innkeeper, who lived at some distance
but at the time  of the sickness came to  assist his father's family, and occu-
pied  with his wife part  of a house about four rods from  the tavern, was
attacked on the 15th October,  and recovered.
  Two cases occurred in the family of Penhallow, residing about eight rods
from  Fuller's tavern.   The patients were children,  one aged seven, and the
other nine years.  The dates of  the attack  in these two cases  were October
16th, and 23d.
  In  the family of Ingraham, residing  about  three rods from the tavern,
were  seven cases  and two deaths.  A son, aged seven years,  was attacked
about the  15th of October; another son, aged  nine years, about  the same
time;  a daughter, aged five years, 29th of October; another daughter, aged
twelve years, 8th of November.  The dates in the three other  cases are not
ascertained.*
  The family of Hallick resided  about ten rods from Fuller's.   Seven cases
occurred in this family, five of which proved fatal.  The dates of attack  in
two cases — these being the only cases of which notes were taken — were  ai
follows: a daughter, aged sixteen  years, 28th  October;  another daughter,
aged  fourteen years, 8th November.
  Four cases occurred in the family of Dobbs, situated about three rods from
the  tavern.  All these cases recovered.   The dates of attack in three of these
cases  are as fullows: a daughter,  aged  one year, 29th October; another*
aged eleven years, 1st November; another, aged eleven years, 8th November.
  Mrs. Hill, aged  about fifty, lived within  twenty feet of the  tavern.   Her
son, aged  about  twenty-one, was attacked; the date not ascertained.
  Three  families, only,  in the settlement, escaped.  One of these, named
Stearns, lived in the house, a  part of which was occupied by Evi  Fuller, son
of the innkeeper,  distant  four  rods from the  tavern.  This  family  consisted
of Mr. Stearns and wife, four children — the eldest about nine years of age —
and a boarder.   This was the only family into which the  disease did not
enter, of those  living Avithin  the  area to  which the disease was restricted.
The reader is  desired to  bear in mind this fact, which has an important
  * I am only able to give dates in the cases of which I have notes more or less exten-
sive of the histories. 
OF TYPHOID FEVER.
383
connection with another fact presently to be mentioned. Another family named
Sprague, lived about forty rods distant, over a stream  three rods in width.
This family consisted of the  husband  and wife, the former being fifty, and
the latter not  far from the  same  age ; and  three others, children that  he
had taken  to support, and a domestic.  A third family, named  Bailey, also
lived  about  forty rods distant.  This  family consisted of  husband and wife,
the  ages respectively being  thirty-six and thirty-four, and either  three or
four children, the eldest eight or nine years of age.
   The ages of  the persons in whose families the  disease prevailed, but who
themselves  escaped, are of importance with reference to the discussion which
is to  follow.  According to estimates by Drs. Lockwood and Baker, to whom
I am indebted  for  information relative to  this and several other points, the
ages were as follows: Fuller, the  innkeeper, about 50; Ingraham, about 50;
Dobbs, about 45; Penhallow, about  40; and Hallick, about 40.
   The wives of all these  persons  were living, and the age was in each  in-
stance not much less than that of the husband.
   Another point of considerable  importance, to which I shall have occasion
to refer, is the condition of the respective families as regards  the necessaries
and  conveniences  of living.  Fuller, the  innkeeper, was in comfortable cir-
cumstances.  All  the other  families  in  which the  disease prevailed, were
 poor, to a degree amounting to considerable destitution.   This was  not true
 of the few  families  which  escaped, viz.: the families named Bailey, Sprague
 and  Stearns.   These were all in a situation to live comfortably.
   The occurrence of a severe form  of disease, affecting, in  a brief  period,
 more than one  half of this small,  isolated community, and proving fatal in so
 large a proportion of cases, as might be expected, occasioned  not a little ex-
 citement at the place.   This was naturally increased by the fact, that  the
 disease  was one presenting, for  that locality, remarkable features, giving
 rise  to  discussion,  and discrepancy  of opinion, among  the  medical practi-
 tioners  of  the  neighborhood.   The popular explanation of the origin of the
 disease, added  greatly to the intensity of the  excitement.  This involves a
 point of importance in  the history.  Between the family of Stearns, resi-
 ding four rods from the tavern, and Fuller, the innkeeper, a bitter feud
 existed, which  had  given rise to various acts of  hostility.   The two families
 had no intercourse,  and, for a reason shortly to be  mentioned, soon after
 the  cases of fever occurred, all intercourse of Stearns' family with  the other
 families at the settlement was broken off.  The other families were on terms
 0f free and frequent intercourse  with the family of the  innkeeper, and with
 each other.  To this point I shall presently have occasion to refer.   Under 
384
TRANSPORTATION AND DIFFUSION
these circumstances, the story was  started that the disease was produced by
some poison, introduced into  the families.affected,  through the agency of
Stearns.   The  family of Fuller, and the other families in the vicinity, with
the exception of that of Stearns, were accustomed to obtain the water used
for drinking and other domestic purposes, at a well situated near the tavern-
It was charged upon Stearns that he had poisoned this well, and that the
disease was  due to this  source.  This story was  fully believed by nearly all
the  inhabitants of the place, so that several pumps were placed in the well,
and an effort made, but without avail, to exhaust all the water it contained.
Some  facts appeared to give a  strong support to  this explanation.  The
family of Stearns did not suffer from the disease.  This  family alone, of all
those in the immediate vicinity, did not draw water from Fuller's well.  Up
to a short time before the sickness occurred, the family of Stearns had been
supplied with water from  Fuller's well; but owing to the hostility between
the two  families, this privilege had been refused to  Stearns, so that he was
obliged to dig out, and  deepen an old well of his  own.   Another of the
three families  which escaped, living over the  creek, did  not  use water
from that well.  By the others it was  used daily.  These facts,  coupled
with the relations existing  between  Stearns and Fuller, and the singular
character of the disease, were  considered to furnish  circumstantial proof  of
guilt sufficiently conclusive.   This belief continued  during  the whole time
the  cases were in progress, and  is still entertained by  some of those  who
resided in the  place at the time.   A quantity of the water was brought  to
this city, and  carefully analyzed by Drs. C. H. Raymond  and George E.
Hayes.   It was found to be remarkably pure — the only foreign ingredient
detected  being a small proportion of saccharine  substance, which was ex-
plained by the  fact  that the vessel in which  the water was transported had
previously been used as a molasses jug!  So deeply rooted, however,  was
the  conviction  of poison, in the  minds  of the  inhabitants, that, to account
for  the  negative result of  the  analysis,  it was supposed,  in some way  or
other the water in the jug,  originally taken from the  well, was changed
before it came into the  hands of the  analysts!   A point of importance
involved  in this popular belief, is, that contagion  was not suspected.   If
the  disease was diffused in that way, i. e., by  contagion, the  exposure was
wholly unconscious, on the  part of those who suffered from  it.   The charge
of poisoning was so  openly made, that  a prosecution was  commenced for
slander bv Stearns, the person to whom  the crime was  imputed, which was
finally settled,  on the payment, by the party  prosecuted,  of one hundred
dollars. 
OF TYPHOID FEVER.
385
  During the progress of the disease, and when the excitement was at its
height, an application was made to the county superintendents of the poor,
on the ground of the poverty of the most of the families afflicted, that a
physician from this city should be sent to assist in inquiring into the nature
and  origin  of the disease.   The writer was  employed  for that purpose.
I visited the place November 5th, and spent the greater part of a day in
personal investigations.  I made an autopsical examination of the body of a
child, about twelve  years  of age, dead  with  the disease,  recording the ap-
pearances, and took notes at the bedside  of the  history  and  symptoms in
nine cases which were then  in  progress.  Dr. Camp, an  intelligent practi-
tioner, since deceased, who had charge of several of the patients, engaged to
keep daily records, and  subsequently placed  at my disposal  histories, more
or less complete, of ten cases.  The facts thus collected, together with farther
information  obtained from  Drs. Allen, Baker and Lockwood, furnish the
evidence of the character of the disease; and  to this subject I will first direct
attention.  The opinion  that the disease was Typhoid fever has been already
 implied.  What are the grounds upon which this opinion  is based ?
   In my former account, communicated for the Am. Jour, of Med. Sciences,
 I have  given the details of the single autopsy, and  of the histories of the
 cases so tar as they were recorded by Dr. Camp and myself.   Of these  de-
 tails I shall select those  only which concern the present object, referring the
 reader who  may desire a fuller description, to the article just  alluded to.
 In the first  place, the intestinal lesions characteristic of Typhoid fever were
 clearly  present  in the case examined.  The record states  that 'an ulceration
 of the  size  of  a shilling  piece  was  discovered about six inches above  the
 ccecum, and fourteen other ulcerations  were  found along the lower third of
 the ileum.  The upper ulcerations were of an oval form.   Above the ulcera-
 tions  the elliptical patches were thickened.   The ulcerations corresponded
 with  the enlarged mesenteric  glands.'  'The mesenteric glands  were en-
 larged; the range nearest the intestine  about the size of peas, some of those
 nearest the spine nearly as large  as a hickory nut, and one quite as large.'
 • Upper third of intestine presented a healthy  appearance.'   The lungs were
 free from  tuberculous  disease, and no morbid appearances worthy of note
 were found in  other organs.   The mode of describing the lesions above men-
 tioned  might be improved, but the description is sufficient to establish the
 existence of the changes, situated in the Peyerian patches and mesenteric
  glands, which  belong to Typhoid fever.  The only possible doubt as to their
  character would involve the supposition of their being due to  tuberculosis,
  and this is disproved by the absence of tubercle in the lungs.
              25 
386
TRANSPORTATION AND DIFFUSION
   Next of the symptoms.  Of the eighteen cases of which histories more or
less complete were  obtained, diarrheea was present in fifteen.   In some of
the cases this symptom was slight, in other cases severe.   It  followed the
operation of cathartic or laxative remedies in some cases, but it occurred, and
persisted in other cases in which these remedies were not employed.
   Of fourteen cases in which  the presence  or absence of Tympanites was
noted, it existed, to a greater or less extent, in eleven.
   Abdominal tenderness was present in seven of nine cases, the histories of
which contain information on this point.  Nausea and vomiting were in no
instance prominent symptoms.
   More or less mental  aberration was noted in twelve cases, and in one case
only is it stated that this symptom was absent.   The aberration consisted of
incoherency especially at night, and muttering.   It was  evidently of a quiet
character.  Drowsiness and  tendency to stupor is  noted  in some of the
cases, and among the  symptoms in  cases  proving  fatal, picking of the bed
clothes and sliding down in bed are mentioned.
   Cough and expectoration  are mentioned in the  history of nine cases,
nothing being stated relative to this symptom  in the remaining nine.  In
some cases these symptoms were prominent, in others slight.
   Information respecting the duration of the access is contained in the notes
of seven cases.  As stated in these cases, respectively, it was as follows:—A
week in two cases;  several days, ten days, five days,  four days, three or four
days,  each in one case.
   The data for determining with precision the duration  of the febrile career
are defective in all but  the fatal cases among those of which notes were made.
In these cases, five in number, the days from  the  date of attack to the time
of death  was, respectively, as follows:—thirteen, in two cases; eighteen, four-
teen, and seven, each in one case.
   The disease was ushered  in  by  slight  chills,  lassitude,  loss  of  appetite,
headache; perspirations occasionally occurred, and in  no  instance did it even*
tuate in intermittent paroxysms of fever.
   An eruption was not generally sought for.  Dr.  Baker, however, at that
time a partner of Dr. Camp, informed me that he  observed spots on the
chest and abdomen in several of the cases.  His attention was inadvertently
directed to them,  without expressly looking for an eruption.   He stated that
the spots resembled flea bites, but were about half the size, and slightly
elevated.  He thinks they were noticed by  him  toward the latter part of the
disease.
   The foregoing account of symptoms is a digest of the diagnostic pointo 
OF TYPHOID FEVER.
387
embraced in the histories of  the  cases which are given in full, so far as ob-
tained, in the former report.   Although not sufficiently complete for all the
purposes of numerical analysis, the facts are  fully adequate to establish the
diagnosis.  On this  point  every reader practically conversant with Typhoid
fever must, I think, be satisfied.   While ample positive proof is  furnished,
there is an equal amount of negative evidence.  That is to say, if the disease
were not Typhoid fever, it must have  been either Typhus, or bilious remit-
tent fever;  and the  facts  excluding the two  latter affections, are not  less
strong than  those which are characteristic of the first.  The diarrhoea and
other abdominal  symptoms;  the pulmonary symptoms; the gradual access,
and the  special lesions after death, are  the positive points distinguishing it
alike from Typhus and Remittent  fever.   The absence of a copious eruption
extending over the extremities and attracting notice, in a series  of twenty-
eight cases, is an  important negative fact distinguishing from Typhus.  An-
other negative fact having a similar significance is the striking preference for
young subjects.   The oldest of the patients  affected was not over twenty-
three years of age.   These cases furnish an excellent illustration of this law
of Typhoid fever, a law  which distinguishes this form of fever from Typhus,
the latter showing no such respect for age.   The prevalence of  the disease,
moreover, was confined to a period of the year during which Typhoid fever is
most apt to occur, viz: in the autumnal months, Typhus showing no predilec-
tion for any particular season, and  remittent fever occurring at an earlier date.
   Among the negative points which serve to  exclude remitting fever are the
non-occurrence of vomiting as a prominent symptom; the absence of distinct
remissions, and the fact that not only in no instance was  the disease converted
into an intermittent, but, at the expiration of eighteen  months, intermittent
fever had not occurred in  any of  the patients who had had the disease.   In
fact intermittent fever, since that time, as well  as before, has not been known
in that locality.
   Assuming, now, that  the disease is clearly shown to have been Typhoid
fever, the question arises, how are its production and diffusion to be accounted
for?   The answer to this  inquiry is implied  in the title of the present me-
moir.  The disease  was transported  to  North  Boston  by the sick  stranger
who died at Fuller's tavern, and  thence  diffused throughout the settlement.
I  need not add, it is with reference  to  this  conclusion that  the foregoing
history is  chiefly interesting and valuable.   What are the  circumstances
embraced in this history upon which is based the opinion that the prevalence
of the disease was due to  contagion ?   Let us review  the facts contained in
the foregoing history bearing on this subject. 
388
TRANSPORTATION  AND DIFFUSION
   In a small, isolated community, consisting of nine families, seven of which
lived within a few rods of each other, a person is  introduced  affected  with
Typhoid fever, and after lingering twenty-nine days, dies with  this disease.
Prior to that event the members of this community  were free from disease of
any kind—the situation was in every respect healthy, and Typhoid fever was
a disease unknown in that place  and neighborhood.   The patient  lingered
and died at the public house, which was a place of  daily resort for the mem-
bers of those seven families with a single exception.  One family, consisting
of several  persons, living but four rods from  the tavern, was on terms of hos-
tility with the innkeeper which precluded all intercourse.   The arrival of a
sick stranger with a severe disease was an event of interest to the inhabitants.
He was visited, more or less, daily by the different  members of the families
living closely at hand, with the exception of the family referred to; and the
members of the family of  the  inn-keeper were of course brought into  close
contact with the disease.   Twenty-three days after the arrival of the stranger,
two  members of the  family of the inn-keeper were  attacked with the disease,
and  subsequently five others in this  family.  In all the other families living
within a few rods of the  tavern, excepting a  single  family, cases  occurred,
more or less in number, within the space of about a month  from the date of
the first case developed after the stranger arrived; and during this period
more than half the population of the settlement were affected.   The disease
then ceased further progress, no cases afterward occurring.   The  family in
which no  cases occurred was the  only family of the seven not  brought into
contact with the disease.  The relations of this family to that of the inn-keeper,
as just stated, precluded all social  intercourse, and shortly after the disease
began to spread, its production being imputed  to the agency of this  family,
all intercourse with the other  families affected with the disease was  at once
suspended.   Stearns, the person whose family is now referred to, has informed
me that he did  not see any  of the patients affected with  the fever.   The
origin of  the disease being supposed to be  from water poisoned by Stearns,
the idea of communicability was not entertained, so that no apprehensions
were felt of danger from  free intercourse with the sick, and no precautions
taken to obviate the  risk of exposure.
   Now in view of this reviewal of the facts, if it be claimed that the disease
was not transported to the place and  diffused by contagion,  it is necessary to
admit a series of coincidences almost incredible.   It will be seen  that the
circumstances which have  just been rehearsed, embrace all  those which had
been previously mentioned as important conditions for a fair  experiment in
order to test the contagiousness of a  disease.   In  fact, if every circumstance 
OF TYPHOID FEVER.
389
connected with the history of the disease at North Boston had been delibe-
rately selected and arranged for a scientific object, they  could hardly have
been rendered more complete or judicious.
   Assuming the transportation of the disease and its diffusion by contagion,
in this instance, to have been proved, an interesting point of inquiry remains to
be noticed, involving some circumstances embraced  in the foregoing history
to which particular reference has  not yet been  made.  Ordinary experience
furnishes small evidence of the contagiousness of Typhoid fever, so that while
there are some who still deny to this disease the faculty of reproduction, all
admit that its power of self diffusion is usually weak.
   The fact of contagion is, for the  most part, established by instances more
or less analogous to the occurrence of the disease at North Boston, of which
several  are  on record.   This fact, if sufficiently sustained by positive proof,
cannot be invalidated by negative evidence, be it  ever so abundant.  But  it
is an apparent inconsistency that a disease should, in the great  majority of
instances, seem to be devoid of the principle of contagion, and occasionally
exhibit this principle in a  striking  degree.   The history of  the disease at
North Boston, taken alone, would show that Typhoid fever is  remarkably
contagious.  How is this  inconsistency to  be explained?  We  may  adopt
two methods of explanation.   It may be supposed that the miasm of conta-
gion is much more  abundant, or potent, at certain times  and  places, than
when  the  disease ordinarily prevails.   This supposition is plausible,  and
appears to be true of different affections, the contagiousness of which is not
doubted, such  as  Typhus,  Variola, etc.  Or, it may be contended  that the
miasm, which generally is  inoperative, becomes  more efficient, not by  any
increase of its strength  or quantity, but by the co-operation of other  agencies
which favor its operation, or render individuals more susceptible  to its influ-
ence.  These two explanations are not incompatible,with each other.  Both
may be  applicable, conjointly, in  a  particular instance.   If we examine the
history of  the disease at North Boston, we shall find several circumstances
which may be suspected to have a bearing on the point under consideration.
In the first place,  the exposure was great.  Contagion not being thought of,
the fear of  contracting  the disease imposed  no restraint.  The houses were
small and situated closely together.   The place was isolated, furnishing few
events to occupy the attention except those which pertained to the domestic
experience  of  the families who were   on  terms of social  intercourse.  It
would naturally follow that the accumulation of contagious  miasm, and the
extent  to which the members of the  community were  brought within its
influence, was greater than would obtain except under circumstances somewhat 
390       TRANSPORTATION AND DIFFUSION OF TYPHOID FEVER.

similar.  But a fact of still  greater importance  in this connection is the
poverty of the families.  I have been informed by several persons competent
to give this information, (as  already stated) that,  excepting the  family of
Fuller, all the others who suffered from the disease  were destitute  even to a
deficiency of wholesome food.  In  other  words,  they found it difficult to
obtain a comfortable subsistence.   It is well known that persons thus situated
are unusually susceptible to the miasm of contagion.  This fact may serve to
explain the  immunity from  the disease of  the two families living at the set-
tlement, but removed at a greater distance than the  others from the focus of
contagion, viz: the families of Sprague and  Bailey.  The latter were  comforta-
ble livers.   It will also serve to account for the disease not  attacking persons
living in the vicinity who visited the place in order to render  assistance to
the sick.  This circumstance was cited, at the time,  as an argument that the
disease did  not spread  by contagion.   Those  persons, living  comfortably,
were  less susceptible to the contagious miasm.
   A  circumstance which protected a considerable number of those of the
population of the place who escaped, doubtless, was the fact that  they had
passed the period of life when the liability  to contract Typhoid  fever exists;
that is, they were over  thirty years of age.
   A circumstance which may  be  considered to have favored the diffusion of
the disease  among the inhabitants who were  susceptible  to contagion, has
been already mentioned in connection with the  diagnosis, viz: the  season of
the year, Typhoid fever being prone to prevail during the autumnal months.

   In  bringing this  memoir to a close, an apology for the space  which it
occupies is  certainly due, if the writer has over estimated  the importance of
the facts which it contains  in  their bearing on  the  mooted question of the
contagiousness, at certain times and places,  of Typhoid fever.  Entertaining,
however, the belief that, with  reference to this question, the occurrence of
the disease at North Boston presented a combination of circumstances rarely
and, perhaps, never associated in any analogous instance reported in the annals
of medicine, he cannot but hope that the time  and  trouble bestowed on
the subject both by himself, and the patient reader, has not been misapplied. 
 
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