A TREATISE ON I THE CONTINUED FEVERS BY JAMES C. WILSON, M.D., PHTSICIAS TO THE PHILADELPHIA HOSPITAL AND TO THE H03PITAL OF THE JEFFBKSOS MEDICAL COL- LEGE, AND LECTURER ON PHTSIOAL DIAGNOSIS AT THE JEFFERSON MEDICAL COLLEOB, FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, ETC. ■WITH AN INTRODUCTION BY J. M. DA COSTA, M.D., PBOFESSOB OF THE PRACTICE OF MEDICINE AND CLINICAL MEDICINE AT THE JEFFERSON MEDICAL COL- LEGE, PHYSICIAN TO THE PENNSYLVANIA HOSPITAL, FELLOW OF THE OOLLBOB OF PHYSICIANS, PHILADELPHIA, ETC. NEW YORK WILLIAM WOOD & COMPANY 27 Great Jones Street 1881 COPYBIOHT WILLLA.M WOOD & COMPANY 18S1 Trow's Printing and Bookbinding Company 201-213 East \ith Street New York f ®o the ittemorg Dr. WILLIAM W. GERHARD, WHO FIRST IN AMERICA APPLIED TO THE STUDY OP THE FEVERS THE METHODS OP MODERN SCIENTIFIC RESEARCH; AND TO WHOM IS DUE THE CREDIT OP HAVING FIRST CLEARLY ESTABLISHED SEVERAL OP THE MOST IMPORTANT POINTS OP DISTINCTION BETWEEN TYPHUS AND TYPHOID FEVERS. ^C'^^oCO \ ilitoli' PREFACE. The diseases considered in tlie following pages constitute a group with most of which the general practitioner is more or less familiar ; it has, therefore, been my aim to describe them at greater fulness than is usual in the text-books, yet without the extreme elabora- tion that mars the usefulness of some of the special treatises. Brief historical sketches have been introduced, and considerable attention has been given to the subject of the special causes of particular dis- eases, as well as to their clinical phenomena and their anatomical lesions. Purely theoretical considerations have been, as a rule, omitted, and all controversial matters have been disregarded. The sections upon treatment are designed to represent recent practical knowledge, rather than to do justice to the changing opinions of which that knowledge is the outgrowth. With reference to tlie title of the book, it is to be admitted that, despite general usage and the highest modern authority, the classifica- tion of the infectious diseases, and in particular of those commonly known as the Fevers, is unscientific and provisional. Diseases being processes and not entities, are properly to be classified upon an etio- logical basis. Our knowledge of the exciting causes of the Fevers does not as yet admit of the employment of such a principle of classifica- tion. Much, however, has been learned within recent years, and new facts are from day to day being brought to light : the expectation that more exact and definite knowledge of the special causes of the Fevers VI PREFACE. V, ill, in the near future, lead to a more satisfactory nosological system, is not without warrant. Meanwhile, we must content ourselves with groupings based upon the broad clinical aspects of diseases. From this point of view, the affec- tions treated of in this volume constitute a group sufficiently well de- fined. They are characterized by notable, persistent elevation of tem- perature, and steady continuance to a definite termination. The group might have been made larger or smaller, but the time has not yet come, it seems to me, to include pneumonia, diphtheria, and acute rheumatism, among the Fevers, and I can find no reason, seeing that the eruptions of dengue are variable and inconstant, for classing it among the exanthematous diseases. I desire to express my thanks to my friend. Prof. Wm. H. Greene, for assistance in reading and correcting the proofs, and for several im- portant suggestions as to the arrangement of the topics. JAMES C. WILSON. 1437 Walnut st., Philadelphia. 28th March, 1881. CONTENTS. Introdtjction by Professor Da Costa, I.— SIMPLE CONTINUED FEVER. Definition, ............. 1 Synonyms, ..... ... ...... 1 Etiology, 2 Clinical History, ............. 3 Analysis of the Symptoms, . 5 Duration, . ............. 7 Dia^osis, ..........••• 7 Prognosis and Mortality, . . . .8 Treatment, 8 II. -INFLUENZA. Definition, 10 Synonyms, ............. 10 Historical Sketch, .12 Etiology, 21 I. — Predisposing Causes, .......... 21 II.— The Exciting Cause, 24 Clinical History, 26 Analysis of the Symptoms, .......... 29 The Fever, 29 The Catarrh, 30 Symptoms Referable to the Nervous System, 32 Complications and Sequels, .......... 33 Pathology, • 36 Vlll CONTENTS. PAOE Diagnosis, -37 Prognosis and Mortality, 38 Treatment, ............. 29 III.— CEREBRO-SPINAL FEVER. Definition, 40 Synonyms, ............. 4G Historical Sketch, ............. 47 Etiology, 5G Clinical History 64 Analysis of the Symptoms, .......... 73 Symptoms Pertaining to the Nervous System, . . ... 73 Symptoms Referable to the Skin, ........ 77 The Phenomena of the Fever, ......... 78 Symptoms Referable to the Organs of Respiration, ..... 84 Disturbances of the Organs of the Special Senses, ..... 85 Complications and Sequels, .......... 87 Pathology, Morbid Anatomy, 89 Diagnosis, .............. 94 Prognosis and Mortality, ........... 97 Treatment, 98 lY.— ENTERIC OR TYPHOID FEVER. Definition, • ... 107 Synonyms, ............. 107 Historical Sketch, = ... 108 Etiology 116 I. — Predisposing Causes, . . . . . . . . , .116 II.— The Exciting Cause, 120 Clinical History, 147 Analysis of the Principal Symptoms, ........ 153 The Phenomena of the Fever, ......... 153 Symptoms Referable to the Circulatory System, ..... 161 Symptoms Referable to the Nervous System, ...... 163 The Skin, 167 Symptoms Referable to the Digestive Tract, 170 Symptoms Referable to the Organs of Respiration, 176 The Urine, 177 Complications and Sequels, . . . 178 Varieties, "... 192 Relapses 196 Anatomical Lesions, 202 CONTENTS. IX PAGE Diagnosis, 210 Prognosis and Mortality, 213 Treatment, 221 I. — Prophylaxis, ............ 221 II. — The General Management of the Patient and Dietetics, . . . 222 III. — Special Forms of Treatment, 227 IV.— The Expectant Treatment, 234 v. — The Treatment of Special Symptoms, Complications, and Sequels, . 235 VI. — The Management of the Patient during Convalescence, . . . 240 • V. -TYPHUS FEVER. Definition, 241 Synonyms, 241 Historical Sketch, 242 Etiology, 251 I. — Predisposing Causes, 251 II.— The Exciting Cause, 256 Clinical History, 260 Analysis of the Principal Symptoms, 264 Symptoms Eef arable to the Nervous System, 264 The Phenomena of the Fever, ......... 269 Symptoms Manifested by the Skin, 277 Symptoms Referable to the Respiratory System 281 Symptoms Referable to the Digestive System, 281 Complications and Sequels, .......... 284 Varieties, 288 Prognosis and Mortality, 290 Anatomical Lesions, ............ 293 Diagnosis, 295 Treatment, 297 VI.— RELAPSING FEVER. Definition, 303 Synonyms, .............. 302 Historical Sketch, .303 Etiology, 309 I. — Predisposing Causes, 309 II.— The Exciting Cause, 312 Clinical History, 320 Analysis of the Principal Symptoms, ......... 324 Symptoms Referable to the Nervous System, 324 The Phenomena of the Fever, 326 Symptoms due to Disturbance of the Digestive Organs, .... 331 X CONTENTS. PAGE Complications and Sequels, 332 Prognosis and Mortality, 335 Anatomical Lesions, 836 Diagnosis, 337 Treatment, 340 VII.— DENGUE. Definition, . . . , 344 Synonyms, 344 Historical Sketch, 345 Etiology, 348 I. — Predisposing Causes, 348 11. —The Exciting Cause, 349 Clinical History, 350 Diagnosis, 356 Treatment, 356 THE CONTIJ^UED FEVERS. INTEODUCTIOK I HAVE been asked to wi-ite an introduction to Dr. Wilson's work on Fevers, and I shall choose for my subject that most important one, the management of Fever. For what is the study of its causation, what the care in its discrimination, what the close pursuit of the le- sions in solids and in blood, unless we are thus to be led to a more clearly conceived, more thoughtful, more successful management of the Fever? As the scope of this work is limited to the Continued Fevers, so my remarks will chiefly refer to them. But there is little that I shall say that in the main would not be applicable to the other members of the great family of Fevers. We naturally have to consider, first, the general management of the fever, as it is influenced by the arrangements of the sick-room, and by tlie attendance to the wants of the patient — those things which imply his nursing. ]^ow, we all agree that good nursing is essential ; but do we all enforce it, and continue to superintend it ? The physician who lays aside his watchfulness on these points, finds at any moment that he is combating with one of his chief weapons broken in his hand. Reports from the nurse — written when practicable, inspection of the arrangements for ventilation, for destroying the discharges, for insuring the cleanliness of the patient, should form part of the occupa- tion of at least one of the da.i]j visits. So much has been said of late years of the functions of the nurse, and there are now so many more well-trained nurses, that it will be quite unnecessary here to go into any details of the nursing of fever- patients. But the last word on this subject can never be spoken. It never can be too strongly enforced that cleanliness, cheerfulness, and regularity, are the three great qualities needed in the sick-room. The cleanliness consists in keeping him personally clean — in spong- ing him with cool or tepid water, or with vinegar, or bay-rum and Xll INTRODUCTION. Mater, morning and evening, only parts of the body at a time, if more fatigue liim ; in seeing to it that his linen is unsoiled ; and that the room is not encumbered with anything useless, and that all objects are fi*ee from stain and in good order. The cheerfulness sustains his spirits, and, mitil his nervous system is stricken with obtuseness, is a vast comfort and aid during his dreary, restless hours. The regularity is indispensable ; everything must be given at hours arranged by the physician. Well-meant but injudicious kindness may give food and medicine of tener, or fail to give them, fearing to disturb. J3ut well-meant though injudicious kindness may thus hasten or cause death. Except nnder the most potent of causes, the schedule arranged by the physician must not be departed from. Of course, in these directions some latitude Avill be left as to how long the patient may be allowed to sleej), or under what circumstances a dose may be re- peated or be omitted. But a careful physician indicates this latitude with his directions. Besides these points essential to good nursing, there are others — some quite, others almost equally important. Equally important cer- tainly is ventilation, admitting light and air both, not excluding them as if they were poisonous. To admit light is to influence the nervous sys- tem favorably, to keep the half-dreamy, wandering attention aroused, to procure better sleep by marking tlie alternations between day and night and invoking the force of habit, to moderate often a delirium. To ad- mit pure air is to give the respiratory functions their full play and to furnish the changed blood with the means requisite for its revival. Moreover, it cools the atmosphere, which indeed, even in winter, should be kept at a very moderate degree of heat ; and this, to the patient consumed witli fever, is both grateful and salutary. We see what a calamity a hot atmosphere is if we are obliged to treat severe cases of typhoid fever in our cities during the summer months. They are likely to do badly — the heat adds to their gravity and prostrates the nervous system. I have often attempted to cool the atmosphere by artificial means, and have used, with at least partial success, cloths wrung out in ice-water, and hung up near an open window ; I have re- sorted to blocks of ice that are allowed to melt in the room, and to- the hand-ball atomizer charged with ice-water or cologne and water, so as to fill the room with the spray. But, with all, the torrid weather of our heated term is a terrible drawback in the treatment of e:rave fevers. Another important point in the care of the sick person is that he should not be needlessly disturbed. And here it is where the well- trained professional nurse is such an advantage. Fussiness is a de- structive quality ; and ignorance is always fussy. Nm-ses who know IlSrTRODUCTIOlSr. xiu their business but imperfectly are apt to be always in motion, always addressing the unfortunate patient, keeping him awake when he wants to sleep, constantly forcing drinks on him, never resting themselves or letting him rest. And it must be said that the overanxious eye and hand of affection are sometimes as injurious as the annoyance of the well-meaning, meddlesome nurse. The solitude which implies seve- rance fi"om loving watchfulness is very bad ; but it may be better than the unrest which loving watchfulness misdirected occasions. A fever-patient should be put to bed early ; it saves his strength. We see what comes of not doing it, in the result of the so-called walk- ing cases, especially in typhoid fever and in yellow fever ; they are very apt to do badly. But how long should the patient be kept in bed ? I think not too long. To put him to bed early and to let him up early is my rule. If the thermometer for three or four days have marked a normal evening temperature, I allow him to get up, at first for half an hour or less, and then daily more and more. I have known this plan succeed admirably in what seemed a protracted convalescence, and put a stop to night-sweats and to temperature-rises to 100° ; for I think we may keep the temperature at that, or let it go back to that, by allowing the patient to stay too long in bed. The diet varies, of course, with the character of the fever. The t}^hoid fever patient, with his ulcerating intestine, will not bear the same diet as the typhus fever or catarrhal fever patient. Yet in the main there is such a thing as a fever-diet, and that is, a restricted diet of bland, easily digested substances. The coated state of the mucous membrane, the difficulty of digestion, the J5,ck of appetite, make the sick man turn almost with disgust from other food. Hence, broths, and milk, and farinaceous food form the staple of the diet, whether he have an intestinal lesion or not ; and by the loathing for food JS^ature restricts the diet, whether we restrict it or not. Indeed, since the memorable words which Graves chose for his epitaph — " He fed fevers " — it cannot be said that the English-speaking races, at least, attempt to curtail the diet much. Our error, I think, is now in the other direc- tion ; in the earlier stages of the fever we do not curtail it enough. As regards the character of food, while the articles mentioned are those generally most acceptable, they need not, except in the case of typhoid fever, be as rigidly adhered to as is the wont. If the patient crave other food — crave solid food not actually indigestible, he may have it. Later in the febrile malady assuredly the tone of the stomach may be better sustained by some solid than by so much liquid nourishment. From the cruel practice of refusing water to the fever-stricken pa- tient, there has been, we all know, a strong reaction. And it is one of XIV INTRODUCTION. the doctrines now unreservedly tauglit, to allow tlie patient an nnllmited supply of pure water or of other bland fluid. That in the main this is right, there can be no question. It is not simply a gratification to quench the burning thirst, but it means to get rid of the poison and of broken-down tissues by keeping skin and kidneys active. Yet, is it proper that the supply should be unlimited ? I think we have gone too far in saying that it shall be. Yery large supplies of water mean that the vessels of the stomach are constantly full, that the process of taking up liquid food is retarded — nay, that the desire for the really essential nourishment is greatly lessened or is changed to repugnance. Closely connected with the subject of food and drink is that of stimulants. I cannot here go into the question of giving alcohol in fevers, because the propriety or impropriety has to be judged in each fever, and general statements are apt to be misleading. "VYe cannot make hard-and-fast rides that will apply equally in t}^:)hoid and in in- fluenza, in cerebro-spinal fever and in relapsing fever. Still there are, besides many special indications, some comprehensive ones which, though in different degree, turn up in all fevers, and are to be met in the same way. Whenever there are signs of failing circulation, when- ever the action of the heart becomes enfeebled, stimulants are de- manded. And we have no better guide in this than the law Stokes enunciated long since in typhus fever, and which more recent observa- tions have applied to typhoid — the state of the first sound of the heart. This, indeed, can be made use of with advantage in all fevers. Let the first sound become short, indistinct, almost suppressed, and we have a certain indication ft)r alcohol ; the fainter the first sound, the more urgent is the stimulus required. jS^ow, the pulse aids also in determining the question ; yet it is not so certain. But both pulse and heart-sounds are much more available than the sphygmograph, which, though employed by some, is quite unsuited to the exigencies of pro- fessional life in framing the treatment of fever-cases. Tremor and delirium are other signs which call for stimulants ; they are mostly the result of failing nervous power. Yet, certainly with reference to delirium, we cannot make our rule too absolute. Delirium may be due, not to defective nerve-energ}^ and poisoned blood, but to intracranial mischief, though, excepting cerebro-spinal fever, such is rarely the case. We now arrive at the treatment of fever by strictly medicinal means. At the very threshold we come across the inquiry : Are there special plans of treatment for these fevers of the Continued Type — plans of treatment approaching to specifics, leading rapidly to cure — having, in other words, the power or something like the ]>ower, INTEODUCTIOIT. XV wliicli the preparations of bark exert over the fevers of the Periodical Type ? Or are we in the main still forced to treat the fevers on what is called the rational plan — to treat, therefore, chiefly the symptoms until the poison is eliminated or its results disappear ? It may be a humiliating statement, but it is true that in the main such is the case. There are in some fevers special plans of treatment which aim at modifying the poison or the disease itself, which are, I believe, worthy of confidence, and are better than the so-called rational treatment ; such I hold to be, for instance, the treatment of the typh-fevers by the mineral acids, of cerebro- spinal fever by opium. But these plans of treatment are few, and are not pre-eminent and striking. The result, on the whole, is better when they are employed, yet they are not curative in the highest degree ; and under any circumstances, there are but a scanty number which have stood the test at all. Most of the special plans proposed are mixed up with a quantity of unmistakable rubbish, and have been cleared away ; the accumulated experience of many minds acting as an ultimate court of appeal has given judgment in favor of very few, and among these have not been any based on remedies of extraordinary kind or preconceived action. The best high road to success is still the high road of the commonplace. But it would be as illogical as absurd to suppose that we shall never possess the coveted means really to cure the continued fevers. Doubtless, to the physician of the time of Charles Y. the radical and specific treatment of the malarial fevers appeared as hopeless and re- mote as the radical and specific treatment of the continued fevers ap- pears to the scientific inquirer of our day. If, then, we are still obliged to treat the fevers of continued type rather on general principles than by remedies that are specific, we have to look to those indications, and to depend largely on those agents which enable us to control the fever-process. Among these indications there are a few of paramount importance. One, certainly, is to watch and to keep up the secretions. It is bet- ter for every fever that the skin should be moist, than that it should be harsh and dry. It is better that the urine should be abundant, than that it should be scanty and thick with tissue-waste. And it is not enough to judge by the rough tests with which the older physicians were familiar— we must resort to the more accurate chemical means. Testing the urine for albumen has much significance. It is some kind of guide to the depth of the impression the fever-poison has made on blood and nervous system. The abnormal ingredient is not present in light cases ; it is rarely absent in grave ones. Watching the stools, too, and seeing that they are regular, is of value. Leaving out the special XVI INTRODUCTIOX. character wliicli comes from the lesion in typhoid fever, in all fevers ' we can judge by them whether the food taken, he it solid or milk, is being digested; whether, therefore, it had better be continued or changed. To reduce the elevated temperature of the fever is to all a most im- portant, and to some the most important indication. This is accom- plished by sponging the skin with cool water, by seeing that it acts freely, and by the use of drugs M'hich lower temperature. But the most potent agent undoubtedly is the cold bath, and the treatment of fevers, especially of typhoid fever, by cold baths, is one which is now being strongly urged on professional attention. Some employ it in all cases, others only in those in which the temperature exceeds 103°. To carry out this apyretic treatment effectually requires, however, such constant repetition of the bath, such extreme care in the assistants, such facilities for resorting to it without fatigue, and such implicit obe- dience on the part of the patient, or rather of his friends, that m pri- vate practice, at least, it is in this country impracticable. And it is not settled that for ordinary cases it is so superior to other plans that we are bound to insist upon the discomfort and annoyance which attend it. Still, for cases of very high temperature, cases of about 105° or up- wards, unless extreme exhaustion or some other contra-indicatiou for- bids, it is right to resort to it. High temperature then becomes in itself dangerous to life, and we try to subdue the bad symptom to pre- serve life. I have several times in the last few years made use of the cold-water treatment under these circumstances, and seen it act well. I have also known the cold-water bath to overcome that bad and de- structive s}Tnptom of fever, sleeplessness, where anodynes had failed. Other means to reduce the temperature are quinine and the salicylate of sodium. Quinine in large doses has, on the whole, proved its power to do so, certainly in t}-phoid and typhus fevers. Yet it is sometimes disappointing, particularly in this, that the effect gained is not at all per- manent. Moreover, we must be careful not to infer that sulphate of quinia is to be employed in all the fevers of the continued type, to bring about the results mentioned. Clinical experience will have to be recorded for its use in each fever. Granting that it always has the same effect, such large doses cannot be given M'itli impmiity in various and dissimilar pathological conditions ; and it is very possible that, while they reduce the temperature, they may aggravate the disease or some of the lesions. That this does not happen in tj^-phoid and typhus fever, has, I think, been proved ; for the other members of the group the problem has not, from this point of view, been worked out. Salicylate of sodium is too new a remedy to have been fairly tested ; that it re- INTRODUCTION. XVll duces temperature we know. But it is more apt to disturb digestion than quiuia, and acting, as it often does, as a depressant to the heart, its use in low fevers will require considerable caution. To control and influence the circulation is an indication second to none in the treatment of the continued fevers. In those, far rarer in- stances, in which the circulation is too active and the powers of the heart increased — in fevers, therefore, of what were formerly called ardent or inflammatory type, there is in my experience no remedy equal to aco- nite in quieting heart and pulse. Li the much more usual indication of defective cardiac action which sooner or later is apt to show itself in the course of most fevers, alcohol steadies the feeble heart more cer- tainly than anything else. Quinia in small doses, or strychnia, aids ; but alcohol exerts by far the most influence. Digitalis, from which we might expect so much, has disappointed me ; at least it has done so re- peatedly in typhoid fever. There is another point connected with the management of fevers as important as any that has been stated. It refers not to the sick-room, nor to the sick man, but to the doctor : he must manage himself. jSToth- ing is worse than a vacillating physician, whom each motion, each wish of the patient, each suggestion of the nurse or of the family, affects. Blown hither and thither by every breath, incapable of taking a broad view of the case, his treatment soon becomes as irresolute as himself, and directions and bottles accunmlate with bewildering raj)idity. The fewer drugs that are used, the better ; the greater the decision with which the drugs are used, the better. To do this effectually the physician must understand the mode of onset of the fever, its probable length, its natural course, the succession and duration of each symptom, its de- pendence or non-dependence upon a fixed lesion, the kind of complica- tion likely to arise and the time at which it is apt to set in ; he must, in one word, be pathologist as well as physician. lie then knows when to act and when not to act. And in so doing we have learned equally from men and nature. From men we have learned what agents to employ when we wish to make strong impressions ; from nature the uselessness or folly of such attempts when the fever is pursuing an even course. Yet, to treat a case with the best chance of success, still something else is required — the practical skill which takes note of the epidemic influence prevailing ; which recognizes that all cases are not alike because they bear the same name ; which does not overlook that in the same dis- ease apparently the brunt may fall primarily on this organ or on that organ, that the nervous system or the circulation may suffer dispropor- XVUl INTRODUCTION. tionately and exceptionally from the onset, or, as in fevers of the worst form, be overwhelmed together ; which lays stress on peculiarity of causation, of temperament, of constitution ; which sees, therefore, not only the disease in the sick man, but the sick man in the disease. And another quality enters into the achievement of greatest success — the tenacity which never abandons a case while there is life. In diseases that are self -limited, to continue to sustain to the last is to give nature the chance of exerting a power of recuperation which art cannot gauge. J. M. DA COSTA. I. SIMPLE CONTmUED FEYER. Definition. — A continued fever, not due to specific cause, usually of short duration, lacking the distinguishing characteristics of the other fevers, rarely fatal in temperate climates, and showing, when death occurs, no characteristic lesion. Synonyms. — Febricula; Ephemeral fever; Common continued fever; Sun and Heat fever; Ardent continued fever; Febris continua simplex; Synocha. Much confusion has arisen in consequence of the use of the term sim- ple continued fever, by different authors, to designate several distinct affections. It has been a category for many cases of uncertain character. It has been made to include cases arising during epidemics of fever, as for example, typhus or yellow fever, that have lacked the distinguishing features of the prevalent disease on the one hand and the traits of the other essential fevers on the other. It has been applied where enteric fever and remittent were endemic, to cases of fever occurring side by side with these maladies, yet not showing the typical pathological events which attend them, or showing them to so faint a degree as to baffle the judgment of the observer. Further observations, conducted with great care and analyzed in sufficient numbers, are needed to determine the no- sological relations of such cases. It is probable that they are not of non- specific origin in most instances, but that, by reason of the smallness of the dose of the fever-producing poison, or an imperfect susceptibility on the part of the individual, the specific fever is of such mildness that its characteristic phenomena are not made manifest — it is, in other words, " abortive." Cases of this kind do not correspond to the definition of simple continued fever. These views have led some observers to deny even the existence of the fever under consideration as a distinct affection. Practitioners of medicine in every clime are familiar with the fever called, from its transient character, ephemera and febricula. From a duration of one, two, or three days, which is common, this fever may, without other modification, in rare examples, be extended over a period of ten or twelve 2 THE CONTINUED FEVERS. days. It is therefore proper to include under the heading, simple fever or simple continued fever, all essential continued fevers that are clearly of non-specific origin, whether they be in the strict sense of the term ephemeral, or be prolonged through several days. As Flint ' has pointed out, the diminutive term febricula has relation to the duration of the fever rather than to its intensity. In many instances the fever is intense. While the affection known as sunstroke is properly referred in sys- tematic treatises to the diseases of the nervous system, Professor H, C. Wood ' has shown that its phenomena are those of fever of great intensity, and that the continued fever following exposure to the sun or to a pro longed high temperature, differs from sunstroke in degree and not in kind. The terms sun fever and heat fever, are therefore properly applicable to the febrile affections brought about by the action of these causes. Etiology. It results, from what has been already said, that only those fevers can be regarded as simple that are due to non-specific causes — that are, in fact, neither contagious nor miasmatic. It is also important, theoretically and in practice, to exclude all symptomatic fevers, such as the fever which follows traumatism and surgical procedures, the formation of abscesses, other local inflammations, and hectic fever. It is indeed the more impor- tant because in frequent instances the symptomatic fever bears a strong clinical resemblance to ephemera. This discrimination is important on theoretical grounds, because the one is secondary to and dependent upon a primary disorder of which it is no more than a symptom, the constitu- tional disturbance resulting from local irritation ; whilst the other is in itself the primary disease and the result of causes affecting the nervous system at large witliout determinable local lesion. It is important in practice, by reason of its obvious influence upon diagnosis and treat- ment. Many different causes are known to be capable of producing the train of febrile phenomena which constitutes simple continued fever. Among them may be named exposure to great heat or cold, excesses in eating and drinking, mental and bodily fatigue, excitement and violent emo- tions. Children, by reason of the relative instability of their nervous organization, are much more prone to this form of fever than adults. It is a malady more frequently encountered in summer than at other seasons of the year, and is often produced by the fatigues of travel and unwonted exposure to the sun. It is not unfrequently due to the combined influ- ence of the excitement, the physical exhaustion, and the exposure to the ' Clinical Medicine. 1879. • Sunstroke and Thermic Fever. Boylstou Prize Essay, 1871. SIMPLE CONTINUED FEVER. 6 direct ravs of a mid-day sun, which are attendant npon surf-bathing. Many cases of simple continued fever occurred in Philadelphia at the time of the Centennial Exhibition in 1876. Citizens and strangers were alike exposed to the action of some of the most powerful causes of non- specific fever. The summer was unusually hot, the distances to be tra- versed were considerable, the fatigue of several successive days spent on the grounds of the exhibition was often beyond the sight-seer's powers of endurance. Add the excitement of mingling with vast throngs of en- thusiastic people, and at evening a hunger out of proportion to the di- gestive powers of jaded men and women, and it seems remarkable not that cases of fever occurred as often as they did, but that they were so comparatively rare. Clinical History. Simple fever begins abruptly. Prodromes are absent. Lassitude, a chill or chilliness, and a sudden rise in temperature, mark the onset of the disease. All the phenomena of fever are rapidly established. Hot skin, rapid pulse, thirst, headache, pain in the back and limbs, harass the patient from the beginning. The bowels are constipated, the urine diminished in quantity, and of high specific gravity. Except in cases due to excesses at table, and the like, vomiting is uncommon. There is loss of appetite. The tongue is white and coated. The rise in temperature is not only very rapid, it is also in many cases very great. In the course of a few hours it may reach 39.4° C. (103° F.) or even 40.5° C. (105° F.). The abruptness of the temperature rise, and the rapidity with which the maximum is reached are characteristic of this fever as compared with the other con- tinued fevers, with the exception of relapsing fever. They are only shared in by some forms of malarious fever (intermittent), variola, measles, and pneumonia.' The continuance of the fever is usually of short dura- tion. In a few "hours, or a single day, defervescence sets in and the tem- perature speedily falls to the standard of health — an instance of crisis. On the other hand, the fever may be prolonged through two, three, four, or, as has been pointed out above, to ten or twelve days, the normal body-heat being regained by several days of gradual defervescence — li/sis. The defervescence is often marked by copious perspiration, but this is not always the case. It is sometimes attended by vomiting or diarrhoea, by a copious deposit of lithates in the urine, or by epistaxis, or hemorrhage from the uterus or rectum.' Simple continued fever is attended by no constant or characteristic eruption. ' Aitken : Science and Practice of Medicine. Third American edition. 1873. - Murchison : The Continued Fevers of Great Britain. Second edition. 1873. 4 TU.K CONTINUED FEVERS. An eruption of liorj)es about tlie lips and nostrils is often observed at the close of the attack. Convalescence is rapid. Murchison describes four varieties of this form of fever, as follows : I. Abrupt seizure with chills or rigors ; the febrile action high ; quick, full pulse ; hot skin ; white, furred tongue ; great thirst, and no appetite ; constipation; scanty, high-colored urine; intense headache, with sometimes restlessness, sometimes drowsiness ; pains, as from bruises, in the limbs. The attack comes to an end in twelve, twenty -four, or thirty -six hours, and is properly called Ephemera. II. , The pyrexia is occasionally prolonged over several days — rarely, however, exceeding ten. The pulse is frequent, full, hard, and bounding ; thirst and the heat of skin are intense ; headache is sharp and distressing; delirium sometimes occurs. Termination abrupt, with copious perspira- tion. This is the Synocha, or Inflammatory Fever of English writers of the last century. It is separable from ephemera only by the difference in duration. III. The Ardent Continued Fever of the tropics, as observed by Dr. Murchison among the European troops at Calcutta in 1853, and in Burmah in 1854, appeared to be merely an exaggerated form of the now rare synocha of Britain. Young, plethoric persons not yet acclimated were chiefly attacked. The fever prevailed during the hot, dry months, when the mercury usually ranged from 33.3° C. (92° F.) to 41° C. (10G° F.) and never fell below 29° C. (84° F.). The symptoms in many cases com- menced after incautious exposure to the sun. A chill, or occasionally nausea and vomiting, ushered in the attack. To these speedily succeeded the frequent, full pulse, burning skin, flushed face, giddiness, intense headache, ringing in the ears, intolerance of light, restlessness, and sleep- lessness, which mark a difference from synocha in degree rather than any difference in kind. Abovit the fourth or fifth day active delirium set in, followed by more or less unconsciousness, with contracted pupils and sometimes complete coma. Between the sixth and ninth days death took place, the patient remaining comatose to the end, or a copious perspira- tion occurred, followed by an increased flow of urine depositing copious urates, and convalescence. The subsidence of the fever was in some in- stances followed by sudden, or even fatal collapse. IV. The term Asthenic Simple Fever is suggested by Dr. Murchison for a variety of the form of continued fever under consideration, in which the febrile action is less intense and the duration more prolonged than in the varieties above mentioned. The patient loses appetite and strength; the pulse is frequent, but rather feeble than tense ; the tongue is slightly furred; the bowels are confined; some headache is present, and sleep is disturbed. These symptoms may extend over a period of two or three weeks without change, except as regards the patient's strength, which gradually fails. Such attacks have been known to follow «rreat bodilv or SIMPLE CONTINUED FEVER. mental fatigue. It is to be borne in mind that these cases are never fatal, and that enteric fever often presents the collection of symptoms just de- scribed. The following case, observed and narrated by Prof. Flint, is a typical example of febricula as it is usually seen in childhood in the United States : A child, six or seven years of age, while playing out of doors, apparently in perfect health, at noontime complained of illness and was taken home. Soon afterward the axillary temperature was 104" F. There was no evidence of any local affection; no remedies were prescribed. At midnight the fever was diminished, after seven hours it was slight, and at noon the thermometer showed absence of fever. There was no return of the febrile condition, although no preventive treatment was employed, and the usual health was at once regained. Analysis of Symptoms. The temperature. — The suddenness of the rise — and the rapidity with which the maximum, 39.4° C. (103° F. ) or 40.5° C. (105° F.), is reached, have been pointed out. In cases terminating by well-marked crisis with criti- cal discharges, either in the common form of copious perspiration or from the bowels, the decline of the temperature is never so rapid as its oncom- ing. In cases of longer duration the fall usually takes the form of a pro- longred and o^radual defervescence. The circulation. — The pulse is in almost all cases frequent and full. In the severer forms it is usually tense and binding. The digestive system. — The tongue is white, furred; thirst is constant, often distressing ; loss of appetite is usually complete ; the bowels are, as a rule from which there is little variation, constipated till the termina- tion of the attack; vomiting, save in cases brought about by excesses in eating or drinking, and occasionally at the onset of the severe variety of the fever met with in the tropics, is uncommon; it occurs in some cases as the febrile action subsides. The ttrine. — It is diminished in quantity, dark in color, and of very high specific gravity, 1030-1035, with increase of solids, and particularly of urea. It presents the very type of febrile urine.' With the decline of the temperature the volume of urine speedily augments, and copious de- posits of urates occur. Albuminuria does not occur. In six cases, exam- ined by Parkes, throughout the whole course of the disease the urine was never albuminous. Tlie skill. — The face is flushed, the surface hot and dry. There is no characteristic eruption. Occasionally an erythematous blush is to be ob- ' Parkes on the Urine. 1860. b THE CONTINUED FEVERS. served upon the loins and thighs; it disappears with the fever. The; eruption of herpes upon the lips and nose is so common at the close of] simple continued fever that this disease has by some persons been called Herpetic J'ever. 7'Ae nervous si/stem. — Chills or rigors are rarely absent at the onset,] except in young children. Headache is a constant symptom. It is acutej Fig. 1.— Temperature in Simple Continued Fever. (Wuuderlich.) Fig. 2.— Teiiipcrat\iro in Simple Continued Fever ; more gradual defervescence. (.Wunderlich.) in character, and is sometimes described as throbbing or darting. It is in severe cases intense. Delirium may follow it. Restlessness and sleep- lessness are cominon ; on tlie other hand, the patient is in some instances dull and drowsy. ]n the variety above described as the ardent fever of SIMPLE CONTINUED FEVER. 7 hot climates, giddiness, intense headache, ringing in the ears, intolerance of light, muscae volitantes, restlessness and inability to sleep, pass into delirium, to be followed by stupor with contracted pupils, and this con- dition may deepen into coma, in which the patient dies. Duration. The whole sickness, as in the case of the child seen by Prof. Flint, a,bove narrated, frequently does not last more than a few hours. Its du- ration, in the mild form of simple continued fever usually encountered in the temperate climates, is from three or four to six days, rarely longer than ten. Several cases seen by the writer in the summer of 1876, in Philadelphia, came to an end with free perspiration about the sixth day. The variety characterized by less active fever, and described as asthenic, may continue two or three weeks. Diagnosis. It is obvious, from what has, been stated, that the diagnosis of simple ■continued fever cannot in all instances be positively established. This statement is not only true of the disease when seen early, but it is also true in some cases after the fever has come to its close and the patient has regained his health. A doubt, arising from the absence of sufficient evidence, must under some circumstances remain in the mind of the can- did practitioner as to whether the case has been in fact a simple non-spe- cific fever, or a mild, abortive, not well-characterized instance of one of the specific fevers. In order to arrive at a satisfactory diagnosis of simple con- tinued fever, the following considerations are to be taken into account: The occurrence of the fever after events that are thought to be ade- <[uate to cause it, as exhausting over-exertion, exposure to heat, excesses at table, and the like. The absence of any discoverable local inflammation, or of the history of any recent injury. The abrupt beginning, without prodromes; the rapid temperature-rise. The early severity of the febrile symptoms, commonly greater at the com- mencement than in either enteric fever or typhus, may sometimes aid in diagnosis. The duration, commonly short. The absence of eruption. Constipation and the absence of the abdominal symptoms of enteric fever. The absence of joint-pains, of jaundice, of the enlargement of the liver and spleen, which are early present in relapsing fever. Its sporadic occurrence and the absence of epidemic diseases. THE CONTINUED FEVERS. Prognosis and Mortality. The prognosis of simple continued fever in temperate climates is in the highest degree favorable as regards a complete recovery. Death rarely if ever occurs. There are no sequels, and perfect convalescence is rapid. Deaths reported as due to this cause are probably the result of enteric fever with latent abdominal symptoms. In the tropics simple fever becomes a formidable and frequently fatal disease. The post-mortem examinations conducted by Dr. Murchison in India revealed " great congestion of all the internal organs, particularly of the lungs, liver, and spleen. The right side of the heart vv^as full of firmly coagulated blood. The sinuses of the brain, and the pia mater vpere also very vascular, and occasionally there was an increased amount of intra- cranial fluid." Martin' speaks of "congestive states of the cerebro-spinal organs." No characteristic lesions are met with. Treatment. The diagnosis of simple continued fever being established, no special treatment is required in temperate climates. The disease tends to recov- ery. Neither complications nor sequels are apt to occur. The sufferings of the patient may be, however, greatly mitigated b}'^ judicious sympto- matic treatment. A purge, to be followed by saline diaphoretics and diuretics, may be ordered. Sponging the surface with cold water, or vinegar mingled with water, is grateful. If the arterial excitement be great, with a full, bound- ing pulse and throbbing head, aconite may be given in the form of the tincture of the root, gtt. j. — iij., q. s. h., the effect upon the pulse being closely watched. Restlessness and vigil may be relieved by the bromides or by chloral hydrate in gramme doses (gr. xv.), p. r. n. Thirst calls for the unstinted use of the alkaline aerated waters, Apollinaris, seltzer, Vichy, carbonic acid water; weak iced tea with lemon-juice is an ac- ceptable draught. By reason of the short duration of the fever in most cases, the supporting diet is not called for; custards, blanc-mange, jellies, and light broths, are all that the patient requires till with the deferves- cence appetite returns. The happiest results have seemed to follow, in my own practice, the treatment of ephemera and febricula in children by purgation, followed by the frequently repeated administration of small doses of chloral hy- drate 0.06 — 0.20 gramme (gr. j. — iij.) quoque hora vel q. s. h., with cool 'James Renald Martin, F.R.S.: The Influence of Tropical Climates. Ne-w edi- tion. 1856. SIMPLE CONTINUED FEVER. 9 drink as craved. But it is to be borne in mind that the inherent tendency of the sickness is to a speedy, and — as compared with other fevers — an abrupt termination, and that its course is in childhood ahnost always of brief duration, so that the most guarded deductions are to be drawn as to the apparent success attending measures of treatment aimed at cutting short the duration of the attack. There exists no doubt of the value of treatment in alleviating the urgency of some of the more distressing symptoms. Quinine, the mineral acids, a nutritious, readily digested diet, and wine are indicated in the so-called asthenic variety of simple continued fever. The ardent fever of the tropics demands, from its intense pyrexia and the urgency of the danger to life, energetic anti-pyretic measures. Cold affusion — the effect upon the temperature being carefully watched, ice- water enemata, quinine, digitalis, jaborandi, are remedies that would ap- pear to be most likely to do good in a disease often fatal by the very in- tensity and persistence of the fever-process, and the effect of the high temperature upon the tissues of the body, and more particularly upon the blood and the nervous system. This variety of simple fever is scarcely less closely allied to sunstroke in its pathology than in its causation, and demands, in fact, analogous therapeutic measures. n. INFLUENZA. Definition. — A continued fever, usually of mild intensity, occurring only in widely extended epidemics, and due to a specific cause; it is essentially characterized by early catarrh of the mucous membrane of the respiratory tract, and in many cases also of the digestive tract; by quickly oncoming debility out of proportion to the intensity of the fever and the catarrhal processes; and by serious nervous symp- toms. There is a strong tendency to inflammatory complications, especially of the lungs; uncomplicated cases are rarely fatal except in feeble and aged persons. The attack does not confer immunity from the disease in future epidemics. Synonyms. — Febris catarrhalis; Defluxio catarrhalis epidemicus; Catar- rhus a contagio; Rheuma epidemicum; Cephalalgia contagiosa; Epi- demic catarrhal fever; Tac; Horion; Quinte; Coqueluche; Ladendo, also written La Dando; Baraquette; Generale; Coquette; Cocote; Allure; Follette; Petite poste; Petit courier; Grenade; La grippe; Ziep; Schaffhusten and Schaffkrankheit ; Huhner Weh; Blitz-Ka- tarrh; Modefieber; Mai del Castrone. There are also several names indicating its supposed origin; thus, it has been called in Russia "Chinese catarrh;" in Germany and Italy, "the Russian disease;" in France, " Italian fever," " Spanish catarrh," and so forth. Of these names several are scientific, but the most are popular. The latter seem to be in many instances the more expressive and important. It is indeed a remarkable fact that in two instances at least the popular name for the disease under consideration has found its way widely into medicine and medical literature, almost to the exclusion of the studied terms by which science has sought to designate it; these are " influenza" and " La grippe." I have omitted from the list of synonyms such obsolete and now meaningless terms as Peripneumonia notha (Sj'denham, Boerhaave), Peri- pneumonia catarrhalis (Huxham), Pleuritis humida (Stoll), as being of INFLUENZA. 11 interest rather to the student of medical history than to the student of medicine. Febris catarrhalis, defluxio catarrhalis, catarrhus epidemicus, rheuma epidemicum, are terms which retain with difficulty the place given them in the literature of influenza by the medical authorities of a past century. Catarrhus a contagio (Cullen) and cephalalgia contagiosa are derived from a view of the nature of the disease which has been the cause of much controversy, and which must, as will be shown farther on, be now re- garded as settled by a compromise. Epidemic catarrhal fever is, with its Latin equivalent, perhaps the most satisfactory of the so-called scientific names for the disease. In the popular names for the affection there is to be noted an indica- tion of the natural character of some, at least of the peoples who have suffered from its frequent visitation. Among the English it is known as cold, or epidemic cold, or, in deference to medical authority, as catarrh, or epidemic catarrh, and at present, both among the folk and with doc- tors, as influenza. Englishmen are not then either quick to see in the disease a resemblance to some common circumstance or thing, nor are they disposed to make a joke about it. The Germans find obvious resemblances. In the labored respiration and the character of the cough they find a suggestion of a common epi- zootic affecting the sheep; hence Schaffhusten (sheep-cough) and Schaff- krankheit (sheep-sickness); or, because the cough is like the crowing of a cock and the disturbance of respiration and the rapid prostration suggest some resemblance to a common disease of the domestic fowl, it has been called Huhner Weh (chicken-disease, whooping-cough), and Ziep, which is about equivalent to " pip." They call it also, from its rapid invasion, Blitz-Katarrh (lightning catarrh) and Modefieber (the fever in vogue). But the French make a jest of everything, and the more serious the subject the better the joke. Hence, they have found a new name for almost every great epidemic of influenza, and each more trivial than the last. Hence, tac (rot); horion (in jest, a blow); quinte, because the spells recur at intervals of five hours (sic) ; coqueluche (a hood, or cowl), from the cap worn by those suffering from the malady; and so on through the long list given above. La grippe is from the Polish chrypka (Raucedo) ; it is thought, how- ever, by some writers, to be derived from agripper (to seize). Influenza is of Italian derivation. It is said that the disease received this name because it was attributed to the " influence " of the stars, or from a secondary signification of the word indicating something fluid, transient, or fashionable. 12 THE CONTINUED FEVERS. Historical Sketch. Epidemics of influenza have been clearly recorded only since the be- ginning of the sixteenth century. There are numerous accounts of earlier epidemic diseases resembling it, but they are neither sufficiently particu- lar nor distinctive to warrant us in inferring its undoubted existence from them. It is supposed to be referred to by Hippocrates, who yet gives no exact description.' An outbreak in the Athenian array in Sicily (415 B.C.), recorded by Diodorus Siculus, has been supposed to he influ- enza. In spite of these statements, and those of others to the effect that it is a disease known from a remote antiquity, it may be said that no accounts can be confidently established, as referring to the disease now known as influenza, in the writings of classical antiquity." As early as the ninth century several epidemics of catarrhal fever, Italian fever and the like, which were probably influenza, were made mat- ter of history. In the year a.d. 837, a cough, which spread like the plague, was recorded. In 876 there appeared in Italy a similar epidemic, which spread rapidly over all Europe. It is related that dogs and birds suffered with symptoms not unlike those characterizing the affection in man. In 976, Germany and all France suffered from a fever of which the chief symptom was cough. No epidemic is noted until two centuries later, when, in 1173, a widespread malady, of which the symptoms were chiefly catarrhal, raged in Europe ; while less important epidemics of a like character are recorded as having occurred during the following cen- tury (1239-1299). Parkes states that in the fourteenth century there are to be found records of six epidemics, and in the fifteenth seven great visitations of influenza are described. Aitken * speaks of a very fatal prevalence of influenza throughout France in 1311, and of an epidemic in 1403, in which the mortality was so great that the courts of law in Paris were closed in consequence of the deaths. Influenza is mentioned in the " Annals of the Four Masters" as hav- ing prevailed in Ireland in the fourteenth century, and a disease, ex- pressed by similar symptoms, is alluded to in early Gaelic manuscripts under the name of Creatan (creat, the chest). The disease is described also in an Irish manuscript of the fifteenth century, under the terms Fu- acht and Slaodan.* The first epidemic that prevailed in the British Isles, of which any ac- ' Parkes : Reynolds' System of Medicine, vol. i. 1868. * Zuelzer : Ziemssen's Cyclopajdia of Medicine, vol. ii. 1875. ^ Aitken's Practice of Medicine, vol. i. 1872. * Theophilus Thompson : Annals of Influenza. 1852. INFLUENZA. 13 curate description remains, is that of the year 1510. The disease came from Malta and invaded first Sicily, then Italy and Spain and Portugal, whence it crossed the Alps into Hungary and Germany as far as the Baltic Sea, extending westward into France and Britain. Its track •widened over the whole of Europe from the southeast to the extreme northwest, and it is said that not a single family and scarce a person es- caped it. It was attended by " a grievous pain in the head, heaviness, diffi- culty of breathing, hoarseness, loss of strength and appetite, restlessness, retchings from a terrible tearing cough. Presently succeeded a chilli- ness, and so violent a cough, that many were in danger of suffocation. The first day it was without spitting ; but about the seventh or eighth day much viscid phlegm was spit up. Others (though fewer) spat only water and froth. When they began to spit, cough and shortness of breath were easier. None died except some children. In some it went off with a looseness ; in others by sweating. Bleeding and purging did hurt," ' Blisters were commonly employed ; two each upon the arms and legs, and one to the back of the head. The description of influenza is sufficiently clear to place the nature of this epidemic beyond all doubt. The epidemic of 1557, starting westward from Asia, spread over Europe and then crossed the Atlantic to America. It circumnavigated the globe. The malady broke out in England after a season of unusual rain and a period of great scarcity of corn, in the month of September. " Presently after were many catarrhs, quickly followed by a most severe cough, pain of the side, difficulty of breathing, and a fever. The pain was neither violent nor pricking, but mild. The third day they expectorated freely. The sixth, seventh, or at the farthest the eighth day, all who had that pain of the side, died ; but such as were blooded on the first or second day, recovered on the fourth or fifth ; but bleeding on the last two days did no service." " Some, but very few, had continual fevers along with it ; many had double tertians; others simple slight intermit- tent. All were worse by night than by day; such as recovered were long valetudinary^, had a weak stomach and hypped." Gravid women either aborted or died. This epidemic spread with frightful rapidity. Thousands were attacked at the same moment. The entire population of Nismes, with scarcely an exception, fell ill of it upon the same day. It was ex- tremely fatal. In Mantua Carpentaria, a small town near Madrid, it broke out in August, and so fatal was the bloodletting and purging which con- stituted the treatment at first, that of the two thousand persons who were bled, all died.'^ The disease raged in some parts till the middle ' Thomas Short : A General Chronological History of the Air, Weather, Seasons, Meteors, etc. London, 1749. Quoted in the Annals of Influenza. ■ Dr. Short : loc. cit. 14 THE CONTINUED FEVERS. of the following year (1558), and carried off, in Delph alone, five thou- sand of the poor. In all cases mild treatment was called for, with warm broths and speedy immersals " to recall the appetite, and keep the vessels of the throat open." In 1580 a great epidemic of influenza spread from the southeast to- ward the northwest over Asia, Africa, and Europe. From Constantino- ple and Venice it overran Hungary and Germany, and reached the farthest regions of Norway, Sweden, and Russia. It spread into England, and has been described by Dr. Short, In Italy it prevailed during Au- gust and September, in England from the middle of August to the end of September, and in Spain during the whole summer. In most places its duration was about six weeks. As a rule the termination was favora- ble, although the disease ran a somewhat protracted course. In the ac- count of Dr. Short it is stated that " few died except those that were let blood of, or had unsound viscera." In some places, on the contrary, the course of the disease was very severe. In Rome two thousand died of it, according to the author just cited, but Zuelzer informs us that the victims of this epidemic in the Eternal City were not less than nine thou- sand, and adds that Madrid must have been almost depopulated by it. This high mortality has been attributed to the bloodletting practised in the treatment of the disease. The symptoms were similar to those of the previous epidemics, with a greater shortness of breath, which continued in many cases for some time after the disappearance of the catarrhal trouble. There was great sweating at the end of the attack. The plague, measles, and small-pox prevailed also, and with consider- able violence during the year 1580.' The disease, unfelt for several years, reappeared in Germany in 1591; an epidemic, extending from Holland through France and into Italy, occurred in 1593; in IGIO, catarrh is said to have prevailed throughout Europe. In 1626-27, epidemic catarrhal fever made its appearance in Italy and France; in 1G42-43, in Holland; in 1647, in Spain and in the col- onies of the Western World, and again in 1655, in North America. According to Webster,' this epidemic of 1647 was the first catarrh mentioned in American annals. In 1658 and 1675, it again visited Austria, Germany, England, etc. The first of these two epidemics is described by Willis,' and the second by Sydenham,'' as they occurred in England, and the accounts are to be ' Theophilus Thompson : Annals of Influenza. ■ Noah Webster : A Brief History of Epidemic and Pestilential Diseases. London, 1800. ^ Dr. Willis : The Description of a Catarrhal Fever Epidemical in the Middle of the Spring in the Year 1058. Practice of Physic. 1684. ■• The Epidemic Coughs of the Year 1675, with the Pleurisy and Peripneumony that supervened. From the Works of Thomas Sydenham, M.D. INFLUENZA. 15. found in the already oft-quoted "Annals of Influenza," It is about this- period that the disease began to be known as influenza, and it is not without interest to observe that the " influence " of the stars suggested it- self, in connection with its sudden appearance and wide prevalence, to the minds of the physicians of this date. Willis writes that " about the end of April (1658), suddenly a distemper arose, as if sent by S07ne blast of the stars, which laid hold on very many together; that in some towns, in the space of a week, above a thousand people fell sick together," Epidemics are recorded as having occurred in Great Britain and' Europe in 1688, 1693, and in 1709, The disease raged in 1713 widely over Europe from Denmark to Italy. In 1729-30, a widespread epidemic swept over Europe. In five months it extended over Russia, Poland, Germany, Sweden, and Denmark. In Vienna sixty thousand persons fell ill of it. In the autumn it spread to England, and reached France and Switzerland ; from there it extended to Italy, and by February it had reached Rome and Naples. Spain did- not escape its ravages, and it is said to have found its way to Mexico. The symptoms did not differ in any important respect from those already described as characterizing previous epidemics. Pains in the limbs and fever marked the onset of the attack; catarrh, oppression, hoarseness, cough, followed. In some cases, delirium, drowsiness, and faintings oc- curred. A petechial eruption was observed, in some instances, between the fourth and seventh days. Zuelzer suggests that spotted fever may have prevailed at the same time. Turbid urine, copious sweats, bilious- stools, and nose-bleeding were often noted. In Switzerland, only children- and old persons died. The disease was not very fatal. Two years later (1733-33) an epidemic, starting from Saxony and Poland, overran Germany, Switzerland, and Holland, and invaded Great Britain in the month of December, Toward the end of January it spread in a southeasterly direction to France, Italy, Spain, and westward to- North America, thence southward to the islands of the West Indies, and on to South America, The course of the disease in this epidemic was favorable. It terminated in from three to fourteen days, with sweating,, bleeding from the nose, or an abundant discharge from the nasal passages. The aged and those suffering from chronic pulmonary diseases mostly perished. In Scotland three forms of the affection were described, namely: the cephalic, the thoracic, and the abdominal. The epidemic slowly spread over Eastern Europe and in a southeasterly direction, and may be said to have lasted till 1737. Concerning this epidemic, John Huxham, of Plymouth, wrote as fol- lows : ' " About this time a disease invaded these parts, which was the ' Observations on the Air and Epidemical Diseases. Translated from the Latin.. London, 1758. 16 THE CONTINUED FEVERS. most completely epidemic of any I remember to have met with ; not a house was free from it; the beggar's hut and the nobleman's palace were alike subject to its attacks, scarce a person escaping either in town or country; old and young, strong and infirm, shared the same fate." The malady had raged in Cornwall and the western parts of Devonshire from the beginning of February; it reached Plymouth on the 10th, which was on a Saturday, and that day numbers were suddenly seized. The next day multitudes were taken ill, and by the 18th or 20th of March scarcely any one had escaped it. "The disorder began at first with a slight shivering; this was presently followed by a transient erratic heat and headache, and a violent and troublesome sneezing; then the back and lungs were seized with flying pains, which sometimes attacked the heart likewise, and though they did not long remain there, yet were very troublesome, being greatly irritated by the violent cough which accompanied the disorder, in the fits of which a great quantity of a thin, sharp mucus was thrown out from the nose and mouth. These complaints were like those arising from what is called catching cold, but presently a slight fever came on, which afterward grew more violent; the pulse was now very quick, but not in the least hard and tense like that in a pleurisy; nor was the urine remarkably red, but very thick, and inclining to a whitish color; the tongue, instead of being dry, was thickly covered with a whitish mucus or slime; there was an universal complaint of want of rest and a great giddiness. Several likewise were seized with a most racking pain in the head, often accompanied by a slight delirium. Many were troubled with a tinnitus auriwn, or singing in the ears; and numbers suffered from violent earaches, or pains in the meatus auditorius, which in some turned to an abscess. Exulcerations and swellings of the fauces were likewise very common. The sick were in general very much given to sweat, which, when it broke out of its own accord, was very plentiful, and continued without striking in again, and did often in the space of two or three days wholly carry off the fever. You have here a description of this epidemic disease such as it prevailed hereabouts, attacking every one more or less; but still, considering the great multitude that were seized by it, it was fatal to but few, and that chiefly infants and consumptive old people. It generally went off about the fourth day, leaving behind a troublesome cough, which was very often of long duration, and such a dejection of strength as one would hardly have suspected from the shortness of the time. " On the whole, this disorder was rarel}' mortal, unless by some very great error arising in the treatment of it; however, this very circumstance proved fatal to some, who, making too slight of it, either on account of its being so common, or not thinking it very dangerous, often found asthmas, hectics, or even consumptions themselves, the forfeitures of their incon- siderate rashness." INFLUENZA. 17 Arbuthnot also described this visitation of the disease.' He regarded the uniformity of the symptoms in every place as most remarkable, and tells us that, during the whole season in which it prevailed, there was " a great run of hysterical, hypochondriacal, and nervous distempers; in short, all the symptoms of relaxation." Most observers looked upon the con- tinued changes of temperature as active in producing this widespread and long-continued epidemic. During the years 1737-38, influenza again swept over England, North America, the islands of the West Indies, and France ; in 1742-43, it pre- vailed in Western Europe and the British Isles ; in 1757-58, in North America, the West Indies, France, and Scotland. In 1761, it overran the North American Colonies and the West Indies. The epidemic of 1762 extended very generally over Europe and Great Britain. In Germany nine-tenths of the population were attacked by the disease. Widely extended epidemics prevailed in Europe and America in 1767 and 1775; in 1772 it raged in North America ; in 1778-80 in France, Ger- many, and Russia. Noah Webster found influenza prevalent in North America in 1781; the next year, one of the most remarkable epidemics of this disease (described as the epidemic of 1782) appeared in Europe. It came from the East, from Asia into Russia. From St. Petersburg it spread during the winter and spring over Sweden, Germany, Holland, and France. In the autumn it was in Italy, Spain, and Portugal. The crews of Dutch and English ships were taken ill with the disease upon the high seas. In Vienna three-fourths of the population fell ill of it with such sud- denness that it got here for the first time its name of " Blitz-katarrh " (lightning catarrh). It was characterized by great pain in the back, breast, and throat, and by extraordinary enfeeblement. Relapses occurred, and inflammation of the lungs and bowels were common. Children re- mained relatively exempt from its seizure. This epidemic broke out in England about the end of April, and raged until the end of June. "The duration of the malady in some was not above a day or two ; but it usu- ally lasted near a week or longer. In a few the symptoms seemed to abate in two or three days, but some returned and raged with more vio- lence than at first." " The disease was not regarded as in itself fatal, and few could be said to have died of it, " but those who were old, asthmatic, or who had been debilitated by some previous indisposition." Yet its in- fluence upon the weekly bills of mortality in London, where it made its ' An Essay Concerning the Effects of Air on Human Bodies. London, 1751. ^ An Account of the Epidemic Disease called the Influenza of the Year 1783. Collected from the Observations of several Physicians in London and in the Country, by a Committee of the Fellows of the Royal Colleges of Physicians in London. Read at the College, June 25, 1783. 18 THE CONTINUED FEVERS. appearance between May 12th and 18th, was so great that it seems worth while to transfer the record from the report of the College of Physicians to these pages. The total weekly returns stand thus : Tuesday, May 7th 299 " " 14th 307 " " 21st 33G " <' 28th 390 " June 4th 385 Tuesday, June 11th 560 " " 18th 437 " 25th 434 « July 2d 296 Numerous recurring outbreaks took place in Europe and America dur- ing the years 1788-90. One of these, as it occurred in America, is well described by Dr. John Warren,' of Boston, in a letter to Lettsom. This letter is dated May 30, 1790, and among other matters of great interest respecting the disease, it is stated that " Our beloved President Washing- ton is but now on the recovery from a very severe and dangerous attack of it in that city " (New York). Webster mentions an epidemic in America in 1790, one in Europe in 1795, and another in Europe in 1797; but there seems to have been no general epidemic of sufficient importance to attract the attention of other writers upon the subject until 1798, when the malady again broke out in Russia and spread over the greater part of Europe, continuing to prevail in various regions till 1803, when it again appeared in England, and is de- scribed by several writers of that country. From 1805 to 1827, influenza prevailed (according to Zuelzer, who tells us that few years during this interval were free from it) in frequently re- curring epidemics in Europe and America. Thompson mentions no visi- tation in England between 1803 and 1831. In the year 1830, began a series of epidemics remarkable for their wide diffusion and the rapid succession with which they followed one upon an- other. The disease began in China; in September it reached the Indian Archipelago; it swept into Russia, and invaded Moscow in November ; in January, 1831, it was raging in St. Petersburg ; March found it in Warsaw; April in Eastern Prussia and Silesia; in May it prevailed in Denmark, Finland, and a great part of Germany, and in the same month it fell upon Paris ; in June it affected England and Sweden ; it still was creeping about Middle Europe, and lingering in Great Britain at the end of July; in the early winter it swept southward into Italy, and westward across the Atlantic to North America, and was still harassing the inhabitants of cer- tain regions of the United States in January and February, 1832. Mean- while it continued in the East, spreading to Java, Farther India, and the ' Thomas Joseph Pettigrew ; LettBom. 1817. Memoirs of the Life and Writings of J. Coakley INFLUENZA. 19 Indian Archipelago. It continued in Hindostan after it had died out in Europe. But in January, 1833, it again visited Russia and rolled thence southward and eastward over the most of Europe. It is recorded that by February it had reached Galicia and Eastern Prussia; in March it was in Prussia, Bohemia, and Warsaw, and had extended to Syria and Egypt; in April to many parts of Germany and Austria, and to France and Great Britain. Midsummer found the disease yet prevailing in some districts of Germany and Northern Italy, and in the early autumn it was in Switzer- land and Eastern France; in November it visited Naples. Epidemics so frequent, so widespread, and so unsparing of individuals wherever the dis- ease appeared, could not fail to excite a deep and general interest. From this period the literature of the subject has been voluminous. A brief period of repose ensued. For three years no epidemic occurred which was of sufficient importance to attract the attention of medical his- torians. In December, 1837, influenza reappeared, and first, as so often before, in Russia; Sweden and Denmark were almost simultaneously affected; in January, 1837, it broke out in London, and rapidly swept over all England, and into France and Germany. In January it appeared in Ber- lin and shortly afterward in Dresden, Munich, and Vienna. The disease spread by February into Switzerland, and into Spain as far as Madrid by the end of March. In London almost the whole population was attacked, and the mortality was enormous. Dr. Bryson ' states that the deaths were quadrupled during the prevalence of the disease. Large populations suffered most. This epidemic spread into the southern hemisphere and prevailed at the same time, and consequently at exactly the opposite season that it prevailed north of the equator, in Sydney and at the Cape of Good Hope. From 1837 till 1850-51, numerous epidemics of influenza occurred. Few years were exempt from them. The epidemic of 1847-48 has been described by many writers, and more particularly, as it occurred in Lon- don, by Peacock ' with great exactitude. It is estimated that one-fourth of the entire population of that city were more or less affected by the dis- ease. The epidemic prevailed in London for six months, and although the deaths registered for the entire period, as from influenza, amounted to only one thousand seven hundred and thirty-nine, it is stated in the report of the Registrar-General that during the six weeks the epidemic was at its height, not less than five thousand persons died, in the metro- politan districts, in excess of the average mortality of the period, the ex- cess showing itself in nearly every class of disease; the local maladies ' Annals of Influenza. ' Thomas Berill Peacock, M.D. : On the Influenza, or Epidemic Catarrhal Fever of 1847-48. 1848. j 20 THE CONTINUED FEVEKS. which had been the predominant affections being doubtless, in many cases, assigned as the cause of death. This epidemic affected between one-fourth and one-half of the popu lation of Paris, and in Geneva the proportion of those attacked was not less than one-third of the entire population. More or less widespread epidemics of influenza are recorded as having' occurred in 1857-58 and 1800 ; in 1864 in Switzerland ; in 1867 in Paris in the spring ; and at various times in the United States and Canada A mild epidemic occurred in 1874, in Berlin, Influenza prevailed over a wide area in the United States during the early months of 1879. The characteristics of this visitation have been well described by Da Costa.* For the most part the disease, since the great epidemic of 1847-48, has affected a smaller proportion of the inhabitants of the localities visited, and has run a less dangerous course than in the epidemics previously de- scribed. It has for this reason occupied a less conspicuous place in the medical literature of recent years. It is nevertheless true that even in the mildest epidemics, w^hen a relatively small number of persons are seized, and the symptoms are in most cases almost insignificant, cases do here and there occur which are of a serious or even fatal character, and that the death-rate from other diseases is for the time considerably increased. Affections of a catarrhal kind have frequently prevailed among the domestic animals at the same time that influenza has been epidemic. Horses, dogs, and cats are subject to these disorders; neat cattle, goats and sheep have been more rarely affected; chickens and pheasants have suffered, and it is stated by some of the older writers that birds, and par- ticularly the sparrow, have deserted localities in which influenza was pre- vailing, while migratory birds have taken flight earlier than usual. These epizootics have sometimes preceded the appearance of influenza among men by a period of some weeks or days, in other instances they have appeared contemporaneously; and in a widespread outbreak among horses in the United States in 1873, in which the symptoms and morbid anatomy, accurately observed, were undoubtedly those of influenza, * the disease did not affect man except to a very limited extent. A want of fulness of description, and the inaccuracy of diagnosis common in the consideration of general diseases of the lower animals, leave the precise nature of most of the epizootics described by the earlier writers in great uncertainty. An extensive but mild influenza has prevailed as an epizootic, chiefly ' The Prevailing Epidemic of Influenza — Its Characteristic Phenomena — Pulmonary, Gastro-intestinal— Cerebral and Nervous — Its wide Distribution, Mortality, and Treat- ment. Medical and Surgical Reporter. Philadelphia, March 8, 1879. 2 F. Woodbury, M.D. : Morbid Anatomy of the Epizootic. Philadelphia Medica Times, December 14, 1872. I INFLUENZA. 21 affecting horses, during the latter part of the summer and the autumn of 1880, in Canada and the United States east of the Mississippi River. Dogs were also affected, but less generally, and human beings to a still slighter extent. In several localities where this invasion of the disease was ob- served by the writer, the horses were first affected, the dogs next, and after the lapse of some weeks, as the animals were recovering, it became epi- demic; but those persons who took care of horses, and were much in con- tact with them, neither suffered earlier nor more severely than others not so exposed. Etiology. 1. Predisposing Causes. Large as has been the place in medical literature occupied by the histories of epidemics of influenza, the nature of the " epidemic influ- ence " which gives rise to the disease is still unknown. There are no well-established facts upon which to base the existence of individual peculiarities that may be regarded as predisposing causes. When the disease appears, a large proportion of the population is attacked without distinction of age, sex, social condition, or occupation. Previous illness, whether acute or chronic, local or constitutional, affords no pro- tection. Aged and infirm persons, and those of nervous temperament, are thought to be especially liable to attack; but the robust possess no immu- nity. All races and dwellers in every climate are the victims of influenza. In a community invaded by the disease, females are apt to be the first at- tacked, the adult males next, and the children last. It has been observed that in some epidemics children are but little liable to be attacked. An attack in one epidemic confers no exemption from the disease in another epidemic, and, independently of relapses, which are not infre- quent, persons have been known to experience a second attack during the prevalence of the same epidemic. Persons dwelling in overcrowded and ill-ventilated habitations, and in low, damp, and unhealthy situations, have in certain epidemics especially suffered, and, according to the report of the Registrar-General, the increase of deaths by influenza during the epidemic of 1847, in England, was much greater in the districts in which there is ordinarily a high mortality than in healthier places. This, as Dr. Parkes observes, must indicate greater prevalence or greater severity of the disease. Influenza appears at all seasons of the year, and affects every latitude, though it is somewhat more common in cold climates. It has no connec- tion with known atmospheric conditions. Many of the earlier writers sought to establish a causative relation between low temperatures and sudden variations of temperature and influenza, and, by reason of the 22 THE CONTINUED FEVERS. confusion in the minds of the people between the disease and common "colds," there has always existed an opinion that such a relation obtains. There is no evidence to sustain this view, and all the later writers upon this subject concur in the statement that neither low temperature nor abrupt changes give rise to the affection. It has prevailed in hot and dry seasons, in the West Indies, on the sea-coast of Java, in India, in Egypt, at the Cape of Good Hope, in the Riviera in summer. The condition of the air, as regards moisture or dryness, does not influ- ence the spread of the disease. It has occurred at sea, on low sea-coasts, and in the dry air of Upper Egypt. Prolonged east and northeast winds have often prevailed at the time of influenza. This fact is in accord with the observation that many epi- demics have extended from east to west and southwest, as, for example, from Russia over Europe. The spread of the disease is, however, not in- fluenced greatly by local winds. It does not move with the same velocity, and even sometimes moves against them. In several well-authenticated instances a dense and foul fog has preceded or attended the outbreak of epidemics. The much greater number of epidemics that have occurred altogether without such manifestations make it in the highest degree probable that this has been a coincidence. Ozone in large quantities, artificially produced, may give rise to the symptoms of ordinary catarrh, but it is not a cause of influenza. The disease is not in any way con- nected with the condition of the soil, elevation, volcanic eruptions, or any other local cause. The history of every epidemic goes to prove this state- ment. Moreover, without this assumption, its diffusion over whole coun- tries and continents — indeed, over several quarters of the globe — would be beyond our comprehension. Before taking up the consideration of the exciting causes of influenza, it is necessary to state the known facts concerning the march of epidem-' ics and the spread of the disease in affected localities. It has prevailed with greater or less frequency in most parts of the world. Epidemics have recurred at irregular periods. It was at one time thought that the course of the disease was cyclical, with a return at intervals of about one hundred years. This view was long ago proved to be unfounded. About every twenty-five or thirty-five years great epidemics have swept over vast areas of the globe, and influenza may be said to be, at such times, pan- demic. Less widely extended epidemics have taken place with greater or less frequency in the intervals of the great outbreaks. But it is not possible to establish anything like a cycle by which the returns of the disease are governed. It has been supposed in some instances to prevail within restricted localities, as, for example, in a single city, but it is probable that such local epidemics are due to local causes, and that they are of the nature of simple ordinary catarrhal fever, rather than true influenza. INFLUENZA. 23 The epidemics extend in great areas, usually in a direction from the east or northeast toward the west and south. At other times they take the opposite direction, and in some years they have appeared to radiate in various directions from several centres. It is in consequence of these facts in reo-ard to the spread of influenza, that two views have arisen in the minds of scientific men concerning the origin of the affection. The first of these is that each epidemic starts out from some single unknown source, and spreads thence from point to point, invading more distant lo- calities successively as it advances, until at length it dies out in regions most remote from the starting-point. This opinion is in accord with the popular belief. Thus, the Italians have called it the German disease; the Germans, the Russian pest; the Russians, the Chinese catarrh; and the geographical relation of these nations indicate the usual track of the great epidemics, as shown in the foregoing historical sketch. The other opinion is that it arises not from a single place, but may start anywhere, and that a widespread epidemic may be due to the suc- cessive outbreak at many distinct points of origin. The evidence that the great epidemics of influenza are due to some gen- eral and pandemic influence, is to my mind conclusive. The point of origin of the great epidemics has not yet been indicated with precision, and must remain beyond conjecture until further facts bearing upon the question of their source are brought to light. When it has prevailed over a large portion of the earth's surface, its progress from place to place has usually been rapid. In this respect, how- ever, the epidemics show a great diversity. It sometimes travels exceed- ingly slowly. It is said to have overrun Europe in six weeks, and it has again taken six months to do so. It sometimes attacks places widely remote from each other within short intervals of time, and it has appeared at the same time in different quarters of the globe. It does not follow the great lines of travel and commercial intercourse. When the influenza enters a city, it continues to prevail, as a rule, from four weeks to two months, but exceptionally it remains a longer time; for example, the epidemic of 1831 was prevalent in Paris for the greater part of a year. It in all instances finally disappears, and sporadic cases do not occur in the intervals of the epidemics. In rare instances, however, the epidemics are heralded by sporadic cases. But commonly they seize simultaneously upon numbers of the in- habitants of affected districts, so that, when the epidemic is severe, the sick are in a short time to be counted by thousands, and business is par- alyzed as by a blow. They rapidly reach their height and subside almost as suddenly as they began. In a large city the disease frequently, per- haps always, makes its appearance nearly at the same time in several different localities, affecting certain streets and quarters solely or more generally than others for a time, and spreading thus from several centres 24 THE CONTINUED FEVERS. through the entire community. Large towns and cities are generally affected earlier than the villages around them, and the latter, though closely adjacent, sometimes escape for weeks. The crews of ships upon the high seas, not sailing from an infected port, are said to have suffered from the seizure, and epidemics have crossed the Atlantic from the Old World to the New, and in some instances in the opposite direction. 2. The Exciting Cause. The question of the contagiousness of influenza is one of grave interest, and has been the subject of much controversy. The great rapidity of the spread of epidemics, the vast areas they overrun, the fact that they do not follow the lines of human intercourse, the suddenness with which great numbers of the inhabitants of an invaded district or city are seized, the fact that the most complete seclusion from intercourse with affected persons, or even the shutting up of houses, affords in most instances no protection whatever, all go to show that the disease spreads, in the main, independently of direct contact, and this opinion has been almost univer- sally entertained. On the other hand, there is evidence to show that the disease is to some extent contagious; and so convincing have the facts bearing upon this point appeared to some, that they have believed it to be propagated entirely by human intercourse. Haygarth ' declares, as the result of his observations during the epidemics of 1775 and 1782, that the influenza spreads " by the contagion of patients in the distemper; " and Falconer,' writing of the epidemic of 1803, says, " I have no doubt that it is contagious in the strictest sense of the word." Watson ^ regards the instances in which the complaint has first broken out in those particular houses of a town at which travellers have arrived from infected places, as too numerous to be attributed to mere chance. Very often those dwell- ing near the invalids are attacked next in the order of time, and when the disease affects a household all do not usually manifest the symptoms at the same time, but one member after another is stricken down with it. In some rare cases the isolation or seclusion of a community has ap- peared to give protection, as in cloisters, prisons, garrisons, and the like ; at all events, there are instances on record where segregated communities of this kind have escaped attack. This is, however, merely negative evi- dence, and cannot carry conviction. ' John Haygarth, M.D., F.R.S. : On the Planner in which the Influenza of 1775 and 1782 Spread by Contagion in Chester and its Neighborhood. 'William Falconer, M.D. . F.R.S.: An Account of the Epidemic Catarrhal Fever, Commonly called the Influenza, as it appeared at Bath in the Winter and Spring of the Year 1803. Bath, 1803. ' Principles and Practice of Medicine. INFLUENZA. 25 A recent, carefully conducted observation, under somewhat unusual circumstances, shows that influenza may be brought from an infected city in such a way as to give rise to a localized outbreak in a remote commu- nity, in which, however, the disease, in the instance under consideration, did not become epidemic. Drs. Guiteras and White ' narrate that, influenza prevailing in Europe, and particularly in Paris and London, an American gentleman in bad health contracted the disease in London, improved, suffered a relapse shortly afterward in Paris, and died there at the end of December, 1879. His body was embalmed and sent home. Following the exposure of the remains of this person to the view of his family in Philadelphia, there was an outbreak of influenza with characteristic symptoms, which affected, in the first place, members of that family; afterward, friends living in close intercourse with them, next the medical attendants of some of them, and finally the housekeeper, and a patient or two of one of the physicians who wrote the paper, the whole number affected in Philadelphia being eighteen, at the time of the publication of the account. Subsequently two or three other cases were developed, but the disease did not extend beyond the immediate circle of those in direct communication with the invalids. Between those holding the opinion that influenza is not contagious, and those imbued with the opposite view, there must be, it seems to me — regard being had to the foregoing facts — a compromise of the question which is to be based upon the degree of contagiousness. This will be conceded by all modern authorities to be but slight. Influenza has been supposed to develop at once without a period of incubation, persons in perfect health being struck down with it as by lightning-stroke. It is now ascertained that a period of incubation, vary- ing from a few hours to several days, and usually without subjective symptoms, exists. Numerous instances are recorded in which persons coming into an infected city have remained well for one, two, or three days, but have eventually shared the sufferings of those into whose midst they had come. There are cases also in which the period of incubation could not have been less than two or three weeks. There is no sufficient evidence of a genetic or causal relation between influenza and any other epidemic disease. The statement that other prevalent diseases abate in frequency and intensity upon its outbreak, is not borne out by well-ob- served facts. Graves ^ holds that those suffering with acute diseases are less liable during the febrile stage, but that they are attacked as conva- lescence sets in. ' John Guiteras, M.D., and J. W. White, M.D. : A Contribution to the History of Influenza; being a Study of a Series of Cases. Philadelphia Medical Times, April 10, 1880. ' Clinical Medicine. 26 THE CONTINUED FEVERS. Some writers have thought that an attack of influenza may degene- rate into intermittent fever. It is more probable, that the instances observed were endemics of intermittents, making their appearance upon the subsidence of epidemics of influenza. The facts in reference to the spread of epidemics of influenza and the course of the disease in infected localities, are comprehensible upon no other theory than that of a specific principle of disease as its exciting cause. What this principle may be, is not yet known to us ; where it originates is equally unknown, and our knowledge of the influences that from time to time call it into activity, and send it forth in definite direc- tions over the earth, is no less negative. So general a disease can only be disseminated by the most general medium, the atmosphere, and its exciting cause must be capable of repro- ducing itself in that medium; otherwise it would be lost by dispersion in traversing distances measured by the boundaries of continents and oceans. The rapid diffusion of influenza, sweeping over continents in a few weeks at one time; its slow migration, creeping about a city and its environs for months at another, are, as Biermer ^ suggests, to be most easily ex- plained upon the theory of a living miasm, capable of being transmitted by the air, and possessing at the same time an independent existence. Such an entity would find certain localities more favorable to its growth, reproduction, and prolonged existence, than others. From this point of view influenza is a miasmatic disease. From a fair consideration of what has been written concerning its local dissemination, it must be admitted that its causes are, to a slight ex- tent, capable of being reproduced in or about the human body, and trans- mitted by personal intercourse, as well as conveyed from place to place by the persons or clothing of those affected, or travelling from localities in which the disease prevails. We are thus led to the conclusion that it is also contagious, though feebly so. Influenza, in view of these theories of its exciting causes, may be de- scribed as a miasmatic-contaffious fever. Clinical Histoby. The course of the disease, in individual cases, presents the greatest variations as regards intensity, from the most trifling indisposition to an illness of the gravest kind, terminating in death. These variations are dependent upon: 1st, the previous health of the in- dividual, his age, and the power of resisting depressing influences which he ' Biermer : Virchow's Handbuch der speciel. Pathologie u. Therapie. Band V. Ite Abth. 4tc LiefcruDg. Erlangen, 1805. s I I INFLUENZA. 27 possesses; 2d, the energy and the amount of the specific cause of the dis- ease to which he has been exposed — in other words, the dose of the fever- producing poison; and 3d, the character of the prevailing epidemic. It is, however, important to observe that, as has already been stated, cases of very great severity are occasionally encountered during the preva- lence of mild epidemics. In every epidemic, on the contrary, a considerable part of the commu- nity suffers from influenza in the mildest, or what has been called the " rudimentary " form. This is characterized by general " malaise," an easily oncoming weariness of bodily and mental effort, a disinclination for business, some inability to fix the attention, and slight mental confusion; to these nervous disturbances are added slight catarrhal symptoms, as coryza, sore throat, a tickling cough, and the like; but the indisposition is subfebrile — it does not amount to a fully developed fever. Another portion of the cases in most epidemics present the symptoms of an ordinary attack of acute coryza, laryngitis, bronchitis, pharyngitis, with great increase in the constitutional disturbances, distresuing head- ache, and pains in the back and limbs. The fever in this class of cases does not range high, yet the patients are ill enough to betake themselves to bed. The onset of the attack in severe cases is usually abrupt. It begins with shivering or a chill, or with fits of chilliness alternating with heat. Fever is rapidly established. It is usually moderate, though it sometimes reaches a high grade. It shows a tendency to morning remissions. Sen- sations of chilliness are apt to occur; they are called forth by even slight changes in the external temperature. These chilly sensations are apt to be followed during the course of the fever by the sensation of flushes of heat, and are, in many cases, attended by annoying sweats. The febrile outbreak is sometimes preceded for a little time by intense frontal headache, with pain in the orbits and at the root of the nose. In other cases these pains quickly follow the chill. Sneezing, redness of the eyes and edges of the nostrils, a more or less abundant thin discharge from the nose, and lachrymation, now occur. In some instances there is bleed- ing from the nose. The throat becomes sore, there is a tickling sensation in the upper air-passages, a dry cough sets in, attended by more or less hoarseness and shortness of breath. The cough is paroxysmal, hard, dis- tressing. It sometimes causes vomiting, like that which occurs in the paroxysms of whooping-cough. Chest-pains, stitches in the side (not pleuritic), frequent sneezing, loss of the sense of smell and of taste, attend the development of the general catarrhal manifestations. The fever is attended by great depression, pains in the limbs, loss of appetite, thirst, constipation, and diminished secretion of urine. The pulse is full, but, as a rule, only moderately increased in frequency. There is in many cases slight, or even decided blueness of the lips and finger- 28 THE CONTINUED FEVERS. tips. The patient is distressed by restlessness and want of sleep. At the end of four or five days the febrile symptoms decline, at times gradu- ally, oftener rapidly, with copious sweats or spontaneous flux from the bowels. The fever continues, however, when severe complications have taken place ten or twelve days. The defervescence is marked by an in- creased flow of sedimentary urine, and considerable amelioration of the subjective symptoms. The catarrhal symptoms outlast the fever two or three days, but cough and expectoration may not disappear for some time. Attendant upon these symptoms and proportionate to the severity of the fever or the catarrh, or both, that is to say, in proportion to the grav- ity of the attack in general, are the evidences of functional disturbance of the nervous system. There is remarkable nervous depression, loss of strength and lowness of spirits, combined with mental weakness, and even stupor and delirium. In some cases slight convulsions take place. Cu- taneous hvperassthesia occasionally occurs, and Da Costa states that areas of burning pain in the skin are to be met with. Neuralgia, muscle-pain, and aching referred to the bones, are very common and often severe. In other cases abdominal symptoms are prominent, while those refer- able to the head and chest are less urgent. The disease assumes the guise of a more or less severe catarrh of the gastro-enteric mucous mem- brane, with hepatic disturbance. The fever and the peculiar nervous de- pression, spoken of in the foregoing account of the course of the affection, are the same. Cases likewise present themselves, but less commonly, in which but little of the usual tendency to localization of the catarrhal pro- cesses is to be observed; there is fever of varying intensity, with great depression, and simultaneous and equal implication of the head and the organs of the chest and abdomen. Many writers have sought to arrange the foregoing different forms of influenza in definite categories. It would be a useless task to reproduce their views upon the subject, or even to enumerate the varieties that they have described. In truth, it is open to doubt whether it would serve any useful didactic purpose to do so, while in practice the various de- scribed types merge so gradually into each other, and are so modified by the individual peculiarities of the sick, and by the complications which arise in the course of the attack in consequence of such peculiarities or of previously existing diseases or tendencies to special forms of disease, that particular cases cannot in most instances be referred to theoretical cate- gories. In illustration of this remark, it is to be stated that h\'sterical persons and those of what we may term a nervous constitution, are prone to suffer especially from the peculiar nervous symptoms of influenza. So also the disease is modified by the age of the subject of the attack, and children manifest, in a high degree, the signs of cerebral congestion, while old persons are subject in a peculiar manner to dangerous pulmonary INFLUENZA. 29 complications, and those of a gouty or rheumatic constitution suffer from muscular pains more than others. The duration of the mildest form of influenza is from two to three days; in well-developed cases without complications, convalescence sets in between the fourth and tenth days, and severe cases with complications may last much longer — several weeks elapsing before recovery is com- plete. Analysis of the Symptoms. For the purpose of separate consideration, it will be found convenient to take up the symptoms belonging to the fever first, then those of the special catarrh, and finally those more particularly referable to the ner- vous system; but we encounter, in the present state of our knowledge of the pathology of influenza — or it would be perhaps better to say, our igno- rance of its pathology — no little difficulty in deciding under which of these headings particular symptoms are properly to be classed, by reason of the close interdependence of the chief processes of the disease and the anoma- lies of its phenomena viewed as a whole. THE FEVER. Temperature. — The older observers concluded, from the diminished frequency of the pulse by day as compared with that of the night, the less urgent subjective symptoms and the relatively cooler skin, that the type of the fever was remittent or subcontinuous. This is doubtless the case, although accurate thermometric observations, by which alone the type of any fever can be with certainty established, are as yet, even in the most recent epidemics, wanting in sufficient numbers to enable us to formulate any law. The intensity of the fever-process is variable. As a rule it is mode- rate or slight ; occasionally it is intense. I observed, in several cases during the epidemic of 1879 in Philadelphia, an evening temperature of only 39° C. (102.2° F.). Da Costa, in the same outbreak, found the febrile movement not high ; the highest temperature he observed was 40° C. (104° F.). Biermer found a temperature of over 39° C. in moderate cases of catarrhal fever, and does not doubt that under certain transient conditions the temperature may reach the height of that of pneumonia or typhus. In weakly persons and the aged, the fever is adynamic. The circidation. — The pulse is variable. Its frequency is moderately increased ; it is sometimes full, sometimes weak. It has no constant character. Some observers have noted a frequent irregularity. Graves informs us that in many cases the condition of the pulse was very change- 30 THE CONTINUED FEVERS. able, and that it often became quite dilTerent in character in the course of a few hours. The secretions. — The urine is usually diminished, sometimes its secre- tion is temporarily suppressed. It often shows but little change, but is more commonly, as in other fevers, concentrated and high-colored. It deposits, on cooling, a sediment of urates, which toward the close of the fever is often very abundant. The defervescence is in many instances attended by a copious secretion of urine. Exact observations as to the composition of the urine in twenty-four hours are wanting. At first the skin is hot and dry ; sometimes frequent sweats occur, free sweating generally marks the febrile remissions, and the deferves- cence not rarely sets in with copious, acid, ill-smelling sweats. In some cases the tendency to sweat shows itself early and continues throughout the attack. Sudamina occur in great numbers. An outbreak of herpes about the lips is occasionally seen. The digestive system. — Disturbances of the digestive tract are more or less prominent in almost all cases. Only in the rudimentary and sub- febrile forms, and even then most rarely, are they absent. In many cases they are such as are usually seen in febrile disorders, namely, loss of ap- petite, thirst, impaired taste, pasty, coated tongue, tenderness in the epi- gastrium, and constipation. Nausea and vomiting sometimes usher in the attack. In other cases (the so-called abdominal form) all the above symp- toms are more severe, and diarrhoea, colicky pains and vomiting are superadded. TJie countenance is changed, in part by the appearance, characterizing an ordinary attack of coryza, of considerable or great severity, and in part by an expression of anxiety and depression. It is pale. Where the pulmonary catarrh is excessive and the dyspnoea great, the lips become bluish. The facies sometimes suggests that of typhoid fever. THE CATAKEH, A more or less extensive hyperajmia of the mucous membrane of the respiratory tract is invariably present, and may be said to characterize the disease. The symptoms are essentially of a catarrhal nature. There is cold in the head, more severe in most cases than ordinary simple coryza. The eyelids are swollen and reddened, there is abundant lachrymation, sneezing is frequent, and the discharge fi'om the nose is abundant. Epistaxis is not rare. Sore throat, with tickling sensations and difliculty in swallowing, are due to inflammation of the pharynx and neighboring parts. In many instances the catarrhal symptoms are refer- able to a pharyngitis and tonsillitis only, the lower air-passages escaping. Hoarseness is common. INFLUENZA. 31 Tlie cough. — This has been in most epidemics a prominent symptom. It is apt to be frequent and distressing — sometimes paroxysmal from the beginning of the sickness, almost always so during its course. Its spas- modic character in some of the older epidemics led to the confounding of epidemic catarrhal fever with whooping-cough. It is apt to be worse to- ward evening and at night, but the sick are often tormented day and night by the racking, loud cough. It often leads to vomiting, and, by its vio- lence and persistence, gives rise to pain and soreness in the muscles of respiration (myalgia), and occasionally to hernia. It is at first dry, or attended with a scanty muco-serous expectoration; later on, the sputa become opaque and muco-purulent, and in consumptive or full-blooded persons, or those having mitral disease, they are sometimes streaked or mingled with blood. Toward the close of the attack the cough becomes less urgent and loses its spasmodic character. In some epidemics cough is not a prominent symptom, and a few cases are encountered in most epidemics in which well-developed influenza runs its course without unu- sual, peculiar, or excessive cough. If the cough be due to bronchitis, we find on auscultation the physical signs of that affection. They are of course wanting when it is due simply to laryngo-tracheal irritation. Hence, we frequently detect sonorous and sibillant, or mucous and subcre- pitant rales upon both sides of the chest in the course of the attack, as in non-epidemic acute bronchitis ; and, on the other hand, cases occur where the auscultatory signs are but little, or not at all, altered from those of health. It is scarcely necessary to add there are no special character- izing signs that can be regarded as diagnostic of influenza. Dyspnoea. — Many patients suffer from this symptom. It is due, in some instances, to complications; but it also occurs with remarkable fre- quency in those in whom none of the objective signs of any lesions can be discovered in the lungs. It is here of nervous origin. Graves assumes a direct disturbance in the function of the vagus as its cause. This view is sustained by the observation that the dyspnoea is now and then inter- mittent, or shows rhythmically recurring remissions, which are unattended by alteration of the physical signs. To Biermer it appears more probable that the congestions so common in influenza, not attended by marked physical signs until they lead to oedema, are to be regarded as the cause of the dyspnoea. It varies greatly in intensity. In many patients it goes on to marked oppression, great shortness of breath, precordial pain, and the like. In certain epidemics, orthopnoea and suffocative attacks were very common. Stitches in the side, and pain under the sternum, are observed without appreciable physical signs. 32 THE CONTINUED FEVERS. I SYMPTOMS BEFERAELE TO THE NEBVOUS SYSTEM. Debility. — Great prostration of muscular strength is a very early symptom, and constitutes, in most epidemics, one of the remarkable fea- tures of the disease. Patients from the onset feel extremely weak, and are exhausted by the slightest bodily effort. The ordinary strength is not regained until convalescence is far advanced. Headache. — Severe frontal pains are scarcely ever absent, Thev ex- tend across the brow, and deeply about the orbits and at the root of the nose, having their seat in the Schneiderian mucous membrane and its prolongations lining the frontal sinuses and the nasal ducts. Sometimes the pain is referred also to the region of the antrum of Highmore, and to the Eustachian tube and the middle ear. It occasionally extends over the whole head. Cutaneous hyperesthesia of the head and neck, and stiffness of the neck-muscles, are also met with. The headache is often most in- tense ; it lasts commonly till the end of the attack, and may even outlast it. It increases in severity toward evening, with the fever and mental agitation. The occurrence of epistaxis affords some relief. Pain. — Among the more constant symptoms of influenza are very se- vere pains in the limbs. Patients experience sensations of soreness and bruising, such as follow the most severe and unaccustomed muscular ef- fort. Dull, tearing, and burning pains are felt sometimes in particular muscles or tendons ; sometimes they are diffused over the whole bodv. Distressing pains of a dragging or boring character, in the loins and the calves of the legs, are complained of. These pains are neither relieved nor aggravated by gentle movement or by moderate pressure. A sense of contraction of the chest, and precordial distress also occur and stitches in the side (pleurodynia), substernal pain, and pains in the throat and nape of the neck, are common. General nervous symptoms. — Patients, when the case is severe, are usually restless, sleepless, and anxious. Dizziness and a tendency to faint occur on rising, particularly in women. Mild delirium is not uncommon ; bnt the more intense forms are also observed. Active delirium was thought to be a mortal symptom in some of the older epidemics. The inability to sleep bears no direct relation to the intensity of the fever. It is seen in some cases where fever is slight or even absent. Somnolent states also occur. Great hebetude and torpor have marked some epidemics. That of 1712 was called the sleepy sickness, by reason of the prevalence of these symptoms. In the gravest cases, painful muscle-cramps, subsultus tendinum, twitchings of particular muscles, and tremblings of the hands, are observed. The mental power is enfeebled, and the acuteness of the special senses is diminished. INFLUENZA. 33 Complications and Sequels. The most important complications of influenza are inflammatory dis- eases of the lungs. The intense hyperaemia and bronchitis, already de- scribed as occurring in the severer cases, cannot properly be looked upon as complications. They constitute rather essential processes of particular forms of the disease. But capillary bronchitis, catarrhal pneumonia, and, less frequently, croupous pneumonia, arise as complications in the course of the disease. Pleurisy, except as associated with lobar pneumonia, is rarely met with. Satisfactory statistics are wanting, but Biermer estimates that from five to ten per cent, of the whole number of patients suffer from inflammatory lung-complications, and holds that the bloodletting so fre- quently practised by the older physicians was due to a desire to combat iiiflammation. The comparative frequency of chest-complications in dif- ferent epidemics varies greatly, but the estimate of Biermer may be ac- cepted as an approximate average. Owing to the masking of the physical signs in the early stages, and the pre-existing pulmonary oedema, it is not always easy to recognize at once the occurrence of capillary bronchitis. It is attended with increasing dyspnoea, decided lividity of the face and extremities, and greater pros- tration. Crepitant and sub-crepitant rales at the lower portions of the posterior dorsal regions, rapidly spreading over all parts of the chest, without dulness at first and with increased resonance later, instead of the signs of condensation which are met with in pneumonia, are the signs which attend its appearance. Catarrhal pneumonia occurs insidiously, with gradual intensification of the bronchitic symptoms about the fourth or fifth day; but it may set in as early as the second day, or much later, during convalescence. It is developed without chill, as a rule, or great increase in the fever. Old per- sons and those of feeble constitutions are more liable to the foregoing complications. Lobar pneumonia is less common. It is a late complica- tion, occurring toward the close of the attack, or even when the patient is beginning to get about. It is easily recognized, and differs in no wise from acute lobar pneumonia occurring under other circumstances. In October, 1880, influenza being in Philadelphia, both epizootic and epidemic, but very mild among both horses and men, I attended a medi- cal student, who, having had what he regarded as a " cold " for about a week, had kept at his work without treatment, until, upon the occurrence of a chill followed by grave thoracic symptoms, he was obliged to betake himself to bed. I first saw him the following day, in the Hospital of th« Jefferson College. There were the symptoms of acute lobar pneumonia, with the signs of extensive consolidation of the left lung and pleurisy of the right side. Moreover delirium and jaundice were present. The urine 3 34 THE CONTINUED FEVERS. was non-albuminous. The next evening lie died. At the same time many members of the class suffered from unquestionable influenza, and a careful inquiry into the history of the case of this young gentleman satisfied me that the pneumonia had arisen as a complication of a neglected and mod erately severe catarrhal fever. Until the eighth day before his death he was in excellent health. No examination of the body was permitted. Graves ' thought that a kind of paralysis of the lungs, with great cedema, takes place in some cases, and attributed it to an affection of the vagus. It was his conviction "that the poison which produced influenza acted on the nervous system in general, and on the pulmonary nerves in particular, in such away as to produce symptoms of bronchial irritation and dyspnoea, to which bronchial congestion and inflammation were often superadded." It is certain that localized collapse of the lung often occurs. Drs. White and Guiteras attributed the consolidations of the lung to congestive collapse due to enlargement of the tracheal and bronchial glands, and " disturbance of the great nervous tract about the root of the lung." They were enabled to satisfy themselves of the existence of the glandular enlargement — admopathie bronchique — in nine of their eighteen cases, by percussion practised in the method of M. Geneau de Mussy,^ who was, as they believe, the first to call attention to the information that may be gained by percussion of the spinous processes of the vertebrae over the course of the trachea. Following this line in the healthy subject, a dis- tinct tubular (high-pitched and slightly tympanitic) sound is elicited by percussion, down to the point of bifurcation of the trachea, on the level of the fourth dorsal vertebra. Opposite the fifth, and downward, we get the lower-pitched pulmonary resonance. When the tracheal and bron- chial glands are enlarged, the tubular sound over the upper dorsal vertebrae is replaced by dulness, which may contrast sharply, above with the tracheal, , and below with the vesicular resonance. They point out some well-recognized peculiarities of the so-called i pneumonias of influenza, as giving weight to their view that the consoli- dations are not, in the beginning, pneumonia at all. Thus, we have at first weakness of the vesicular murmur, then its absence; the respiration soon becomes bronchial without being preceded by dulness or the crepi- tant rale; the extension of these consolidations from one part of the lung to another is very irregular; the process is more apt to involve both sides than one; the disappearance of the consolidation is frequently very rapid. The physical signs in one of their patients were very interesting, as supporting the theory of collapse from the nerve-disturbance consequent upon enlargement of the lymphatic glands. The case presented, one day, pectoriloquy and bronchial breathing at the root of the left lung; the next day there was dulness of a large portion of the left lower lobe, with bron- ' Annals of Influenza. ^ Clinique Medicale. Paris, 1874. INFLUENZA. 35 chophony and bronchial breathing over an area extending from above the angle of the scapula to the base, and out to the axillary line. That is to sav, there was, first, engorgement of the left bronchial glands, and the next day the congestive collapse of portions of the lung. On the day after this, no traces could be found of the consolidation. This is certainly not the history of catarrhal pneumonia. The relations of cause and effect between collapse and catarrhal pneu- monia are so close, that it is not diflBcult to see how the condition spoken of may lead to secondary lobular or catarrhal pneumonia. In truth, this is a frequent result of collapse from any cause. They do not adduce any post-mortem facts in support of their theory. Peacock,' however, observed in the epidemic of 1847, softening and en- lar the discomfort of the suiferer, who is debarred from lying upon his back, and turns from one side to tlie other with the utmost pain and difficulty. The duration of this, as of most of the symptoms of cerebro-spinal fever, is very variable. Sometimes it lasts only a few days, at others weeks, and patients have been confined to bed by it till the fourth and even the sixth week from the beginning- of the attack. Ziemssen states that he has seen convalescents going about with rigid spines. Pleurosthotonos, or contraction of the spinal muscles of one side, has been encountered by some observers. Levy saw it twice in tifty-seveu cases. It is extremely rare. The stilfness of the neck is sometimes absent. This observation has been made in some instances where the ordinary anatomical changes, and particularly the inflammation and exudation, have been present in the spinal meninges to an extent as great as that usually met with. Its ab- sence cannot be explained. Trismus has been observed only in patients who were extremely ill and comatose. It is highly ominous. Of five cases encountered by Hirsch, four speedily perished. Stiffness and contraction of the muscles of the extremities occur in a considerable proportion of the cases. Active movements are executed in such instances with awkwardness and pain, and passive movements are Fig. 3.— Attitude of Child in severe Cerebro-spinal Fever. (J. Lewis Smith.) resisted. The usual position of such patients, in bed, is with the head drawn back, the forearms flexed upon the arms, and the knees drawn up upon the abdomen, with or without forward arching of the spine (Fig. 3). Clonic sjKisms or convulsions occur with less frequency than muscular rigidities. They are met with, however, in a considerable proportion of the cases, particularly in children, with whom they sometimes occur as an earh^ symptona, replacing the initial chill. General convulsions have been observed to usher in, the attack in adults also, but much more rarely. They vary in degree from twitchings of single muscles or groups of mus- cles, to violent epileptiform seizures attended with loss of consciousness; the latter constitutes in adults a symptom of great gravity. 76 THE CONTINUED FEVERS. ' Tremors and subsultus tendinum are less frequently observed. l^arahjsis is of much less common occurrence than the character of the lesions would lead us to expect. It occurs in a small proportion of the cases, and affects one or both extremities, upper or lower, and may be more or less complete. Hemiplegia may also occur. Palsies of certain associated groups of muscles, as those of deglutition, articulation, and others, are relatively more common. Paralysis is very rare as an early symptom; it appears toward the close of the disease. If the patient re- cover, it usually passes away in the course of a few days or weeks; ex- ceptionally it is of long persistence, or even permanent. More or less complete general paralysis is encountered as one of the phenomena of approaching dissolution. The facial expression is indicative of the severe pain which attends the disease. The features wear a fixed and rigid look, which passes with the exhaustion into an expression of apathy, without relaxing into the ■flushed dulness of typhus, nor the languid expression of enteric fever. The face is usually pale. Pain in the spine (rachialgia), and especially in the neck, is a fre- quent symptom. It varies greatly in extent and intensity, as well as in duration. It appears sometimes coincidently with the headache, and has been observed as an occasional symptom late in convalescence. A dragging pain in the neck has already been mentioned as one of the pro- dromes. This pain, like the headache, is subject to remissions and exacer- bations. Severe pains in the extremities, especially in the legs, also frequently occur. They are often evoked or intensified by movements of the spine. Lightning-like pains invade other parts of the body, and an intense sick- ening neuralgic pain in the abdomen, particularly in the epigastric and umbilical regions, is very common. This pain is sometimes associated with uncontrollable vomiting. It was so common a symptom in the epi- demic observed by Dr. Sanderson in the Lower Vistula, that, as he in- forms us, the disease acquired among the people the trivial designation of "The Belly-Ache." Pain of a similar nature is sometimes referred to the chest, and at times is associated with difficulty in breathing. Asthmatic attacks are spoken of as occurring in some cases. It is probable, from their rarity, that they are incidental symptoms. Hyperaisthesia of the skin, the joints, and other soft parts, though far from being a constant symptom, is to be regarded as characteristic when it does occur, and as sharply drawing the boundary line between this and any other disease with which it can possibly be cor^founded. It is absent altogether in many cases and in some epidemics; in others it is a very common symptom, and was frequently observed in the later epidemics in the United States, and in that of the Lower Vistula in 18G5. It occurs CEREBKO-SPLN-AL FEVER. 77 early in the course of the attack, often on the second or third day, and is often so extreme as to cause great additional suffering, the patient lying as quietly in the bed as the restlessness so common in the affection will permit, in order to avoid this pain, which a movement of his limbs, a light touch upon the surface of his body, even the shaking of the bed, will evoke. It is a symptom which often, when present, interferes greatly with the examination of the sick. Its commonest seat is the anterior surface of the body, especially of the legs and thighs, though it is everywhere present. It is often associated with marked intolerance of light and sound. Ancesthesia of portions of the surface in some instances follows the symptom just described. Stille observed it in many cases during the epi- demic which is recorded in his writings. It is sometimes marked, some- times a mere numbness. It disappears, as a rule, during the progress of the case. SYMPTOMS BEFERABLE TO THE SKIN. Many observers state that the skin is apt to be dry in the early days, of the disease, and afterward bathed in moisture, especially the head, face, and neck. But in this respect cases furnish no constant condition. The pallor and cyanosed appearance of the surface, especially of the face, which is uniformly present, has been already more than once alluded to in the description of the disease. Cutaneous lesions are very common and constitute a group of phenom- ena of great interest in the study of this affection. In some epidemics, they are present in by far the greatest number of the cases, while in others no eruption whatever can be discovered in most of the instances of the disease. Were this statement not correct, it would be impossible to recon- cile the conflicting accounts of many competent observers. Ziemssen remarks that it would be difficult to understand from obser- vations of the German epidemics why the disease has been called " spotted fever " by American physicians. Many recorded observations of epidemics, in the United States, however, go to show that in not infrequent in- stances eruptions are altogether absent, or present in but a small number of the cases. There can be no doubt that roseola and petechiae are more common in cerebro-spinal fever in this country than in Europe. Herpes is the most common of the eruptions. It is usually confined to the face (her^Jes facialis), but may appear upon the trunk as shingles- {herpes zoster), or in circumscribed patches upon the extremities. It be- gins generally in the region of the mouth, upon the upper or lower lip^ and extends to the nose, cheeks, ears, and eyelids. In many cases one or both sides of the face are covered with a hideous mass of herpetic vesi- cles or crusts. This eruption is also met with on the mucous surface of 78 THE CONTINUED FEVERS. tlie nostril and cheek, and upon the scalp. It is in many cases an early symptom, appearing on the second or third day ; but irregular outbreaks of vesicles often take place late in the convalescence. No prognostic significance can be ascribed to it. Petechioe occur in the next order of frequency. The mottling is more or less distinct and widely dilfused over the surface, sometimes even involving the face. Larger spots of like character resembling the erup- tion of purpura are likewise common. Wide effusions of blood and its coloring matter beneath the skin (vibices, ecchymoses) also occur. They have sometimes a regular, sometimes an irregular or ragged edge or border, which may remain fixed from the time of its appearance, or may extend rapidly over large surfaces. They are sometimes light or bright red in the beginning, and grow dark or livid in the lapse of a short time; of- tener, however, they are dark purple or black from the first, and have been likened to splashes of ink. They often resemble the livid staining of the skin in the cadaver. These extensive effusions of the coloring matter of the blood are of ominous significance as betokening the gravest disintegra- tion of its corpuscular elements. Dr. J. Lewis Smith has observed that the size and position of such spots is sometimes determined by bruises which the patient receives dur- ing his spells of restlessness. The purpuric spots are sometimes hard to the touch, with defined margins. Vesicles may form and superficial gangrene of the skin take place, which, if recovery follows, gives rise to permanent scarring. A cyanosed appearance of the surface and livid mottlings may also occur without distinct eruption. Less frequent are roseola, erythema, urticaria, erysipelas, and suda- onina. Not infrequently a patient presents three or four separate forms of cutaneous eruptions. The symmetrical distribution of the eruptions of cerebro-spinal fever have often been made the subject of remark. It is not uncommon to find similar eruptions and patches of eruption seated in the same position, upon both sides of the body or on the two extremities. This, together with the variety of the forms, their frequency and the hypera?sthesia and ances- thesia, point to disturbance of innervation in the central nervous system directly affecting nutrition (disturbances of trophic innervation). The purpuric eruptions are chiefly due to the breaking up of the red blood-cor- puscles, and the solution of their coloring matter in the serum ; and per- haps in part, to other causes not yet known. THE PHENOMENA OF THE FEVEB. The temperature during the course of the disease does not give rise, when depicted in the graphic method, to a typical curve. It is above the normal in every case, except perhaps those of the ful- CEKEBRO-SPINAL FEVER. 79 ininant variety, in which the patient falls speedily into a state of collapse. It is generally moderately high, not always on the first day, but from the second or third day. In some instances it rises rapidly after the chill, which mai'ks the onset of the attack. After the characteristic symptoms of the disease are fully established, the temperature rarely falls below 37.5° C. (99.5° F.), and ranges in adults from 38° C. (100.4° F.) to 40° C. (104° F.) for average cases. In children it is frequently higher. J. Lewis Smith has recorded a temperature (rectal) of nearly 42° C. (107.4° F,), a few hours after the onset of the attack, in a young child who died on the third day, and in two other instances a temperature of over 41° C. (106° F.). Both of these cases also terminated in death, one on the ninth day, the other in the ninth week. In severe cases it is apt to be high, and in particular, it rises as death approaches. Periods marked by long-con- tinued subfebrile temperatures of ten occur in the course of an attack, and very irregular variations, both below and above the average range, are common. During such periods of relatively low temperature the other symptoms remain unabated. There is no constant and notable difference between the morning and evening, as in typhoid and typhus. A gradual fall (lysis) marks the beginning of convalescence ; an abrupt fall ushers in collapse or death. A critical fall in temperature does not occur to sig- nalize the favorable termination of this disease. "VVunderlich ' concluded, from a study of thirty cases, that three vari- eties of the fever course may be distinguished : " (a) In some very severe and rapidly fatal cases the temperature, though not invariably very high at the beginning of the disease, reaches very striking heights in the briefest time. It remains high, rising even higher at the approach of death, till in the very moment of death it may attain 42° C. (107.6° F.), and more. In one of his cases it reached 43.7° C. (110.7° F.). It may rise some tenths of a degree after death. In the case just cited, it was 44.1° C. (111.5° F.), three-quarters of an hour after death. There were also some fatal cases in which the temperature for some time was very moderate, and rose rapidly with abruptness at the close of life. " (b) On the other hand, relatively mild cases exhibit a fever of only short duration, although there are sometimes considerable elevations of temperature and often an interrupted course. Recovery does not take place by crisis, but happens rather with a remittent defervescence (lysis). Here and there cases occur which, after defervescing and apparently al- most recovering, relapse all at once with a rapid rise of temperature and run a course like the cases marked (a). " (c) In contrast with these brief courses of fever with either very severe or slight character, we find cases which are more or less protracted. ' The Temperature in Diseases. Trans, of New Sydenham Society. London, 1871. 80 THE CONTINUED FEVEKS. The height of the temperature in these may be varied, and indeed may ex- hibit manifold changes in the very same case, though tiiis chieily depends Temperature. Day of the I. II. III. IV. Disease. — '^ — — ' — — ■' — — 40° 10-4.° V. VI. Pulse. III. IV. VI. 100.4= %.S° , K |M|E |ill E,JI;E I M, E lil. E I M E .M i; .M 1, .M i; M E , -U , E Fig. 4. — Temperature Ilange aud Pulse in Cerebro siiinal Fever, Severe Form. Day of the Disease. C. I F. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. XVI. 09.5° ;)8.(;° 160 150 1-40 130 120 110 100 90 81 E .M Fig. 5, E JI : E ! M , E I M i E I -M , E ] m" E I M 1 E i JI , E -^1 , E M , E , M , E .M , E , M ; E | il | E , M j E .—Temperature Range and Pulse in Cerebro-spmal Fever, Moderately Severe Form. upon the varied complications which supervene in the shape of bronchial, })ulnionary and intestinal affections, and affections of serous membranes." CEREBRO-SPINAL Jb'EVEK. 81 Githcns made records of the temperature in forty-four of his ninety- ei<»'lit cases, with the following results. "In two cases only did the ther- niometer in the axilla reach 105°. In fifteen cases it was between 104° and 105°; in twelve between 103° and 104°; in seven between 102° and 103°; ]n six between 101° and 102°, and in two it was below 100°. The figures given are the highest points reached in each case. The difference in the temperature at the evening and morning observations was not so marked as in most other fevers — a fall of more than one degree being un- usual, and frequently there was no change. A regular and gradual de- scent indicated the beginning of convalescence ; a rapid fall was the sure precursor of collapse." Sanderson found that exacerbations of pain were always accompanied ))y a rise in temperature of from two to three degrees Fahrenheit. One of the more notable characters of the febrile phenomena of this malady is their extreme irregularity. The temperature ranges not only do not coincide, they also do not even approach an ideal type. Finally, I transcribe from the pages of Ziemssen diagrams illustrat- ing the curves of the temperature and pulse in severe, mild, and the so- called intermitting cases. They are accompanied with brief abstracts of the clinical notes of the cases: Case I. — Severe form. — " L. W., aged fifteen years, a plasterer's apprentice. Ac- cess abrupt, with chills, cephalalgia, vomiting, trismus, tetanus of cervical and spinal muscles. Conjunctivitis, hyperae.sthesia of skin. After the fourth day, herpes facialis, roseola, erythema, urticaria, and petechias on the extremities. Moderate fever, with retardation of imlse. Furious delirium followed by sopor. With rapid elevation of temperature and pulse, death ensued on the seventh day of the disease. Autoj)i^y. — Purulent cerebro-spinal meningitis. Remains of old pleurisy and peri- hepatitis. Partial atelectasis of lungs, and lobular pneumonia. Cadaverous softening of stomach and diaphragm (five hours after death). Suppurative tendo-synovitis in the left hand. Areas of degeneration in the spinal and recti abdominis muscles. Ulceration of cornea '' (Fig. 4, p. 80). Case II. — Modcnitely severe foi-m. — '' M. V., aged twelve years, daughter of a stocking-weaver. Access abrupt, with chill and vomiting, which lasted during the first four days. Frontal headache. Stiffness and pain in the spine, jactitation, urgent thirst. Mind at first clear, afterward delirium and somnolence. Petechia} on the second day, herpes on the face on the seventh, on the thumb on the tenth day. Effu- sion into the right wrist-joint. Conjunctivitis and keratitis. Aphthae. Temperature at first high, but gradually diminishing, while pulse became very rapid. Tedious con- valescence. Duration of the disease about six weeks " (Fig. 5, p. 80). Case III. — Mild form. — " C. H., aged ten years, daughter of an umbrella-maker. After a prodromal stage of two days' duration, patient was taken ill with pains in the head, extremities and epigastrium, nausea, vomiting, stiffness of neck, delirium, premature menstruation ; herpes on the fourth day, conjunctivitis, and transient fever. Improvement at the end of the first week. Duration of the disease, three weeks " (Fig. 6). Case W .—Intermittent form. — " Th. M., aged nineteen years, student. Prodro- niata for eight days. Access abrupt, with cephalalgia, vomiting, slight convulsions, f> 82 TJIE CONTINUKIJ FEVEKS. unconsciousness. Neck somewhat stiff. No fever during the first few days. Exacer- bation on the fourth day, with fever of short duration, followed by apyrexia and dis- appearance of the malaise. On the fifth, seventh, and eighth days, the exacerbations recurred with marked spinal symptoms. Then followed daily exacerbations, but of less intensity and shorter duration. No eruption. Complete cessation of febrile attacks after the eighteenth day. Recovery. Duration of disease six weeks ; of con- valescence, four weeks" (Fig. 7). In these cases the thermometer by no means shows the regularity that characterizes malarial fevers, or that a superficial study of the symptoms 36° 96 8° ToiuiJcraLuie. I'lilsc. II. III. IV. V. VI. VII. VIII. II. III. IV. V. VI. VIL VIII. E|M|E|M|E|M|E|M|E|MlE|iM|E|M |E|M|E|M|E|M|E|M|B|M|E|M|E Fig. 6. — Temperature Range and Pulse in Cerebro-epinal Fever, Mild Form. n. ni. IV. VI. VII. VIII. IX. 41° 105.h' 40° 1G4° 39° 102.2' 38° 37° I 98.(i° 36°' 96. 8f XI. xu. xm. XIV. XV. XVI. xvii.xviii.xrx. !■■■■■■■■ !■■■■■■■■ . -JWHnw^i«iBB!!!BSSBgK«gBBB£>!!!uiB, SSS[ !!■■■■■■■■■■■■■■■■■■■■ M|EiM|BiM|E|M|ElM|B|M|E|M|ElM|E|M|E|M|ElMlB|M|E|M|B|M|ElM|E|M|ElMlB |M|E Fig. 7. — Temperature Range in Cerebro-spinal Fever, in so-called Intermittent Form. would indicate. True intermittenee, ia the sense that the term carries when applied to ague, does not belong to cerebro-spinal fever. Ziemsseii regards the exacerbations of fever as due to the irregular progress of the inflammation at the beginning and during the course of the attack; as due to slight returns of the inflammation when they occur during con- CEREBRO-SPINAL FEVER. 83 valescence; and finally, as in the retrogressive stage, presenting the char- acter of the absorptive fever, often met with during the retrograde metamorphosis of purulent exudations in other serous membranes (pleura, peritoneum). The pulse is as variable as the temperature. Diminished heart-power, and a tone so impaired that slight causes give rise to extreme depression as manifested in a rapid, feeble, and compressible pulse, characterizes the circulation in this fever. The frequency of the pulse by no means constantly corresponds to the intensity of the febrile action and the gravity of the other symptoms. It is in many cases scarcely increased in frequency beyond the normal, in others moderately quickened, and again it may be very frequent indeed. In children it is constantly accelerated. It is rarely retarded, in this respect differing from the pulse in tuberculous basilar meningitis. A slow pulse is in some instances present in the beginning of the disease, ere the temperature has risen; but, as a rule, it quickly, with the onset of marked fever-symptoms, rises in frequency. In fatal cases it is often so rapid that it cannot be counted. Perhaps the most constant character of the pulse is its variations in rapidity. Within a few hours it often varies from forty to fifty beats per minute, and a difference of twenty or thirty beats may be counted within the lapse of a few minutes. A very rapid pulse, which continues so, is to be regarded as unfavorable. In quality, the pulse may be normal, or its fulness and tension may be augmented. When depression comes on, it becomes small, weak, and often intermittent. The feebleness and rapidity of the pulse in cases tending to a fatal issue, and particularly in those patients who rapidly approach death, is notable. To quote Githens: "The pulse varied from normal to 150 beats per minute in uncomplicated cases, and as high as 160 in two puerperal women; it was in all very weak, with dicrotic ten- dency; sometimes entirely imperceptible in the radial artery, and always interrupted by a very slight pressure." Da Costa' has observed well- marked blood-murmurs in the heart, even early in the course of the dis- ease. The 7iutrition of the patient generally suffers seriously. The wasting is very rapid and extreme in severe cases. When death takes place after a long illness, the corpse presents a high degree of emaciation. This is due not alone to the fever and grave inflammatory lesions of the nervous system, but the loss of appetite, obstinate vomiting, restlessness and pain, also contribute a large share in bringing it about. An early, sudden and great loss of strength is a frequent and promi- nent feature of this malady. Syncope sometimes occurs at the beginning of the sickness. The patient is not only the victim of an extreme de- ' J. M. Da Costa : Medical Diagnosis. Philadelphia, 1864. 84 THE CONTINUED FEVERS. bility during his illness, but he comes out of it thoroughly exhausted, and is a long time in regaining his strength. Tiie prostration which is so prominent a symptom of cerebro-spinal fever cannot be said to be char- acteristic of this disease as distinguished from some of the otlier continued fevers, but is notable for the frequency with which it occurs, the high de- gree which it attains, and the early period in the course of the attack at which it appears in the affection under consideration. It is to this char- acter of the disease that it owes the old misleading names of " Sinking Typhus," " Typhus Sj^ncopalis," etc. SYMPTOMS REFEEABIiE TO THE ORGANS OF RESPIRATION. In mild, uncomplicated cases, the respiration is for the most part quiet and easy, though slightly accelerated. Its rhythm is undisturbed. If cough be present, it is usually slight and accidental. In the grave cases the resjiiration is more or less disturbed. It is sighing, labored, or in- terrupted. As the case draws to a fatal termination, the breathing be- comes more and more embarrassed; it grows very rapid, arhythmic, and often presents that alternation of respiration with respiratory pauses, known as the Cheyne-Stokes respiration. It is probable that pressure upon, or oedema of, the medulla oblongata, gives rise to the interrupted respirations. There can be no doubt, how- ever, that the tonic contraction of the spinal muscles, and other groups more directly concerned in the perfox'mance of the acts of respiration, has much to do with the embarrassment of breathing, which is still more common. The organs of digestion are deranged. In addition to the vomiting which has already been described, there is nausea and more or less com- plete loss of appetite. The tongue is moist and coated with a light or thick, white fur. In cases attended with great prostration, and in collapse, the tongue is dry and brown. If the patient rally from the prostration, the tongue quickly becomes moist again with the reappearance of the whitish fur. It is some- times clear at the tip and edges. A moderate degree of retraction of the belly is sometimes present. Constipation is the rule. Diai'rhoea sometimes occurs. The latter is more frequent in children, and in some cases pre- cedes the attack. If constipation be present, it readily yields to the action of purgatives. TJdrst is almost constantly a tormenting symptom. It is unappeas- able, and frequently persists till convalescence. Jaundice occurs in a few cases. No other symptom of disturbance of the liver is noted. TJxe sj)lcen is very rarely sufficiently enlarged to occasion an increase of its area of dulness discoverable durinnf life. CEREBRO-.SPINAL FEVEK. 85 The urine is sometimes normal in quantity, oftener increased. It may be much increased, even during active fever with high temperature. Urates, as in all fevers, are often thrown down as the urine cools. The reaction is usually acid. A moderate amount of albumen is occasion- ally to be detected, and more rarely cylindrical casts and blood-corpus- cles. Phosphates may be present. In delirium and in coma, retention of urine may be overlooked, and if catheterization be delayed, cystitis may result. Polyuria is very common in children, and has been observed in rare cases as a symptom persisting for years after convalescence. Transient albuminuria has also occurred. Inflammation of the joints, resembling rheumatism, is occasionally met with. It is commonly slight, but in rare instances may run on to a sup- purative arthritis. The wrist-joints are most frequently affected. Swelling of the parotid glands \s3in infrequent accident of the disease. It may be slight, or it may run on to suppuration. Tourdes saw suppura- tive parotiditis in two fatal cases. Githens met with it in two out of ninety-eight cases, both of which recovered, and Stillc saw two or three cases. DISTDBBANCES OP TECE OBGANS OF THE SPECIAIj SENSES. The eye and ear are frequently involved, and are often the seat of serious lesions. It is not known to what extent the taste and smell may be affected. In mild cases the perception of odors is normal; the taste is perverted, as it is apt to be in the catarrhal state of the mouth and stomach which belongs to fever. In grave cases the condition of the patient pre- cludes the investigation of this point. .1. Lewis Smith ascertained that in one nostril the sense of smell was lost altogether, in a case under his observation. To return to the consideration of the eye and ear. TJie pupil is often normal during the whole course of the disease. In other instances it dilates toward the end ; again it is frequently contracted in the beginning, and dilates after some days' sickness; not infrequently the pupils differ in size, one being contracted, the other dilated, and the two responding differently to the same light. Feeble response to light is a common symptom. Intolerance to bright light is an almost constant symptom. Nystagmus may occur in consequence of clonic spasm of the muscles of the eyeball, and spasm of particular muscles or groups of muscles may give rise to transient strabismus, which may appear and disappear several times before convalescence sets in. Paralysis of certain of the ocular muscles also causes squint, which may last several weeks, or even be per- manent. Paralysis of the various cranial nerves depends mostly upon 86 THE CONTINUED FEVERS. the lesions consequent upon the extension of the meningeal inflammation to their trunks, and arises either from the pressure exerted by the sur- rounding exudation, or from contraction of the hyperplastic connective tissue of the nerve-sheath. The further lesions of the eye consist of inflammatory affections of the organ of sight itself, and are: (a) inflammatory hyperiemia of the con- junctiva. This is of frequent occurrence. There is a uniform diffused redness of the conjunctiva, not so dusky as in typhus. It is an early symptom. At times it amounts to an intense conjunctivitis, with oedema of the eyelids and a free muco-purulent secretion. When it is severe the cornea becomes opaque and the seat of ulceration. Ziemssen has pointed out the fact that this form of destructive keratitis is frequently due to the exposure of the cornea to the action of the air, as a result of partial palsy of the orbicularis palpebrarum muscle, and consequent imperfect closure of the ej'elids: (b) severe, suppurative irido-choroiditis, or pan- ophthalmitis. The media grow cloudy, the iris discolored, the pupils be- come irregular and are blocked with inflammatory exudation. The storm subsides, leaving distorted pupils, the lens cataractous, the retina de- tached, and ultimate atrophy of the globe ensues ; or, in rarer cases, the eye is destroyed by perforating ulceration of the cornea and the forma- tion of anterior staphyloma : (e) optic neuritis terminating in atrophy of the nerve. Disturbances of hearing are noticed within the first few days. The patient is annoyed by loud sounds ; humming and ringing in the ears are speedily followed by more or less complete deafness. These manifesta- tions are usually bilateral. They are due to two processes: (a) inflamma- tion of the middle ear. If it be catarrhal in character and mild, as is most commonly the case, it subsides without loss of hearing; if it be puru- lent and severe, perforation of the membrana tj'mpani occurs, and an otorrhoea of variable duration ensues : {b) suppurative inflammation of the labyrinth, with destruction of the membranous labyrinth. The patient loses his hearing without otorrhoea, otalgia, or other local symptom. The loss of hearing does not always come on at the same period of the disease; tlie majority of cases are observed to be deaf as soon as the stupor goes off and full consciousness returns, while in rarer instances those who be- come deaf are able to hear more or less distinctly at this time, but lose this function in the course of the convalescence. This form of deafness is complete and permanent. It affects both ears, and has been observed in some instances to be associated with a staggering gait.' It is probable that the inflammation makes its way within the sheath of the auditory nerve (A. Heller). ' See Proceediugs of Philadelphia Pathological Society, Philadelphia Medical Times, January 31, 1874. CEREBKO-y PINAL FEVER. 87 Serious lesions of the eye and ear, resulting in the permanent and complete loss of sight and hearing, occur in some cases that run a mild course as regards the general phenomena of the affection. Dr. Schaffner' records a case in which a boy aged six, after a sickness of two weeks with symptoms of mild character, complained of blindness. On examination the loss of sight was found to be due to optic neuritis. Complications and Sequels. Some of the complications — those involving the eye and ear, the joints and the parotid glands — have already been considered in the analysis of the symptoms. Catarrhal and croupous pneumonia, bronchial catarrh, pleurisy, endo- carditis, pericarditis, also occur as complications in some cases of almost every epidemic. Atelectasis and broncho-pneumonia are more common in those patients who for a long time have suffered from orthotonus (Ziemssen). The combination of croupous pneumonia with cerebro-spinal fever has been observed to be of common occurrence in some of the re- cent German epidemics. This serious complication has been encoun- tered with greater frequency at the close than at the beginning of the epidemic, "as if the infectious poison had then lost its violence, and was able to resume its activity only when aided by the force of other dis- eases." Intestinal catarrh also occurs as a complication. Malarial and enteric fcvei", and measles, scarlet fever and cholera, have been met with as inter- current affections. Convalescence is irregular and uncertain. After severe cases it is apt to be tardy. Relapses are not uncommon, and are often fatal. The sequels are: {a) prolonged debility and emaciation, dyspepsia, boils, carbuncles due to the blood-changes that take place in this as in other infectious diseases; and {b) those due to the lesions resulting from the inflammation of the brain and cord, and their membranes, and its ex- tension to the organs of the special senses, namely: pareses and paralyses, impairment of intelligence in consequence of chronic meningitis and chronic hydrocephalus, and more or less complete deafness and loss of vision. General motor loeakness a,x\({ paralyses of single extremities or partic- nlar nerves are not very infrequent. They depend upon lesions of the brain or spinal cord, or on the results of injury to the parts in consequence of the pressure exerted by the contraction of the organized inflammatory exudation. Feebleness of the intelligence and weakness of nieniory, with defects of ' Philadelphia Medical Times, May 16, 1874. 88 TJIE CONTINUED FEVEKS. speech, are often sequels. In most cases, they gradually disappear in the course of some weeks or months, and when permanent are the result of chronic inflammatory processes affecting the brain. On© of the most important of the cerebral affections left by this fever is chronic hydrocephalus. The symptoms are paroxysmal; they consist of severe headache, in- tolerance of light and sound, vertigo, pains in the neck and limbs, vom- iting, involuntary discharges, convulsions, loss of consciousness. The attacks occur either at long and irregular intervals or in rapid succession. The mental and bodily condition of the patient during the intervals is sometimes such as to lead to delusive hopes of his recovery. If partial recovery take place the mind remains weak, and the limbs paralyzed and deformed. In the rarest of instances has an approach to complete recov- ery been recorded. In a majority of instances the condition in the intermissions is such as to preclude all expectation of recovery, the mind being irritable and un- steady, the limbs slightly palsied, muscular movements inco-ordinate, and the development of the body in the young retarded. The head is large, the skull thin, and the eyes prominent. Headache is a common symj)- tom. Ziemssen gives the following account of the successive anatomical changes which attend the development of this process, as the result of his autopsies during the epidemic and in following years: " During the second week the meningeal exudation, which has hitherto been little changed, or perhaps somewhat thickened, undergoes fatty de- generation of the cells and fibrin, and is thus slowly or rapidly absorbed, or ultimately shrinks into caseous matter, if absorption does not occur; the connective tissue of the ai-achnoid and pia mater proliferates, the hyper- iemia of the substance of the brain disappears, and the purulent effusion in the ventricles increases. From the twenty-seventh to the thirtieth week the arachnoid and pia mater exhibit a pulpy hyperplasia or already a cica- tricial thickening; the caseous remains of the meningeal exudation are still more shrunken; the ventricular effusion has become more moderate in amount, but quite clear, owing to the inspissation of the cellular elements into small, caseous flakes on the dependent parts of the ventricles. The earlier hyperemia of the brain is completely gone; the brain is an;i?mic, even oedematous; the ependyma of the ventricles thickened and distinctly granulated, and the choroid plexus bloodless. Unless the hydrocephalic effusion be moderate, the brain-substance is atrophied sometimes to a very considerable degree. In a boy two years of age we found the medullary and cortical layers of the cerebrum together only seven and a half lines in thickness, while the central ganglia were much flattened." The same author states that the interval of apparently progressive convalescence which usuallv occuis between the acute stasje of the mcnin- CEREBRO-SPINAL FEVER. 89 gitis and the appearance of the symptoms of hydrocephalus, renders probable the supposition that the increase of the ventricular effusion may be due to the shrinking and thickening of the pia mater. The various lesions of the eye and ear that give rise to defects of or loss of sight and hearing, as sequels, have already been pointed out. These lesions are either the result of the extension of the inflammatory process from the pia mater along the sheath of the optic and auditory nerves to the respective organs, or of a simultaneous localization of the inflammation in the pia mater and the eye and its tunics, and in the pia mater and the labyrinth and tympanum, as effects of a single disease- producing cause. Complete deafness in young children who have not yet learned to talk, and even in those who have more or less perfectly acquired the power, results in deaf-mutism. In those who have learned to talk, speech is, after several months, understood with difficulty, and gradually, in the course of a year or more, becomes quite unintelligible. It is necessary for such children to be sent to institutions for the education of deaf- mutes. Some observers have noticed that deaf-mutism is an uncommon result of this fever, even when complete deafness occurs, and Hirsch has called attention to the fact that impairment of speech, and even aphasia, may arise coincidently with the loss of hearing as a co-effect of the meningeal inflammation. When the loss of speech is a result of the deafness, it is preserved for a time after the meningitis subsides, and gradually grows more and more imperfect, till it is, as articulate language, lost altogether. Pathology, Morbid Anatomy. The essential pathological processes in cerebro-spinal fever are two- fold: (a) the constitutional disturbances due to the direct action of the infecting poison upon the blood, giving rise to the group of symptoms constituting fever; and {b) the local inflammation. As is seen by the foregoing study of the clinical phenomena of the disease, one or the other of those processes may predominate, and the course and symptoms of the attack vary accordingly. If the phenomena of infection are most conspicuous, and the symptoms of the local inflammation are but slight- ly developed, the affection presents striking resemblances to some of the other infectious diseases, while on the other hand the latter symp- toms may be so prominent as to overshadow the infectious nature of the affection, and present the appearance of a simple inflammation with attendant symptomatic fever. The latter form is met with during the epidemic prevalence of the disease, but is most common in the sporadic cases. 90 THE CONTINUED FEVEUS. Between these two extremes every variety of combination of the two processes is to be encountered, but in all a careful study of the course and symptoms of the attack will reveal the manifestations of both. In like manner tiie morbid anatomy reveals the lesions due to the in- fective character of the disease, and those resulting from the local inflam- mation which is its constant attendant. These lesions are constant. They vary only in the degree of their development. The emaciation, in cases of long duration, is extreme. Cadaveric rigidity is marked and long continued. Exteiisivc discolor ations of the dependent parts rapidly show them- selves. Large patches of a livid hue may even appear elsewhere upon the body. Stille has published the account of a case in which the whole body became rapidly almost black, during the two hours before death, but the countenance afterward nearly regained its natural hue. As a rule the purpuric spots on the anterior surface, the redness of the eyes and the like, fade as the staining of the posterior parts of the cadaver deepens. The skin shows the vesicles and crusts of herpes, the mottlings and staining of petechiee. Patches of superficial gangrene, and bed-sores are sometimes seen. T7ie muscles are dry, soft, brownish red, sometimes pale, and atrophied. They are found to have undergone granular degeneration. These changes especially affect the muscles extending along the spinal column. The heart is often flabby, and contains dark, thin fluid blood, with loose soft coagula, or less frequently it contains fir/n fibrinous clots. The cardiac muscle shows the same histological changes as the voluntary mus- cles. In the fulminant variety it is unchanged. Klebs ' found the condition of the blood very variable. In rapidly fatal cases it was very fluid and the clots were soft and scanty. Dr. Levick ' states that the blood is in all cases fluid. Upon microscopical examination, the red corpuscles are shrivelled, crenated, not formed into rouleaux, and " numerous white corpuscles are found in the field." Multiple abscesses have been found both in the subcutaneous connec- tive tissue, and in that of the intermuscular planes. When the joints have been swollen and tender during life, they have been found the seat of sero-purulent effusions. The lungs show frequent changes. Hyperemia, hypostatic conges- tions, oedema, bronchitis with a tenaceous secretion, are often met with. The infiltrations of catarrhal and, less frequently, of croupous pneumonia, are also encountered. ' Zur Pathologie der epidemischen Meningitis. Virchow's Archiv, xxxiv. - See Report of the Committee on " Spotted-Fever, so called," by James J. Levick, M.D. Transactions American Association, vol. xvii., 18(j6. CEREBUO-SPINAL FEVER. 91 The pleuroe, ami pericardiuin are sometimes inflamed, ecchymosed, and contain purulent exudation. Recent endocarditis is rare. The liver is congested, but rarely enlarged. Its cells show a granular,, albuminoid, or fatty cloudiness (Klebs). The spleen is very variable in size. It is usually small, but sometimes moderately, never greatly enlarged. It is usually softened. The intestinal mucous memhrane is usually normal. It is sometimes injected and thickened. The solitary and agminate glands are enlarged and sometimes ulcerated. The lymphatic glands nearly always present a reddened appearance. The kidneys are generally congested. The tubules are sometimes blocked with fat-granules and fibrinous casts. The lesions thus far described are for the most part those met with after death, from infectious diseases in general, and are not distinctive. Those which we now come to discuss are as characteristic as the intestinal lesions of enteric fever. They are the results of the inflammator}^ pro- cesses which have their seat in the cerebro-spinal axis and its enveloping membranes. The calvarium in many instances shows no change; it is most fre- quently congested, especially in the line of the sutures. The dura mater of the brain is often tense, smooth on the outer sur- face, at points firmly attached to the inner table of the skull, and show- ing scattered punctiform hemorrhages or small effusions of blood; the inner surface hypersemic, and more or less closely adherent to the arach- noid. The sinuses are distended with thin fluid blood, and contain soft post- mortem clots or firm thrombi. The arachnoid is often found quite normal, especially in cases that have run a rapid course; it is sometimes hyperaemic or stained with blood, or again it may be dry, lustreless, and opaque. The space between the dura and the arachnoid has been observed to contain a considerable quantity of serous effusion, or more rarely of pus. After a protracted illness, when the exudation has begun to become organized, the arachnoid is rough and thickened. The jt>ia mater is hyperjemic, with intense, diffuse capillary injec- tion and points of capillary hemorrhage. It is adherent to the surface of the brain, from which it can be separated with difficulty, and often only by tearing the brain -substance. In those cases which end fatally in the course of a few hours, this hyperajmia is, as a rule, the only change in the meninges discoverable by the unaided eye. Free exudation is ab- sent. But upon microscopical investigation the pia mater is found to be densely infiltrated with cells, especially along the line of the vessels. If the case have been a more protracted one, this membrane becomes cedema- •92 THE CONTINUED FEVERS. tous from the transudation of serum into its meshes, and in one or two days, a cloudy serum, or a thin, yellowish exudation accumulates in the sub-arachnoid space. By the second or third day the exudation is found to be distinctly purulent, of a butter-like, gelatinous, or firmer consistence, and from one to four lines in thickness. It is of a yellowish or greenish color, or may be deeply tinged with blood. It is at times distributed in a broad layer over considerable spaces, both on the convexity and at the base, most abundant in the sulci, along the course of the vessels, over and around the optic chiasm, over the pons Varolii, the cerebellum, medulla oblongata, and in the great fissures of the brain. In rare cases the exuda- tion uniformly covers the whole surface of the brain. It sometimes ex- tends in strips along the vessels and in the integral spaces, at others it is scattered in detached, island-like plaques. The extent of the exudation and its amount vary greatly in dilferent cases. No part of the pia of the brain or cord may be free, or it may be limited to patches or strips on the convexity, at the base, or on the cord. It occupies the subarachnoid space; the arachnoid space is free. The thickening of the visceral arach- noid is due to purulent infiltration. The seat of the primary inflamma- tion is the pia mater. The exudation consists of fibrin, mucine, pus-cells, xind free granules. The membranes of the spinal cord present similar anatomical changes. The dura is often separated from the vertebra; by collections of extrava- sated blood, its inner surface smooth, or in many cases injected or slightly adherent to the arachnoid; or finally, collections of serum or pus occupy regions of the space between these two membranes. The arachnoid is often normal, in other cases cloudy and infiltrated with pus. The pia is, as in the brain, but, as a rule, less deeply and less extensively hyper^emic. It is also roughened, thickened, and intimately adherent to the substance of the cord. The exudation here also appears early as a cloudy serum, but a little later in bands or strings of fibrino-pus, which often assume an ir- regular, net-like appearance, and later still as thick layers of pus, resem- bling in ail its character the exudation described above. Its seat is almost exclusively upon the posterior surface of the cord, very rarely, and never wholly, in the cervical portion, but commonly extending from the cervical to the dorsal enlargement of the cord downward to the Cauda equina, and it is most abundant in the lumbar region. The roots of the spinal nerves are frequently imbedded in it. The anterior surface is much less rarely the seat of the exudation, and when this is the case, the wliole cord is surrounded. According to Hirsch, the accumulation of the exudation upon the lower portion and the posterior surface of the cord, is chiefly due to the fact that it flows there by gravitation whilst fluid, and Ziemssen observes that in the rare cases where the whole cord is imbedded, the variation from the rule depends mainly upon the viscidity of tlie exudation from the beginning. CEREBRO-SPIWAL FEVER. 93 The hrain-subatance is frequently congested, with numerous "puncta vasculosa " upon the incised surface, and the secondary development of local areas of softening-, which are most abundant in the neighborhood of the purulent exudation and about the ventricles. The nerve-elements are more or less disassociated as a result of the imbibition of fluids. Oc- casionally the entire brain is somewhat softened. In rare instances it is oedematous, even after an illness of only a few days.' This condition is more common in cases that have been very acute or very long-continued. The latter, class of cases present a brain with a smooth, level surface, and a watery appearance on section. More rarely the consistence of the brain is firmer than normal. In most cases, and in particular in those in which the illness has been protracted, the ventricles contain more or less turbid serum, and in some cases they are distended with pus. The choroid plexus and the ependyma are deeply congested, or even ecchymosed, and covered with pus and lymph. The same anatomical changes are found in the third and fourth ventricles. In cases terminating after a long ill- ness, the effusion may reach an enormous amount, and give rise to atrophy of the brain-substance with flattening of the convolutions, and oedema of the brain and spinal cord. The retrogressive changes consist of resorption of the sei'ous effusion, shrinking and organization of the exudation between the arachnoid and pia mater, with opaque thickening of these membranes or caseous degen- ei-ation of the exudation. In rare instances, diffuse purulent encephalitis takes place and purulent infiltration of the brain-substance or deposits of pus are found at the necropsy. Like changes are met with in the suhstmice of the spinal cord, namely, hyperaimia, serous infiltration, and softening. They are less marked, as a rule, and less uniformly distributed. In a girl, aged fourteen, who died on the fourth day, the autopsy dis- closed a large, serous effusion, purulent exudation into the ventricles, in- cluding the fourth, and dilatation of the central canal of the cord, which was filled with pus (Ziemssen). In cases of the fulminant variety, where death quickly follows the on- set of the sickness, it is probable that the subject is overwhelmed by the poison ere the characteristic anatomical changes have time to develop, as occurs in rapidly fatal cases of other epidemic and infectious diseases, as variola, scarlatina, etc. The amount of the exudation and the extent of the secondary changes in the substance of the brain and cord, are not always proportionate tO' the intensity of the symptoms or the duration of the case. Hutchison: American Journal Medical Sciences, July, 1866. :94 THE CONTINUED FEVERS. Diagnosis. The direct diagnosis of epidemic cerebro-spinal fever usually pre- sents but little difficulty if the attack be primary and occur during the -epidemic prevalence of the disease. Under certain circumstances, as when it develops as an intercurrent affection in pneumonia, typhoid fever, or other acute diseases, or vv^hen very young infants are the subject of the attack, and when sporadic cases occur either beyond the limits of the territory in which the disease is rife, or at the beginning of the outbreak, the diagnosis is attended with the greatest difficulty, and often cannot be made until some days have elapsed. The character of an epidemic outbreak of the disease may be inferred from the suddenness of its oncoming and the rapidity of its spread. The diagnosis of individual cases is based upon the presence in vary- ing combinations of the characteristic symptoms of the affection. Most prominent among these are, furious headache, with acute pains in the neck, spine, and extremities, faintness, with a sinking sensation in the epigastrium, and vomiting which is uncontrollable; and contraction, first of the cervical muscles, later of those of the spine, with general cutane- ous hyperaisthesia. Add to these morbid phenomena the abruptness of the attack, with or without prodromes; extreme restlessness; delirium al- ternating with periods of quasi-consciousness and merging into stupor or •coma; the occasional convulsive spasms; the eruptions, especially herpes; the irregular temperature, and the extraordinary variations of the pulse in frequency and volume, and the case presents a picture not difficult of recognition. The uncertainties which beset the diagnosis of sporadic cases of the affection arise from its less abrupt onset, its less acute course, the fre- quently indistinct spinal symptoms and the great rarity of its occurrence. In these cases, also, the pains in the back and limbs, the orthotonus and the hyperajsthesia of the skin and soft parts, are often altogether wanting, and the stiffness of the neck is less perfectly developed than in the epi- demic disease. Tuherculoiis basilar meningitis is to be distinguished from cerebro-spi- nal fever by the long duration of the period of prodromes, which is rarely absent, by the less abrupt and less violent onset, by its slower course marked with remissions, its slow pulse, the great irregularity of the res- piration, and the absence of eruptions. Furthermore, there will usually be elicited some history of scrofulous and phtiiisical affections, or of a hereditary tendency to tuberculous disease. But in children, or during the prevalence of an epidemic of cerebro-spinal fever, or in those cases in which the tuberculous process extends to the membranes of the spinal cord (Hirsch), the diagnosis is far from easy. CEREBROSPINAL FEVER. ^5 Pernicious intermittent fever, with its fulminant manifestations, its speedy collapse and fatal coma, may be confounded with the fulminant variety. The diagnosis rests upon a consideration of the etiological fac- tors of the two diseases. The season of the year, the nature of the country, which is usually in the highest sense insalubrious, and the en- demic or epidemic prevalence of ordinary intermittent or remittent fever, tend to clear up the obscurity arising from any accidental resemblance of the symptoms. Moreover, an attack of intermittent fever rarely declares itself as pernicious or malignant in the first paroxysm; it is only after one, two, or more seizures, differing not at all, or but slightly, from the common manifestation of the disease, that it discloses its true character. Scarlet fever in some instances may resemble, in its sudden onset, high febrile movement, vomiting, convulsions and stupor, cerebro-spinal fever as it occurs in children. The presence of the peculiar redness of the palatine half-arches, which is characteristic of the former disease in its earliest stage, may aid in the diagnosis. In a few hours the efflorescence will clear up any uncertainty. Enteric fever in its typical form presents marked points of differ- ence from the fever under consideration. Yet it has in more than one local outbreak presented symptoms that have for a time rendered it doubtful which of the two diseases was present. The following brief tabular arrangement of the prominent symptoms will serve to contrast the two diseases: Cerebro-spinal Fever. Abrupt, overwhelming onset, with or without prodromes. Headache, acute, agonizing. Vomiting, constant. Muscular contraction within the first two or three days. Constipation the rule. Active delirium, alternating with stupor, or stupor deepening into coma. Curve of temperature extremely irregu- lar and atypical. Attack reaches its maximum within four or five days. Various eruptions, chiefly herpetic and petechial ; they appear early. Enteric Fever. Gradual approach with marked pro- dromes, and often obscure beginning. Headache, dull, heavy. Rare. Absent altogether. Diarrhcea the rule. Mental hebetude, muttering delirium, stupor. A typical thermal line. Develops slowly to its maximum. A characteristic lenticular, rose -colored eruption, which does not appear until the end of the first week. Much confusion has arisen from the fact that not a few among the older writers, and some of a later date,' have confounded cerebro-spinal See Murchison : London Lancet. April, 1865. 96 THE CONTINUED FEVEKS. fever with t>/p/'"-^', or regarded it as a variety of t>/2^/ufs. Tliesc diseases are not only, as is at tliis day universally admitted, unlike in every respect save their infectious nature, but — as has been pointed out by Stille, whose learned treatise has done much to finally settle every question of doubt concerning the identity of these two diseases in this country — they are also in strong contrast in respect of their causes, symptoms, course, lesions and sequels, and all physicians who have witnessed epidemics of both af- fections agree in pronouncing them to be radically different. I venture to transcribe, from the pages of the last named author, a table of the important phenomena of these two affections, believing that, by so doing, their essential independence and the striking points of differential diagnosis between them will be most clearly demonstrated: Ei'iDEjiic Meningitis (Cerebro-spinal Fever). A pandemic disease. Occurs in places remote from one another, and without in- tercommunication. Attacks all classes of society. Is never primarily developed by squalor and de- ficient ventilation. Is not contagious. More males than females attacked. More young persons than adults. Generally occurs in winter. Eruptions are wanting in at least half of the cases ; they occur within the first day or two. The eruptions are very various, including erythema, roseola, urticaria, herpes, etc. Ecchymoses are common. Headache, acute, agonizing, tensive. Delirium often absent ; often hysterical, sometimes vivacious, sometimes maniacal. Generally begins on the first or second day. Pulse very often not above the natural standard ; often preternaturally frequent or infrequent. Is subject to sudden and great variations. " The temperature is lower than that recorded in any other typhoid or inflam- matory disease." It is also very fluctu- ating. The body has no peculiar smell. The tongue is generally moist and soft ; Bordes of the teeth, etc., rare. Typhus Fever. Essentially an endemic disease. Always due to local causes. Spreads by inter- communication only. Attacks primarily the poor, filthy, and crowded alone. Contagious to a high degree. The two sexes equally affected. More adults than young persons. Ejndemics are irrespective of season. The eruption is rarely absent, and dis- appears between the fourth and the seventh days. The eruption is uniformly roseolous and then petechial. Ecchymoses are rare. Headache, dull and heavy. Rarely absent ; usually muttering. Rare- ly begins before the end of the first week. A slow pulse exceedingly rare. Its rate is pretty constantly between 90 and 120. The temperature is always more or less elevated, and it does not fall until the close of the disease. ' ' The skin is hot, burning and pungent to the feel." The mouse-like odor of typhus is char- acteristic. The tongue is generally dry, hard, and brown ; and the teeth and gums fuliginous. CEREBRO-SPINAL FEVER. 97 Epidemu: Meningitis (Cerebro-spinal , Fever). Vomiting, generally of bilious matter, is aa almost constant and urgent symptom, especially in the first stage. Pains in the spine and limbs, of a sharp aad lancinating character, are usual and evidently neuralgic. Tetanic spasms in a very large proportion of cases, and within the first two or three days. They are due to an inflammatory exudation within the spinal canal. Cutaneous hyperjesthesia is a common symptom. Strabismus common. The eye, if injected, has a light red or pinkish color. The pupils are often unequal. Deafness often complete and permanent. Duration very indefinite, but generally from four to seven days. Relapses are common. The blood is often highly fibrinous. The lesions, unless in the most rapid cases, consist of a fibrinous or purulent exudation in the meshes of the cerebro- spinal pia mater. Mortality from twenty to seventy-five per cent. Typhus Fever. Vomiting is rare and not urgent. Pains are dull, heavy, and apparently muscular. Tetanic spasms are unknown in typhus. Convulsions sometimes occur, due to " py- semia." The sensibility of the skin is generally blunted. Rare. The blood in the conjunctival vessels has a dark hue. Always equal. Hardly ever permanent or attended with signs of the disorganization of the ear. Duration from twelve to fourteen days. Relapses are rare. The blood is never fibrinous. There are no inflammatory lesions what- ever. Mortality from eight to forty per cent. Stille. Certain cases of cerebro-spinal fever occurring in nervous females at the close of epidemics, or sporadically, have presented a delirium so peculiar and an array of symptoms so little characteristic, that they have been looked upon as the manifestations of hysteria. It is to be hoped that a period has been reached in the progress of medicine, in which such an error can no longer arise — a period in which this term shall be used with a degree of circumspection proportionate to the vagueness of its meaning. The use of the thermometer will clear up any uncertainty of diagnosis between this fever and most cases of functional distur- bance of the nervous system. Prognosis and Mortality. The course of the disease is very variable. In individual cases the prognosis can never be made with certainty. The abortive cases and those of the fulminant variety run the most rapid course. Hirsch has emphasized the fact that certain cases, whicli at the onset present the 98 THE CONTINUED FEVERS. symptoms of cerebro-spinal fever, promptly recover after an illness of a few liours, whicli terminates in free sweating. The most intense cases, on the other hand, prove fatal in a few hours — as few as five, and constantly as early as the second or third day. The course of the moderately seveie cases continues one or two weeks, to the beginning of convalescence, but it in other cases extends over months. Sad examples of the ravages of the disease are to be encountered after every epidemic. In the fulmi- nant cases death is by far the most common termination; in cases of aver- age severity it is still frequent, and it not seldom occurs in cases that have run an apparently mild course, in consequence of complications or se- quels. The first week is the time of greatest danger; if the patient survive that, hope of his recovery may be entertained. The symptoms that render the prognosis unfavorable are: a very high degree of excite- ment, the early appearance of depression, return of the vomiting, intense headache, continuous coma, recurring convulsions, and irregular respi- ration. In cases of average severity, and in mild cases, a guardedly favorable prognosis may be based upon the uniform gradual amelioration of all the symptoms within the first or second week, and the establishment of con- valescence without the occurrence of grave complications or sequels. It is to be borne in mind that relapses are not infrequent, and that they are often fatal. The high death-rate that attends cerebro-spinal fever places it among the most dreaded of epidemic diseases. The mortality varies greatly in different epidemics; in the mildest, it is about thirty per cent., in the most severe, seventy-five per cent. The average may be stated at about forty per cent, A comparison of the statistics of the epidemics of the early and middle periods of the century with that of those that have prevailed within the last two decades, suggests the probability of a gradual diminution of the violence of the disease. This difference in the death-rate is, however, without doubt due in part to the fact that the energetic depletory meas- ures of treatment formerly extensively in vogue are now wholly aban- doned. Mode of death. — Death occurs in a majority of cases by failure of the respiratory nerve-centres, in some instances from asthenia, and in the fulminant variety probably from necrsemia. Treatment, Our ignorance of the precise etiological conditions of the disease, limits prophylaxis to general sanitary measures for the purification of houses and localities, and attention to personal hygiene. This, as all epi- demic diseases, assumes, as a rule, its worst form, and numbers the most victims, where anti-hygienic conditions most abound. Attention to the CEREBROSPINAL FEVER. 99 cleanliness of streets and dwelling-places, to the condition of drainage and sewerage, the prompt removal of accumulations of refuse matter, and the avoidance of overcrowding, cannot fail to diminish the severity and mor- tality of the disease. The evidence that the fever-poison, in some instances, spreads among the different members of a household, either from the individual first at- tacked, from his personal effects, or in consequence of some unknown fav- oi'ing condition of the surroundings, renders it advisable that, where prac- ticable, the dwellings in which the disease has made its appearance, should be abandoned until after the close of the epidemic (Ziemssen). It is rec- ommended that all the linen and other articles used by the patients should be carefully disinfected, or perhaps burned. The use of plain and wholesome food, the avoidance of unusual fatigue, both bodily and mental, and of excesses of every kind, are important. Moderate exercise, quiet, and regular living, may afford some, but by no means complete security during the epidemic. Nervous persons and those in feeble health, should, when possible, leave an infected district upon the outbreak of the disease. The treatment of the disease has been almost as various as its various physiognomy. In different epidemics and at different periods, divergent and even opposite methods of treatment have been adopted. On the one hand, a vigorous tonic and stimulant plan has been pursued by tl?ose to whom the disease has presented, in an extreme degree from the onset, the symptoms of depression; again, the urgent symptoms of an intense inflammatory process localized in the membranes of the brain and spinal cord, have seemed to some to indicate the energetic use of deple- tory and other antiphlogistic remedies, including the administration of mercurials, while others have been content with a modified expectant plan of treatment, in which a careful regimen and efforts to combat the symp- toms as they arise, play the chief part. In the present state of knowledge, it is impossible to decide whether or not any plan of treatment yet resorted to is capable of so affecting the mortality as to lower the death-rate in particular epidemics, while there is reason to believe that the extreme fatality characterizing some of the older epidemics has been in part due to the repeated and copious blood- lettings, and other depressing measures entering into the treatment. The difEculties connected with the consideration of the treatment of this dis- ease are partly inherent to the subject of the treatment of the infectious diseases in general, in which, the cause being beyond our reach and its nature unknown, we are compelled to direct our therapeutic efforts alone against the consequences of its action. They are, however, in a much greater degree dependent upon the variable and diverse forms in which this disease presents itself. Efforts to deduce, from statistics, conclusions in regard to the success of different modes of treatment in an epidemic 100 THE CONTINUED FEVERS. disease in which the mortality ranges between thirty and seventy-five per cent., must yield unsatisfactory, if not fallacious results, Tt is not only impossible to compare the results of treatment in different epidemics, but, from the capricious nature of this affection and its various manifestations, it is even impossible to compare cases in the same epidemic, or indeed, to compare the cases which occur during the rise, the maximum, or the decline of the same epidemic. We have to do with cases of this fever to which the term average cases may be aptly applied, as qualifying the intensity of the morbid phenomena and the rate of mortality which attends them, M'hich yet differ among themselves by as many shades as there can be va- rious combinations of the infectious or blood element and the local in- tlauunatory element which jointly underlie its manifestations. Cases are far from rare in which the attack is of the mildest form, only to be recog- nized by the lurid light of the outbreak in which they occur, cases re- quiring no treatment, sometimes not even compelling the subject to take to his bed. In strong and terrible contrast to such cases are those in which, in the midst of health, W'hile at his ordinary occupation or on awaking from sleep, the patient is overwhelmed by the poison as by an avalanche, and passing rapidly from agonizing suffering to coma, perishes- in the course of a few hours. Here the brevity of the course and the na- ture of the lesions alike show the powerlessness of our efforts to control the attack. Medicine, with all its resources, is neither adequate to combat it, nor responsible for its result. As Stille has said, "' the first symptoms of the disease are the first phenomena of death." We are driven then, in estimating the results of treatment, to restrict our observations to the effect of remedies upon the individual patients,, the immediate influence upon their symptoms, both objective and sub- jective, and the permanence of that influence. A judicious troatment must be based upon the broad general princi- ples of therapeutics. Antiphlogistic treatment would seem to be indicated by the promi- nence of the symptoms of inflammatory congestion of the meninges at the onset of the attack, by the nature of the lesions constantly found after death, and by the relief it affords in a large proportion of the cases. But, in view of the infectious character of the cause of the affection, its rapidly disintegrating effect upon the blood, the early and often alarming debility in some cases, the marked depression that in others follows the active symptoms, the great emaciation and the tedious convalescence, measures of depletion must be employed with the greatest caution, and are in all but the sthenic cases contraindicated. In the young, and particularly in children, the abstraction of even small quantities of blood is liable to be followed by alarming symptoms of depression. Dr. J. Lewis Smith re- ports a case in which the application of a leech to each temple in a child aged four years was followed bv extreme and almost fatal exhaustion. CEREBRO-SPINAL FEVER. lUl General bloodletting is in no case admissible. It is to be borne in uiiud that the pulse is almost always, even from the onset, such as would contra- indicate the abstraction of blood, and if the urgency of the symptoms of the local inflammation and the critical state of the patient seem to call for the employment of energetic measures, the clinical history of the dis- ease reminds the physician that a no less marked depression is speedily to follow and calls for a thoughtful regard for the future. Even in tlio sthenic cases the local application of cut cups to the nape of the neck and along the spine is to be employed with caution. Leeches may be applied to the temples and in the neighborhood of the mastoid processes. These measures are of great value in mitigating the headache and spinal pains which form so prominent a symptom in many cases. If such local abstractions of blood be contraindicated by the state of the patient, dry cupping may be emj^loyed with advantage. The direct application of cold to the head and spine by means of ice, snow, or a freezing mixture in rubber bags made for the purpose, and to be had at the apothecaries' shops, is not open to the same objections as bloodletting, and at the same time is attended with satisfactory results as regards the symptoms of inflammation. If the bags cannot be pro- cured, a bladder filled with cracked ice mixed with bran may be substi- tuted. In children gentle cold affusions may be practised. The applica- tion of cold by these means is in most cases followed by very marked mitigation of the pains, and often by quietude or sleep. It should be continued as long as the patient is comfortable, and repeated upon the return of the symptoms. Patients frequently require the continuous ap- plication for hours at a time. A hot mustard foot-bath, or a general hot bath, 38°— 39^ C. (100.4°— 102.2** F.), should be employed as early as pos- sible, care being taken that the strength of the patient be in no wise taxed. This may be followed by gentle frictions with some stimulating- liniment, or with oil of turpentine, if the surface be cold and the circu- lation depressed. A stimulating enema may at the same time be ad- ministered. The patient should also be covered with warmed blankets, and artificial heat applied to his sides, thighs, and extremities. In all cases it is well, while using the cold to the head and spine, to counteract its depressing effect by the application of moderate heat elsewhere. This may be accomplished by means of hot flannels, bags of hot sand or salt, bottles filled with hot water, or heated billets of wood well wrapped up. At the same time, if necessary, sinapisms are to be applied to the ex- tremities and the prsecordium. Bartholow holds that the application of ice to the head and spine may do mischief by the depression of the circulation which it causes. He ad- vises, instead, the use of hot water applied by a sponge passed over tlio spine every two or three hours. The best modern American authorities agree in advising the continuous use of external heat, to anticipate and 1U2 THE CONTINUED FEVERS. counteract the early depression which is so grave an element of the dis- ease, a practice very general in the early epidemics in this country, but for a long time strangely overlooked here, and altogether neglected abroad. Blisters upon the occiput and upon the nape of the neck are not only to be advised upon theoretical grounds, but they are of great practical value in relieving pain and in diminishing delirium, spasm, and coma. They should be applied early in the course of the disease. The use of mercury, except at the onset of the attack, in the form of a dose of calomel as a purgative, is to be discountenanced. No single drug has been employed to a greater extent than mercur}' in the treatment of cerebro-spinal fever, but almost all authorities at this time regard with disfavor the employment of the preparations of this metal for its sup- posed antiphlogistic or antiplastic effect, or its absorbent effect upon the exudation. Among the most recent German writers, Ziemssen, how- ever, recommends its use in the form of mercurial ointment or calomel, " for the purpose of preventing the extension of the meningeal inflamma- tion and exudation." He employs free inunctions and the internal use of calomel " in almost every case," but admits that when used in connec- tion with other remedies, it is difficult to ascertain its share in the com- mon effect, and that even when used alone its efficacy is by no means clearly established. The antipyretic treatment by cold baths and enormous doses of quinia, as practised by the Germans in diseases attended by hypyrexia, can be rarely necessary, for the reasons that in most cases the fever is moderate, and in those cases characterized by an excessively high temperature, the fatal event is due to other causes than the fever. Quinia has no control over the intermittent variety of the disease. In the report of the Committee of the American Medical Association, written by Dr. Levick, above quoted, the use of quinia in large doses, at the very heginning of the dis- ease, is favorably spoken of; but its administration in the later period, Avhen the phenomena all point to intra-cranial exudation, is said to be of no use and liable to prove even hurtful, except in small doses as a tonic to an enfeebled system. The statement that this drug has appeared to abort the disease in some instances is not borne out by sufficient evidence. There is no abortive treatment. Opium, by the concurrent testimony of observers in all countries, now holds the highest place in the treatment of this disease. It was used in this country in the early part of this century, adopted as a treatment in France at a later period, and has recently found favor in the eyes of the physicians of Germany. Ziemssen says of morphia, that it '* may he re- garded as one of the most indispensable remedies in the treatment of epi- demic meningitis." All the distressing symptoms, the headache and spinal pains, restless- CEREBRO-SPINAL FEVER. 103 ness, the spasm, the hyperaesthesia, and the inability to sleep, call for the administration of this drug. At the same time our knowledge of the nature of the lesions suggests its use. Opium slows the heart and in- creases arterial tension. It is to be employed at the earliest moment possible, and in full doses. By this means we may anticipate the occur- rence of exudation, or limit it. Experience has shown that a remarkable tolerance for this drug exists in most cases of cerebro-spinal fever. Some of the older physicians gave large doses. Strong ' in one case " gave sixty drops of laudanum every hour till half a fluid ounce was taken. The whole of it was retained, and it subdued the excitement and relieved the pain, but produced no sleepi- ness or other apparent effect of opium. Others among the early American writers gave enormous doses, 16 c.c. or half an ounce of the tincture, or from 2 — 4 grammes (thirty to sixty grains) in substance, in the course of twelve hours, being necessary to control the urgent symptoms. Such cases recovered. Chauffard," to whom Hirsch erroneously ascribes the first advocacy of the opium treatment, gave it in doses of from 0.2 — 1.0 gramme (three to fifteen grains). Boudin ' frequently gave up to 0.45 — 1.0 gramme (seven to fifteen grains) at a single dose at the commencement of the attack, and afterward 0.065 — 0.13 gramme (one to two grains) every half-hour. As soon as the symptoms abated or the patient became drowsy, the dose was diminished. Stille gave 0.065 gramme (one grain) every hour in very se- vere cases, and every two hours in moderately severe cases without nar- cotism, or even an approach to that condition. He adds that " under the influence of the medicine, the pain and spasm subsided, the skin grew Avarmer and the pulse fuller, and the entire condition of the patient more hopeful." The remedy must be given for its effect, and the quantity necessary is to be prescribed. Its action is to be carefully watched. Its greatest usefulness is to be reached only by its administration early in the course of the disease. After the symptoms indicative of effusion appear, it must be given in lessened doses, and its utility is greatly diminished. It is among the most notable facts respecting the use of opium in this dis- ease, that the early American physicians did not hesitate to employ it when coma, a condition usually thought to preclude the use of narcotics, threatened, nay, Strong and others have recorded their opinion that it is a powerful agent in removing such comas as are not " absolutely irrecov- erable." When the condition of the patient is such as to render its administra- ' Quoted by Stille. •' Revue medicale, LXXXVI. 1842. " Histoire typhus cerebro-spinal, par C. M. Boudin. Paris, 1854. 104 THE CONTINUED FEVERS. tion by tlie mouth impracticable, or when tlie repeated vomiting pre- vents its absorption, it may be given in the form of enemata or supposi- tories, by the rectum, or one of the morphia salts may be substituted in hypodermic injections. The latter is in most cases the best plan of treatment. In view of the fact that children are peculiarly susceptible to the action of this drug, the dose must be regulated with caution. A boy aged six, under the care of Dr. J. Lewis Smith, was quieted by the subcutaneous injection of ^'^ of a grain (0-002 gramme) of morphia sul- phate. Ergot and belladonna have been used upon theoretical grounds, on ac- count of their influence in diminishing vascularity of the nervous centres, but the evidence of their value is not satisfactory. Rosenthal ' urges great caution in the administration of belladonna and in the hypodermic use of atropine. Cannabis indica, the fluid extract of gelsetnium (Bartholow), zinc oxide, large doses of chloral hydrate and inhalations of chloroform, have been employed in the management of the excitement. Chloral is to be emphatically condemned in the treatment of a disease attended with vomit- inar so continued as often to interfere with the assimilation of food, and characterized by a tendency to extreme exhaustion ; and chloroform inhala- tions, when from the outset we often have to do with a feeble and irregu- lar action of the heart, showing itself in extreme weakness and irregularity of the pulse, and a tendency to syncope upon assuming the upright pos- ture; of the others it may be said that they are useful auxiliaries to treatment, but that they do not in severe cases constitute an efficient medication. The last remark holds true also of the potassium bromide, a remedy, which has, however, great value in the treatment of mild cases, and in the treatment of children. It may be advantageously combined with opium or morphia. In cases of extreme urgency, the inhalation of Squibb's ether may be resorted to for the purpose of securing temporary relief from the tortur- ing pain, the jactitation, and the spasm. Upon the approach of depression, excitants and stimulants are to be resorted to. Among the more useful are aminonium carbonate, spirits of chloroform, turpentine, and the preparations of alcohol. Cold affusion, practised several times a day, is recommended by German writers. It is a remedy scarcely likely to be widely used in this country. Quinine may be given in moderate doses. Al'^oholic stimulants are required at some time in the course of the ma- ' Rosenthal : Diseases of the Nervous System. Aqaerioan edition. New York, 1879. CEREBROSPINAL FEVER. 105 joiity of cases. Their use as a remedy in the treatment of this fever, in- dependently of the indications which govern their use in the general management of diseases, has not been followed by satisfactory results, n^hey are to be promptly resorted to when symptoms of depression of the nervous system show themselves, whether it be at the onset of the attack or later in the progress of the case. Their amount must be regulated by the effect which they produce. The pulse and the first sound of the heart are the best guides. If the pulse, after the free administration of alcohol becomes less frequent, stronger and fuller, and the first sound more distinct, it is beneficial; but if the pulse increases in frequency, the heart's action being excited, the tongue grows dry, and the excitement augments, the alcohol must be given in decreased doses or abandoned altogether. If the need be urgent, and the patient unable to swallow, brand}' should be given hypodermically. During the convalescence the vegetable tonics and iron are to be employed. Arsenic, and especially potassium arsenite, are also useful at this period. The latter has been praised as a remedy of value in the man- agement of the acute disease. These praises are unfounded. Cod-liver oil is of use, and in proper cases potassium iodide is of proved service in promoting the resorption of the exudation. Its use should be long- continued, and at the same time flying blisters, daily hot affusions, and, after all acute symptoms wholly cease, mild continuous currents should be employed. The potassium iodide is not of use in the treatment of cerebro-spinal fever during its acute course. Ziemssen states that he has not found it of the slightest benefit in the chronic hydrocephalus occurring as a sequel — a result which the natux'e of the lesions in that affection would lead us to expect. Diet. — A generous alimentation is to be given from the beginning of the sickness. During the continuance of the febrile phenomena, milk, eggs, meat-juice and broths should be given at regular intervals, and continued in severe cases during the night. If food cannot be taken by the mouth, an attempt should be made to administer nutritious enemata. As soon as he is able, the patient should be allowed an abundance of solid food. The appetite is often excellent, even in the early days of con- valescence. When there is thirst, the desire for water must be freely gratified. This symptom is often very distressing. Constipation may be relieved by a dose of calomel with or without jalap, by other simple drugs, or by enemata. Neither constipation nor diarrhoea are, as a rule, difficult of relief. When there is much prostration, and, indeed, in most cases, the pa- 106 THE CONTINUED FEVERS. tient should be guarded against assuming the erect posture, or, in truth, against ev'en sitting upright in bed, on account of the danger of syncope. The room should be darkened, and all noises and other disturbing in- fluences avoided. Delirium, spasm, and irritability of the stomach, too often, in the se- vere cases, render the administration of medicine and food impracticable. IV. ENTERIC OR TYPHOID FEVER. Definition. — An acute, endemic, febrile disease, of long duration, due to a poisonous principle associated with certain forms of decomposinar animal matter. It is characterized by a gradual and often insidious commencement ; dull headache, followed by stupor and delirium ; a red tongue, occasionally becoming dry and brown ; in most cases tympany, abdominal tenderness, and diarrhoea ; an eruption of iso- lated, slightly elevated rose-colored spots, disappearing on pressure and developed in successive crops ; increased splenic dulness ; epis- taxis ; late prostration and tardy convalescence. After death, con- stant lesions of the solitary and agminate glands of the ileum, with enlargement of the mesenteric glands and of the spleen, are found. Synonyms. — Typhus nervosus; Typhus mitior; Abdominal typhus; Darm- typhus; Synochus and typhus with abdominal affection; Typhus gan- gliaris vel entericus; Ileo-typhus; Typhia; Typhus; Fievre typhoide ; Typhoid fever ; Mild typhoid fever. Febris non-pestilens ; Endemic fever; Autumnal or fall fever. Remittent fever ; Infantile remittent fever. Febris lenta; Slow or lent fever; Febris chronica; Chronic con- tinued fever ; Fievre continue. Nervous fever; Slow nervous fever; Irregular low nervous fever; Low fever ; Nervenfieber; Fievre nerveuse. Febris putrida ; Febris putrida nervosa; Sepimia ; Entente septi- cemique. Febris hectica; Infantile hectic fever. Febris gastrica; Febris acuta stomachica aut intestinalis; Febris glutinosa gastrica; Febris gastrica acuta; Gastrisches Fieber; Fievre gastrique; Epidemic gastric fever; Gastric fever; Febris biliosa; Bil- ious fever; Bilious continued fever ; Febris biliosa putrida ; Synochus biliosa ; Bilio-gastric fever ; Gastro-bilious fever. Febris colliquativa ; Febris stercoralis ; Febris mucosa ; Febris pituitosa; Morbus bilioso-mucosus; Febris pituitosa nervosa; Schleim- Fieber; Fievre muqueuse ; Mucous or pituitous fever. Febris mesenterica maligna ; Febris intestinalis vel mesenterica; 108 THE CONTINUED FEVERS. Febris mesenterlca acuta ; Enteritic fever ; Gastro-enterite ; Entero- mesenteric fever ; Dothienenterie ; Muco-enteritis ; Fever with affec lion of the abdomen ; Fever with ulceration of the intestines ; Gas- tro-enteric and gastro-splenic fever ; Enterite foUiculeuse ; Enteric fever ; Febris tympanica ; Intestinal fever. Night-soil fever ; Cesspool fever ; Pythogenic fever. Rock fever ; Mountain fever. The above long list of the terms under which this fever has been de- scribed at various periods and by many different authors, is taken, with] few exceptions, from Dr. Murchison's great work upon the "Continued Fevers of Great Britain." They are variously derived from its supposed relationship to typhus, its mode of prevalence, its remittent character, its long duration, its supposed nervous origin, the occurrence of septic or putrid symptoms, its hectic phenomena, the presence of symptoms denot- ing disturbance of the stomach and liver, the intestinal symptoms, the morbid anatomy, its mode of origin, and localities in which it has pre- vailed. The term " abdominal typhus " and its equivalents, in general use in Germany and elsewhere upon the Continent, are open to the ob- jection that they suggest a relationship with typhus that is now acknow- ledged on all sides not to exist. They are, in fact, due to the opinion formerly generally entertained, that there existed between the two affec- tions an essential pathological identity — that they were, in fact, two varie- ties of a single species of fever. This opinion is no longer tenable. " Typhoid," suggested by Louis in 1829, is open to the same objection, since the labors of pathology during the past half-century have shown with increasing clearness, not that the fever in question is like typhus, but that it is unlike it. This term has, however the sanction of very gen- eral acceptance in France and among English-speaking physicians. The strongest objection to its use for any purpose whatever, lies in its com- mon employment as an adjective to designate a condition or group of symptoms that may appear in the course of any acute disease — a use that has given rise to endless confusion of thought and vagueness of descrip- tion. The term " e«^e?7'c /ewer," proposed by the late Professor George B. Wood, possesses the advantage of designating at the same time the .anatomical seat of the constant primary lesion, and, by a now accepted usage of the word fever in combinations of this kind, the infectious na- ture of the disease. It was adopted in the " Nomenclature of Diseases," in 18G9. Historical Sketch. Enteric fever has been separated from the general group of the fevers as a substantive disease only in the present century. It is probable, jiowever, that it has come down to us from a roniote antiquity. The 1 ENTET^IC OR TYPHOID FEVEPw. 10^ description of a continued fever mentioned by Hippocrates as prevalent in the autumn, and characterized by diarrhoea, bilious vomiting, tympany, abdominal pain, red rashes, bleeding at the nose, sleeplessness or a tendency to coma, delirium and subsultus, irregular remissions, a long duration and great emaciation, doubtless refers to tliis disease. It has been thought likewise that Galen described it under the name of " hem.Uritoeus^'' a name applied to a disease resulting from the grafting of a tertian upon a quotidian intermittent. Dr. Murchison thinks there is little doubt that the ^^febrls semitertiana'''' of the writers of the seven- teenth century was true enteric fever. Spigelius (1684), Panarolus (1654) and Baglivi (1696) in Italy, Thomas Bartholin (1641) in Copenha- gen, and Willis (1659) and Sydenham (1685) in England, recorded their observations of cases of fever, which both in the symptoms and the post- mortem appearances corresponded with enteric fever as we know it. During the eighteenth century many accounts of» enteric fever were published, and the difference between its symptoms and those of typhus, as well as the prominence of the intestinal lesion, attracted the growing attention of British and Continental physicians. Strother (1739) distinguished the epidemic fever of 1727-29 in Lon- don, which we know to have been typhus, from the sloio fevers, one variety of which, " the lent fever, is a symptomatical fever, arising from an in- flammation, or an ulcer, fixed on some of the bowels." Gilchrist (1734), Languish (1735), and Huxham (1739), called atten- tion to the differences between the Nervous Fever, or the Slow JVervous Fever, and the Malignant Continued Fever, or Putrid Malignant Pete- chial Fever, generally prevalent in England and Scotland. Sir Richard Manningham (1746) published an account of the " Symp- toms, Nature, etc., of the Febricula or Little Fever." This fever was described as of insidious origin, and apt in the beginning to be disre- garded; but at length conspicuous and very terrible symptoms arose, upon which the physician was sent for in the greatest haste, and " the little,, neglected fever proves of very difficult and uncertain cure, and too often becomes fatal in the end." Its prominent symptoms were a red tongue, often dry, abdominal pains, diarrhoea, hemorrhage, a quick pulse, loss of memory, and sometimes slight delirium. It was known popularly as the Nervous or Hysteric Fever, Loic Contimicd Fever, Fever on the Spirits, Vapors, Hypo or Spleen. Others, at this period and later, regarded the febris nervosa as a very different disease from the febris carceruni, and in particular, Willan (1799) "observed that Cullen had improperly comprised under the term typhus the slow or nervous fever described by Gilchrist and Huxham, which may rather be considered as a species of hectic, and is not received by infection." It is at this point worthy of remark that the term hectic, thus employed by Willan, seems singularly appropriate in view of the 110 THE CONTINUED FEVEKS. modern doctrine of a primary and secondary or septic fever in the course of the disease, and that Matiningham's observation that the " little, neg- lected fever " might prove at length " very difficult and uncertain of cure," and " often fatal in the end," is in full accord with the now well-known fact that cases untreated in the beginning are apt to be very serious and often fatal. The Irish physicians of the last quarter of the eighteenth century also make frequent mention of the febris nervosa, a continued fever of three or four weeks' duration, more frequently occurring in the autumn, and at- tended by diarrhoea and by hemorrhages. Upon the continent, during the same period, many accounts of enteric fever were published. De Haen, of Vienna (1760), describes it as Miliary Fever ; Stoll (1785) as the Pltuitous or the Slow Nervous Fever ; others as Febris Intestinalis. About the beginning of the present century the pathologists of France began to study the pathological anatomy of fever with great earnestness. Prost (1804) announced that mucous, gastric, ataxic and adynamic fevers have their seat in the mucous membrane of the intestine. Broussais (181 G) advocated similar views. He regarded it as useless to distinguish between the ulcerations found in fever and frequently having their seat in the intestinal glands, and inflammations of other portions of the intestines. He believed that the symptoms were due to the inflamma- tion, gastro-enterlte, and upon this opinion he based his advocacy of copious depletion. Petit and Serres (1813) described enteric fever as the Fievre entero- i/tesentei'ique. They called attention to the fact that the disease differed from ordinary enteritis, and were the first to look upon it as specific. They regarded the lesions as the result of the introduction of a poison, and as of an eruptive nature, like the pustules of variola, failing, how- ever, to localize the processes of the disease in the solitary and agminate glands. To these observers is due the credit of having first pointed out the fact that the intestinal lesions are limited to the ileum, and principally to its lower parts. In 1818, Bretonneau began at Tours the series of anatomical re- searches that enabled him to prove that the solitary and agminate glands of the ileum are always implicated in the processes of this fever, and that it differs essentially from all other inflammations of the bowels. He maintained that the disease was due to a poison communicable from the sick to the healthy, and regarded the intestinal lesion as analogous to the cutaneous eruptions of the exanthemata. He pointed out the fact that the severity of the general symptoms bears no relation to the intensity of the eruption. He named the disease dothieu enteric, or dothienenterite {^odvqv, a small abscess, boil, and evrcpov, intestine), the " Dothinenteria" of the translators of Trousseau. These views were made known in Paris ENTERIC OR TYPHOID FEVER. Ill in 1820, but were first published by Landini ' and Trousseau.' pupils of Bretonneau in 1826, and by Bretonneau ' himself in 1827. Louis's elaborate work, " Recherches sur la maladie connue sous les noms de gastro-enterite, fievre putride, adynamique," etc., appeared in 1829. It not only contained an admirable and exhaustive description of the fever, but also an analysis of the symptoms and pathological phe- nomena so accurate and full, to use the words of Gerhard, " as to surpass any other description of individual diseases." Enteric fever was so well studied by Louis, and its symptoms so well set forth in this work, that it served from that time as a standard of comparison for other affections less thoroughly understood. It may be said then, with truth, that the ap- pearance of this work marked an important epoch in the history of the continued fevers. Louis gave to the disease the nsune^fi^vre typho'ide^ which was a few years later adopted by Chomel (1834), and soon passed into general use in France and among English-speaking physicians. At the period of these investigations into its pathology, enteric fever was very prevalent in Paris and elsewhere in France. There was, ac- cordingly, abundant opportunity for its clinical and anatomical study. Typhus fever was, on the other hand, unknown. An epidemic of typhus, brouglit back by the retreating armies of Napoleon after the disastrous campaigns of 1813-14, in Germany and Eastern France, had prevailed extensively in Paris and elsewhere in the large cities, and had been every- where extremely fatal. But, from the date of the subsidence of this out- break, typhus had not occurred within the borders of France, and was, to the French physicians of the time of Louis and Chomel, practically un- known. These observers therefore fell into the error of regarding the con- tagious fever of camps and armies, and of the British writers, as identical with the prevalent fever known to them as dothienenterie or typho'lde. At the same time English physicians were not idle in the study of the pathology of fever. As a result of their investigations, however, it was discovered that in by far the greatest number of fatal cases the intestines showed no evidences of disease. To this general statement there were, nevertheless, numerous excep- tions. Sutton (1806), William (1801), Muir (1811), Bateman (1819) and others, published accounts of outbreaks of fever, prevailing principally in the autumn, and attended by diarrhoea, in which, after death, the in- testines were found to be "inflamed and gangrenous." Edmonstone (1818) recorded an extremely interesting history of an outbreak of enteric fever at Newcastle in 1817. This fever presented striking contrasts to ' These inaugurale sur la dothienenterie. Paris, 1826. ■ De la maladie a laquelle M. Bretonneau a donne le nom de dothienenterie ou de dothienenterite. Archiv. gen. de medecine, Ser. I. , Tome X. , 1826. Notice sur la contagion de la dothienenterie. Archiv. gen. de medecine, Ser. I., Tome XXI., 1829. 112 THE CONTINUED FEVERS. the epidemic fever then prevalent in various parts of the kingdom, and which at a later period fell upon Newcastle itself. Many of the first cases occurred among the better classes, and among servants residing in the best-aired parts of the town. Children and young adults in the vigor of life were almost exclusively affected. The duration of the attack was from fourteen days to a month. The disease was thought not to be con- tagious, and several members of a family were seized at the same time. It was almost unknown in the portions of the town inhabited by the poor, and in which typhus, upon its appearance, chiefly prevailed. The symp- toms included vomiting, purging, bleeding at the nose, and hemorrhages from the intestines. Abercrombie (1820), Hewett (1826), and Bright (1827) recorded cases of fever in which the lesions of enteric fever were found after death. Alison (1827) stated that he had encountered in Edin- burgh the intestinal affections described by French authors; but he main- tained that they were not found after death from the ordinary typhus. Tweedie and Southwood Smith (1830) recorded a number of cases that had fallen under their observations in the London Fever Hospital, in which, after death, the intestines showed ulceration and the mesenteric glands were enlarged; in other cases, however, these parts were unaffected. These lesions thus came to be regarded by the English and Scotch pathol- ogists as accidental complications of fever, and one of the earliest results of the awakened interest in the study of the morbid anatomy of fever was that the clinical distinction between the slow nervous fever and the malignant fever of camps and jails was lost sight of, both in France where the former only was prevalent, and in the British Isles, where the two fevers were constantly met with side by side. In Germany, however, this distinction was recognized. Hildenbrand (1810) pointed out the difference between the contagious typhus and the non-contagious nervous fever. From this period the typhxis exanthema- ticiis and the typhus abdominalis were regarded as well-marked varieties — a view which is not yet finally abandoned at all hands in Germany, and which, while it was in advance of the doctrines held in France and Eng- land at the period of which we are writing, nevertheless has since had great influence in retarding the spread of the doctrine that they are es- sentially distinct, separate, and independent infectious diseases. The distinction between the two fevers, based upon their clinical differ- ences, that have arisen in the eighteenth century, had been lost sight of; that resting upon the differences in their morbid anatomy failed of recog- nition because of the confusion of the symptoms. It remained to study at the same time the symptoms during life and the appearances after death, and to compare them; in other words, to apply to this epidemic fever of Great Britain, typhus, the analytical method of study that Louis had applied to enteric, the endemic fever of France. This done, the two fevers were no lono-er to be regarded as the same disease; when it was thoroughlv ENTERIC OR TYPHOID FEVER, 113 done, they were not even to be looked upon as varieties of the same dis- ease; they were to unprejudiced eyes clearly seen to be separated by their causes, their symptoms, their course, their duration, and their anatomical characters, and no more closely related to each other than that they are both acute, specific, infectious diseases. The process of accumulating the necessary facts upon which to base a convincing demonstration of the non-identity of typhus and typhoid fever was a slow one. From the appearance of the first edition of Louis' great work in 1829, in which the^filivre typho'ide and the typhus of English writers were spoken of as identical, till the issue of the second edition in 1841, the question of the identity or non-identity of these two fevers attracted the widespread interest of medical men both in England and France. Prominent among the names of those engaged in the discussion which this question called forth are those of Drs. Peebles, A. P. Stewart, Perry, Barlow, Lumbard, Messieurs de Clautry, Montault, Rocheux, and Dr. Staberoh, of Berlin.' To Drs. Gerhard and Pennock, of Philadelphia, belongs the honor of having first in America clearly set forth the distinction, between the two fevers, that was gradually taking form in the minds of the British and continental physicians. These gentlemen had studied enteric fever both in France, with Louis, and afterward in America, and had arrived at the conclusion that the dotkienenterie or fi^vre typho'ide, of the French, and the prevalent continued fever of this country are identical. Upon the appearance of typhus in Philadelphia, in the spring of 1836, they recog- nized it as a different disease and after a careful study of the epidemic, they were enabled to point out the most important points of difference between the two affections, and to classify the epidemic fever among the continued fevers, " distinguished by the terms typhus, typhus gravior, petechial fever, etc." '• By diagnosis," Dr. Gerhard wrote, " we mean the comparison of all the symptoms appreciable by us in disease. This comparison requires a careful examination of the symptoms presented during life, and of the phenomena observed after death, in such cases as terminate unfavorably. AVe do not base our classification of diseases solely upon their anatomical lesions, although those lesions are oftentimes more constant than any other single symptom whatever ; but we group together lesions and symp- toms whenever they occur together with sufficient frequency to admit this process of generalization." Proceeding to compare the two fevers upon this plan, they showed that tlie lesions of Peyer's patches and of the mesenteric glands invariably present in enteric, were never found in typhus; and that English obser- ^ For a detailed account of the conclusions reached by these observers, see Murchi- son. It is to his work on the continued fevers that I am indebted for the outline and for most of the factri of this historical sketch. S 114 THE CONTINUED FEVERS. vers were in error in regarding these lesions as merely complications of typhus; that there was a " marked difference between the petechial erup- tion of typhus and the rose-colored spots of typhoid fever ; " that the train of symptoms associated with the intestinal lesions was very different from those of typhus, and that " the distinctive characters of the two diseases were such as in practice would not allow them to be confounded." They pointed out the fact that typhus is very contagious, whilst they were con- vinced that " dothinenteritis is certainly not contagious under ordinary circumstances," although in some epidemics, they said, " we have strong reason to believe that it becomes so." Their observations and conclusions were published by Dr. Gerhard in February and August, 1837.' Dr. Shattuck, of Boston (1839), strongly insisted, after watching some cases in the London Fever Hospital, upon the existence of two fevers in England, and pointed out, in a paper communicated to the Medical Soci- ety of Observation in Paris, the distinctions between them with consider- able minuteness. During 1840 several able papers, setting forth the differences between the two fevers, made their appearance; and in 1841, in the second edition of his work, Louis declared that " the typhus fever of the English is a very different disease from that with which we are occupied." Other French and English physicians adopted similar views ; but the doctrine of non-identity met with general opposition, and the opposite view continued to be taught in most of the medical schools. In America, Bartlett, in his work on the " History, Diagnosis, and Treatment of the Fevers of the United States," ^ treated of typhus and typhoid fevers as distinct diseases. Sir William Jenner, in a series of papers upon " Typhus Fever, Ty- phoid Fever, Relapsing Fever, and Febricula, the diseases commonly confounded under the term Continued Fever"' (1849-52), contributed greatly to the final overthrow of the doctrine of the identity of the two fevers first named. He not only confirmed and extended the distinctions between the symptoms and post-mortem appearances, pointed out by previous observers, and in particular by Gerhard and Pennock, support- ing his statements by the histories of carefully recorded cases and elabo- rate analyses of the symptoms and anatomical lesions of many cases of both fevers, but he also demonstrated the non-identity of the causes of the two fevers, and showed by an analysis of all the cases admitted to the London Fever Hospital in two years, that they did not prevail to- gether and that the one did not give rise to the other ; and he called at- ' W. W. Gerhard, M.D. : On the Typhus Fever which occurred at Philadelphia in the Spring and Summer of 1837. American Journal of Medical Sciences February and August, 1837. - Philadelphia, 18-12. - Medical Times. November, 1849. to March, 1851. ENTERIC OR TYPHOID FEVER. 115 tention to the fact that an attack of one of them mostly confers immunity from subsequent attacks of the same, but not of the other fever. From the period of the appearance of these papers, the doctrine of the specific distinctness of enteric and typhus fevers was gradually ac- cepted; it is now generally entertained in all parts of the world. If there be those who are exceptions to the rule that competent observers regard these two diseases as essentially distinct, they are very few, and their pro- tests no longer retard the progress of knowledge. The geographical distribution of enteric fever is wide. It has been ob- served in all countries and in every climate. It is endemic in the British' Isles, all parts of Europe, and in North America, Hirsch' has reached the conclusion that its general prevalence in Europe and America dates no farther back than the second and third decades of the present century — that is, from the period at which typhus (der Petechialtyphus) became less common, and in part disappeared altogether. Enteric fever is, according to Murchison, common in Scotland, more common in Ireland, and most common in England, but everywhere preva- lent within the United Kingdom. Dr. Cayley, in his Croonian Lectures,* declares that upwards of eighty per cent, of the cases, if properly nursed and fed, that is, if treated upon the expectant plan, will recover. Some idea of the extent of the prevalence of enteric fever in England may be formed from his statement that upwards of 73,000 persons have died of it during the past nine years in that country alone. There is, in medical literature, abundant evidence that this fever is also endemic in France, Spain, Italy, Turkey, Switzerland, Germany, Russia, Norway and Sweden, and in Iceland. In North America it is endemic from Hudson's Bay to the Gulf of Mexico. In new and sparsely settled districts, where the land is being gradually, strip by strip, so to speak, brought under cultivation, the ma- larial fevers prevail; after a time, as populations increase, the malarial diseases and typhoid fever occur side by side, the one often modifying the symptoms of the other and complicating its course ; and finally, when the land has been generally taken up and drained and tilled for some genera- tions, and when the population has grown dense and villages and cities abound, the malarial diseases, true agues and remittents, come to impress communities but faintly, or they disappear altogether; but enteric fever grows very common, and asserts itself as the predominant endemic disease in proportion to the neglect of the sanitary measures by which alone it can be kept in check in populous localities. ' Handbuch der historisch-geographischen Pathologie. By Dr. A. Hirsch, Erster Band. Erlangen, 1860. ■' On Some Points in the Pathology and Treatment of Typhus Fever. By Wm. Cay- ley, M.D.. F.R.C.P. London, 1880. 116 THE CONTINUED FEVERS. It is far from uncommon in tropical and subtropical countries. Many observers have met with it in India. It has been reported as occurring in Egypt, Algeria, the west coast of Africa; in the West Indies, Mexico, and upon the Pacific slopes; Central America has not escaped it, and it is said to be extremely common in Brazil and Peru. Enteric fever has also been encountered in the British settlements of Australia, New Zealand, and Van Diemen's Land. In tropical countries it has doubtless been frequently confounded with reiiiittent fever. Etiology, i. predisposing causes. donate, not of itself, but indirectly as determining the mode of life in communities, has a manifest influence upon the extent of the prevalence of enteric fever. This, like many other widely prevalent infectious dis- eases, is met with, as has been just indicated, in all parts of the world, but manifests, at the same time, a decided preference for certain broad areas or belts of the earth's surface. It is especially frequent and con- stantly present everywhere in Europe, Great Britain, and in the United States, and Southern Canada. These countries lie within the limits of the northern temperate zone, in which enteric fever possesses a fixity of tenure. The season of the year is a predisposing cause of great importance. Epidemics of enteric fever commonly occur during the last half of the year, and the number of cases in localities where it is endemic is usually greatest from August to November, decreasing in December; and is low- est from February to May, again increasing in June. Hirsch found that 519 epidemics of typhoid fever were distributed among the seasons as follows: in the spring, 29; in the summer, 132; in the autumn, 168; and in the winter, 140; and of 116 circumscribed epi- demics occurring in France between 1841 and 1846, recorded by de Clau- brey, 20 began in the first quarter of the year, 21 in the second, 39 in the third, and 36 in the fourth. The following table shows the relative frequency of typhoid fever in the different seasons: Number. Locality. 488 Cases.. . 74 Cases.. . 355 Deaths. 14,547 Cases... 645 Cases. . . 3,826 Deaths. 183 Cases.. . 131 Cases.. . 5,988 Cases... I Lausanne. Geneva. Geneva (Canton). Nassau (Duchy). Lowell (Mass.). Massachusetts. Strasbourg. King's Collej^e Hosp. London Fever Hosp. Observer, j Delaharpe Lumbard. D'Esjiiue. Franque. Bartlett. Curtiss. Forgret. Todd. Murchison Date. Spring. 'Summer' Autumn! Winter. 1851 1834-37 1838-45 184(M7 1846-48 1841 1860 1848-70 44 7 70 3,597 102 429 38 31 759 122 24 75 3,095 163 671 49 35 1,490 211 2S 115 4,837 350 1,183 60 51 3,461 111 15 95 4,028 130 544 36 34 1,278 ENTERIC OR TYPHOID FEVER. 117 This fever is so much more common in the latter part of the year that it has received in some districts of the United States the popular names of " Autumnal " or " Fall Fever." The development and spread of enteric fever is favored by the high temperature of summer, and checked by the lovv temperature of winter. The maximum of temperature and the period of greatest prevalence of the fever are separated by an interval of two or three months, the former occurring in July, the latter in September and October; and the minimum of temperature, occurring in January, precedes the period of the least pre- valence of tlie fever, in February or April, by a like interval, so that if the curves of temperature and of the frequency of enteric fever be projected diagrammatically, as has been done by Liebermeister,' they v?ill be seen to nearly correspond. The interval of about two months is not accounted for by the suppo- sition of Murchison that the cause of the disease is called into action by the proti acted heat of summer and autumn, and that the 2^^otracted cold. of winter and spring is required to impair its activity or destroy it; but this time is probably consumed, as Liebermeister suggests, in the penetra- tion of the warmth to the places where the poison is elaborated, its de- velopment outside the body, the stage of incubation, and the period from the beginning of the attack to the admission of the patient to hospital or his death. On the other hand, the time between the lowest temperature and the least prevalence of the disease is to be accounted for by the stage of incubation and the length of the patient's illness before admission to the hospital, or death as the case may be, the poison having already been introduced into his body, and by the infection of new cases from sources of contagion within dwellings, where it remains unaffected by the outside temperature. Closely connected with the subject of the temperature as influencing the prevalence of enteric fever is the state of the loeather as regards dry- ness and moisture. Hot and dry summers favor the development of the disease; cold and wet summers check it. This statement is supported by the concurrent testimony of observers in all countries. In England the summers and autumns of 1865, 18GG, 18G8, and 1870 were remarkable for their great heat and prolonged drought, and for an unusual and early in- crease of enteric fever. On the other hand, there have been few years in wliich the summer and autumn have been more cold and wet than in 1860, while the remarkable diminution of the prevalence of enteric fever over the whole country in that year, and in London during the wet autumn of 1872, Avas a subject of general observation. The admissions into the London Fever Hospital for 1860 fell to one-half of the average of the pre- vious twelve years, and this diminution was due to the absence of the ordinary autumnal increase (Murchison). ' Ziemssen's Cyclopsedia of Medicine, vol. i. 118 THE CONTINUED FEVERS. An analysis of the outbreaks of enteric fever which occurred in Stutt- gart from 1783 to 1837, made by Cless, shows that all arose at the end of the summer or in the autumn, and that all had been preceded by unusual- ly hot seasons. Virchow also found that, in Berlin, the years in which the rainfall was small were attended with severe epidemic and typhoid affec- tions, while in wet years the mortality from enteric fever was decreased. Dryness of the atmosphere alone does not, however, lead to an in- crease of enteric fever. In cities and other localities supplied with a sys- tem of underground drainage, warm damp weather often leads to an out- break of the disease, while heavy rainfalls, by flushing the drains, remove the causes to which its origin and spread are chiefly due. On the other hand, outbreaks of enteric fever may be traced to the influence of abun- dant rains in washing the germs of the fever into water used for drinking purposes, particularly where the water-supply is derived in part from ma- nured fields. Pettenkofer and Buhl have shown that the prevalence of enteric fever in Munich is dependent upon changes in the height of the deeper springs of water. When the water steadily rises, typhoid decreases; when the water sinks, it increases. This observation corresponds with the state- ment just made, that enteric fever is much more frequent after hot and dry summers than after cold and wet ones. These observers explained the \'^rying prevalence of enteric fever in connection with changes in the ground-water by the assumption that the causes of typhoid fever lie deep in the earth. "When the water-level sinks, the la3-ers of earth, con- taining moist organic substances and exposed to the air, undergo changes which lead to the development of the fever-poison. When, on the con- trary, the water rises, these layers of earth are again covered and the de- velopment of the germs arrested. The explanation advanced b}' Buchanan and Liebermeister, namely that the lower the water is, the greater must be the proportion of solid matters suspended in it, and that therefore in localities where typhoid fever is endemic and the specific cause is in the earth, or soaks from privies into the earth, this poison must be relatively more abundant in the water the lower it is, is probably correct. Age is of great importance among the predisposing causes of enteric fever. It is pre-eminently a disease of adolescence and early adult life. Of 5,911 cases admitted to the London Fever Hospital during twenty- three years (1848-70), nearly one-half, or 46.55 per cent., were between fifteen and twenty-five years of age, and more than one-fourth, or 28.58 per cent., were under fifteen. Less than one-seventh, 13.3 per cent., were above thirty, and only 1 in 71 exceeded fifty, (Murchison). The mean age of 1,772 cases was 21.25, that of the males being inconsiderably higher than that of the females. It may be stated that the greatest predisposi- tion is between the ages of fifteen and thirty, and that it diminishes pro- gressively both above and below these limits. Cases in the first year of ENTERIC OR TYPHOID FEVER. 119 life are exceedingly rare. The same is true of old age, although well authenticated cases of enteric fever in persons seventy, eighty, and even ninety years of age, are reported. The infrequency of the attack in the latter periods of life is doubtless to be accounted for, in part, by the fact that many persons, having already passed through the disease, are insus- ceptible to its poison. ISex exerts little influence as a predisposing cause. The statistics of enteric fever, almost exclusively collected from the reports of hospitals, show a marked preponderance in the number of males. This preponder- ance is to be explained, not by an increased liability on the part of men, nor, in truth, to increased exposure to the causes of the disease, but by the fact that in most places more men than women seek treatment in hos- pitals. Of 138 cases observed by Louis in Paris, 106 were males. This excess, however, is accounted for by the circumstance that a large number of males were strangers in Paris, and could not be treated at their lodgings. Occupation exerts no influence whatever as a predisposing cause of enteric fever. The mode of life of the individual is also without influence. Enteric fever is as common in the houses of the affluent as in the most crowded and destitute localities. In fact, the presence of stationary wash-stands in bedrooms, and the arrangement of bathrooms and water-closets near sleeping-rooms, expose the well-to-do to dangers of infection that the less fortunate escape. Enteric fever attacks by preference strong and healthy persons, passing by those, for the most part, who are the subjects of pre- vious severe or wasting disease. There is no relationship whatever between enteric fever and variola, and enteric fever is not, as has been suggested, at all more prevalent in communities protected by general vaccination than in those less fortunate in this respect. The suggestion of Dr. Harley that scarlatina and enteric fever are different manifestations of the same poison, or that enteric fever is an abdominal scarlatina, is untenable. The two diseases are essentially dif- ferent in their causes, course, symptoms, duration, and lesions after death. Habitual exposure to the poison of enteric fever confers an immunity from the disease. Instances are recorded where successive visitors at the same house, at intervals of months, or even years, have been seized shortly after their arrival with enteric fever, or intestinal catarrh, from which the ordinary inhabitants were exempt. Persons changing their residence, from one part of a city to another, have not unfrequently been attacked with enteric fever, and persons coming from the country into cities very fre- quently become the subject of the disease. The French observers strong- ly insist upon recent residence as a predisposing cause. Of 129 cases Louis found that 73 had not resided in Paris more than ten months, and 102 not more than twenty months. 120 THE CONTINUED FEVERS. It has oeen suggested that one of the causes of the frequency of ty- phoid fever in the early autumn in our American cities, among well-to-do j3eople, is to be found in the circumstance that, during an absence of two months or more in the mountains or by the sea, they have to some extent lost the immunity acquired by habitual exposure to sewer-emanations, and return to the atmosphere of the city unprotected. Severe mental disturbance, fear, sorroio, care, and great fatigue, doubt- less render individuals less able to resist morbid influences, and therefore act as accidental predisposing causes; but that they can give rise to enteric fever, as was held by the older authors, is a view wholly at vari- ance with modern theories of the cause of the disease. Pregnant and lying-in women, and those who are nursing infants, enjoy a relative immunity from enteric fever. n. THE EXCITING CAUSE. Up to the present time the exciting cause of enteric fever has eluded all attempts to demonstrate its nature, either by chemical analysis or microscopical examination.' It is known to us, as are the causes of most of the infectious diseases, only by its effects. ' Prof. C. J. Eberth, of Zurich, has recently examined the lymphatic glands, spleen, the affected parts of the intestine, and the liver, kidneys, as well as other organs, with a view to discovering the character of the lower organisms said to be the excit- ing cause of typhoid fever. Of twenty-three cases examined, micro-organisms were found in twelve — twelve times in the lymphatic glands and six times in the spleen. They were much more numerous in the lymphatics. Eberth does not regard these organisms as micrococci. They usually assume the rod shape, and are about the size of the bacilli found in decomposing blood, only with the difference that they usually take a narrow, oval, or stumpy spindle shape rather than a cylindrical outline. They are slightly rounded at the end, not cut off sharp. Together with these rods, small egg-shaped forms are met with, resembling micrococci. Undoubted spherococci were not observed. The peculiar delicate outline of these bodies serves to distinguish them from the bacilli of putrefaction. They contain one to three spore-like bodies, and are not so easily stained in methyl violet as the ordinary micrococci and bacilli. Eberth gives several interesting facts regarding the number of organisms found at different stages of typhoid, and concludes by asserting the probability that they stand in some relation to the essence of the disease. — Virchow^s Archiv, Band LXXXI., 1880. Professor Klebs, of Prague, also believes that he has discovered the micro-organ- ism which con.stitutes the specific agent of typhoid fever, and develops his views in a paper entitled "Der Ileotyphus eine Schistomycose," published in the ArcMofilr Experimentnle PatTiolo[iie, T. XII., 1880. Professor Klebs has for a long time, assisted by his pupils, been making researches in this direction. He writes that he has been able to find, at the necropsy of twenty-four persons carried off by dothinenteritis, microbes in various organs : in the intestinal mucous membrane, in the thickness of the cartilages of the larynx, in thtf pia mater, in the foci of lobular pneumonia, in the mesenteric ganglia, in the parenchymata of the liver, and generally diffused in the organs which showed the most decided lesions. These micro-organisins showed them- ENTERIC OR TYPHOID FEVER. 121 The view that it is an organic poison is tenable only when the term poison is understood in the broadest sense. A poison produces sickness and destroys life, but it cannot infect. Much less is it capable of indefi- nitely reproducing itself either within or outside of the body, or of a pro- longed continuous existence, during which it successively affects an end- less series of individuals exposed to its influence in precisely the same manner and without exhausting its noxious power. The ingenious sugges- tion that it may be some derivative of albumen capable of setting up, in other albumen and albuminous compounds, chemical changes by " cataly- sis," and of thus inducing the series of changes in the body, which, taken together, constitute enteric fever, lies wholly within the domain of hy- pothesis. Without entering upon a detailed discussion of its improbabil- ity and its inadequacy to explain the well-proved facts of the patho- genesis of the disease, it is only needful to state that no derivative of albumen possessing such "catalytic" properties is known, and that organic compounds of the kind indicated are unstable; so that it is im- probable that they would remain undecomposed, in such localities as are the favorite lurking-places of the germs of enteric fever, for any length of time, much less during the lengthened periods that such places retain their power of distributing the infection. Without doubt the fever-producing principle is an organized germ, a micro-organism, a protomycete, a contagiicm vivuni. It is by this theory alone that we can understand the known facts bearing upon the origin and transmission of the disease. Although the nature of the germ which produces enteric fever is unknown, many of its properties are established, 1. It is invariably derived from a previous case of enteric fever. 2. When introduced into the human body, it is, under favorable cir- cumstances, capable of indefinitely reproducing itself. 3. It is eliminated with the fecal discharges. 4. It is not capable of producing enteric fever in other persons at once, but must undergo certain changes outside the body before it ac- quires this power. 5. It retains its activity, when it finds its way into favorable situa- tions, for a lengthened period after it has passed out of the body, the selves in the form of rods, about eighty micrometres in length and 0.5 to 0.6 micro- metre in thickness. They have been constantly observed in the bodies of dothinen- teric patients since the attention of Professor Klebs was drawn to the subject, and they are always absent from the organs, and specially the intestines, of subjects who have died from any other disease than typhoid. — British Med. Journal, Oct. IG, 1880. Further researches are necessary to establish the causal relation between particular forms of protomycetes and enteric fever, but it may be"confidently predicted that ere long the specific cause of this and many of the other infectious diseases will be demon- strable. 122 THE CONTINUED FEVERS. requirements to this end being decomposing animal matter, especially fecal discharges and moisture. Hence, cesspools, sewers, drains, dung- heaps, wet manured soils, are its usual habitat. G. There is reason to believe that in such situations it is capable of reproducing itself. 7. It remains suspended in, and may be conveyed by, water used for drinking purposes, and usually finds access to the body by this means. 8. Suspended in the atmosphere, it also reaches the blood by means of the inspired air. These statements are supported by the following facts and observa- tions : 1. From the assertion that the specific cause of enteric fever is mvari- ably derived from a previous case of the disease, many observers, even among the most recent authorities, strongly dissent. Among them Dr. Murchison is most prominent. It had long been held that air and drinking-water, polluted with de- composing sewage and other kinds of putrefying organic matter, were capable of causing fever; but it was Murchison who first, in 1858, pointed out that the fever thus produced was different from that arising from other causes. He showed that the fever thus caused is always enteric, and never typhus or relapsing fever; that its origin in substances of this kind accounted for its endemic prevalence and the occurrence of circum- scribed epidemics; that it also accounted for its attacking the rich as well as the poor, its occurrence in isolated country-houses as well as in towns and cities, and for its increased frequency in autumn and warm seasons. He adduced many conclusive facts in support of these statements. It is now universally admitted that the cause of enteric fever is traceable to air or drinking-water defiled with decomposing organic matter, and, in ])articular, with the emanations from seM'age. The name "pythogenic," signifying, as it does, "produced by putre- faction," is based upon this generally received opinion. It was first sug- gested by Dr. Murchison. But Dr. Murchison and his followers go much farther thaw this. While admitting the now unassailable doctrine that the poison of enteric fever finds its way into drains, sewers, and the like, by means of the dejections of persons ill of the disease, and that a single case may in this manner give rise not only to other cases, but even to extensive epidemics, they also insist that the specific cause of this disease may be generated de novo in sewage, without the presence of the enteric excreta. In support of this opinion two principal arguments are adduced. The first rests upon the well-established fact that persons may be exposed to recent typhoid stools in their most concentrated form, and fail to contract the fever unless decomposing sewage be present. Thus, in hospitals the disease rarely extends to the medical officers, the attendants upon the ENTERIC OR TYPHOID FEVER. 123 sick, or to the other patients. In nine years there were treated in the London Fever Hospital 3,555 cases of enteric fever, in the same wards with 5,14:4: patients not suffering from any specific fever. Not a single case of enteric fever arose among the patients suffering from other maladies in the whole course of this time, although it was a common practice for them to use the same water-closets and night-stools, and the use of disinfectants was exceptional. In tlie same hospital, during a period of twenty-three years up to 1870, 5,988 cases of enteric fever were treated, and seventeen of the resident medical officers contracted the dis- ease, but of this number only five were in communication with the enteric fever cases, and twelve occurred at a time when serious defects existed in the drainage of the house. Since 1871, 1,447 cases of enteric fever have been received and treated in the same wards with 693 patients suf- fering with other diseases, and in this period only three nurses, and not a single patient, have contracted the disease. On several occasions, how- ever, cases lying in other wards have been infected. Liebermeister states that up to 1865, in the hospitals he had visited, namely, at Greifswald, Tubingen, and Berlin, he had never seen a single patient, nurse or physician attacked by enteric fever, although such cases were placed in the general wards. Similar observations have been made in the hospitals at Paris and elsewhere on the Continent. In this country it is customary to treat typhoid cases in the wards of general hospitals side by side with other patients. I have never known of the transmission of the disease to other occupants of the wards, nor to the attendants. When the disease has appeared as an epidemic in hospi- tals, it has seized upon persons occupying separated wards or rooms, and has almost invariably been traceable to defective water-closets or leaking drain-pipes. There are, nevertheless, observations of an opposite character. Epi- demics have on many occasions appeared in hospitals, and particular hospitals have suffered repeatedly from local outbreaks; but these ex- tensions of the disease may be traced to local causes. Thus, Liebermeis- ter states that, in the hospital at Basle, during his service of six years from 1865 to 1871, such hospital infections occurred repeatedly. During this period one thousand nine hundred cases were treated, of which, in forty-five, the disease originated in the hospital. In addition to these a number of cases of slight febrile affection, probably due to slight infection, also occurred, and cases of afebrile intestinal catarrh, which were to be imputed to the typhoid infection, were very numerous. Of the forty-five cases of the developed disease, many had never been brought in contact with the fever patients. For example, a patient, who had gone through an attack of variola in the isolated wards set apart for that disease, was attacked immediately after his discharge, with fatal typhoid fever. In 124 THE CONTINUED FEVERS. the wards for syphilis, also isolated, and in the surgical wards, some cases arose. Many of the officers of the house, and the washer-women in par- ticular, who never entered the wards, also contracted enteric fever. But there were facts that clearly indicated the existence of foci of infection within the hospital. Cases occurred, for example, with notable frequency .among the patients and nurses in two rooms, one directly above the other. A wooden pipe, leading from the main sewer to the roof, passed by both .these rooms. The sewer was faulty in construction at this point, so that jnatters accumulated there. It was, in fact, liable to become choked. Attention to this defect and its correction in part was followed by satis- factory improvement. It would appear that the hospital at Basle, where ■enteric fever is very prevalent, is saturated with the poison of this disease, and that its drainage is far fi'om efficient. Not only have numerous cases •of infection occurred since the observations of Liebermeister, but it is stated that almost all the new attendants have suffered from abdominal ■catarrh without fever. Observations of this kind, which appear to show that enteric fever is not transmitted from the patient to those about him, and that it occurs promptly in those who are subjected to the emanations from choked drains and otherwise defective sewerage at a distance, lose their value in view of the fact, now generally admitted, that the specific germs cannot produce the disease in their fresh state, in the recently voided dejections of the typhoid patients. In truth, these very observations are evidence in support of this view. If the water-closets in connection with the wards occupied by fever patients are in order and the drains free, no infection takes place; the excreta are swept away before there is time for them to develop their poisonous properties. But, if the closets are in bad order and the dejec- tions remain and undergo decomposition, other cases arise among those who use them; or, if the drains are choked, infection arises — not in the neighborhood of the patients, but at distant parts of the hospital, at the point of obstruction, that is, where the emanations from the arrested, or leaking and decomposing excreta, escape into the atmosphere. The well-known fact that patients taken ill at a distance rarely trans- mit the disease to those about them on being removed to their own homes, is without value in support of the doctrine of the independent origin of the fever from decomposing sewage without the previous introduction of the poison; but the fact that such cases sometimes do give rise to epi- demics, and that in such instances there is alwaj^s either defective drain- age, or direct or indirect contamination of drinking-water by soakage or otherwise, from the dejections of the patient, is of the most convincing force in support of the opposite view. Persons ma\' be exposed to the direct emanations from decomposing human excreta, and drink water rich in the leakage from neglected privy-wells with impunity, as regards the danger of enteric fever, for an indefinite period; but the day a case of the ENTERIC OR TYPHOID FEVER. 125' disease appears upon the scene, the danger becomes direct and enormous, and, unless it is at once appreciated and provided against, other cases arise. That which was foul and indecent, injurious yet incapable of occasioning a specific disease, becomes a nidus for the growth of a poison and a focus of infection. The following case, which very fully illustrates this statement, came under the observation of Dr. Flint: ' " In 1848, in a little settlement called North Boston, situated eighteen miles from the city of Buffalo, consisting of nine families, all being within an area of a hundred rods in diameter ; but the few houses in which the disease occurred were closely grouped together around a tavern, the house farthest removed from the tavern being only ten rods distant. A stranger from New England, travelling in a stage-coach which passed through this settlement, had been ill for several days, and, on arriving at this stopping-place, was unable to proceed farther. He remained at the tavern, and, after a few days, died. He was seen by several physicians of the vicinity, and there can be no doubt that his disease was the same as that with which others were subsequently aflEected. Up to this time typhoid fever had never been known in that neighborhood. The sick stranger was seen by the members of all the families in immediate proximity to the tavern, with a single exception. One family named Steams, having quarrelled with the tavern-keeper, had no intercourse with the family of the latter, and very lit- tle with the other families, all of whom were tenants of the tavern-keeper. No mem- ber of the family of Steams saw either the sick stranger or any of those who were taken ill after the stranger's death. Members of the family of the tavern-keeper were the first to become affected, the first case occurring twenty -three days after the arrival of the stranger. Other cases speedily occurred in the surrounding families. In a month more than one-half the population, numbering forty-three, had been affected, and ten had died. Of the families immediately surrounding the tavern, that of Stearns alone escaped ; no case occurred in this family. " The occurrence of the disease produced great excitement in the neighborhood ; poisoning was suspected, and Stearns was charged with having poisoned a well used in common by all the families except his own. A fact which encouraged this suspicion was, the common well, being owned by the tavern-keeper, he had refused permission to use it to Stearns, who had, in consequence, been obliged to dig a well for his own use. An examination of the water from the common well showed it to be perfectly pure. '• The disease was undoubtedly typhoid fever. Visiting this settlement during the prevalence of the disease, and recording the symptoms of several cases then in prog- ress, the clinical history furnished abundant evidence of the nature of the disease. Moreover, I made an examination of the bodj^ of one of those who had died with the disease, and found the Peyerian patches ulcerated and the mesenteric glands greatly enlarged. " Dr. Flint was of the opinion that the spread of the fever was due to- personal intercourse with the sick stranger, but it is beyond doubt that the water from the well served as the means of transmission. The second argument is based upon the not uncommon observation ' A Treatise on the Principles and Practice of Medicine. By Austin Flint, ^I.D; Second edition. Philadelphia, 1867. 126 THE CONTINUED FEVERS. that enteric fever has broken out in isolated localities in which it had not hitherto been known, and the inhabitants of which, as far as could be dis- covered, had had no communication with any place in which the disease existed. The following instances are taken from a large number of observations of like character collected by Dr. Murchison. *' In August, 1829, twenty out of twenty-two boys, at a school at Clapbam, within three hours were seized with fever, vomiting, purging, and excessive prostration. One other boy, aged three, had been attacked with similar symptoms two days before, and had died comatose in twenty-three hours ; another boy, aged five, died in twenty- five hours ; all the rest recovered. Suspicions were entertained that they had been poisoned, and a rigorous investigation ensued. The only cause which could be dis- covered was that a drain at the back of the house, which had been choked up for many years, had been opened two days before the first case of illness, cleaned out, and its contents spread over a garden adjoining the boys' play-ground. A most offensive effluvium escaped from the drain, and the boys had watched the workmen cleaning it out. This was considered to be the cause of the disease by Drs. Latham and Cham- bers, and by others who investigated the matter, and also by Sir Thomas Watson. The morbid appearances in the two fatal cases were described as ' like those of the common fevers of this country.' Peyer's patches and the solitary glands of the small and large intestines were enlarged like ' condylomatous elevations,' and, in one case, the mucous membrane over them was slightly ulcerated. The mesenteric glands were enlarged and congested." In June, 1861, a case similar to those at Clapham came under Dr. Murchison's observation. "A girl, aged nine, was seized with febrile symptoms, vomiting, purging, and in- tense headache, followed by acute delirium, and died forty-seven hours from the com- mencement of her illness. After death the characteristic lesions of enteric fever, in an early stage, were found in the bowels. Accompanied by Dr. Stewart, I visited the rooms, over a stable, occupied by this girl's family. The privy was in the stable, and drained into a cesspool near the door, which had become choked up. Over the cess- pool was an open grating, by which the stable drained into it, and frorn which the most offensive smells had issued since the beginning of the warm weather — so offen- sive that the horses had sometimes to be removed. The girl had been playing close to this grating at the time of her seizure. The cesspool did not communicate with the public drain, and no other cases of fever had occurred in the mews." *' About Easter, 1848, a formidable outbreak of fever occurred in the Westminster School and the Abbey Cloisters, and for some days there was a panic in the neighbor- hood respecting the ' Westminster Fever. ' No case of fever had occurred in the Abbey Cloisters for three years, and there was no evidence of its having been imported. Within little more than eleven days it affected thirty-six persons, all of the better class, and in three instances it proved fatal. Shortly before its first appearance 'there occurred two or three days of peculiarly hot weather,' and a disagreeable stench, so powerful as to induce nausea, was complained of in the houses in question. It was found that the disease followed very exactly in its course the line of a foul and neglected private sewer or immense cesspool, in which fecal matter had been accumu- lating for years without any exit, into which tiio contents of several smaller cesspools ENTERIC OE TYPHOID FEVER. 127 had been pumped immediately before the outbreak of fever. This elongated cesspool communicated by direct openings with the drains of all the houses in which it occurred ; the only exception was that of several boys who lived in a house at a little distance, but who were in the habit of playing every day in a yard in which there were gully- holes opening into the foul drain." These observations are open to the serious objection that in none of them has the possibility of the presence of germs derived from previous cases of enteric fever been excluded. The account of the outbreak at the school at Clapham is not sufficient- ly explicit as to the condition of the drain at the back of the house, which had been choked up for many years. It is not stated whether or not it connected with drains with the neighboring houses, nor whether there had been, some time before, cases of fever in the house or neighbor- hood, nor how many years the drain had been choked up. If this case has value at all as illustrating the subject of the etiology of enteric fever, it seems to me that it is in this, that it shows that the germs of the dis- ease may retain their vitality, under favorable circumstances, for a long period — )iicmy years, and that, when so long imprisoned, it becomes highly infectious and capable of producing the most profound disturbances of the functions of the body with great rapidity. In the second example, the possibility of the child's infection from an entirely different source, distant from her home, while visiting or at school, must be excluded in order that the observation may have weiglit in the argument. In the third example it is distinctly stated that there had been no case of fever for three years, and that there was no evidence of its having been imported. There was, however, " a foul and neglected private sewer or immense cesspool, in which fecal matter had been accumulating for years without any exit, into which the contents of several smaller cesspools had been pumped immediately before the outbreak of the fever." It is to be remarked that fever probably had occurred in the neighborhood three years before, as the expression used in the account indicates. Now, there is reason to believe that the poison retains its activity outside the body for a long time under favorable circumstances, and farther on examples will be given to prove that it does actually re- tain it for many months. Is there a limit to the time ? Where then is it ? If the contagion remains active many months, why not three years ? In this " immense cesspool " the conditions for its survival, perhaps also for its multiplication, were complete. Moreover, there was no exit. Im- mediately before the outbreak of fever the contents of this pool had been agitated by the pumping into it of several smaller depots of ordure ! Who can be sure that a person suffering from typhoid fever, in a mild or even grave form, had not used some one of these numerous wells during the period preceding the occurrence of this epidemic ? 128 THE CONTINUED FEVERS. These observations are certainly inconclusive, and they are neitlier better nor worse than tlie others of a long list adduced in defence of a view that, in spite of the ablest advocacy, is gradually giving way before the overwhelming force of accumulating facts that need no logic to ren- der them convincing. In addition to the example observed by Dr, Flint at North Boston, and given above, the following facts are cited by Dr. Cayley to show that the contamination of drinking-water by fecal matter may exist for an in- definite period without giving rise to enteric fever, but that upon the ar- rival of an infected person, the disease speedily makes its appearance as a local epidemic. One is tho. well-known outbreak at Over Darwen. " The water-supply pipes of the town were leaky, and the soil through which thej passed was soaked at one spot by the sewage from a particular house. No harm re- sulted till a young lady sufiEering from typhoid fever was brought to this house from a distant place ; within three weeks of her arrival the disease broke out, and one thou- sand five hundred persons were attacked." A second took place at Calne. " A laundress occupied the middle one of a row of three houses supplied by one- well, into which the slop of the laundress's house leaked. She, on one occasion re- ceived the linen soiled by the discharges of a case of typhoid fever, and after fourteen days cases occurred in all three houses." ' ' At Nunney a number of houses received their water-supply from a foul brook contaminated by the leakage of the cesspool of one of the houses, but no fever showed itself till a man ill with typhoid came from a distance to this house. In about four- teen days an outbreak of fever took place in all the houses." The record of the outbreak at Lausen, in the Canton Baselland, in 1872, is of great value as illustrating this and other facts in the patho- genesis of enteric fever. From the time of the passage of the allied armies in 1814, Lausen had suffered from no epidemic of typhoid fever. Isolated cases had never spread the infection. During the seven years preceding 1872, not a single case of typhoid had occurred. " This village is situated in the Jura, in the valley of the Ergolz, and consists of one hundred and three houses, with eight hundred and nineteen inhabitants ; it was remarkably healthy, and resorted to on that account as a place of summer residence. With the exception of six houses, it is supplied with water by a spring with two heads, which rises above the village at the southern foot of a mountain called the Stockhalder, composed of oolite. The water is received into a well-built covered reservoir, and is distributed by wooden pipes to four public fountains, whence it is drawn by the inhabitants. Six houses had an independent supply — five from wells, one from the mill-dam of a paper factory. "On August 7, 1873, ten inhabitants of Lausen. living in different houses, were seized by typhoid fever, and during the next nine days fifty-seven other cases occurred, the only houses escaping being those six which were not supplied by the public foun- ENTERIC OR TYPHOID FEVER. 129 tains. The disease continued to spread, and in all one hundred and thirty persons were attacked, and several children who had been sent to Lausen for the benefit of the fresh air fell ill after their return home. " A careful investigation was made into the cause of this epidemic, and a complete explanation was given. " Separated from the valley of the Ergolz, in which Lausen lies, by the Stockhal- der, the mountain at the foot of which the spring supplying Lausen rises, is a side valley called the Furlenthal, traversed by a stream, the Furlenbach, which joins the Ergolz just below Lauseu, the Stockhalder occupying the fork of the valleys. The Furlenthal contained six farm-houses, which were supplied with drinking-water, not from the Furlenbach, but by a spring rising on the opposite side of the valley to the Stockhalder. "Now, there was reason to believe that, under certain circumstances, water from the Furlenbach found its way under the Stockhalder into one of the heads of the fountain supplying Lausen. It was noticed that when the meadows on one side of the Furlen- thal were irrigated, which was done periodically, the flow of water in the Lausen spring was increased, rendering it probable that the irrigation water percolated through the superficial strata, and found its way under the Stockhalder by subterranean channels in the limestone rock. Moreover, some years before, a hole on one occasion formed close to the Furlenbach by the sinking-in of the superficial strata, and the stream be- came diverted into it and disappeared, while shortly after the spring at Lausen began to flow much more abundantly. The hole was filled up, and the Furlenbach resumed its usual course. " The Furlenbach was unquestionably contaminated by the privies of the adjacent farm-houses, the soil-pits of which communicated with it. Thus, from time immemo- rial, whenever the meadows of the Furlenthal were irrigated, the contaminated water of the Furlenbach, after percolation through the superficial strata and a long under- ground course, helped to feed one of the two heads of the fountain supplying Lausen. The natural filtration, however, which it underwent rendered it perfectly bright and clear, and chemical examination showed it to be remarkably free from organic im- purities ; and Lausen was extremely healthy and exempt from fever. " On June 10th one of the peasants of the Furlenthal fell ill with typhoid fever, the source of which was not clearly made out, and passed through a severe attack, with relapses, so that he remained ill all the summer ; and on July 10th a girl in the same house, and in August a boy, were attacked. Their dejections were certainly, in part, thrown into the Furlenbach, and moreover, the soil-pit of the privy communicated with the brook. In the middle of July the meadows of the Furlenthal were irrigated as usual for the second hay crop, and within three weeks this was followed by the out- break of the epidemic at Lausen. " In order to demon.strate the connection between the water-supj^ly of Lausen and the Furlenbach, the following experiments were performed : the hole mentioned above, as having on one occasion diverted the Furlenbach into the presumed subterranean chan- nels under the Stockhalder, was cleared out and eighteen hundred- weight of salt were dissolved in water and poured in, and the stream again diverted into it. The next day salt was found in the spring at Lausen. Fifty-six pounds of wheat flour were then poured into the hole, and the Furlenbach again diverted into it; but the spring L'lusen continued quite clear, and no reaction of starch could be obtained, showing that the water must have found its way under the Stockhalder in part by percolation through the porous strata, and not by distinct channels." It is a matter of the commonest observation that the decomposition of organic substances, and the drinking of water containing the products 9 130 THE CONTITs^UED FEVEES. of such decomposition, are not of themselves sufficient to produce enteric fever. These are the conditions favorable to the development of the poi- son; but, in order that the disease may be produced, something more is necessary, and that is the specific poison itself. The view that enteric fever never originates spontaneously, but tluit every case is due to the continuous transmission of the poison, the sewers or drains serving as the ordinary means of conduction, or as "a direct con- tinuation of the diseased intestines," was first taught by von Gietl, in Munich. It was afterward ably advocated in England by Dr. Budd,' and is to-day, though not generally accepted, steadily gaining ground. If we assume tliat a fever so specific in its clinical and anatomical characters must be due to a specific cause, and that the specific cause is an organism of some kind, the view that the poison does not arise independently, but in every instance from a parent stock, becomes a logical postulate of these assumptions; otherwise, we are forced to accept the theorj' of spontane- ous generation. If we admit that the decomposition of organic and ex- crementitious substances in some instances can produce enteric fever — a specific disease, but in by far the greatest number of instances, even when every predisposing influence to the disease exists, fails to do so — we are yet left to grope in the dark for the cause of the different behavior of such substances. It is conceded on all sides that when outbreaks of the disease follow the introduction of a case into a locality previously free from it, the affection spreads not by direct contagion, but by the well- recognized methods of sewage contamination from the dejections of the patient. Examples of this abound in recent medical literature. The ac- cidental presence of the specific poison, and its prolonged latent existence, are capable of explaining every case of the apparently spontaneous origin of the disease, with less violence to our sense of the relation of cause and effect than the doctrine of independent origin. Moreover, there are two general truths relative to the etiology of the infectious diseases that aid us in reaching a reasonable conclusion. First, a mild case of such diseases may produce by infection the gravest forms of the disease in other persons. Thus, a walking case of typhoid fever, not recognized as such, or a case of mere intestinal catarrh, due to the cause of typhoid, may im- port the specific germs into a locality previously exempt, and in this man- ner give rise to an outbreak apparently spontaneous. Secondly, the contagium is capable of being transported in the bedding or clothing of patients, and in other substances which may serve as foniites. There is abundant reason to believe that the changes in the stools of typhoid fever, ' On Intestinal Fever : its Mode of Propagation. By W. Budd, M.D. Lancet, Tol. ii. 185G. Intestinal Fever Essentially Contagious, etc. Ibid. Vol. ii. 1859, On Intestinal Fever. Ibid. Vol. i. 18G0. ENTERIC on TYPHOID FEVER. 131 •which give rise to the infection, uia\^ take place not only in drains, sewers, and other similar situations, but also in the excrement discharged into the clothes or the beds of the patients. In this manner the germs may gain access to localities in which no case of the disease has occurred within the memory of man; and if, as is most probable, they retain their activity for a long time, all connection with any previous case disappears from the memory of those who may have known of it, and when new cases arise they present the appearance of being autocthonous. It is possible to conceive of other methods by which the germs may be imported with- out the importation of cases. Moreover, the people are always, the physicians often, untrained to the kind of scrutiny which alone will re- veal the channel by which an infectious disease reaches a new quarter, unless it be so plain that the wayfaring man need not err concerning it. The following observation is recorded by Dr. Cayley. It illustrates the statement that the poison, not at first active, becomes so within a short period in the bed, or the clothing, or about the person of the pa- tient, just as in the drain of a defective water-closet : " A boy was admitted into the Middlesex Hospital, under my care, on March 27. 1879, suffering from a very severe attack of typhoid. For several days he lay in an unconscious condition, and during this time he had very profuse diarrhoea — twelve to twenty liquid motions daily — which were, for the most part, passed in the bed In the next bed was a boy aged six, who had been admitted on April 10th, with acute renal dropsy and bloody urine. He was kept strictly confined to bed, and never got up to go to the water-closet, down which the motions of the typhoid case were thrown. On May 11th, when he was convalescing, the dropsy having disappeared and the albumen much diminished, he was seized by typhoid fever, and passed through a moderately severe attack, with a well-marked rash and characteristic symptoms. This at first eight appeared to be a case of direct contagion, but there is no doubt that the true explanation is this : the bedding of the first patient was constantly kept saturated by hia liquid motions, and, though every care was taken to change the linen fre- quently, it was ob\aous, from a distinctly fecal smell which was always present, that the bedding or mattress remained contaminated, and thus time was given for the poison to develop its infectious properties. Another patient in the same ward, ad- mitted for acute rheumatism, was also attacked by the fever. He occupied a bed on the opposite side, and never came near the first case; but, being convalescent, he used the water-closet down which the motions of the typhoid case were thrown ; and it so happened that at this time the closet was out of order, the contents were retained, and an offensive smeU was constantly present. Hence, there can be no doubt but that he was infected by the emanations from the evacuations of the first ca-se." Murchison relates the following fact, which was communicated to him " on excellent authority." It proves beyond question the possibility of the transmission of the infecting principle of enteric fever to a consider- able distance, without the direct importation of a case, and without the person who serves as the vehicle of importation necessarily becoming the subject of the disease: 132 THE CONTINUED FEVERS. " In 1859, the wife of a butcher residing in the small village of Warbetovve, situate between Launceston and Camelford, on the Cornish moors, travelled to Cardiff, in Wales, to see her sister, who was ill and soon after died of ' typhoid fever.' She brought back her sister's bedding. A fortnight after her return to Warbstowe, another sister was employed in hanging out these clothes, and soon after was taken ill with ' typhoid fever,' which spread from her as from a centre. The woman who had been to Cardiff never took the fever herself ; there had been no cases in Warbstowe pre- vious to her return ; neither were there any cases in the neighboring villages, either before or after. " The frequency with which washer-women are attacked is to be ex- plained by the fact that the dejections undergo the changes necessar}'' to render them capable of producing- the disease in the bed-linen and clothes of the patient. The weight of evidence is decidedly against the doctrine of the inde- pendent origin of the disease from decomposing animal matter or fecal discharges. There remains, however, another method by which enteric fever has been supposed to originate, namely, from the eating of diseased meat. The following are some of the most important of the observations upon which this supposition rests : " On July 10, 1839, the local choral society held a festival meeting at Andelfingen, in the Canton of Zurich, after which 513 persons of all ages sat down to a cold colla- tion, consisting chiefly of veal and ham. It was noticed at the time that neither the veal nor the ham were perfectly good. Some portions of the former had a greenish color and a disagreeable smell ; the ham also is said not to have tasted well. But most of the guests observed nothing amiss, and ate heartily. Of the 513 persons who partook of this collation, A21 were subsequently attacked by an acute febrile disease, which was regarded at the time as typhoid. Thirty-four inhabitants of Andelfingen were also attacked, who had taken no part in the choral festival, but all of whom, it was ascertained, had been supplied by the same butcher who had furnished the veal and ham for the festival. ' • The day after the festival there was a wedding in the neighborhood of Andelfingen, at which 15 persons were present, only one of whom had attended the choral meeting. The meat — veal and beef — for the wedding-breakfast was supplied by the saxne butcher. Of these 15 persona 11 were attacked. '' The period of incubation of this epidemic was very variable. A few were seized with nausea and vomiting on their way home, but this was ascribed to their having drunk too much wine. Out of 230 cases in which the incubation period was ascer- tained, 43 were taken ill during the first five days, 123 during the second five days, 48 during the third five days, and 10 during the fourth five days, 6 being attacked on the nineteenth day. '' The symptoms were those of severe gastro -intestinal irritation, with high fever, delirium, stupor, congestion of the lungs, and great prostration. No rose rash was observed, but in some cases there were petechias. The duration of the milder cases was about eight days ; of the severer ones, three to four weeks. Convalescence was slow, and often the hair fell out. The mortality was slight, and on post-mortem ex- amination, in some cases there were infiltration and ulcerations in the lower part of ENTERIC on TYPHOID FEVER. 133 the ileum, with enlargement of the spleen ; in others these changes were not ob- served. "There can be no doubt as to the meat having been the cause of the epidemic, as only those persons who had partaken of it were attacked ; while a very large number of persons from all parts of the canton were present as singers or spectators, who did ■not share in the collation, and they all escaped. But great doubts have been expressed as to whether it really was typhoid fever, or a form of poisoning resembling sausage- ipoisoning." Liebermeister, recognizing the importance of this outbreak in refer- ence to the etiology of typhoid fever, made a careful study of the printed accounts of it, and came to the conclusion that it was certainly not ty- phoid fever. Of more than five hundred persons who fell ill, only nine or ten died. He was at first led to the conclusion that it was an unusual form of trichinosis, but this opinion was not confirmed by the microscop- ical examinations that had been made. Liebermeister considers it proba- hie that there is a special form of disease produced by meat-poisoning. An epidemic, apparently due to the same cause as that which occurred at Andelfingen, but which was in part undoubtedly typhoid fever, oc- H 1 B a a a a a a aBnillSE^araiiillBii«il|iiHHni '■^^BB BBgH IBBIBBiBiaflflBaflBBiaaBBBBBBBr SniHBBiaHBaBBBiBBflaflnflBi banasiisimsasiHiiBBiq^^^^ issBrsmi!sns8BU»HBS9imagg^ jasiiiaRgsBiaaaaaBmaaas! ■BSBaaggiiBBMhiaBBIBBIBaBBBBBBM^ ■laBiaiaiBfliia^siiBiaiaafliBHiBifliiBggaBBii iaaiaiBBBiniaBBIBBlPEZlBBBBMIBBIBflBBBBH InBiBiBnflHBflBiac^^iBaaaBBiBiBBiBflflflflnB ■IBBIBiaBBBBBBBfllBBIfllBBBi^ZinBBBflflBflBnfl ■laaiaiaaaaiiaaBiaauuic^^BaiBiiBiBBBBBigg ■flBBBBBBaaBBBaaBBBaiaiaaaiiBiir — — — — BiBaBBBBBBBflBBBBBBflBniaBBBlBC^iBBIilBBBBB ■HnHaaflHBfllBBIIIBBBBflBBBIBflBBiSgUI ■ MBBB B M ENTERIC OR TYPHOID FEVP:R. 155 zag, in such a manner that during the time occupied in attaining the maximum it rises from 1°-1.5° C. (1.8°-2.7° F.), from each morning till evening, and falls again from the evening to the following morning .S**- .75" C. (.9°-1.3° F.). On the third or fourth evening a temperature of 40° C (104° F.) may be reached or even exceeded. The daily rise begins about noon, and is completed some time between seven and eleven o'clock in the evening. The fall begins about midnight, and the temperature is lowest, as a rule, between six and eight o'clock in the morning. In order to make satisfactory records of the temperature in any case, it is therefore necessary to take two observations daily, one as nearly as possible at 8 A.M., the other about 9 p.m. Critical studies of the temperature of enteric fever have shown that a single daily maximum is the rule, but that in many cases the diurnal curve presents two maxima — one early in the evening, and the other about midday, usually of less intensity. The highest evening temperature in the typical course of the fever is usually attained at the close of the first, or in the beginning of the second period, and is as a rule somewhere between 40°-41.5° C. (104°-106.7° F.). This maximum is commonly observed upon one day only, sometimes on twO' days, rarely on three. It is very seldom that an attack of enteric fever occurring in a healthy man, or even an invalid, provided he be free from fever, does not approxi- mate to the above type in its initial stage. It is still more rare, for any other form of disease except enteric fever, to show a similar initial stage. This course in the first week thus of itself alone possesses very great value for diagnostic purposes {Wunderlich'). The second period is characterized by a fever that has been described as continuous. This term is not to be understood as meaning that the temperature remains the same throughout. If we employ it in so literal a sense, there is no such thing in the whole domain of pathology as a con- tinuous fever. As is seen in the schematic representation of the course of the fever, the temperature is higher in the evening and lower in the morning, but the diurnal variations are not greater than in healthy per- sons in a state of quiet. No distinct remissions occur. It is only in cases in which the fever is very high that the temperature-curve shows a morn- ing fall decidedly less than that which takes place at the same hour of the day in health. Toward the close of this period the evening rise, ex- cept in very severe and protracted cases, often falls a little, and at the same time the morning fall is a trifle greater. The third period is marked by morning remissions, which from day to day become more distinct, while the evening exacerbations attain the height reached toward the close of the second period. The change from ' On the Temperature in Diseases. By Dr. C. A. Wunderlicli : Sydenham Society's Transactions. London, 1871. 156 THE CONTINUED FEVERS. the continuous to the remittent type during this period of the disease is usually a gradual one, but it is not unfrequently sudden, and is then ushered in by perturbations of temperature — often an unusually high evening exacerbation, followed by a decided morning remission. It may take place as early as the fourteenth day, and when sudden it suggests the critical perturbations which occur toward the close of relapsing and typhus fevers. During the fourth period the fever gradually changes from the remit- tent to the intermittent t^'jie. The morning fall is each day lower and the evening rise a little less decided, but the range between them is con- siderable; so that, for several days after the morning temperature has become normal, the evening shows marked fever, and upon the whole we tind a defervescence of the most gradual character (Fig. 9). Convalescence is not established until the evening temperature ceases to rise above the normal standard. In the early days of convalescence the temperature is often subnormal, especially in the morning, and it is liable to decided fluctuations in consequence of slight causes, such as overexer- tion, even within the limits of the bedroom, excitement, the visits of friends, or animal food. Griesinger narrates the case of a girl, whose fever had fallen to 37.3° C. (99.1° F.) in the morning, and to .38° C. (100.4° F.) in the evening, who ate sausage. Her temperature rose that evening, with general aggravation of the symptoms, to 40.5° C. (104.9° F.), and did not fall to its former level again until after three days. Jaccoud also re- cords a case in which a lad, eighteen years of age, suffering from abortive enteric fever, was allowed, on the thirteenth day of his sickness, an egg. The temperature of the previous evening was 38.3° C (101.5° F.), and on the morning in question 37.3° C. (99.1° F.). The same evening it reached 40° C. (104° F.). Two days later it had fallen to 37.G° C. (99.6° F.) in the morning, and the patient was allowed to eat a chop ; that evening the temperature rose to 40.8° C. (105.4° F.), and, while it fell to •almost the previous level on the morning of the sixteenth day, it rose that evening to 40° C. (104° F.), and only resumed the regular curve of the gradual defervescence again on the seventh day. Here the Jhbris carnis, as this distinguished clinician terms this transient fever, lasted two days. Those cases must be looked upon as severe in which the evening tem- perature steadily rises, and the morning fall diminishes, in the latter half of the second period; so also those in which the morning temperature does not, from day to day, fall below 39.5° C. (103.1° F.), or in which it reaches 40° C. (104° F.), Recovery rarely takes place after a morning temperature exceeding 40.5° C. (104.9° F.), or an evening temperature exceeding 41.75° C. (107.15° F.), although occasional exceptions to both these statements have been recorded. A persistently high temperature, in which the difference between the morning and evening range is slight. in III niipnniiHiiiiKssa I ■HH dill ■r mill HMH miiiiii ■I B 1 B B B B B B ^3 B B ■ 11 - BBB aaaB B nmnumsisisinsgiai aHMfflililBiMBBB SSg— mHiMaaiBaj a— ■■ HMIiiSainimHimM MIIHWW ■■■■■■■imHBssammm—i —niM B siayisiiS5SiifiisiF«™"»"« lEaRniiBiianinn a B B H SB M S B 19 H 158 THE CONTINUED FEVEIiS. is much more unfavorable than a temperature characterized by high even' ing exacerbations and considerable morning remissions. In other words, the greater the regular daily fluctuations of the fever, the less severe is it likely to prove. A persistent elevation of temperature, after convalescence is estab- lished, can only arise from some complication or sequel, or from the oc- currence of a relapse. A close study of the temperature, of enteric fever in its relation to the symptoms and the lesions found after death, impresses us with two facts of great practical importance. Of these the first is this: that the fever, like that of scarlet fever and of small-pox, is made up of two dis- tinct febrile movements — first a primary fever, resulting from the infec- tion of the tissues of the body by the specific virus, and later a second- ary, irritative, or hectic fever caused by the localized ulceration of the intestines, the formation of slough, and the resorption of septic materistls. The second practical fact with which we are impressed by a near examination of the temperature-range in a considerable number of cases, is that the balance between the heat-production and the heat- elimination in enteric fever is extremely unstable — to use the words of Dr. Cayley, the temperature is labile. It is quickly depressed or raised by causes that would in health have little or no effect. Thus, slight exertion, changes in diet, mental emotion, will often cause considerable transient alteration, not only in the convalescence, but also during the course of the attack. The action of remedies still further illustrates this point. Large doses of quinine scarcely affect the temperature in health, while in enteric fever 1.3-2 grammes (20 or 30 grains) given at once, or in the course of as many minutes, will reduce the temperature three or four degrees, and keep it down for several hours. Marked deviations from the typical course of the temperature are always due to special causes (Fig. 10). These causes in many cases cannot be discovered by the most searching investigation. On the other hand, upon inquiry, clinical facts of impor- tance are often discovered, and it is therefore the duty of the physician, in every case where marked deviations occur, to make diligent search for their cause. The fact that we have a primary and a secondary fever to deal with, in the course of an ordinary attack, is of considerable importance, both with reference to our knowledge of the pathology of the disease and the treat- ment. In this respect, as I have already pointed out, enteric fever re- sembles small-pox, in which we have, first, the primary fever due to the direct action of the poison, and lasting usually about three days; this is then followed by a period of remission, to which there finally succeeds a •secondary septic fever due to suppuration. In simple cases of scarlet fever the primary pyrexia lasts five or six days, and terminates commonly in lysis; but, where ulceration of the throat or implication of the glands ■H !!!H!!!S!!!!!!B!!!EE!!!!MHi™iHin™uiuH>HH iininiiiiiiiiHiiiiiniiiiniBiiiiiiiKSiiHiiiiiiii lllllll!HllinillllllllllllHIIHIK:^-S5nBninilH ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■iiniiiiniiuiiim»?iii iiiiiiiHiHnHiiHiiiiiiiiiiiiiinic===s««Hiinii lllinillllllllllllllllllMIIIHIIIIIIHIliKSillllll IIIIIIIIIHIIIHIIIIHIHIIIIIIIIK^==«!llllllllllllll, !!!!B!!a!!!!!!!E!!!!S!!!!!!!!!!™™"ni^™iHHil iiiiiiiiiiiiiiBiiiiiiiiiiiiiiiiiiiiiiiiiiiiK:==-iaBaaiBaii nMiiiiiiiiiiiiiiiiHiiniiiiiiiiE?4iiiiiiiiiiiiiiiiiiii| ■■■■iiiniiiiiiiiHiiiiiiniiiiii»»£iiiiiiHiiiiiHiiiil IIIIHIIIIIIIIIIIIIIIIIIIIIII^^illlllllllllllllllllllllll i!iiiiiiiiiiiiiiiiiiniiiE«iiii|iiiiimiiiHiiiiiiiin|R| ■iHHiniiiiiiiiniiiiiii^iiiiiiiiiiniiiiiiiiniiiiilS nillllUIIIIIIIIIKss=SH!!!!nilllllllllllllllllMIII iiiiiiiiiniiiiiiiiiiiiiiiiiim^iiiiiiiiiiiiiiiiiiiiii linnilHIIIIIIIIIIIIKss-HHilgllHIIIIIIIIIIMIIIIj iiiiiiiiiiiiiiiiiiiiiiiiiiiiMainmmgiginiinHii IIIIHIIinnilllllllllllllKilllHIIIIIIIIHIIIIHIIII lllllllllllllllllllllllilSSSiiifBIIIIIIIIIIIIIIIIIIIIII iiiiiniiiiiiiiiiiKsssioaniiiiiiiiniHiniiHiiHiiSl iiniiiiiiiiiiiiiiiiiiiiui'aiiiiniiiniiiiHiiniHi^ ■■■■■■iiiiniiiii:fi=s=!!i|iniiiiiniiiiiii!!ii!!!i|ii ssKUHSSsr.rjsam^^ iiniiiiiliiiHiiiiiiiiiniiMinmniiiMigiim^ ■iuiiiiiBiiiiiiiiniiiiRSSiiiiiiiiiiiiiii!!!!!!!!!!!S ■IHIIIIIIIIIIIIIIinilllSlinilHIHIIHIIIIHIIIIII ■■■■■■■■■■■■■■■■■■■■■■■■■■■liLSiiinHiiiuiiminiiig!! ■iiiiiiiininiiiiiiii^aiiiiiiigHiiHininiMiiinji BaaiaasaiaBSBBKaaaBiiass aiHiaBgiB BBB!88SSBir^^SB8BB|^.g8mg| BBBiBBaaBtisaiiasiaasaBBaBgiaBBBiiii 160 THE CONTINUED FEVERS. occurs, we have a secondary septic fever coming on, either with or with- out a period of remission. On the other hand, in typhus fever, wliich is, as a rule, unattended by suppurative or ulcerative processes, there is no secondary fever, and Iflie long pyrexia, due to the specific cause, comes to an end by crisis on or about the fourteenth day. Between typhus on the one hand, and scarlet fever on the other, enteric fever stands midway. It resembles typhus in the long duration of the primary fever; it resembles the protracted cases of scarlet fever in that the secondary fever arises before the subsidence of the primary, so that there is no intervening period of remission. The change is indi- cated, however, by the alteration in the type of the fever, which com- monly takes place during the third period, and not unfrequently as early as the fourteenth day. This change is, as a rule, gradual. It is sometimes, however, sudden, and is marked by a distinct perturbation of tempera- ture, consisting often of an evening rise in excess of that of the previous days. This rise resembles the precritical rise of typhus and relapsing fevers, and is followed by a considerable morning fall, which is analogous to the crisis of the diseases just named. The analogy between enteric and typhus fevers, in respect of the duration of the primary pyrexia, is made more apparent by the fact that it is at this period, namelj', about the middle of the third week, when the type of the fever becomes dis- tinctly remittent, that copious perspirations take place, together with the eruption of sudamina, and that the rose-colored spots now cease to appear. This resemblance becomes still more apparent from the con- sideration of the abortive forms of enteric fever, which are characterized by sudden onset, rapid augmentation of the temperature to a consider- able height, continued intense febrile movement until about the four- teenth day, when defervescence takes place by rapid lysis, altogether unlike the lingering decline of fever that is characteristic of ordinary cases. Such cases are analogous to modified small-pox, in which we have the primary fever well marked, but, in consequence of the slight local lesions of the skin and the absence of suppuration, there is no secondary fever. It is probable that they are to be explained upon the same ground, namelv, that, while the constitutional disturbance due to the primary action of the typhoid poison is very great, the intestinal lesion, for some unknown reason — doubtless dependent upon the constitutional peculiari- ties of the patient — is moderate, and the glandular deposit undergoes resolution without ulceration or sloughing. Dr. Cayley suggests that the cases of enteric fever that are from time to time described as having been cut short by special remedies or plans of treatment, are really of this character, the observer having ascribed to the remedy changes which are, in fact, natural phenomena of particular cases of the disease. ENTERIC OR TYPHOID FEVER. 101 SYMPTOMS KEFEKABLE TO THE CIRCUIjATORY SYSTEM. The pulse is increased in frequency. This increase is directly and chiefly, in enteric fever as in other febrile diseases, dependent upon the rise in temperature. In general terms the frequency of the pulse corre- sponds to the temperature. It rises during the first week, continues high during the second and third, and gradually diminishes in frequency dur- ing the fourth. It is further true that the daily variations in the pulse run parallel with those of the temperature. The pulse is less frequent in the morning than in the evening. The absolute frequency of the pulse is, however, less in enteric than in other fevers. There are, in fact, some cases in which, although high fever is present, the frequency of the pulse does not, for some part of the time, exceed that of health; and in the mildest cases of enteric fever, and in cases of intestinal catarrh without fever, due to the cause of enteric fever, the pulse is sometimes less fre- quent than in health. These facts, as Liebermeister has pointed out, render it probable that infection by the poison has a depressing influ- ence upon the pulse. During the period of the primary pyrexia the pulse does not usually rise above 120, and in many cases it does not exceed 100 during the whole course of the disease. In 100 cases Murchison ascer- tained that it exceeded the normal standard, at some time of the fever, in all but one; in 97 cases it exceeded 90; in 85 cases it exceeded 100; in 70 cases it exceeded 110; in 32 cases it exceeded 120; in 25 cases it exceeded 130; in 10 cases it was above 140; and in 2 above 150. In 6 cases of 100, the same observer found the pulse fall to 60; to 56 in 2; and in a single case to 52; in one case under his observation the pulse fell to 37, and never, throughout the whole course of the disease, ex- ceeded 56, but rose with convalescence to 66. In severe cases the pulse is apt to be frequent; and where in an adult it continues steadily above 120, the prognosis becomes 'pro tanto unfavorable. Cases, however, occasionally prove fatal, in which the pulse does not exceed 100. The frequency of the pulse in enteric fever is, like the temperature, readily modified by slight causes. Simply lifting the patient into the up- right position may temporarily accelerate the pulse from 20 to 30 beats per minute. During the first week or ten days of the attack the pulse often retains to a moderate degree the force of health; but after this, or sometimes earlier, it becomes soft, compressible, and dicrotic. In the ad- vanced stages of severe cases it may be small, undulating, irregular, or uncountable. These alterations are dependent upon changes in the heart, and where death takes place without complication at the height of the disease, it is commonly due to heart-failure. The following series of sphygmographic tracings show the progressive changes of the pulse dur- ing the course of the attack (Figs. 11 to 15). ]1 1G2 THE CONTINUED FEVERS. The enfeeblement of the heart, characteristic of enteric fever in its later periods, and which is a direct result of the continued high tempera- ture, is manifested also by changes which take place in the impulse, and the quality of the systolic sound. These in severe cases become progress- FlG. 11.— End of First Week. Strong Heart Action ; Moderate Dicrotism. Frequency, lU-1. \/V^VAiVAJV\J Fig. 12.— Third Week. Action of Heart Strong ; Marked Dicrotism. Frequency, 108. Fig. 1.3.- Third Week. Action of Heart Weak. Frequency, 128. ■piQ 14.— Beginning Heart Failure. Frequency of Pulse, 144. Fig. 15.— Heart-Failure after Profuse Intestinal Hemorrhage. ively feebler, until the former is imperceptible and the latter almost or even quite inaudible. To the enfeeblement of the circulation are also referable a certain amount of venous stasis showing itself in duskiness of the surface, and ENTERIC OR TYPHOID FEVER. 163 a lowering of the arterial pressure which shows itself in diminished se- cretion of the urine. Hypostatic congestion of the lungs and many other complications arise from the same cause. It is to the diminished power of the circulation also, that is due the marked coldness of the hands and feet often occurring in severe caSes, while the internal temperature still remains high; this condition is, there- fore, an important sign of impending danger from failure of the heart. To the same cause we must refer the common danger of collapse in en- teric fever. The greater the weakness of the heart, the greater does this danger become. Collapse may result from various accidents, such as in- testinal hemorrhage, the shock following perforation, or even a sudden copious diarrhoea or violent vomiting. A sudden fall of temperature, either spontaneous, or in consequence of the administration of remedies, may also occasion collapse. Still more frequently collapse occurs as a re- sult of the sudden change from the recumbent to the erect posture. Whatever its cause, collapse must be looked upon, under all circum- stances, as an extremely dangerous accident of the disease; for the tran- sient weakness of the heart may quickly pass into complete paralysis, and so cause death. Liebermei^ster states that the collapse which occurs in consequence of a sudden fall of temperature is generally devoid of dan- ger, and may even be a favorable sign. SY>IPTOMS KEFERABLE TO THE NEKVOUS SYSTEM. Headache is one of the earlier and more constant symptoms. The proportion of cases in which it is absent is extremely small. Louis found it to be absent in but 7 out of 133 cases, and Murchison in 5 out of 82. It is probably not less common in children than in adults. It is most severe in the first week, and by the end of the second week, or earlier, it has usually ceased. According to Sir William Jenner, it usually ceases spontaneously about the tenth day.'* It is commonly confined to the fore- head or temples, sometimes it extends over the whole head, and more rarely it is referred to the occipital region alone. Its intensity, usually mod- erate, commonly increases toward evening. It is described by patients as dull rather than shooting or darting, although in some instances I have known it to be sharp, piercing, or agonizing. Slight vertigo is often associated with the headache in the early days of the disease. As a rule, it comes to an end at the same time as, or before the headache; exceptionally it remains till the close of the attack. Pains in the back and extremities are commonly present from the on- set, in this, as in most of the other acute infectious diseases. These pains are sometimes vague; at others they are fixed, and aggravated by movement, like the soreness which follows bruises. Sometimes the pa- ' On the Treatment of Typhoid Fever. Lancet, November 15, 1879. 164 THE CONTINUED FEVERS. tients describe them as aching- or boring. Occasionally they assume a distinctly neuralgic character, and sometimes they are confined to the joints, and are attended by tenderness, slight swelling and redness, so that they simulate acute rheumatism. They usually subside some time during the second period of the disease. Delirium occurs in a majority of all the cases. Many cases, however, pass through the whole course of tlie attack without delirium or distinct impairment of the mental faculties. Thus, Louis found that in 32 out of 134 cases there was neither somnolence nor delirium; and Murchison states that, out of 100 cases in which this matter was noted, 33 passed through the attack without impairment of the intelligence. These cases do not necessarily belong to the lightest forms of the disease ; of Murchison's 33 patients, 3 died — 2 from perforation of the bowel and 1 from epistaxis; and of Louis' 32 cases, in which there was no delirium, 8 were fatal— 6 from perforation. These statistics are of interest as showing that no direct ratio exists between the local intestinal lesions and the intensity of the primary febrile movement. For, although there is good reason to believe that the disturbance of the nervous system, in the early days of typhoid fever, is in a measure directly due to the action of the poison, it is certain that the graver disturbances of the nervous system, among which are to be classed somnolence and delirium, and which in their complete development constitute the "typhoid state," are largely due to the prolonged high temperature. Here, however, we see a considerable proportion of cases, in which the graver nervous symp- toms are absent, perishing in consequence of the extent and intensity of the local intestinal lesions. The character of the delirium varies greatly; it is often slight and occasional, occurring chiefly in the night-time, or upon waking from sleep, in patients who are otherwise entirely rational. This form of delirium may become active and noisy, and then, as the patient becomes more pros- trate, may pass into the low, muttering delirium, to which the name of ty- phomania has been given, or into a wandering, fatuous state, with trem- bling like that of alcoholism. Sometimes the delirium is active and noisy from the first, the patient talking in a loud voice, screaming or shouting, and being restrained with difficulty. This form of delirium may suddenly supervene upon either of the others; it is therefore of the utmost impor- tance that the patient should at no time, after the appearance of delirium, be left to himself, even for brief intervals. Exceptionally, maniacal de- lirium occurs early in the disease, and sometimes it is the first symptom which attracts the attention of the friends of the patient. As a rule, however, delirium does not commence before the middle or end of the second week, upon the subsidence of the headache. In a small proportion of the cases it does not appear till late in the course of the disease, and lasts only a few days. ENTERIC OR TYPHOID FEVER. 1G5 In children it occurs somewhat earlier than in adults. In many instances delirium, if mild, occurs only at night, and in all cases it is more marked during the night-time. During the first and second periods of the disease the patient is often disturbed by loaJcefulness. This symptom is, however, much less marked in enteric than in typhus fever. Soinnoleace usually supervenes some time during the course of the second week. It is at first slight, but becomes, especially in severe cases, gradually more profound. It usually precedes delirium, and, after it is established, alternates with periods of wakefulness and spells of delirium. The patient is often dull and drowsy by day, and wakeful, restless, and de- lirious during the night. In cases of great severity the somnolence becomes more constant and deepens into complete unconsciousness, which lasts to the termination of the case. Somnolence is met with also in children. Muscular weakness is present, to some extent, in all cases from the be- ginning of the attack, and increases with its progress. A large propor- tion of the patients are, nevertheless, able to assist themselves, to sit up in bed, and even to rise to stool throughout the whole course of the attack. In the mild forms of the disease, patients, although very weak, are often able to go about, and it is not rare to encounter walking cases as hospital outpatients, in the second or third week of the attack. In grave cases muscular debility is very often complete. Muscular tremulousness is present in a considerable proportion of the severer cases. The tongue trembles as it is protruded, the lips quiver, and movements of the hands are trembling and uncertain. This phenomenon is most common in those addicted to the use of alcohol, and in old and very feeble persons. More rarely it occurs in young and temperate persons, and it is occasionally observed where there is no impairment of the men- tal faculties. Eetentio/i of urine and involuntanj evacuations occasionally occur. They are apt to take place in those cases in which the prostration is ex- treme. Migid contractions of groups of muscles in the trunk, neck, or ex- tremities, are met with in a few cases. They are most frequent in fe- males. In the advanced stages of severe cases, suhsultus tendinum, pick- ing at the bedclothes, and vague graspings in the air, are observed. In such cases protracted hiccougli may also occur. General convulsions are rare. They occur with greater frequency in children than in adults. It would appear that, although occasionally associated with albuminous urine, they also occur independently of that condition, but are, in all in- stances, of the gravest prognostic import. Liebermeister distinguishes four different degrees of febrile disturb- ance of the nervous system, which occur successively in severe cases. In the first degree there is general malaise, restlessness, headache, and dis- 166 THE CONTINUED FEVERS. turbed sleep. These symptoms correspond to the first half of the first week. They are not associated with disturbance of the intellect, and can- not be distinguished from the symptoms of the prodromic period, which are due to the action of the poison upon the nervous system, without in- crease of temperature. In the second degree the patient is apathetic, dull, his memory is blunted. There is temporary disturbance of the in- tellect, amounting to transient delirium. These symptoms correspond to the second half of the first week and the beginning of the second. In the tliird degree there is marked somnolence, from which the patient, how- ever, can be temporarily aroused. This alternates with delirium, some- times muttering, sometimes violent and associated with restlessness and excitement. This group of systems begins, in severe cases unmodified by treatment, some time in the second week, and continues into the fourth. In the fourth degree of the disturbance of the nervous system there is loss of consciousness, out of which the patients can no longer be aroused. This degree is gradually developed from the third degree, and commonly begins some time in the third or fourth week. With the defervescence, the mental condition slowly improves; it is long, however, before the pa- tient regains his old sharpness of memory and ability for continued men- tal effort. Tlie organs of sjyecial setise present certain symptoms whicii are suffi- ciently common to have a certain amount of diagnostic value in obscure cases. Thus, epistaxis is common. It may occur at any period of the dis- ease, but is apt to occur early in its course. It is often slight, not ex- ceeding a few drops, and is for this reason frequently overlooked. To this fact is doubtless to be ascribed the varying statements of the books as to its frequency. I am satisfied that slight epistaxis occurs in a con- siderable proportion of the cases of enteric fever in Philadelphia, at some period of the course of the disease, and often repeatedly. The quantity of blood lost is seldom great; yet Murchison states that it may amount to several pounds, or even be so profuse as to occasion death. If epistaxis be considerable, it is sometimes followed by a transient fall of temperature; but, with this exception, it is never followed by any relief to the general symptoms or to those of the nervous system. Da Costa states that epis- taxis is not often absent in grave cases. Suhiectwe auditory seyisations, ringing and humming, often annoy pa- tients during the early days of the disease. They are said to be most marked, and to last longest, in the cases that are most severe. Deafness is very common. It usually affects both ears, but may be confined to one. It is sometimes very marked. It commonly appears toward the end of the second week, and, in most instances, is in part due to catarrhal processes implicating- the Eustachian passage, and in part to the blunted sense-perceptions incident to the action of the poison. One- sided deafness has been ascribed to local inflammation of the ear. Deaf- ENTEKIC OR TYPHOID FEVER. 167 ness of both ears was at one time looked upon as a favorable symptom, but the closer investigations of more recent observers show that this opin- ion is no longer tenable. Among the symptoms connected with the or- gans of special sense, the condition of the pupil demands attention. In a large proportion of the cases the pupils are abnormally dilated at some period of the disease. Murchison found the pupils dilated in at least three-fourths of his cases. This symptom commonly coexists with delirium, and comes on, like delirium, upon the cessation of the headache. It may, however, be present after the middle of the second week, in cases where de- lirium is absent. In respect to the condition of the pupils, most cases of enteric fever are in strong contrast with typhus, in which the pupils are, for the most part, contracted. But, in certain grave cases of the former fever, after great stupor or unconsciousness has occurred, the pupils are contracted, and may be as small as they are in typhus. Conjanctival injection is very rare in enteric fever, which differs in this respect from typhus and relapsing fever. If present at all, it ap- pears later than in typhus, and is usually much less intense. It was noted by Murchison in 8 out of 100 cases, by Louis in 38 out of 60, and only three times in 13 cases observed by Jenner. It is not a symptom of importance. Cutaneous hypercesthesia was observed by Murchison in about five per cent, of the cases under his care. It is most common in children and females, and appears both during the course of the disease and in the convalescence. It is usually restricted to the abdomen and lower extrem- ities, and is commonly associated with symptoms of spinal origin, such as rhachialgia, tenderness over the spinous processes of the cervical and dorsal vertebrae, and the like. The tenderness of the abdomen due to this cause is sometimes exquisite, and is to be carefully distinguished from that of peritonitis. Cutaneous and muscular aiiwsthesla, with numbness of the extremities, also occur in rare instances. This group of symptoms is more common in severe epidemics than in the sporadic forms of the disease, and is to be regarded with apprehen- sion. Murchison, however, states that hypertesthesia alone is not a for- midable symptom. THE SKIN. TTie eruption of enteric fever appears, as a rule, between the seventh and twelfth days. Exceptionally it is met with as early as the fourth, or not discovered until as late as the fourteenth day. In children it appears a little earlier than in adults. It is not invariably present. Out of 5,988 cases admitted into the London Fever Hospital dur;ng twenty-three years, it was noted in 4,606, or in 76.92 per cent. Dr. Murchison's suggestion that, in some of the remaining 1,382 cases, the fact of the spots not being 168 THE CONTINUED FEVERS. observed was perhaps due to their not having been looked for with suffi- cient care, is probably correct. The same observer states that the spots are more frequently absent in patients under ten and over thirty years of age, than between ten and thirty, and illustrates his remark by the fol- lowing statistics: of 1,413 cases between ten and thirty, the eruption was absent in 143, or 10 per cent. ; of 253 patients over thirty, it was noted as absent in 40, or nearly 16 per cent.; out of 107 cases under ten, it was not noted in 37, or 34.5 per cent. From the same series of statistics we learn that no eruption was discovered in 127 of 905 males, and in 97 of 910 females. There is no relation between the abundance of the eruption and the severity of the symptoms. The typhoid eruption is characteristic of the disease, and, when found, clearly establishes the diagnosis. It consists of small, slightly elevated, rounded or oval, isolated spots of a rose-pink color. They are from half a line to two lines in diameter, indistinctly marginate, and alike to the eye and the touch, faintly rounded and convex, but not acuminate, although some observers state that a minute vesicle may in rare cases be discovered at their centre. They are frequently compared to flea-bites, from which, however, they differ in the absence of the central mark and in their paler color. They disappear wholly on strong pressure, and return immediately when the pressure is removed. They may be made to dis- appear and reappear under the eye by placing a finger upon each side of the spot and making traction : as the skin becomes tense they disappear ; when it is relaxed they return. They are developed in successive crops, each spot lasting three or four days, and, as it fades, being replaced by a new one at no great distance, which runs the same course, fading in its turn, and so on, till about the middle of the third week. They are not found during convalescence, but reappear, along with the other character- istic symptoms of the disease, in true relapses. They are never present on the dead body. Their most common situation is the abdomen and the lower part of the chest, anteriorly. They are occasionally present upon the upper part of the thigh, and are sometimes to be met with between the scapulas. In some instances, they are present upon the back alone, and in doubtful cases should be sought for in this situation. They have been met with, in very rare instances, upon the arms and legs, and Murchison mentions a single case in which they were found upon the face. The duration of the eruption, in cases that are not unduly protracted, is eight or ten days. The spots are usually few in number, and discrete ; hence, they may be readily overlooked. It often happens that not more than six or eight can be discovered, and in most cases the number present at one time does not much exceed a score. They are, however, sometimes very numerous, but are never confluent as in typhus. ENTERIC OR TYPHOID FEVER. 109 Each spot runs its course without change, and usually disappears, leaving no trace upon the skin ; although in some instances a faint pig- mentation, which does not disappear upon pressure, persists. Tabular arrangement of the chief points of distinction between the eruption of enteric fever and that of typhus: Enteric Fever. The spots are pink or rose-colored uutil they i'ade, leaving no trace. Undergo little or no change. The spots are neither converted into petechijB, nor do petechiic appear inter- spersed with them. Circular or slightly oval in outline. Usually restricted to the abdomen, tho- rax, and upper part of the thighs, and the interscapular space. Few in number and discrete. Elevated throughout. Momentarily disappearing on pressure. Rarely appear before the seventh day. Appear in successive crops. Each crop lasts three or four days, and fades as others appear. No subcutaneous marbling or mottling. The abundance of the eruption not at all proportionate to the general gravity of the case. Not seen after death. Typhus. The spots are pink or dirty pink at first, subsiding into reddish brown stains. Become darker, and often show a minute extravasation of blood at the centre. Petechite very often appear. Less regular in outline. Commonly distributed over the greater part of the body and extremities, with the exception of the neck, face, head, and pal- mar and plantar surfaces. Copious and confluent. Raised at first, but persisting as stains after the elevation disappears. Disappearing upon pressure only during the first day or two. Commonly on the fourth or fifth day. Appear at once, and arise in successive crops, although their efllorescence may occupy several hour.s, or a day or two. Mo.st of the spots last until the defer- vescence. Skin often indistinctly marbled or mot- tled between the spots. In many instances the severity of the general symptoms is in direct ratio to the copiousness of the eruption and the dark- ness of its color. Often geen after death. The eruption is occasionally preceded by a faint scarlet rash seen in patients whose skin is fair and delicate. This rash is not very common; it is not peculiar to enteric fever; but it is met with in other diseases at- tended by pyrexia. If well-marked, and particularly if it be associated with slight sore throat, as has sometimes happened, the disease may be mis- taken for scarlet fever. True petechite are rare. Sudamina appear at a later period in the disease. They consist of minute, transparent vesicles, scattered plentifully over the body, and are 170 TIIK CONTINUED FEVERS. often, but not invariably, attended with profuse sweatiiifj-. They are very common in typhoid fever, but are without specific character, and occur with perhaps equal frequency in other febrile affections. Slight desquamation occasionally occurs during convalescence; the hair falls out; and changes occur in the nails indicating the arrest of nu- trition which has attended the course of the attack. Emaciation is usually great; often extreme. llie jihysiognomy of persons ill of t^'phoid fever is peculiar, though less characteristic than that of typhus. Some patients, especially if the attack be mild, show but little alteration of expression during its whole course. Much more commonly the expression is dull, weary; the face pale, with circumscribed flushing over one or both cheek-bones. This comes and goes, and is sometimes called forth or intensified by the admin- istration of food or stimulants. The dilatation of the pupils adds to the peculiarity of the expression; and, in the later stages of the attack, the wasted tissues, the sunken eyes, the circumscribed flushing and hurried breathing, suggest the appearance of patients in advanced pulmonary phthisis. SYMPTOMS KEFERABLE TO THE DIGESm^E TRACT. T7ie tonr/ue at first has a somewhat swollen and flabby appearance; it is at this period also moist and covered with fur, commonly thin and whit- ish, or yellowish white, sometimes thick and creamy or pasty. Its edges and tip are unusually red. It may remain moist and furred during the whole course of the attack, or, during the second week, the coating may break up into flaky patches of a whitish color, while the surface of the tongue remains bright red. This redness is in peculiar contrast to the pallor of the lips in the advanced stages of the disease, and has given rise to the name of " red-tongue fever," by which enteric fever is known in some sections of the West. It is more common, after the middle of the second week, to find the tongue dry, red, glazed, and slightly or even deeply fissured, or it is dry, with a brownish streak along the middle, or a triangular brownish patch at the tip. In cases in which the typhoid state is well-developed, the tongue is usually covered with a more or less tliick, brownish crust. It is rare to find the tongue firmly retracted into a globular mass, as is sometimes seen in typhus, and inability to protrude it is less common than in that disease. The lips often crack and bleed, and in children, by reason of picking, they frequently become very sore and painful. In gravi cases sordes collect upon the teeth. Hemorrhage from the gums is a rare occurrence in enteric fever. In the first week there is usually slight catarrhal inflammation of the faucial mucous membrane, with enlargement of the tonsils. The accumu ENTERIC OK TYPHOID FEVEK. 171 lation of the altered secretion in the naso-pliaryngeal space occasions in some patients considerable discomfort. Later the throat becomes dry, and there is, as a result, more or less difficulty in swallowing. Tlie appetite is, as a rule, greatly impaired ; it is wholly lost when the tongue becomes dry. In mild cases, when the tongue retains its moist- ure, some appetite may be present throughout the attack. I have seen a case in which, with a very red but moist tongue, evenly coated at first, but later showing only flaky patches of whitish fur, the appetite was good during the whole course of the disease. In this patient, a lad aged nine- teen, the highest evening temperature was 40° C. (104 ° F.), The secre- tion of saliva is in most cases greatly impaired, and there is good ground for believing that a like impairment of the secretion of the pancreatic juice takes place. For this reason starchy articles of food are not so well digested as albuminous foods; and it is probable that, while small amounts of arrow-root or gruel may be advantageous in certain cases, because they augment the food-volume, in the majority of instances any considerable quantity of starch is injurious and likely to add to the intestinal irri- tation. Thirst is commonly present in the early stages; in many instances it is urgent. Nausea and vomiting occur in the early stages of a small proportion of the cases. These are sometimes among the earlier symptoms, and being associated with headache and general malaise, lead the patient to suppose that he is suffering from " biliousness." More frequently these symptoms appear during the second week. The vomiting in most cases is only oc- casional; it is sometimes persistent and distressing. In the latter case it is apt to be associated with epigastric soreness and pain. Some ob- servers look upon vomiting at the beginning of the attack as a favorable symptom; by others it is regarded in the opposite light. There are no statistics by which to settle this question, but so far as my own obser- vation goes, early vomiting, which is not common in enteric fever as it occurs in Philadelphia, has been followed by the severest forms of the disease. Vomiting after the end of the second week, is of grave import; it is often the first sign of peritonitis. The matters vomited usually con- sist of food, sometimes in a partially digested state, or they consist sim- ply of gastric mucus stained green with bile. Abdominal tenderness and pain are present in the majority of the cases. They are not, however, necessary symptoms, and are sometimes absent throughout tlie attack. Palpation is to be made with circumspec- tion in the later periods of the attack, lest mechanical violence give rise to peritonitis, or even perforation of the ilium at a point of deep ulcera- tion. Bartholow ' mentions a case in which fatal peritonitis, due to rup- ' Practice of Medicine, 1880. 172 . THE CONTINUED FEVERS. ture of the spleen, was caused during convalescence by a not violent blow. The tenderness is elicited by light pressure in the right iliac fossa, but it is not necessarily limited to that region. In many cases it is also experienced in the umbilical region and even in the left side of the abdo- men. Spontaneous pain is also often complained of. Pain and tender- ness in the abdomen are largely, if not wholly, due to local morbid pro- cesses, and are to be looked upon as to some extent the measure of the extent and intensity of the intestinal lesions. This statement must, how- ever, be qualified by adding that a most serious, or even fatal lesion of the gut may sometimes occur without previous marked pain or tenderness. Meteorism is present in most cases ; according to Sir William Jenner ' it is observed to some extent in all cases. Murchison states, on the other hand, that out of 100 cases he found meteorism in 79, and that the abdo- men remained flat throughout in 21 ; and Louis noted meteorism in only 89 out of 134 cases. The amount of distention varies from slight fulness to a tympany so great as to interfere with the contraction of the dia- phragm and impede respiration. In this way meteorism increases the danger of congestion of the lungs. It does not usually appear until after the first week, and is most developed in severe cases. Thus, Murchi- son noted it in 20 out of 21 fatal cases; Jenner in 18 out of 19 fatal cases, and Louis in one-half of his fatal cases. Furthermore, the first- named of these observers found that, out of 17 cases in which extreme tympany arose, 7 died ; while of G2 in which it was moderate or slight, 14 died, and of 21 where it was absent, none died, and Louis noted great meteorism in only 7 cases among 88 in which recovery took place. These statistics are of great interest as indicating the importance of the intes- tinal lesions in regard to the prognosis. Tympany, like abdominal ten- derness and pain, is in part a measure of the extent of the mischief wrought in the intestines. It is due to excessive development of gas and to deficient expulsive power in the bowels. The first of these factors has its pathological genesis in the impaired quality of the digestive fluids, and a tendency to the rapid decomposition of imperfectly digested food; the second in general lowering of nerve-tone, or in local injury to the bowel. Jenner calls attention to the fact that a single deep ulcer will paralyze the action of the bowel and lead to such an accumulation of flatus as produces enormous distention of the abdomen. Weakness of the abdom- inal muscles contributes also to the accumulation of flatus. The condi- tions which underlie abdominal distention in this disease attain their maximum during the latter half of the third and in the fourth period of the fever, and it is at this time that meteorism may, in the more severe cases, become both a troublesome and an alarming symptom. The spleen is, as a rule, enlarged. — Augmentation in the bulk of this ' On the Treatment of .Typhoid Fever. Lancet, November 15, 1879. ENTERIC OK TYPHOID FEVER. ITS organ is a prominent and characteristic symptom ; it occurs early, and may often be demonstrated before the close of the first week. It in- creases during the second week, and diminishes again during the fourth. The amount of enlargement is usually considerable ; at the height of the disease the organ sometimes attains three times its natural bulk, or more, and can be felt through the abdominal wall. The enlargement is greatest in persons under thirty years of age. In a few cases it is absent altogether, and this is more common in old than in young persons. Diarrhoea is one of the most common symptoms in enteric fever. Although cases occur in which this symptom is absent throughout the whole course of the attack, they are to be looked upon as exceptional. Out of 100 cases in which diarrhoea was made the subject of special obser- vation by Murchison, it occurred in 93. The time at which the diarrhcea first appears is very variable. It is sometimes present in the prodromic period, or if not present at this time, it is often induced by purgatives taken by the patient under the impression that he is suffering from a bilious attack. Diarrhcea sometimes appears early in the course of the disease, but ceases after a few days, and does not return. More com- monly it is a prominent symptom during the whole course of the illness. It sometimes happens that diarrhoea is absent until the third or fourth week of the disease, and is then profuse. The movements are not often attended with pain, and never by tenesmus. Their frequency varies. In the greater number of cases they do not exceed three or four a day ; not infrequently, on the other hand, they may amount to twelve or fifteen in the course of twenty-four hours. There is no constant relation be- tween the urgency of the diarrhoea and the extent of the intestinal lesions. Diarrhoea may be altogether absent in cases in which, after death, exten- sive and deep ulceration is found. Profuse hemorrhage or perforation sometimes occurs in cases unattended by diarrhoea or any other previous abdominal symptom. Prolonged constipation is attended with the dan- ger of the formation of firm scybala which are liable to do harm by in- creasing the extent and depth of the ulceration, or by directly leading to perforation. When diarrhcea occurs during the first week, the stools are thin and brownish ; but toward the end of the second week they assume the ap- pearance peculiar to the disease. They are then liquid and of an ochrous color. On standing, the stool separates into two layers ; a supernatant fluid and a flaky sediment. The former has a yellowish or pale brown color ; its specific gravity is 1015, and it contains about 40 parts in 1,000 of solid matter, which consists chiefly of albumen and soluble salts, particularly chloride of sodium. The deposit is made up of particles of undigested food, disintegrating intestinal epithelium and blood-corpuscles, shreds of sloughs, which are separated from the intestinal ulcers, and multitudes of crystals of triple phosphate (Murchison). The reaction of 174 THK CONTINUED FEVEKS. « the typhoid stools is alkaline. Sometimes, ii)stead of being watery, they are frothy or pultaceous, or they may be mixed with blood. Gurgllnc) in the right iliac fossa is often elicited upon palpation. Associated with tenderness, this symptom undoubtedly has diagnostic value; but it occurs so constantly in other affections, attended by diar- rhoea, that it cannot be looked upon as a characteristic phenomenon of en- teric fever. Hemorrhage from the bowels is of frequent occurrence and constitutes a s3nnptom of the gravest importance. Sometimes it amounts merely to a few streaks of blood, or a little bloody mucus ; in others it is more abundant; or it may be even copious, amounting to one or more quarts. The color of the blood is oftei) bright red, particularly if it be promptly discharged ; it may be of a syrupy consistence, or loosely clotted. If it be retained for some time in the intestine (concealed hemorrhage), it be- comes tarry in consistence, and of an olive-green or brown color. Mur- chison states that hemorrhage, amounting to over six ounces, occurred in 58 of 1,564 cases under his observation, or in 3.77 per cent. It occurred in 8 of 134 cases noted by Louis, or in 5.9 per cent. In this estimate the milder cases appear not to have been included. Liebermeister found that hemorrhage from the bowels occurred among the cases treated in the hos- pital at Basle in 127 of 1,743 patients, or in 7.3 per cent. The proportion among men was 5 per cent, of all cases ; that among women, 10. In this series of cases, the lighter hemorrhages are included, those only being thrown out in which a mere trace of blood was discovered. Griesinger observed 32 cases of hemorrhage in 600 patients, or 5.3 per cent. It is somewhat less frequent in children than in adults. The date of the appearance of the hemorrhage shows, according to the statistics of different observers, considerable variation. Liebermeister found that in 81 cases of intestinal hemorrhage in which the chronology was carefully kept, 7 took place during the first week ; 33 during the second ; 19 during the third; 14 during the fourth; and 8 at a later period. Griesinger, in 32 cases of hemorrhage, found no instance in which this accident occurred during the first week ; during the second, and chiefly toward the end of it, there were 10 cases ; during the third week, 8; during the fourth, 8; in the fifth, 2; in the sixth, 3. Of 60 cases ob- served by Murchison, the bleeding commenced during the second week, mostly toward its close, in 8; during the third week in 28; during the fourth in 17; during the fifth in 1; during the sixth in 3; during the seventh in 1, and during the eighth in 1; while in one case the date of its occurrence was not noted. In three of Murchison's cases, where it took place on the sixteenth, eighteenth, and nineteenth daj's, it recurred respec- tively on the forty-ninth, thirty-third, and forty-fourth days. The last named author states that he has known slight intestinal hemorrhage to take place as early as the fifth or sixth day, and even copious hemorrhage ENTERIC OR TYPHOID FEVER. 175 at a period so early in the disease as to preclude, in all probability, the ■existence of intestinal ulceration. The source of the hemorrhage varies with the period of its occurrence. During the early period of the disease, prior to the latter part of the sec- ond week, the hemorrhages arise from the rupture of minute vessels within the relaxed and highly vascular tissues of the infiltrated patches; in the third and fourth weeks, they are due to the separation of sloughs; and at this period, or later, to the destructive action of progressive ulcera- tion. Hemorrhage from the bowels is occasionally associated with nose- bleeding, the spitting or vomiting of blood, or with hsematuria, and with petechise, as evidences of profound alteration of the state of the blood, in consequence of the action of the typhoid poison; or hemorrhages from various mucous tracts may occur during the course of the disease, as evi- dences of the existence of the hemorrhagic diathesis. Extensive hemorrhage may take place into the bowel, and death en- sue in consequence, without the escape of the blood externally. If a large amount of blood escape into the intestine, whether it be voided ex- ternally or not, symptoms of collapse speedily ensue. The patient sud- denly becomes extremely prostrate; his face grows pale; his pulse weak and frequent; his extremities cold; while the temperature falls, with great abruptness, several degrees. If the blood be not discharged, an area of the abdomen, previously tj^mpanitic, becomes dull. The temperature sometimes falls to a point below the normal. This fall is followed by the same general amelioration in the condition of the patient that results from a decided remission of fever under other circumstances; in particular, by the diminution or disappearance of serious nervous symptoms due to the prolonged high temperature. The change is, however, usually transitory; within twenty-four hours the temperature rapidly regains its former height, or rises beyond it, and the disease resumes its course. It is to this transient amelioration of the general symptoms of the dis- ease that is doubtless due the opinion entertained by some observers that the occurrence of hemorrhage is productive of benefit to the patient. Among those who hold this view are Graves and Trousseau. The great ma- jority of observers, however, concur in the opinion that it is a dangerous symptom. Of Murchison's 60 cases, 32, or 53.3 per cent., terminated fa- tally; in 11 of these the immediate cause of death was peritonitis; of the remaining 21 cases, 14 died within three days of the bleeding; and of these 14 cases, 8 within a few hours. Of Liebermeister's 127 cases in which liemorrhage occurred, 49, or 38. G per cent., died. Of Griesinger's 32 cases, 10, or 31.2 per cent., died, 7 of them within four days. Most of the cases in which copious intestinal hemorrhage occurs, have been previously severe, and attended by considerable diarrhoea; in a small proportion of them, however, the previous symptoms have been mild; and in a few of them, diarrhcea has been absent. It would appear then that 176 THE CONTINUED FEVERS. hemorrhage occ-urs most frequently in the severer cases of the disease, where the mortality would be high without the occurrence of this acci- dent. Furthermore, the fall of temperature attendant upon hemorrhage and the consequent amelioration of the general symptoms of the disease, if they occur in the later periods of the fever, may usher in a permanent improvement. It is probable, therefore, that intestinal hemorrhage, al- though unquestionably influencing the prognosis unfavorably, is less dan- gerous than some observers have been led to suppose. A slight hemor- rhage probably affects the result but slightly, if at all; even in a grave case, it is of little importance, except in so far as it excites the fear of a profuse recurrence. Copious hemorrhages at any period of the disease are to be regarded with apprehension, because of the increased debility arising from the actual loss of blood. If they occur early, they render the patient less able to bear the prolonged fever; if late, death may ensue from collapse. It has been thought that the danger of intestinal hemorrhage is in- creased by the treatment by means of cold baths. And it would appear that the application of cold to the entire surface of the body, by inducing contraction of the superficial blood-vessels, must drive the blood to the internal organs, and thus favor hemorrhage. Liebermeister, however, found that of 8G1 cases treated before the introduction of the cold bath- ing, 72, or 8.4 per cent., had intestinal hemorrhage; but that of 882 cases treated after the introduction of the cold baths, hemorrhage occurred in 55, or G.2 per cent. He concludes, therefore, that " the frequency of intes- tinal hemorrhage has materially diminished under the cold-water treat- ment." This point cannot at present be looked upon as settled. SYMPTOMS BEPERABLE TO THE ORGANS OF RESPIRATION. The frequency of respiration varies with the intensity of the febrile movement, in the absence of pulmonary complications. It rises with the pulse; but in cases characterized by an unusually slow pulse, there is no corresponding slowness of the breathing. At times the respiration is shallow, noisy, or irregular, but these symptoms arise for the most part in the gravest cases. A certain amount of bronchial catarrh is so frequent in enteric fever that it merits consideration as a symptom of the disease rather than as a complication. In a majority of the cases this does not manifest itself by cough; and the cough, when present, is often by no means proportionate to the intensity of the bronchial congestion. Upon auscultation we de- tect rales which are often loud and ringing. IIy2)ostasis gives rise to notable enfeeblement of the respiratory murmur at the most dependent portions of the lungs, and to impairment of resonance upon percussion. ENTERIC OR TYPHOID FEVER. 177 THE UEINE. The urine is diminished in quantity during the first and second ■weeks. Notwithstanding the increased amount of fluid consumed by the patient, the urine excreted may not exceed one-half or even one- fourth the normal quantity. In most cases it is diminished from the commencement of the attack until convalescence, when it becomes, as a general rule, copious and of low specific gravity. Sometimes, however, a considerable increase in quantity takes place about the end of the sec- ond week. Its color is at first darker than in health, in consequence of the rapid destruction of the pigmented tissues of the body, and particu-* larly of the red blood corpuscles. In the advanced stages of the disease, and during convalescence, it is pale. As a general rule the urine is acid throughout the disease; toward the end of the attack, however, the acid reaction becomes less intense, and in some instances the urine is at this time even feebly alkaline. The specific gravity varies in proportion to the amount. The scanty urine of the early periods ranges from 1020 to 1030; after tlie close of the second week, in some instances, and almost invariably during convalescence, the specific gravity falls to a point con- siderably below the normal. The abundant limpid urine of early conva- lescence is often as low as 1008 or 1005. The daily excretion of urea is invariably increased at some period of the attack, and in almost all instances throughout the whole course of the disease. This increase is greatest during the first, week; after that, the quantity usually falls off somewhat until convalescence, when it may re- main for several days lower than normal. According to Parkes, the average increase is about one-fifth, but occasionally this amount is far exceeded. The quantity of urea excreted is usually greatest, when the temperature is highest, and, as the temperature subsides, the urea dimin- ishes to the standard of health or below it. The amount of urea does not appear to be dependent upon the frequency or intensity of the diar- rhoea. It would appear from the observations of Dr. Parkes, that the urea may be reduced during the occurrence of inflammatory complica- tions. In one case, this observer ascertained that the amount of urea, during an intercurrent attack of pleurisy, was one-third less than the average before the occurrence of this complication. The uric acid is always increased. During the latter period of the disease the amount falls to the normal, and during convalescence, it is less than in health. Copious deposits of the urates may occur at any time in the course of the disease. They are not necessarily critical, and are therefore without prog- nostic value. The chlorides are greatly diminished. Sometimes they do not exceed a mere trace. This diminution in the chlorides cannot be wholly explained either by the diminished amount ingested or by the increased amount voided with the stools. It would appear that they are 12 178 THE CONTINUED FEVERS. temporarily stored up in the tissues. With the advent of convalescence, the chlorides are greatly increased. In many cases the urine contains albumen. Of 549 cases, collected by Murchison from various sources, albumen was discovered in 157, or in 28.6 per cent. It rarely appears earlier than the middle of the third week; the amount is small, and in most cases the albuminuria is tran- sient, disappearing shortly after the abatement of the fever. The ap- pearance of the albumen in the urine is due to the parenchymatous degeneration of the kidneys, and is a direct consequence of prolonged high temperature. It coincides in the chronology of the disease with the appearance of cerebral symptoms of gravity and the other phenomena of the typhoid state (third degree of disturbance of the ners'ous system — Liebermeister). Acute parenchymatous nephritis occasionally occurs; it will be spoken of under the head of complications. Hematuria is occasionally encountered; it is commonly associated with other hemorrhages. Blood-corpuscles may be found, in connection with albumen and renal epithelium, in the urine of severe cases. Tube- casts are commonly discovered along with the albumen; they are also occasionally met with where albumen is absent. Leucine and tyrosine, creatinine, and the urinary indigo are occasion- ally met with. In the later stages of the disease, when the urine is feebly acid in reaction, it often contains large amounts of the phosphates. Complications and Sequels. Enteric fever is conspicuous among the acute diseases for the number and variety of its complications and sequels. The prolonged high tem- perature, the serious impairment of nutrition which affects the tissues of the body in the most general manner, and the enfeeblement of the cir- culation characteristic of the developed disease, contribute directly and indirectly to the excessive development of certain of the lesions. Thus, on the one hand, phenomena of the disease itself attain the importance of secondary affections, while on the other, the length of time during which the powers of resistance to evil influences from without are lowered, renders the patient especially liable to the development of intercurrent affections, not essentially dependent upon the primary disease, but of an accidental kind. Hence, the complications and sequels of this disease fall of themselves into two general classes. Of these, the first comprises those which are closely connected with the pathological processes of the particular form of fever, and which are to be regarded as due to an unusual development of the same, either in extent or in intensity. Here are to be considered those complications which we must look upon as the accidents of the intestinal lesions, such as hemorrhage, which is so common that it has already been ENTERIC OR TYPHOID FEVER. 179 treated of as a symptom, perforation, and peritonitis, with or Avithout perforation. The general lesions, which are of the nature of a wide- spread impairment of nutrition, leading to parenchymatous degeneration of the muscular system, the glands, and the tissues of the nervous system, may be followed by ruptures of muscles, abscesses, parotitis, nephritis, and various affections of the nervous system; and finally, the enfeeble- ment of the circulation leads to various venous congestions, hypostasis, (jedema, thrombosis, embolism, infarction, and secondary pathological processes dependent upon these occurrences. The second group com- prises occurrences not necessarily dependent upon the malady, but to which the condition of the patient renders him peculiarly liable. These are mainly acute inflammatory attacks, such as pneumonia or pleurisy, and the development of intercurrent diseases of an infectious character, as erysipelas or diphtheria. The impairment of nutrition characteristic of the developed disease manifests itself in a peculiar tendency on the part of the tissues to break down under the influence of slight causes. Hence, trifling injuries may give rise to serious destruction of tissue. The pressure of the teeth, or the sharp point of a tooth, may cause an ulcer upon the tongue which spreads, becomes gangrenous, and refuses to heal until the defervescence. In a like manner, bed-sores are not only intractable while the fever lasts, but they tend to become deep and extensive, despite the most careful efforts to guard the parts from pressure. Venereal ulcers tend to become gan- grenous, and sometimes result in the extensive destruction of parts, and Liebermeister has seen old fistulous tracts, dependent upon former disease of the bone, reopen, and necrosis of the bone supervene. It is a matter of common observation that wounds do not heal well, if the patient develop enteric fever. Diseases of the respiratory tract constitute an important group of the complications of enteric fever. Laryngitis occasionally occurs. It is a serious complication, and is not infrequently the cause of death. The laryngeal inflammations, which occur as complications of fevers, may be grouped under these headings: 1, QEde- matous Laryngitis; 3, Ulcerative Laryngitis; 3, Laryngeal Perichondritis.' " Practically it is often exceedingly difficult to separate these various forms even at the post-mortem, so far do they overlap each other. Qi^de- ma may exist alone, or it may result from either of the others; ulceration may march steadily deeper until the cartilages are involved; or the peri- chondritis may produce an abscess which will burst, and so form an ulcer, Pow much more difficult, nay often impossible, then is it to diagnosti- cate precisely the form of the disease, when, happily, the patient recovers. Dyspnoea, suffocation — this is the one great overshadowing clinical fact ' See the Fifth Toner Lecture (On the Surgical Complications and Sequels of the Continued Fevers), by W. W. Keen, M.D., Washington, 1877. 180 THE CONTINUED FEVERS. which groups them all together, whatever the form of the disease, or of the preceding fever." — (Keen.) This is a rare complication in this country; it is rare also in England. Of 13,000 eases treated in the London Fever Hospital, Murchison records only 21 of laryngitis; 8 of these proved fatal. Laryngitis occurred in but 3 or 4 cases of enteric fever. On the other hand, it appears to be very common in Germany. Griesinger met with laryngeal ulceration in 31 out of 118, and Hoffmann in 28 out of 250 cases examined after death. These ulcers are sometimes found in the dead body, in cases where there had been no symptoms referable to the larynx during life. They were at one time regarded as specific in their character, and as due to " typhoid " in- filtration of the laryngeal glands. According to Liebermeister they are due to secondary changes, resulting from circumscribed " diphtheritic " infiltration of the mucous membrane. Others do not believe that they are of specific origin, but that they are to be referred to the depraved nutri- tion of fever-patients, in consequence of which a low grade of inflamma- tion readily follows slight irritation, and tends to rise rapidly into ulcera- tion, and even into local gangrene. Dr. Keen suggests that local stasis of the blood, or clots in the vessels, are not unimportant factors in the production of the laryngeal lesions. The areas of ulceration are usually small; they may, however, become extensive, and the ulcers may extend in depth, implicating the cartilages. They may be few in number, or nu- merous and confluent. Their most common seat is the posterior wall of the larynx, which is most abundantly supplied with blood-vessels. Hence, they frequently involve the insertion of the vocal chords. They are not uncommon in the epiglottis, particularly at its margins. Hoarseness, even aphonia, difficulty in swallowing, and a troublesome, tickling cough are among the symptoms to which they give rise. The laryngeal complications of the continued fevers are far more rare in children than in adults, and somewhat less common in women than in men. Cases in which cough has been prominent during the course of the attack, or where the patient in his delirium has used his voice exces- sively, are especially disposed to these troubles. Laryngitis, during con- valescence, may occur from various causes and thus constitute a sequel of the primary fever. Acute oedema glottidis may arise in consequence of laryngeal ulcers of small extent. It is more commonly due to erysipelas or parotitis, and it is thought by some observers to occasionally occur as a simple oedema in consequence of asthenia. Perichondritis may occur without previous ulceration, as is shown by the fact that in some instances submucous abscesses are found in connection with local necrosis of cartilage, where no opening in the overlying mucous membrane exists; in other cases the necrosis of cartilasre is secondarv to the ulcerative processes. ENTERIC OR TYPHOID FEVER. 181 Necrosis of the nasal cartilages has been observed, in rare instances, as a result of fever. Bronchial catarrh is of sufficiently common occurrence to acquire a certain amount of diagnostic significance. It is sometimes unattended by cough, or by subjective symptoms, and is discovered only upon auscul- tation. As a general rule the cough is slight, and expectoration scanty, or altogether absent. Exceptionally, there is spasmodic cough, with paroxysms of dyspnoea. When the catarrhal processes affect the smaller bronchial tubes, they often give rise to lobular collapse and lobular pneumonia. In a consider- able proportion of the cases which terminate fatally prior to the end of the second week, death is due to pulmonary complications. Bronchitis, usually associated with hypostasis, is often a troublesome condition in the fourth week, when it may contribute to the fatal termination, or to the in- definite retardation of the convalescence. Lobular pneumonia was noted by Hoffmann' as present in 38 out of 250 cases examined after death. Of these 38 patients, 3 had died in the second week, 8 in the third, 7 in the fourth, 6 in the fifth, and 14 at a later period. Hypostatic congestion of the lungs and pulmonary oedema arise in consequence of the failure of the circulation. Hypostasis develops itself as soon as the force of the heart is notably reduced. This may occur in the course of the second, but is common in the third week. The patient lies quietly upon his back, and the influence of gravity upon the blood in the vessels of the lungs is added to that of the enfeeblement of the circu- lation. The blood stagnates in the most dependent portions of the lung, in which regions the air is gradually forced out of the alveoli, and there results an airless condition of the pulmonary tissue, not due to inflamma- tion, which is termed splenization. If a sluggish inflammatory process arise in this tissue, hepatization results in consequence of hypostatic pneumonia. These conditions are to be recognized by the enfeeblement of the respiratory sounds to which they give rise, by dulness at the bases posteriorly, a little more marked upon one side than upon the other, and by the well-marked weakness of the heart with which they are associated. They are chiefly to be diagnosticated from lobar pneumonia, by the slight degree of difference in the two sides, by the absence of rigors or increase of fever, and by the gradual manner in which the physical signs of con- solidation are developed. Pulmonary hypostasis aggravates the condition of the patient by cutting off extensive areas of alveolar surface, and thus curtailing the function of respiration ; it is also to be viewed with appre- hension, as an indication of cardiac weakness. Pulmonary oedema is very common in connection with other affec- ' See Ziemsseo's Cyclopaedia, vol. i. , Article Typhoid Fever. 182 THE CONTINUED FEVERS. tions of the lungs. When death takes place by gradual failure of the heart, it is associated with the development of extensive oedema of the lungs, and the patient is drowned in the serum of his own blood. Hemorrhagic infarcts occur. They are difficult of diagnosis during life. If due to heart-clot, of which fragments are swept into branches of the pulmonary artery, they may be absorbed. They may, however, un- dero"o purulent changes, resulting in the formation of abscesses, or they may result in circumscribed gangrene of the lung. They are apt to occa- sion pneumonic infiltration and pleurisy, and in all cases increase the dangers of the patient's condition. Lobar pneumonia is a common complication. Occurring in the course of the disease, it has the character of secondary pneumonia; the cough is not increased, the chest-pain is absent or slight, and rusty sputa do not occur. It is to be recognized by the signs with which its onset is at- tended, by the sudden increase in fever, and by the evidences of infiltra- tion discovered upon physical examination of the chest. In rare cases it occurs early, but it is much more common at the height of the disease, that is to say, in the last part of the second or in the third week, and it may not arise till after convalescence is fairly established. In the last case the ordinary characters of primary pneumonia are apt to be present. When it occurs early, or before the patient has come under observation, this complication may be mistaken for the primary disease. The term " typhoid pneumonia " has been applied alike to idiopathic pneumonia with " typhoid " symptoms, and to cases of typhoid fever in which the pulmonary compli- cations have been prominent. It is an unfortunate term, leading to no little confusion, and richly deserves to be discarded from medical writings. Gangrene of the lung occasionally occurs. It may be diffuse or cir- cumscribed. The former may result from the breaking-down of a lobar infiltration ; it manifests itself by the ordinary symptoms, and is, there- fore, recognized during life. Circumscribed gangrene frequently follows hsemorrhao-ic infarction; it may result from the necrobiotic processes in the tissues of patches of lobular pneumonia. It usually remains circum- scribed, and is not recognized during life. Chronic 'pneumonia^ in consequence of the delayed resolution of in- flammatory products, not rarely supervenes upon the various pulmonary complications of enteric fever. It may, after a duration of variable length, terminate favorably ; much more frequently, the infiltrated portions of luno- ultimately break down with the formation of cavities, and the patient succumbs to rapid phthisis. Although no exact statistics upon which to base the opinion exist, it is generally thought that consumption is a much more common sequel of enteric than of the other fevers. This opinion is probably correct. Acute miliary tuberculosis is an occasional sequel. It may be devel- oped immediately after the attack, or not until the lapse of some weeks. ENTERIC OR TYPHOID FEVER. 183 Pleurisy with more or less abundant effusion is more frequent after enteric than after typhus fever. It occasionally results in empyema. As has been already pointed out, to the failure of the power of the circulation is largely due many of the complications of the disease. This failure is a direct result of the degeneration of the muscular tissue of the heart, which is to a greater or less extent present in all severe cases. The general nutrition of the tissues is impaired because they do not receive their usual supply of blood, not less than because the supply is of an inferior quality. The amount of blood being decreased and the force of the circulation diminished, it is apparent that a slight amount of inflamma- tory infiltration may cut off the local supply altogether, and destructive ulceration and gangrene readily ensue. But the mere slowing of the blood- current within its ordinary channels gives rise to many complications of im- portance. Those implicating the respiratory tract have been alluded to. Dilation of the cardiac ventricles, both upon the right and the left side, occasionally occurs in consequence of the degeneration of their mus- cular walls, other recognized causes being absent. This sometimes reaches an extent that enables one to diagnosticate it during life. It is more com- mon upon the right than upon the left side. In a majority of cases termi- nating in recovery, the increased area of dulness recedes as the quality of the systolic sound and the force of the impulse improve. Excessive weakness of the heart, combined with dilatation, often leads to the forma- tion of heart-clot. Ante-mortem clots occur on both sides of the heart. If fragments of such clots are swept from the right ventricle into the branches of the pulmonary artery, they result in embolism and the forma- tion of hemorrhagic infarcts; while the detachment of fragments from a clot in the left ventricle produces embolism somewhere in the course of the general circulation, oftenest in the spleen or kidneys. To the same cause, namely, weakening of the force of the circulation, we must refer the occurrence of venous thrombosis, which is most fre- quently met with in the femoral vein. It is a complication of moderately frequent occurrence. Murchison encountered it in fully one per cent, of his cases. Of 17 instances in which it occurred under his observation, it was restricted to the left leg in 14; to the right in 1; and both limbs were implicated in 2. Of these 17 cases, 3 proved fatal, and it is of in- terest to note that they were cases in which the evidences of the gravest impairment of nutrition existed; thus one died of intestinal hemorrhage and pleural effusion ; one in consequence of extensive bed-sores and sloughing of the nates, and the third proved fatal six months after the commencement of the fever, death being preceded by the occurrence of jaundice, albuminuria, and the signs of a very feeble heart. In the hospital at Basle, 31 cases of thrombosis of the veins of the lower extremity occurred among 1,743 enteric fever patients, the majority being among men. This complication made its appearance commonly 184 THE CONTINUED FEVEES. during convalesence, but in a few instances in the third or fourth week of the fever. In 24 cases, 16 occurred in men, 8 in women; 18 impli- cated the femoral vein, 3 the saphena, and 1 the popliteal. Thrombosis of the femoral vein on both sides occurred twice, four times on the right side alone, and twelve times on the left alone. The greater frequency of the occurrence of this accident upon the left side has been explained by the fact that the left common iliac vein, being crossed by the right com- mon iliac artery, does not admit of so ready a flow of blood as the vessel of the other side (Liebermeister). Of the 31 cases referred to, only two proved fatal. The foregoing statistics show that the mortality to be at- tributed to this complication is low, if due regard be paid to the fact that it occurs late in the disease, and is of itself an evidence of grave impairment of the heart-power, and of the general nutrition of the body. Spontaneous gangrene, in consequence of arterial thrombosis, is much less common in enteric than in typhus fever. Endo- and pericarditis are very rare as complications or sequels of en- teric fever. The complications and sequels arising in consequence of affections of the intestinal tract are numerous; some of them are among the most se- rious connected with the disease. Ulceration of the tongue and of the buccal mucous memhrane are noted as of common occurrence by systematic writers on enteric fever. It would appear that these complications are more common in Europe than in this country. They frequently lead to gangrene, which is usually superficial, but may be deep, extensive, and destructive. Catarrh of the mucous membrane of the pharynx and nasopharynx is of sufficiently common occurrence to merit consideration as a symptom rather than as a complication, and has already been spoken of as such. Diphtheritic processes occasionally involve the tonsils, half arches, the lower part of the pharynx, and the upper air-passages. All these pro- cesses may, by extension, implicate the Eustachian tube and middle ear, and give rise to serious lesions of the organ of hearing, and more or less permanent deafness. Difficidty in sxcallowing may arise from mere dryness of the throat, from any of the inflammatory infections of the pharynx, which have just been spoken of, or in consequence of more or less perfectly developed palsy of the muscles of deglutition. In children it appears to be occa- sionally due to pharyngeal hyperrpsthesia, attempts to swallow occasion- ing spasmodic cough, with the rejection of fluids through the nostril. Swelling of the parotid glands occasionally occurs. It is much less common in this country than in Europe. The enlargement occasionally undergoes resolution without suppuration. More commonly it terminates in the formation of pus, at various points in the gland itself, and in the connective tisssue overlying it, and is then very often fatal. It usually ENTERIC OR TYPHOID FEVER. 185 implicates one, much less commonly both sides. Suppuration of the other salivary glands does not occur. Jaundice occurs in a small proportion of the cases, and is a symptom of great gravity. Murchison met with it in three cases, all of which proved fatal, although, in one of them, the jaundice had disappeared be- fore death. Louis, Frerichs and Jenner have also recorded cases of jaun- dice, all of which proved fatal. Out of 600 cases, Griesinger observed jaundice in 10, in several of whom recovery occurred. Jaundice is of much less common occurrence in typhoid fever than in any other acute febrile affection. It is sometimes due to an extension of the catarrhal processes from the intestine to the biliary passages. In a certain proportion of the cases, however, it is to be attributed to the parenchymatous degeneration of the liver, incident to the prolonged fever. This degeneration may reach an intensity so great as to amount to a distinct complication, pre- senting the group of symptoms characteristic of icterus gravis or acute yellow atrophy of the liver (Liebermeister). In two of Murchison's cases the liver is noted as havingr been small and its secretins: cells loaded with oil. Other observers speak of the occurrence of a high grade of fatty degeneration of the liver, in fatal cases attended with jaundice. Abscesi of the liver belongs to the rarer of the complications of enteric fever. The consideration of intestinal hemorrhage belongs properly to the discussion of the symptoms of the disease rather than its complications, and has already received attention in a foregoing division of our subject. Closely related to this subject, however, as it is one of the accidents of the ulceration, is perforation of the intestine. This is the most important and dangerous complication of the disease, and is met with, in the course of no other acute disease, with the exception of rare cases of dysentery. Of 1,721 autopsies recorded by various observers in Britain and on the con- tinent, Murchison found 196 instances of perforation, that is to say, 11.38 per cent, of the fatal cases. The same observer states that it occurred in 38 of 1,580, or 3.04 per cent, of the cases under his care; it occurred in 14 out of 600 cases, or 2.3 per cent, of the cases observed by Griesinger. Perforation is much more common in males than in females. In gen- eral terms, it may be stated that age does not especially influence the liability to this accident, although some authorities entertain the opinion that it occurs less frequently in children than in adults, and that it is much more rare in persons over forty years of age than in the earlier periods of life. Intestinal perforation occurs by far most frequently in the severest cases of the disease, and particularly in those in which diarrhoea, tympany and abdominal pains have been prominent symptoms. In many instances intestinal hemorrhage has preceded the occurrence of perforation. On the other hand, it is of the utmost importance to bear in mind that this ac- cident may occur in cases of the mildest description, and in those in which 186 THE CONTINUED FEVERS. the bowels have been constipated or confined throughout. It has even occurred where the intestinal ulceration has been limited to a few points. Perforation is most liable to occur during the third, fourth, or fifth week of the disease, although it sometimes occurs at a later period. Out of 58 cases observed by Murchison, four occurred in the second week; 13 in the third; 16 in the fourth; 13 in the fifth; 8 in the sixth; one in the eighth; one in the ninth, and one as late as the tenth week. Of 22 cases noted by Liebermeister, perforation took place in 2 at the end of the second week; in 6 in the third week; in 2 in the fourth; in 6 in the fifth; twice each in the sixth and seventh weeks, and twice at a later period. According toNiicke,' of 183 cases, 84 occurred during the course of the first three weeks, and 99 at a later period. One of the more important lessons conveyed by the foregoing statis- tics relates to the danger of perforation not only after the termination of the fever, but even long after convalescence has been fairly established. Instances are not rare in which perforation has occurred after the patient has been allowed to leave his room, or even to go about, and was in every respect apparently almost well. The earlier perforations take place about the time of the separation of the sloughs from the ulcerated areas of the intestine. The later per- forations are due to the extension of ulcerations that show no disposition to heal. Among the immediate causes of perforation may be enumerated indigestible food, hardened fecal masses, ascarides, over-distension of the gut with gas or faeces, vomiting, straining at stool, and sudden changes of posture. When the ulceration has extended to, or has implicated the serous membrane, the most insignificant causes may produce this acci- dent. The vermicular movement following the injudicious administra- tion of a purgative, or excited by an enema, is sufficient to rupture the thinned wall of the bowel. The most frequent seat of the opening is at the lower portion of the ileum. It may occur higher up in the small in- testine, or in the caput coli, particularly at the appendix vermiformis. From the statistics of Niicke, we find that of 133 cases, perforation oc- curred in the ileum 106 times; in the colon 12 times, and in the appen- dix 15 times. Of 20 cases observed by Hoffmann, the perforation was located in the colon once; in the appendix twice; in the small intestine 18 times. In one case, the perforation being double, was counted twice. The position of the 18 perforations of the small intestine was as follows: once immediately above the ileo-caecal valve; four times at from four to six inches above it; nine times at from eight to twenty inches; twice at from four-and-a-half to six feet; once ten feet; and in one remarkable case there were from 25 to 30 perforations in the jejunum. ' Ueber Darmperforation ira Typhus Abdominalis. Wiirzburg, 1873. This work is referred to by Liebermeister. ENTERIC OR TYPHOID FEVER. 187 The perforation is usually a small opening in the serous coat, varying in size from a pin's head to a split pea : it forms the apex of a funnel- shaped ulceration at some point in a Peyer's patch, and is then surrounded by more superficial ulceration ; or, and this is less frequently the case, it occurs in a solitary follicle. The margins of the opening are rarely torn or ragged, but usually present a * punched-out ' appearance, and are often surrounded on the peritoneal surface by a narrow ring of recent lymph. The immediate result of perforation is acute peritonitis, which is, in by far the greatest number of cases, diffuse, although in rare instances the extension of the inflammation has been discovered to have been lim- ited by rapidly formed adhesions resulting in the formation of a circum- scribed peritoneal abscess ; or a minute opening has been blocked by ad- hesions formed with the abdominal wall, some adjacent coil of intestine, or a fold of mesentery. The patient experiences, at the moment of perforation, an intense sud- den pain, which rapidly extends over the whole abdomen, but of which the focus is at first in the right iliac fossa. This pain may be accompanied by rigors of greater or less intensity, or it may occur without them. Tympany, if present, usually increases, or if it have previously subsided, recurs. The abdomen becomes exquisitely tender; the patient lies upon his back with his legs drawn up, his face drawn and pinched. Vomiting often occurs. The pulse is small, rapid, or uncountable; the breathing shallow and thoracic; there is tormenting thirst and mostly suppression of urine. Shock commonly occurs, and the patient falls into a state of col- lapse, with cold extremities, sweating, and a more or less decided fall of temperature. With this fall the mental state of the patient improves, and he may even pass from stupor into a state of mental clearness. In sud- den and severe cases death sometimes takes place in the course of a few hours, the mind remaining clear until the end. Much more commonly the patient survives the shock and the temperature rises again; but the symp- toms of peritonitis overshadow those of the primary disease and he per- ishes in the course of from two to four days. In a considerable propor- tion of the cases perforation takes place without the occurrence of distinct symptoms of peritonitis, and death may result from this cause in cases where it has not been suspected. Its advent may be announced by no other symptoms than a sudden deepening of the prostration, an increase in the pulse frequency and an abrupt temperature-rise; or sudden vomiting, and coldness of the extremities, may be the only changes observed. Death may in some few cases be delayed for several days or weeks, and there is abundant evidence to prove that in rare cases recovery from this accident has taken place. If this statement rested upon no other basis than that of the occasional sudden occurrence of the symptoms of peritonitis in the advanced stages of enteric fever, in patients in whom permanent recovery ultimately took place, it would be open to the criticism that the peritoni- 188 THE CONTINUED FEVERS. tis might be due to other causes than perforation. But it is supported by more direct evidence derived from cases where, after the subsidence of the symptoms following perforation, death has resulted from other causes, and the perforation has been found closed by adhesion to some ad- jacent structure. Buhl ' relates the case of a patient who had symptoms of perforation on the twenty- fifth day of enteric fever and was recovering, but died twenty days later, of profuse hemorrhage ; a perforation was found completely closed by adhesions to the mesen- tery. Analogous cases have been reported by many observers. Recovery has in many instances taken place after the formation of a circumscribed peritoneal abscess, the contents of which have after a time been evacu- ated either by the bowel, or by an external opening. A£Eections of the genito-urinary tract occur as complications of enteric fever. Transitory albuminuria occurs in nearly one-third the cases. It is, therefore, under ordinary circumstances to be looked upon as a symptom rather than a complication. Acute Bright's disease occasionally occurs, but is far less frequent after enteric fever than after scarlatina. Accord- ing to Liebermeister it is even less frequent after enteric fever than after pneumonia, facial erysipelas, or measles. HcBmaturia occurs in connection with hemorrhages from the other mucous tracts, and is not unfrequently one of several evidences of the hemorrhagic diathesis. Catarrh of the bladder not rarely occurs during convalescence. It is commonly slight and speedily passes away; sometimes it is acute and troublesome. It is chiefly to be attributed to over-distention of the blad- der during the course of the fever. But this is not always the case; at this time there is under my care a gentleman convalescent from a light attack of typhoid, who still suffers from mild vesical catarrh, although con- valescence is, in other respects, complete. There was not the slightest undue retention during the whole course of his sickness. Orchitis and epididymitis may occur without previous gonorrhoea. Menstruation often occurs prematurely during the course of the attack, and is, as a rule, more profuse than is habitual with the patient. Pregnancy affords a relative, but by no means complete, immunity from the attack. It undoubtedly adds to the danger of the patient, but is not to be looked upon as a formidable complication. Of fourteen cases observed by Murchison, ten recovered; of these ten, two carried the child throughout the attack; the four fatal cases aborted. Herpes labialis is very rare. ' Quoted by Murchison. ENTERIC OR TYPHOID FEVER. 189 Facial erysipelas occasionally occurs at the height of the attack or during convalescence. It is a serious complication. Hemorrhages into the ski7i, true petechise, vibices and the like, occur in persons subject to the hemorrhagic diathesis, or who develop it in thqi course of the disease. They may also occur in others, but are rare. Soils and abscesses in the integuments, the muscles, or the intermus-* cular connective tissue are met with in a small proportion of the cases during convalescence. Much more rarely, suppuration of the lymphatic glands of the axilla, and in other regions, takes place. £ed-sores constitute a common and troublesome complication in severei cases. They are far more frequent in enteric fever than in any other acute disease, a fact that is to be explained by the long duration of this, fever, the great emaciation, the feebleness of the circulation and the grave general impairment of nutrition. They occur not only over the sacrum and trochanters, but also at the elbows, heels, and occiput, 77ie hair /alls during convalescence. The new hair is often lacking in lustre, but gradually acquires a normal appearance. The nails both of the hands and the feet show markings that indicate the impaired nutrition of the tissues during the attack. These markings consist of bands or furrows across the whole width of the nail. The por- tion of the nail developed during the attack is duller than the rest, rough, white, and more or less thinned. Similar changes occur during the course of other severe febrile diseases. They have been described by Vogel,* Longstreth," and others. Among the more important of the complications and sequels of enteric fever are those referable to the nervous system. The importance of this group of secondary affections arises from their gravity rather than from the frequency of their occurrence. Fff^usions 0/ blood are noted as of rare occurrence. They may take place into the meninges, or into the substance of the brain itself, and usually occur at the height of the disease. A previous condition of de- generation of the walls of the vessels is a necessary predisposing cause of this accident. Liebermeister states that slight effusions into the men- inges give rise to no symptoms, but that considerable effusions occasion symptoms of compression; while effusion into the substance of the brain is followed by the symptoms of apoplexy. Meningitis occurs but rarely in the course of enteric fever. The cere- bral symptoms attendant upon ordinary cases of the disease are in no way dependent upon inflammatory processes affecting any part of the nervous system. A number of cases are recorded in which meningitis has oc- ' Die Nagel nach fiebethaften Krankheiten. By A. Vogel : Deutschea Archiv fiii klin. Med., viij. 1870. -' Trans. College of Physicians of Philadelphia. 1877. 190 THE CONTINUED FEVERS. curred in the course of the disease, or during convalescence, in conse- quence of disease of the internal ear, or of the development of acute tuberculosis. Murchison states that meningitis may occur, in rare in- stances, independently of such causes. Feebleness of intellect and attacks of mania show themselves in a small proportion of the cases during convalescence, or at a considerable time after apparent recovery. They are most apt to appear in persons who have a hereditary tendency to mental disorders. These affections are not peculiar to enteric fever, but they occasionally occur after other acute febrile disorders. They are commonly transient, lasting a few days or weeks, less often several months; but all authorities agree in stating that they result in ultimate recovery. Palsy is an occasional sequel of enteric fever. It presents all the va- rieties met with after the other acute diseases, and may occur during the course of the attack, or not until several weeks after the commencement of convalescence. Trousseau mentions a case of typhoid fever, in which the begii)ning of the disease announced itself by a violent pain in the lumbar region, and a true paraplegia such as is occasionally seen in variola. The most common form is paraplegia; but hemiplegia, paralysis of the portio dura, strabismus, and paralysis of individual spinal nerves, may also occur. Laudouzy ' has collected cases illustrating the more common forms. Among these is one case of enteric fever in a soldier, where paraplegia began gradually during convalescence about the seventh week after ad- mission to the hospital. There was also squint (paralysis of the left exter- nal oblique muscle), which lasted six or eight days, and retention of urine, which made the use of the catheter necessary. The urine was albumi- nous. This patient recovered. A second patient, a woman twenty-nine years of age, suffered from paraplegia nearly three months after the de- fervescence; there was vesical and rectal palsy, and paralysis of the velum palati; recovery took place. Other cases are detailed in which hemi- plegias, paralyses of the dilator muscles of the glottis, necessitating tracheotomy, aphasia, etc., occurred. The greater frequency of aphasia among children than among adults has attracted the attention of all ob- servers. More frequently the paralytic symptoms are developed at the period of decline of the fever, or in the early days of convalescence. This group of paralyses has a natural tendency to recovery. Paraplegias, hemiplegias, aphasia, the various local and limited paralyses, due to le- sions of the nervous system incident to typhoid fever, disappear generally in the course of some weeks or months. There is, however, another group of paralyses encountered as com- ' Des paralysies dans les maladies aignes. Par Dr. Louis Laudouzy. Paris, 1880. See also Bailly : Paralysies coneecutives a quelques maladies aigues. Paris, 1872. ENTERIC OR TYPHOID FEVER. 191 plications or sequels of enteric fever, of which the foregoing- statement is not true. The fever is not the primary cause of the affections of the nervous system; it merely calls forth an individual predisposition already existing, and the future of the case depends upon the pathological con- ditions underlying the paralysis, that is, upon the individual peculiari- ties of the patient. Palsies in such patients may result from attacks of little severity. Paralysis of the bladder is not uncommon. In this respect enteric fever differs from diphtheria, which is rarely followed by vesical paraly- sis — a difference that is remarkable in view of the fact that in other re- spects the palsies following these two diseases closely resemble each other in kind, though not in frequency. Finally, we must include among the paralyses the sudden death that occasionally takes place in the advanced stages of the disease, from arrest of the heart in diastole, and the paralysis of accommodation, which is often present in the early days of convalescence. Neuralgias and disturbances of sensation are less frequent after enteric fever than after some other acute affections. The organs of special sense are occasionally the seat of affections that result directly or indirectly from enteric fever. Otorrhcea is by no means rare, especially in children. Inflammatory affections of the internal ear occasionally result in meningitis. Deafness, independently of destructive inflammation of the ear, occa- sionally persists. Paralysis of accommodation, amMyopic conditions, and even slough- ening of the cornea, occur in rare instances, and are to be referred to lowered nutrition. It is often a long time before the patient, emerging from a sever© attack of enteric fever, regains his previous health. He may gain rapidly in flesh and present all the appearances of vigorous health, yet lack the ability to sustain any but the most moderate physical or mental effort. As a rule, in such cases, the normal standard of health is gradually re- gained. It is a remarkable fact that the personal habit of the individual occasionally undergoes marked changes after a severe attack of enteric fever, that is to say, a lean person may exhibit a tendency to corpulence, or a fat person become lean; and it is even more remarkable that changes in disposition also sometimes occur. The patient may, however, remain permanently weak and ansemic, and continue to emaciate without obvious cause, or the existence of any dis- tinct, local, or constitutional affection. Cases occasionally prove fatal in this way, months after the cessation of the fever, and after death no lesion is discovered, except an abnormally smooth appearance of the mu- cous membrane of the ileum, and a shrivelled condition of the mesenteric glands (Murchison). 192 THE CONTINUED FEVERS. Varieties. The numerous forms attributed to typhoid fever are, for the most part, merely differences in the mode of onset, or in the prominences of certain symptoms or groups of symptoms. The form called ^^ bilious" is only a typhoid, which begins witu gastro-duodenal catarrh, implicating the biliary passages, and which, therefore, presents among the number of its initial symptoms, catarrhal Jaimdice, and all the accidents which are associated with that conditiou, notably nausea and vomiting. After sev- eral days, rarely more than seven, these epiphenomena disappear, and the typhoid fever runs its ordinary course, sometimes mild, sometimes se- vere, but in such a manner that no constant relation can be established be- tween this mode of beginning and the ulterior evolution of the sickness (Jaccoud). The form called " mucous " and the form called "nervous " are separa- ble from the disease, as it is met with in general, by no more warrantable ])riiiciple of division; and to distinguish an ataxic from an adynamic form, or other varieties based upon the prominence of particular symptoms, such as an abdominal variety, a thoracic variety, or a cerebro-spinal va- riety, is neither scientific nor convenient, but only serves, both at the bedside and for purposes of description, to darken counsel. Such methods of classification are to be discarded. A great variety of forms of enteric fever is, however, met with. Many of these are clearly to be referred to the varying degree of inten- sity with which the specific poison of the disease acts upon different in- dividuals; others are to be referred to the relative intensity of its action in producing local or constitutional effects, and still others to individual peculiarities on the part of the patient. Hence, we find, upon the first principle of division, a series of cases ranging from the mildest affections attributable to the especial cause of enteric fever, to the gravest forms of the typical disease; upon the second, a series in which the cases vary according to the relative prominence of the intestinal disease, or the constitutional disturbance (zymosis), the former predominating in some instances, the latter in others; and again, we observe that enteric fever presents notable differences in its course and evolutions at different points of life. Without attempting a closer analysis of the forms, we may divide the cases into typical and atypical, or, with Liebermeister, into perfect and imperfect. The typical or perfectly developed cases present the complexus of symptoms already described as constituting the clinical history of the dis- ease, and further illustrated in the analysis of the symptoms, and in the consideration of the complications and sequels. ENTERIC OR TYPHOID FEVER. 193 The atypical or imperfect forms constitute, in most epidemics, a large proportion of the cases, and, when the attention of physicians is more closely turned to the study of enteric fever from an etiological as well as from a clinical standpoint, they will be found, I believe, to be much more common where the disease is endemic than has usually been thought. The cases are partly due to mild infection, or, to use an expression already employed in this work, in speaking of other fevers, the smallness of the dose of the fever-producing principle; partly to an imperfect suscepti- bility on the part of the patient. Those cases which approach most nearly to the typical form of T.lie disease are to be grouped as the mild cases. A second group is consti- tuted by the abortive cases, and following the lightest forms are, first, the cases of intestinal catarrh with fever, and finally those of afebrile intesti- nal catarrh. The mild cases present the symptoms of the typical disease modified as respects intensity, and in particular is this true of the febrile move- ment, which is of lower grade. The commencement of the attack is usually gradual ; there are prodromes, which pass step by step into the declared disease. Chilly sensations may occur; a decided chill is unusual. There is headache, diarrhoea; the nose may bleed, and the eruption ap- pears or not, as the case may be. Upon the fourth or fifth day the tem- perature may reach 40° C. (104° F.), but it rarely exceeds that point, and much more commonly does not attain it. The temperature-range corre- sponds to that of the typical form, save that upon corresponding days it is about a degree lower. The duration of this form may be four full weeks; it is perhaps oftener less than this, each of the four periods not exceeding four or five days. The febrile movement corresponds to the primary and the secondary fever of the fully developed disease. The in- testinal lesions do not undergo resolution, but go on to sloughing. Ac- cording to Jiirgensen,' the spleen is enlarged in the mildest cases. The latent, or ambulatory form {^calking typhoid) belongs to this group. Jiirgensen is of the opinion that walking typhoid (typhus ambu- latorius) is nothing more than mild typhoid (typhus levissimus) prolonged by repeated errors in diet. In this form all the symptoms are mild, the fever shows itself only in general malaise, prostration, and elevation of temperature, yet the sickness extends over three or four weeks, and the intestinal lesion proceeds to sloughing and ulceration. Herein lies the danger of this form of the disease. Tlie patient regards himself as suffer- ing from some slight indisposition, a " cold," or a " bilious attack," and continues to go about in a wretched way, or even, if he be a person of determined will, to attend to his ordinary occupations, and to eat such ' Ueber die leichteren Formen des Abdominaltyphus. Sammlung kliniscber Vor- trage. No. 61. Leipsic. 13 194 THE CONTINUED FEVERS. food as his appetite permits, until sudden delirium reveals to his friends the serious character of his illness, a profuse hemorrhage occurs, or, and this is still more common, symptoms of perforation supervene, and are followed, after a few hours, by death. Occasionally more fortunate pa- tients of this class come under the observation of the physician, and the thermometer reveals a temperature of 40° C. (104° F.) or higher, and the history of the case and ensemble of symptoms show the disease to be in its third or fourth period. The abortive form appears to be not uncommon in Europe. In this country it is certainly rare. The attack begins abruptly ; prodromes are usually of short duration, or they may be absent altogether. The tem- perature-range is that of the typical disease, save that it in some instances more rapidly attains its maximum. By the evening of the third or fourth day the temperature may reach 40—40.5° C. (104°— 104.9° F.). The in- vasion is often accompanied by rigors, sometimes by a decided chill. In some instances of abortive typhoid the absolute temperature is very high. Liebermeister has observed in such cases an axillary temperature of 41.1° C. (106° F.) or even higher. There is usually moderate diarrhoea, tympany, enlargement of the spleen, sometimes epistaxis, and often more or less bronchial catarrh. The characteristic eruption is frequently- observed, and transient albuminuria is met with. Somewhere between the seventh and the fourteenth day " the sickness takes a sudden turn, and runs a course similar, as regards ordinary enteric fever, to that which varioloid runs as reo-ards variola " (Jaccoud). Cases have been observed where the duration did not exceed five days (Griesinger). The defervescence is rapid, often being completed in from 24 to 72 hours, and is often attended by profuse sweating. Convalescence is rapid. It is in the highest degree probable that in these cases the intes- tinal lesions undergo resolution, their evolution being arrested short of the ordinary necrotic processes. We, therefore, have to do with the primary fever due to the action of the special poison, and not with the secondary or septic fever due to ulceration and the formation of sloughs. The parallelism between these cases as compared with typical enteric fever, and varioloid as compared with variola, is complete. The imperfect cases are to be recognized by the occurrence of the eruption, enlargement of the spleen, and their occurrence in the same house with, or otherwise in such relation to well-developed cases, as warrants the supposition that they are due to a common infection. In 100 cases of this class Liebermeister found that enlargement of the spleen occurred in 71, diarrhcea in 41, and roseola in 21. A still slighter disturbance of the functions of the body may result from the infection, and give rise to cases of abdominal catarrh with eleva- tion of temperature so slight and so irregular that it scarcely deserves the name of fever, 38° C. (100. 4° F.). And finally, cases of intestinal ca- ENTERIC OR TYPHOID FEVER. 195 tarrh occasionally occur, in consequence of typhoid infection, in which there is no elevation of temperature at all. Liebenneister found among such cases many with evident enlargement of the spleen, and a few with an unmistakable eruption. The action of the bowels was irregular; in some instances there was diarrhcea, in others, obstinate constipation; but all the cases manifested a decided impairment of the general health, lassi- tude, depression, vague pains, often headache and loss of appetite, and a furred tongue. The duration of an apparently trilling indisposition was particularly noticeable, and he calls especial attention to the fact that there was marked diminution in the frequency of the pulse without ap- preciable alteration in its character, and that the pulse increased in fre- quency with convalescence, before the patient had quitted his bed. Dr. Cayley states that many cases and even epidemics of typhoid have been met with in which the temperature has been subnormal throughout the whole course of the disease. He cites the following instance of such an outbreak, which was observed by Dr. Strube: During the siege of Paris by the Germans in 1870, an epidemic of typhoid fever broke out among the troops, beginning to show itself during the march to Paris, and attaining its greatest height in October. In November a decline took place, which was followed by a fresh outbreak in December. These two outbreaks differed greatly in their characters ; the later one resembled in all respects the ordinary form of typhoid ; the earlier one presented very different features. In many of the cases the tempera- ture throughout was subnormal, and in others never exceeded the normal point. The roseola was usually profuse ; the nerve-symptoms were of marked severity, and were in inverse ratio to the temperature, consisting of violent delirium alternating with stupor ; the duration of the fever was very short, defervescence usually taking place at the end of a fortnight. Of the twenty-three fatal cases, in twenty death took place during the first fourteen days. The abdominal symptoms were slight, but the charac- teristic lesions were found on post-mortem examination. All the cases were charac- terized by great prostration. These cases presented some features which were probably due to this peculiarity of the temperature : thus, the pulse was but little accelerated, seldom exceeding a hundred ; the tongue did not become dry and brown, and the en- largement of the spleen was either absent or much less marked than usual. Dr. Strube attributed the peculiar features of this epidemic to the depressed condition of the troops ; they had been exposed to great hardships on the way to Paris, over-fatigued by forced marches, and very insufficiently supplied with food, and the supply contin- ued deficient for some time after their arrival, owing to difficulties of transport. In the later outbreak these conditions were no longer present. Infantile remittent fever. — This term has been applied to enteric fever as it occurs in children, for the reason that the pyrexia often assumes in them a distinctly remittent type throughout the whole course of the attack. The symptoms and complications are modified by the age of the patient. Children are very susceptible to enteric fever, and Murchison calls attention to the fact that they are often attacked in houses where adults escape. 196 THE CONTINUED FEVERS. In the advcDiced 2}^ri<) don, 1873. Pp. G52, G53. ENTERIC OK TYPHOID FEVER. 229 other cases treated at the same time, and in all respects in the same man- ner, with the exception of the use of the iodine. The following table sliows the percentage of mortality, those cases not being included which proved fatal within six days after their admission to the hospital: n -HT T%- J Percentage of Cases. I.O. Died. Mortality. Treated Hon-specifically. 335 47 13.2 Treated with calomel 216 19 8.8 Treated with iodine 229 25 10.9 In this country Professor Bartholow has used, apparently with decided success, the following modification of the iodine treatment : 5. Tinct. iodinii 8.00 c.c. fl. 3 ij. Acid, carbolic 4.00 c.c. fl. 3 j. M. Sig. — 1 to 3 drops three times a day. TJie antipyretic treatment consists of the systematic employment of measures to reduce the temperature of the body. In view of the fact that by far the greater number of fatal cases of typhoid fever die from the direct or indirect effects of the prolonged high temperature, this plan of treatment has much to recommend it upon theoretical grounds. The concurrent testimony of those observers who have applied it system- atically to large numbers of cases points to substantial practical results, both in mitigating the severity of the symptoms, and in notably reducing the mortality. The principle upon which it is based is by no means new. From the earliest days of medicine the reduction of the temperature has at all times been looked upon as one of the most important indications in the treatment of fever. The main point in the management of enteric fever is to control the temperature. The measures by which this can be accomplished are hydrotherapy, quinine, the salicylates, and digitalis. These are capable of depressing the temperature for a more or less ex- tended period; their systematic employment in such a manner as to con- trol the febrile movement throughout the attack constitutes what is technically known as the antipyretic treatment. The cold-water treatment was first systematized by Dr. James Currie, of Liverpool (1797), who used it in febrile affections, according to certain clear indications. He employed, as a rule, cold affusions, frequently repeated, and occa- sionally cold baths. His method was adopted by many physicians, and soon came into extensive use both in England and on the continent, in the treatment of many febrile affections, and especially in the manage- ment of typhus and typhoid fever, and scarlatina. It gradually fell into neglect and was for a long time almost forgotten. The cold-water treat- 230 THE CONTINUED FEVERS. ment of fevers was revived by Dr. Ernst Brand, of Stettin (1868), and rapidly came into use in Germany, Austria, and Switzerland. The methods of hydrotherapy are various. Cold water may be so ap- plied as to reduce the temperature, by means of the cold bath, the gradu- ated bath, cold affusions, cold packing, cold compresses, and cold sponging. These methods vary in their effects, and different methods are applica- ble to special cases ; but that one of them is to be preferred by which the desired end is reached with the least inconvenience to the patient. Tlie cold hath is, for general use, not only the most effective, but it is also the least troublesome to apply. The following is the plan employed by Liebermeister at Basle; it differs but little from that generally in vogue elsewhere upon the continent, and that now practised by Dr. Cay- ley in London. I am not aware that the treatment of enteric fever by cold bathing has been practised with the same degree of system and vigor, and upon an extended scale, by any observer in America. " For adult patients the full-length cold bath, of 20° C. (68° F.) is to be prepared. The same water can be used for several successive baths for the same patient; the bath-tub remains standing full, and the water, representing about the temperature of the room, answers the purpose without change. The duration of the bath should be about ten minutes. If prolonged much beyond that, it becomes unpleasant to the patient, and may even prove injurious to him. If feeble persons are much affected by the bath, remaining cold and collapsed for a long time, the duration should be reduced to seven or even to five minutes. A short, cold bath like this, will have a much better effect than a longer one of lukewarm water. Immediately after the bath the patient should have rest; he is, therefore, to be wrapped up in a dry sheet and put to bed. (The bed may with advantage be warmed, especially at the foot.) He should be lightly covered and given a glass of wine. With very feeble patients it is well to begin with baths of a higher temperature, say 24° C. (75° F.); but a less decided effect will follow. In such cases the method of Ziems- sen is to be especially recommended, if the surroundings permit. A bath of 'do°C (95° F.) is at first employed; cold water is gradually added until the temperature of the bath is reduced to 22.2° C. (72° F.), or be- low. These baths should be of longer duration." In severe cases the temperature is taken every two hours, day and night. As soon as 39.5*^ C. (103.1^ F.) in the rectum, or 39° C. (102.2° F.) in the axilla, is reached, the bath is given. Individual peculiarities are to be regarded. It may be advisable to give the bath before the tem- perature runs qtiite up to the heights above mentioned, or to give a bath of shorter duration, or of warmer temperature, or the gradually reduced bath of Ziemssen. The aim of this plan of treatment is to keep the temperature during the whole course of the disease within the bounds of a moderate fever ENTERIC OR TYPHOID FEVEIi. 231 heat. This cannot be accomplished by one bath or by a few baths. If the treatment be systematically carried out, from four to eight baths in the course of twenty-four hours will in ordinary cases be necessary. In very severe cases Liebermeister has repeated the baths every two hours, so that twelve baths have been given every twenty-four hours, and in some instances the number of baths required by a patient during his en- tire illness has exceeded 200. Each bath ought to cause a reduction of temperature of 1°— 1.66° C. (2°— 3° F.). If the temperature be not modi- fied to this extent, the following baths should be colder or longer. It is not necessary to take the temperature in the bath, for the reason that it continues to fall for some time afterward; it should be taken about half an hour after the removal of the patient from the bath. In children the baths may be made warmer and of shorter duration. In cases marked by great nervous depression with only a moderate elevation of tempera- ture, cold baths of short duration, or cold affusions, are recommended for their stimulating effect on the nervous system. The graduated bath is particularly useful in the treatment of children, and where the cold baths are inadmissible, as in aged persons, or those suffering from disease of the heart or lungs, and in cases of extreme pros- tration. Cold affusion is regarded by the advocates of the antipyretic treat- ment as of inferior value in reducing temperature. It is, however, more pleasant to the patient, and may be employed in cases where baths are inadmissible, or where a stimulating effect upon the nervous system is desired. Cold packs are also inferior to bathing as a means of reducing tem- perature. They are usually well borne even by feeble patients, and are particularly applicable in the treatment of children, to whom they may take the place of baths. They are very troublesome to apply. The bed being protected by a gum cloth, the patient is thoroughly wrapped in a sheet wrung out of cold water, the face and feet alone being left free; he is then lightly covered with a blanket. A course of four consecutive packs, of ten to twenty minutes' duration each, is said to be about equiva- lent in its effect upon the temperature to a single cold bath of tea minutes. Cold compresses give rise to local lowering of temperature, but have no great influence on the general heat of the body. Cold sponging has but little influence upon the internal temperature; it therefore cannot be regarded as entering into the antipyretic treat- ment, properly so called. It is useful for purposes of cleanliness, and is in most instances grateful to the patient. I am in the habit of ordering my patients sponged two or three times daily with water containing aro- matic vinegar. Among the more important contraindications to the antipyretic treat' 232 THE CONTINUED FEVERS. ment, and in particular to tlie cold baths, are hemorrhage from the bowels, great feebleness of the circulation, and coldness of the extremities and surface of the body, with high internal heat. This method of treatment is also inadmissible in subjects advanced in years, and in those suffering from chronic bronchitis, pulmonary emphysema, and organic disease of the heart. Dr. Cayley does not regard albuminuria as a contraindica- tion. Among the medicines capable of reducing the temperature of the body, quinine occupies the first place. In order to secure its full effect it must be given in large doses. It is useless to give small doses at con- siderable intervals. From 1.3 to 2.G grammes (gr. xx. — xl.) are necessary to produce a decided fall of temperature in an adult. This amount should be administered within the space of an hour, 0.5 gramme (gr. vijss.) being given every ten minutes until the full dose is taken. A decline of 1.6° — 2.2° C. (3° — 4° F.) usually follows in the course of from six to twelve hours. As the effects of the medicine pass off, the temperature gradually rises again, but does not usually attain its original height until the expi- ration of twenty-four hours. It is best given at night, some time after the evening exacerbation has reached its height, as the effects are more marked upon a falling than upon a rising temperature. It may be ad- ministered in powder or in solution, and should be followed by small amounts of hot broth. If vomiting occur, quinine may be administered in small enemata along with opium. Symptoms of cinchonism usually follow, but they are less marked than after similar doses in afebrile dis- eases or in health. Among the more constant effects of large doses of quinine is profuse sweating. The salicylates, given in large doses — 4.0 — 6.9 grammes (gr. Ix. — cv.) in the course of twenty-four hours — rapidly and powerfully depress the temperature. Sodium salicylate has come largely into use in the treat- ment of typhoid fever in Germany. Its administration in large doses is sometimes followed by gastric disturbances, increase of diarrhoea, and a tendency to hemorrhage. It also appears to exert an unfavorable influ- ence upon the kidneys, occasionally manifested by an increased tendency to albuminuria. The chief objection to this medicine relates to its de- pressing effects upon the circulation. Digitalis, administered in full doses, is also capable of depressing the temperature in typhoid fever. For this purpose 0.666 — 1.3 grammes (gr. X. — XX.) are recommended to be given in divided doses extended over a period of about thirty-six hours, and followed by a full antipyretic dose of quinine. By this procedure a complete intermission can be produced, even in severe and obstinate cases, where quinine alone has but little effect upon the temperature. Digitalis, both in substance and in the form of the infusion, is often badly borne by the stomach; it is inadmis- sible where the action of the heart is feeble, the rule for its administra- ENTERIC Oli TYPHOID FEVER. 233 tion In enteric fever being exactly opposite to that which regulates its use in the treatment of organic diseases of the heart. The advocates of the antipyretic treatment of enteric fever claim that under its use not only is the mortality greatly reduced, but that, to use the words of Liebermeister, the entire appearance and bearing of patients is such that the old picture of a typhoid fever patient is no longer to be seen, and that the disease has in fact lost a great part of its terrors. This observer informs us that, in the hospital at Basle, there were treated upon the expectant plan, between 1843 and 1864, 1,718 cases of typhoid fever; of these 469, or 27.3 per cent., proved fatal. From 1865 to Septem- ber, 1866, there were treated, under an incomplete antipyretic plan, 982 patients; of these 159, or 16.2 per cent., died. Between September, 1866, and 1872, there were treated, by the antipyretic plan systematically car- ried out, 1,121 cases; of these 92, or 8.2 per cent., died. After the elimi- nation of certain errors in these statistics, he concludes that the mortality under the antipyretic treatment is ten or eleven per cent, against a mor- tality of twenty-five or thirty per cent, under the expectant plan. In the hospital at Kiel, the mortality under the antipyretic plan, as pursued by Jurgensen, was 3.1 per cent.; that under the expectant plan, between the years 1850 and 1861, was 15.4 per cent. In the military hospital at Stet- tin, the mortality under the antipyretic plan was 4 per cent.; under the expectant plan, 25.6 per cent. Dr. Brand found that, of 8,141 cases treated antipyretically, 600 died, making a mortality of 7.4 per cent. In by far the greater number of enteric fever cases, as the disease is known to American physicians, the systematic antipyretic treatment, by means of cold baths, is clearly unnecessary by reason of the mildness of the pyrexia; in many others it is clearly inadmissible, and in all cases it is difficult of application, requiring a degree of attention and a number of trained assistants not always available in hospitals, scarcely ever to be secured in private practice. To these causes is doubtless largely due the fact that it has not come into use to any considerable extent in this coun- try. Prejudice in the minds of the people, and perhaps also among medical men, contributes to the opposition to this method of treatment. Even the suggestion of a modified antipyretic treatment, necessary to save life, too often encounters the decided opposition of the friends of the patient, who look upon cold compresses, the pack, or the douche, as add- ing to the horrors of the situation. ]\Ioreover, those physicians who are favorably impressed with the accounts of this treatment and its results, enter into half-way measures at a late period of the disease, without the energy and enthusiasm necessary to the realization of its best effects. With reference to the reduction of temperature by means of drugs, and especially by means of large doses of quinine, the way is clearer, and 234 THE CONTINUED FEVERS. this practice is growing in favor in America. For my own part, I look upon large doses of quinine, at intervals of forty-eight to seventy-two hours, as an essential part of the management of all cases iu which the evening temperature rises above 40° C. (104° F.). IV, THE KXPECTANT TREATMENT. The expectant or rational treatment of enteric fever is that generally employed at the present time. Notwithstanding the diminished mortality following the employment of the antipyretic treatment in Germany, it has never been generally introduced in France, Great Britain, or the United States, and the physicians of these countries for the most part still adhere to the expectant or the modified expectant plan. This method of treatment is based upon the knowledge that enteric fever, like the other acute infectious diseases, is of definite duration and cannot be cut short, that is to say, cured, by therapeutic measures. The patient, once having become the subject of the infection, must pass through the suc- cessive stages of the fever before he regains his health. If then life can be maintained for a definite time and no serious complication or sequel remains, recovery will take place. The patient is to be carefully watched, he is to be placed under the most favorable hygienic conditions, disturb- ing and injurious influences are to be prevented or removed, and efforts are to be made to combat unfavorable symptoms and to avert complica- tions. The successful management of enteric fever upon this plan pre- supposes on the part of the physician an intimate knowledge of the course of the disease, of the relative importance of the symptoms, of the order of their appearance and their duration, and a familiarity with the ana- tomical lesions, the connection between the lesions and symptoms, and the complications that are likely to arise. Absolute rest in bed, intelligent and careful nursing, a restricted diet, cleanliness of the person and the bedding, and ventilation, form the basis of the treatment. " If," in the words of Jenner, the most able, as well as the most recent advocate of this method, " medicinal in addition to hygienic treatment is required, it is because special symptoms by their severity tend directly or indirectly to give an unfavorable course to the disease My experience has impressed on me the conviction that that man will be the most successful in treating typhoid fever who watches its progress, not only with the most skilled and intelligent, but also with the most constant care, and gives unceasing attention to little things, and who, when prescribing an active remedy, weighs with the greatest accuracy the good intended to be effected against the evil the prescription may inflict, and then, if the possible evil be death, and the probable good short of the saving of life, holds his hand." The special symptoms that are apt to give an unfavorable course to ENTERIC OR TYPHOID FEVER. 235 the disease are to be treated for the most part in accordance with the general principles of therapeutics. Some of the symptoms, complications, and sequels are best managed in accordance with the following rules of practice: V. THE TKEATMENT OF SPECIAIi SYMPTOMS, COMPIiICATIONS, AND SEQUELS. Headache occasionally causes the patient considerable distress in the early days of the attack. It generally requires no special treatment, and subsides spontaneously about the middle of the second week of the dis- ease. Absolute quiet, darkening of the room, and local applications, sometimes cold, sometimes warm, are, as a rule, all that is necessary to control it. Sleeplessness is occasionally an important symptom in the early stages of the disease. Like the headache, it commonly disappears or diminishes, without special treatment, some time during the course of the second week. This, however, is not always the case. Sleeplessness is occasionally per- sistent and exhausting. It then becomes necessary to treat it. During the primary fever potassium bromide and chloral yield the most satis- factory results. They may be used either in combination or separately. In the personal experience of the writer, chloral alone, in moderate doses, has proved adequate to overcome this symptom in most cases, and its administration has been unattended by cardiac depression or other un- favorable effects. If other hypnotics fail, opium in sufficient doses will secure sleep. This drug and its preparations, in doses sufficient to induce sleep, must be regarded as objectionable during the early stages of the disease, on ac- count of its unfavorable influence upon digestion and the secretions — an influence not wholly obviated by the hypodermic use of morpliia. After the middle of the second week, that is to say, during the secondary fever, opium becomes at once our most efficient and safest means of controlling prolonged sleeplessness and excitability, and its use in fever dependent upon gangrene and sloughing is in accordance with well-established prin- ciples of surgery. In the later stages of the disease, chloral is, by reason of its depressing influence upon the circulation, even more objectionable than is opium in the early stages. Somnolence, stupor, and delirium, are to be treated by stimulants and the abstraction of bodily heat. In the treatment of these symptoms, alcohol stands first and almost alone among the stimulants ; spirits of chloroform and camphor are of use ; am,monium carbonate is of inferior value, and has been objected to on theoretical grounds, as being liable to increase the alkalinity of the blood. It is frequently used in the treat- ment of pulmonary complications. If delirium continue or coma threaten, great benefit is often derived from the local application of cold to the 236 THE conti:nued fevers. head, by means of either the cold douche, or an ice-cap. If the brain- symptoms are specially severe, the head may be shaved, and blisters may be applied to tlie nape of the neck or to the temples ; these measures are of doubtful value, and are only to be resorted to in desperate cases. The lighter forms of disturbance of the functions of the brain, as somno- lence and transient delirium, do not call for special measures of treatment. They are often relieved, to some extent, by coffee. Tremor is an important symptom. It indicates extreme prostration. Sir William Jenner has called attention to the fact that tremor, out of all proportion to the other signs of nervous prostration, is to be looked upon as a sign of deep ulceration of the intestines. A small, deep slough, the separation of which is especially liable to give rise to intestinal hemor- rhage or perforation, will often occasion great tremor. Tremor of this kind is to be treated with full doses of alcohol and opium, not only for their general effect upon the nervous system, but also with a view to their local effects in limiting sloughing and ulceration. Dryness of the tongue, and the accumulation of sordes upon the teeth and gums, are to be obviated by the frequent administration of fluids or by pieces of ice allowed to dissolve in the mouth. The patient, if able to do so, should rinse his mouth frequently with pure water, or water containing small quantities of claret, aromatic vinegar, or tincture of myrrh. Diarrhoea, so long as the stools are of moderate amount and do not exceed in number three or four in the course of twenty-four hours, does not call for special treatment. If, however, the passages are copious or very frequent, the strength of the patient is endangered, and it becomes necessary to control them. Sometimes diarrhoea is due to errors in diet, such as the use of solid food, or of excessive amounts of food, particularly milk and the strong animal broths, and abates upon the correction of such errors. It may arise in consequence of the patient's drinking excessive amounts of fluid, which passes through the bowel without being absorbed, and stimulates excessive secretion from the intestinal mucous membrane (Jenner). In the absence of these causes, diarrhoea is to be attributed to catarrhal inflammation of the intestinal mucous membrane. It is best treated by hism,uth carbonate or siibnitrate, in large doses, 1.3 gramme (gr. XX.) s. q. quarta vel sexta horii. To these powders may be added, if necessary, opium in 0.01 — 0.016 gramme (gr. \ — \) doses, or deodor- ized laudanum \xv doses of from three to five drops. Other astringents, such as alum, sugar of lead, nitrate of silver, tannin, catechu, and kino, either alone or in combination with opium, are recommended for the control of the diarrhoea. It is more sati^actory at the bedside to use one or two efficient remedies, than to resort to a number of uncertain drugs; and in bismuth freely given, or in opium in repeated small doses, either by the mouth or by enema, or in these two remedies combined, will ENTEEIC OR TYPHOID FEVER. 237 be found, in almost all cases, an efficient medication ag-ainst excessive diarrhoea in enteric fever. If the stools be fetid or highly ammoniacal, Jenner recommends the occasional administration of a teaspoonful of charcoal — animal charcoal being preferred, and care being taken that it is in impalpable powder. Creosote and carbolic acid are also of service. Constipation occasionally occurs. If it be but slight, it is often due to the absence of extensive intestinal lesions and the catarrhal inflamma- tion with which such lesions are associated. Hence, in mild cases slight constipation requires no treatment beyond the occasional administration of small doses of calomel or castor-oil, or the juice of an orange. Con- stipation may, however, be due to torpidity of the large intestine, the fecal matter being retained for a long time and the stools being hard and dry. Under these circumstances a sort of secondary diarrhoea, due to irritation of the lower bowel by the retained fecal matter, may arise. This form of diarrhoea is attended with a feeling of local distress and tenesmus, which are unusual in enteric fever, and will be promptly re- lieved by the removal of its cause. Prolonged constipation is by no means to be taken as an indication of moderate intestinal lesions; on the contrary, deep ulceration of one or more of Peyer's patches is not only frequently associated with constipation, but, by its paralyzing in- fluence upon the intestine, it is very often the cause of constipation. Aperients administered by the mouth are therefore to be shunned, lest by inducing peristalsis they forcibly detach a deep slough, or otherwise mechanically give rise to perforation where the sloughing extends to, or implicates the serous coat of the intestine. Large enemata are also at- tended with danger arising from their liability to set up energetic peri- staltic movements, which may extend to the lower part of the ileum. The constipation of enteric fever is most safely and satisfactorily treated by the daily administration of small enemata of strong, warm soap-suds or of thin gruel. Tympany is present to a greater or less extent in almost all cases. It may be due to deficient power of expulsion, or to an undue generation of gas in the intestine, and reaches its maximum, as a general rule, during the latter part of the third, or in the fourth week of the fever ; for at this period the causes that produce it are fully developed. These causes are: first, sloughing and ulceration of the intestine, which in itself, if deep, is sufficient to cause paralysis; second, general prostration leading to defi- cient contraction alike of the intestinal walls and of the abdominal mus- cles; and third, alteration in the character of the digestive fluids, which, no longer possessing the antiseptic properties of health, permit the speedy decomposition of the intestinal contents. Flatus accumulates in part in the small intestine, but chiefly in the colon; it varies from an amount scarcely greater than that of health to enormous abdominal distention, 238 THE CONTINUED FEVERS. interfering with the play of the diaphragm, and, by the outward pressure of the accumulated gas within the gut, adding to the danger of perfora- tion. The indications for the treatment of this symptom are twofold; the first have reference to the loss of nerve-energy, and call for increased stimulation. The second have reference to the nature of the food, and the arrest of the gas-generating decomposition of the intestinal contents. Thus, alcohol is to be given, or, if already employed, the amount is to be increased. Turpentine, campJior, and minnte doses of opium may be added to the treatment; the abdomen should be gently rubbed with the hand alone, or with turpentine, at short intervals, or turpentine stupes may be applied. Charcoal is to be administered with a view of prevent- ing decomposition of the intestinal contents, and only such food is to be given as will probably leave little or no residue to undergo decomposi- tion in the intestine. At the same time pepsin is to be administered along with the mineral acids. If the amount of flatus in the large in- testine be excessive, paralysis from over-distention may arise. It may then become necessary to carefully introduce into the bowel an oesopha- geal tube with a view of mechanically removing a portion at least of the accumulated gas. If constipation coexist with tympany it is to be relieved by the ad- ministration of small enemata, such as have been described above, or with the addition of turpentine, once or twice a day. Suddenly developing tympany is sometimes a symptom of peritonitis. Intestinal hemorrhage, if it be slight, does not call for other meas- ures of treatment than the most absolute rest of the patient, the restric- tion of his diet to substances capable of being most readily digested and absorbed in the stomach and upper intestine, such as essence of meat in small doses, wine-whey, koumiss, etc., and opium in moderate doses, either by the mouth or by enemata. Food and drink are to be iced, and lumps of ice held in the mouth and swallowed. The action of the bowels is to be as far as possible controlled. If the loss of blood be profuse, the danger becomes imminent, and more active measures are to be promptly resorted to. In addition to opium, the remedies to be mainly relied upon are gallic acid, turpentine, and ergot. Murchison states that in his practice the following mixture was, dur- ing many years, almost invariably successful for arresting the bleeding: ]^. Acid, tannic 0.66 grm. gr. x. Tinct. opii 0.66 c.c. TTl x. Spirit, terebinth 0.99 TH, xv. Mucilag 8.00 3 i j. Tinct. chloroform 1.33 TH xx. Aq. menth. pip ad. 33 | j. M. ft. haust. s. q. s. h. ENTERIC OR TYPHOID FEVER. 239 ErgoUne, may be injected hypodermically in doses of 0.6G grm, (gr. x.) at intervals of half an hour or an hour, until the evidences of bleeding cease. An ice-bag or bladder, filled with broken ice mixed with bran, is to be applied to the abdomen. It is not to be hoped that any direct local effect upon the intestinal lesions will follow the use of the astringent pre- parations of iron either by the mouth or by the rectum. Peritonitis, whether due to perforation of the intestine or to other causes, calls for the free administration of opium. To an adult, as much as 0.133 gramme (gr. ij.) may be given at once, followed by half that amount every second or third hour until moderate stupor is produced. For at least a time no nourishment, excepting concentrated meat-juices, a spoonful at a time, and brandy and water in not larger amounts, is to be administered. The abdomen may be smeared with a mixture of equal parts of sweet oil, laudanum, and turpentine, or warm fomentations or turpentine stupes may be applied to it. Better than these, however, is the application of large, thinly spread mush or flaxseed poultices well smeared with lard. The Germans recommend ice-bags and ice-poultices. If opium be not well borne by the stomach, morphia is to be adminis- tered hypodermically. Should the patient's life be prolonged, it is of the utmost importance that the bowels be confined as long as it is possible to keep them so. In most cases a movement will take place at the end of several days, even under the continued use of opium; otherwise, after all evidences of peritonitis have subsided, small, lukewarm enemata may be cautiously employed. In enteric fever palpation of the abdomen is to be practised with great caution, on account of the danger of exciting peritonitis, of causing perforation, or of rupturing the spleen. The suprapubic region is to be examined by palpation and percussion twice daily as a matter of routine, and whenever necessary the catheter is to be employed. Frequent exploration of the chest by the methods of physical diagno- sis is necessary; complications capable of determining a fatal result may be arrested by the prompt detection and treatment of pulmonary lesions attended by insignificant subjective symptoms. Hypostatic congestion is to be prevented by guarding against the heart-failure to which it is chiefly due. The control of temperature and the use of stimulants constitute the most important means to this end. Digitalis is a dangerous remedy in the feebleness of the heart due to the acute granular degeneration occurring in the continued fevers, and is to be administered with great caution. The patient's position is to be changed from time to time, with a view of preventing hypostasis, and he is to be histructed to occasionally take three or four deep inspirations. If congestion occur, the occasional application of turpentine stupes to the chest is of great advantage. 240 THE CONTINUED FEVERS. JDed-sores are to be prevented by frequent change of position, and the removal of pressure by means of cold-water bags or air-cushions. Scrupulous cleanliness and care with regard to the bed are important. So long as the skin is sound, the parts especially subjected to pressure, and therefore liable to gangrene, are to be frequently bathed with equal parts of alcohol and lead-water. If erosions appear they are to be treated in accordance with general surgical principles. Bartholow regards a mixture of equal parts of copaiba and castor-oil as the best dressing for a bed-sore. Other complications and sequels are to be treated in accordance with general therapeutic indications. VI. THE MANAGEMENT OF THE PATIENT DUKING CONVALESCENCE. During the early days of convalescence the temperature remains labile, and abrupt recrudescences of the fever are apt to arise from slight causes. It is therefore important that the patient be cared for assiduously for some time after defervescence is complete. For at least a week, morning and evening temperature observations should be taken; and during this time the diet is to be restricted to milk, eggs, custards, farinaceous foods, light puddings, and animal broths or jellies. The visits of friends are to be limited both in number and duration. Undue exertion, even within the limits of the chamber, is to be carefully guarded against, and all conver- sation upon business affairs, or other matters liable to give rise to excite- ment or to depressing emotions, is to be avoided. At the end of a week, solid food, and particularly meat, may be resumed; but the effect of such changes of diet upon the temperature and general condition of the patient is to be carefully watched. The liability to intestinal hemorrhage, perforation, or a relapse, are to be constantly borne in mind, and for a long time the patient's diet is to be restricted to articles of a readily digestible character. If diarrhoea persist, it is to be treated by bismuth and small doses of opium, either alone or combined with the mineral acids; if there be a tendency to con- stipation, simple enemata may be employed for its relief. Laxative medicines, with the exception of castor-oil in small doses, are inadmissi- ble. Milk-punch, egg-nogg, and wine, are often of service during conva- lescence; but, in the case of ^''oung persons, or of those not in the habit of using alcoholic beverages previous to their sickness, it is important to ■wholly dispense with alcohol as early as possible. Quinine, iron, and cod- oil, are to be employed if the convalescence be tardy and anaemia persist. A brief sojourn at the sea-shore is not less agreeable than useful; the patient gladly escapes from the apartment which has been the scene of his tedious illness, and finds change of air and of scene invigorating alike to body and mind. y. TYPHUS FEYEE. Definition. — A specific febrile disease of from ten to twenty-one — usually fourteen — days' duration, highly contagious, arising under circumstances of general destitution and overcrowding, and pre- vailing in more or less extensive epidemics. It is characterized by sudden invasion; great and early prostration; a dull, flushed face; injected conjunctivae; wakefulness, with mental torpor and confu- ■ sion, passing at the end of the first week into delirium, which may be active and noisy, but is commonly low and wandering; stupor tending to coma; tremors and involuntary evacuations; a furred tongue, soon becoming dry and brown; in most instances, constipa- tion; a copious rash appearing between the middle and the end of the first week, disappearing upon pressure at first, but speedily be- coming persistent, and often associated with petechias. After death no specific lesion ; the blood is broken down, the heart and voluntary muscles are degenerated and softened, the internal organs hyperaemic. Synonyms. — True Typhus: Febris pestilens; Parish Infection; Infectious Fever; Pestilential Fever; Der ansteckende Typhus; Typhus contagieux; Tifo conta- gioso; Contagious Fever; Contagious Typhus. Febris epidemica; Epidemic Fever. Morbus pulicaris; Febris purpurea epidemia; Febris stigmata; Febris petechialis; Typhus exanthematicus; La pourpre; Fleckfieber; Das Fleckenfieber; Das exanthematische Nervenfieber; Febbre petecchi- ale; Spotted Fever; Petechial Fever; Petechial Typhus; Typho-rube- oloid. Typhus comatosus; Brain Fever. Febris asthenica; Fievre ataxique; Fi^vre adynamique; Adynamic Fever. Febris putrida et maligna; Synochus putris; Febris maligna pesti- lens; Febris continua putrida; Fievre putride et maligne; Faul- 16 242 THE CONTINUED FEVERS. fieber; Febbre putrida; Putrid Malignant Fever; Putrid Continual Fever. Pestis bellica; Typhus bellicus; Morbus castrensis; Febris militaris; Typhus castrensis; Typhus des camps et des armees; Die Kreigspest; Camp Fever. Typhus carcerum; Febris carceraria; Maladie des prisons; Jayle Fever; Jail Distemper. Fievre des hopitaux; Malignant Hospital Fever. Febris nautica; Ship Fever; Infectious Ship Fever; Ochlotic Fever. Catarrhal Typhus; Irish Ague. The foregoing are some of the many names by Tvhich the fever under consideration has been knov?n and described. For a more complete list the reader is referred to the pages of Murchison.^ They are variously derived from the contagious character of the fever, its prevalence in epi- demics, the eruptions, the presence of cerebral symptoms, the adynamia which attends it, its suj^posed putrid character, and its malignancy; or from its prevalence in armies, in camps, in hospitals, in prisons, in ships. Ochlotic [6x^0^, a crowd) is an adjective of modern application, derived from the supposed mode of origin of the fever in overcrowding. Typhus (riKpo^, smoke), used by Hippocrates to define a confused state of the mind, with a tendency to stupor, expresses a prominent con- dition of the disease. It was first used to designate certain forms of con- tinued fever by Sauvages in 1760. Within the last forty years it has been employed by English writers in a more restricted sense, to desig- nate the particular specific fever which is the subject of the present arti- cle. Among continental writers it is still adapted to a vaguely defined group of the continued fevers. Historical Sketch. According to Hirsch,' it must remain uncertain whether the pestilence prevailing in Athens at the time of the Peloponnesian war, and described by Thucydides, was typhus fever or not. Equally uncertain is the nature of the numerous epidemics of contagious fever which occurred in differ- ent parts of Europe during the first fifteen centuries of the Christian era, many of which have been supposed by some authors to have been typhus fever. The descriptions of the historians and of the physicians who chroni- cled them, are alike wanting in precision. The first satisfactory account of typhus dates from the year 1501, when, according to Fracastorius, it ' The Continued Fevers of Great Britain. "Handbuch der hist.-geograph. Pathologie. TYPHUS FEVER. 243 spread from Cyprus into Italy as a new, unheard-of, and, to the Italian physicians, altogether unknown disease. For more than twenty years it prevailed in Italy. If, says Hirsch, we may place confidence in the phy- sicians and historians of that period in the different countries of Europe, we are compelled to believe that, in the beginning of the sixteenth cen- tury, typhus fever (Exanthematische Typhus) had for the first time at- tained general prevalence over the continent. By the middle of this cen- tury it had become, in connection with the plague, the predominant form of epidemic disease. At that time the movements of armies and military enterprises contributed, as in fact they have at all periods, greatly to its development and extension; but during that and the two following cen- turies it appears also as the abiding form of continued fever in every country of Europe, in all states of society, and as playing, under many different names, the most prominent part among epidemic diseases. As Murchison well says: " A complete history of typhus would be the history of Europe for the last three and a half centuries." Consult his work for a very full and satisfactory account of the epidemics that have been the subjects of general and medical history, and for an exhaustive bibliogra- phy of the whole subject. The brief outline of the following pages is based principally upon the works of the authors already named — Hirsch and Murchison. In the years 1550-54, a petechial fever prevailed in Tuscany and de- stroyed upwards of 100,000 persons. In 1557, typhus was widely preva- lent in France. It again prevailed in that country some years later, in connection with the plague. In 15G6, typhus appeared in Hungary, in the army of Maximilian II., and spread over all Europe. In 1580, an epidemic of typhus arose in Verona. The historian of this epidemic, Petrus a Castro, states that the fever was called " La pourpre " by the French, " Tabardiglio " by the Spaniards, " Petecchie " by the Italians, and "Fleckfieber" by the Germans. Bleeding, both gen- eral and local, was recommended at the beginning of the disease, but in the later stages it was regarded as dangerous. This epidemic spread over Italy. In 1591, famine prevailed in Italy, and at the same time a contagious fever fell upon the people far and wide. The symptoms were the same as those described as attending the epidemic beginning in Verona eleven years before. A similar fever prevailed in Holland in the latter part of the sixteenth century. During the thirty years' war (1609-1638) all Europe was devastated by famine and by a contagious fever, which, from the descriptions of vari- ous observers, was beyond doubt typhus. The plague appeared in Leyden and elsewhere in Holland, in 1635, 244 THE CONTINUED FEVERS. and again in 1G69, and on each of those visits it was preceded and followed by a contagious " spotted fever." About the year 1700, F. Hoffman, professor of medicine at Halle, published a very accurate description of typhus which he had seen among the German troops in 1G83. He described the disease under the name of '' JFbbris Petechialis yera." He advised acid medicines, nourishing food, and regarded nothing better than wine. Under the name of febris pes- tilens, applied by the authors who preceded him to typhus, he described the plague. From 1757 to 1759, typhus prevailed in Vienna. It was, for the most part, prevalent in overcrowded localities. About the same time (1757-58) occurred the first epidemic of typhus in Berlin of which any authentic record exists. Its origin was traced to overcrowding, with deficient ventilation and scarcity of food. • In 17G4, a dreadful epidemic of typhus and dysentery prevailed at Naples. There was, at that time, great scarcity of provisions, and the poorer classes suffered from starvation. The people from the surround- ing country flocked into the city, and their overcrowding and misery were beyond description. The disease raged principally among the poor. An epidemic of typhus occurred in 1797-1800, at Genoa, at that time besieged by the French. It broke out when the garrison was half-fam- ished. With the wars which, during the first fifteen years of this century, swept over almost every part of Europe, typhus anew became generally epidemic upon the Continent. It prevailed in the contending armies and among the inhabitants of the countries that were the seat of war, and, arising invariably under circumstances of want and wretchedness, it was especially frequent and fatal among the inhabitants and garrisons of be- sieged cities. In 1816-17, true typhus was epidemic in Italy. Since the peace of 1815, typhus has frequently occurred, in limited or extended epidemics, in different parts of Europe. The Baltic provinces of Russia and Poland have often suffered from it; Northern and Middle Germany have been frequently infected. In Silesia, wide-spread epidemics have raged on several occasions, and particularly in 1847-48, 1850-57, 1868-69 — the last being likewise typhus years in East and West Prussia, and in the Prussia of Posen (Lebert). Sporadic cases of typhus occur in the large cities of Germany almost every year, and sporadic cases or isolated epidemics have also in late years been ob- served in Sweden, Denmark, Holland, and Belgium. Northern Italy, of old and in recent years, has been a typhus-centre. The fever spreads thence to Middle and sometimes even to Southern Italy on the one hand, and on the other it crosses the Alps, following the lines of travel into Switzerland. TYPHUS FEVER. 245 The statement that typhus does not occur in France is not true. Murchison has collected evidence to prove that it prevailed at Beaulieu in 1827, at Toulon on many occasions between 1820 and ISoG, at Rheims in 1839, at Strasburg in 1854. In the winter of 1854-55, it made its appearance among the English and French troops in the Crimea; but its prevalence was slight compared with that of the following winter, when it was mainly confined to the French and Russian armies. During the first six months of 185G, it is estimated that, out of a force of 120,000 French, 12,000 were attacked with typhus, of whom one-half died (Murchison). Turning our attention to the British Islands, we find that in 1522 the first of the " black assizes," hereafter to be described, occurred in Cam- bridge. Murchison regards this outbreak of fever as typhus. In 1577, a second " black assize " occurred at Oxford, and in 158G a third at Exeter. These outbreaks of fever, apparently communicated to the public by prisoners brought from foul jails into open court, appear to be the earliest distinct records of typhus fever in England. But these islands, and in particular Ireland, have been the geographical home of typhus fever. For more than two centuries and a half this disease has been endemic in Ireland. In the spring of 1G43, at the siege of Reading, a fever broke out in the army of the Earl of Essex, and in the garrison, which was commanded by Charles I, The soldiers of both armies were greatly overcrowded. The fever presented the symptoms of typhus. It was very contagious, and was communicated to Oxford, and thence spread to the neighboring country, where it proved very fatal. In 1658, a similar fever spread over England. The great plague of London (1G65) was preceded and followed by a malignant continued fever, the symptoms of which point to typhus. Sydenham describes an epidemic of fever which began in London in 1685, and extended over the whole of Britain. In the autumn of 1698, after a great failure of the crops, a fatal spotted fever began to prevail all over England. From a period probably extending as far back as the beginning of the seventeenth century, typhus had been known in Ireland as the " Irish Ague." Gerald Boate (1652) mentioned, among other diseases there prevailing, " a certain sort of malignant feavers, vulgarly in Ireland called Irish agues, because at all times they are so common in Ireland, as well among the inhabitants and the natives as among those who are newly come thither from other countries." About the beginning of the last century, medical men in Ireland began to pay great attention to epidemic diseases, of which chronological his- tories, extending over a long series of years, were published later in the century by Rogers, O'Connell, Short, and Rutty. From these authors we 246 THE CONTINUED FEVERS. learn that in the winter of 1708-9, after a poor harvest the preceding year, and during extremely cold weather, a fever then prevailing in Cork reached its climax. It then " declined sensibly for a year or two," and disappeared. In 1718, a fever, " in all respects the same " as that of 1708, became epidemic in Ireland, and prevailed until 1721, when "it abated of its severity, dwindling insensibly away, till at length it was rarely to be met with." From the* description of this fever there can be no doubt that it was typhus. A similar fever arose in York and elsewhere, in England, in 1718, and, reaching its maximum the following midsummer, declined rapidly, and ceased about the close of the year 1719. From 1721 till 1728, there was " scarcely any " fever in Ireland. In the latter year, however, after three successive bad harvests, it reap- peared, and continued to prevail for four years, reaching its greatest vio- lence in 1731. This fever " did not bear bleeding." On the contrary, a tonic and stimulant treatment was necessary. This epidemic was general over Ireland, and extended also into various parts of England. Petechial fever was prevalent in Ireland in the spring of 1735, and in 1736, but no great epidemic arose, after 1731, till 1740. The preceding winter was intensely cold, both in Great Britain and Ireland; numbers of cattle and poultry were frozen to death, while the harvests, and in par- ticular the potatoes, were destroyed. There was great distress among the poorer classes, many of whom died of starvation. In August, 1740, a fever which may be recognized as typhus swept over the whole of Ireland, raging with greatest violence in the province of Munster, where the poor were worst provided for. This epidemic con- tinued through the following year (1741), abating in fury toward its close. In the winter of 1742, after an abundant harvest, it had almost ended. The poor were first attacked, but the rich did not escape. O'Connell computed the loss of life in Ireland in 1740-41, by famine and fever, at 80,000. Murchison calls attention to the fact that there are evidences of the association of relapsing fever with typhus in Rutty's description of this outbreak. A little later, in 1740, a very fatal epidemic appeared in England and Scotland. It spread to London in 1741. This fever "could not bear bleeding." It was best treated with bark and acids. In 1750, and again in 1751, Sir John Pringle described typhus as the "hospital or jayl fever." He remarked that "the hospitals of an army, when crowded with sick, or at any time when the air is confined, produce a fever of a malignant kind and very mortal. I have observed that the same sort arise in foul and crowded barracks; and in transport-ships, Avhen filled beyond a due number and detained long by contrary winds, or when the men were kept at sea under close hatches in stormy weather." TYPHUS FEVER. 247 Of treatment he said: " Many have recovered after bleeding, but fev?- who have lost much blood," Pie recommended bark and serpentaria, and con- sidered wine of great use. The writers of this period constantly allude to fevers arising in jails, hospitals, camps, and ships, and attribute them either to the concentrated emanations from living human bodies, or to contagion. On shipboard, typhus was then a very common disease, esjoecially on the long voyages to this country. In 1770-71, typhus again broke out, after a long interval, in Ireland, and raged with great violence for about a year. In 1797, there arose in that ill-fated land another great epidemic of fever, which did not terminate till 1803. It was a period of great calam- ity; Ireland had been threatened with foreign invasion, and was torn with internal rebellion. Political feeling ran high, and the upper and lower classes were arrayed against each other, A great part of the ten- antry of the large estates were deprived of work. There was a series of poor harvests; in the summer of 1797 heavy rains injured the crops. The three following years were no better. This condition of things resulted in a lack of food among the poor. The prices of the necessaries of life rose enormously. It was the poor who chiefly suffered, but in proportion to the number of persons attacked the fever was most fatal in the middle and upper classes. The harvest of 1801 was abundant, and provisions of all kinds were supplied at moderate prices; the epidemic at once began to decline, and by the end of the following year had almost spent its force. It spread to England, but was there less prevalent than in Ireland. This epidemic was mainly, but not wholly typhus ; in Ireland relapsing fever was also observed. It was largely in consequence of the prevalence of fever at this time that separate hospitals, for the reception and treat- ment of fever-patients, were first established throughout the kingdom. In 1817-19, there arose a very wide-spread epidemic of fever in Ire- land; it extended also to England and Scotland, but prevailed in both much less extensively. It is probable that this epidemic was chiefly con- stituted of relapsing fever cases, although a considerable proportion of typhus cases were observed. It is estimated that in this epidemic 800,000 of the 6,000,000 inhabi- tants of Ireland fell sick, and of these 45,000 died, partly of fever, partly of famine and dysentery. The next great epidemic appeared in 1836. It began in Dublin in May, 1826, and prevailed till March, 1827. Meanwhile it spread to Scot- land, where it reached its acme in 1828. It prevailed to a limited extent in London. This, like the preceding epidemic, was composed of relaps- ing and typhus fever cases together. For a period of eight years typhus fever was endemic rather than epi- 248 THE CONTINUED FEVERS. demic. In 1831-32, " there was a considerable increase " of it in Glasgow and Edinburgh. But it was not until 183G that it assumed the magnitude of an epidemic. This time, as so often before, it broke out in Ireland, and found its way thence into Scotland and England. The fever of this outbreak was typhus. Hence, the mortality was far in excess of that of the previous epidemics, which were, in great part, made up of relapsing cases. In 1842, fever again became epidemic. This differed from previous outbreaks in neither originating in Ireland, nor in implicating it. The disease was general over Scotland, but was by no means restricted to the large cities. It invaded England, but its ravages there were much less extensive than among the Scotch. It was chiefly prevalent among the poorest and most wretched of the population, who were at the time of its outbreak in a condition of, even for them, unusual distress. The cases were almost exclusively relapsing fever; typhus was rare. The mor- tality was from two and a half to four per cent. Bleeding was but little resorted to; the treatment was of a supporting kind; many cases were thought to demand stimulants. The distinction between relapsing and typhus was clearly recognized in this epidemic, and the cases were sep- arately entered in the registers of the infirmaries of Glasgow and Edin- burgh. Toward the end of the year 1846, a fever epidemic of great magnitude and severity arose in Ireland after an extensive failure of the potato-crop, and at a time of great consequent hunger and want among the people. It prevailed two years, sweeping also over Scotland and England. In the latter countries the cases were mainly typhus, while in Ireland the pre- dominant form was relapsing fever. The amount of suffering caused by this outbreak was appalling. In Dublin alone, 40,000 cases of fever oc- curred, and it is estimated that, in the whole of Ireland, the total number exceeded 1,000,000. In England, 300,000 cases occurred, and in Liverpool there were 10,000 deaths from typhus. In Edinburgh, 2,503 persons died of the fever, and it was estimated that not less than 19,254, or one- ninth of the population, were ill of it. The death-rate of this epidemic was everywhere high, but was always highest when the proportion of cases of typhus to relapsing fever was greatest. In Ireland, 8 per cent, died; in Edinburgh, 13 per cent.; in Glasgow, 14.41 per cen.t.; but, separating the cases of relapsing fever from those of typhus, we find that in Edinburgh the mortality of relaps- ing fever was 4 per cent., of typhus 24.7 per cent.; and in Glasgow, that of relapsing fever 6.38 per cent., of typhus 21.2 per cent. At this period (1847-48) a great epidemic of typhus and relapsing fever prevailed in Upper Silesia and elsewhere in Germany. In Great Britain, and especially in Ireland, typhus fever has its chief geographical home. Pestilential centres of typhus seem to exist upon TYPHUS FEVEK. 249 the Continent — for example, in Northern Italy, the Baltic provinces, and in Silesia; but nowhere in modern times have typhus epidemics occurred so frequently as, or excelled in magnitude, those of the British Isles. Nowhere in the intervals between epidemics have sporadic cases and iso- lated outbreaks been so constantly observed as there. In these lands, and particularly in Ireland, typhus fever is peculiarly endemic. No authentic account exists, according to Murchison, of typhus, as it is known in European countries, in Africa or the tropical parts of Amer- ica; nor has it been observed in Australia or New Zealand, except, on rare occasions, among the passengers landed from emigrant-ships. The same author concludes, after a review of the somewhat conflicting statements of writers upon the diseases of India, with reference to this subject, that typhus fever must henceforth be regarded as one of the diseases of that country. Hirsch informs us that together with the plague, it is endemic in Simla. The natives of tropical countries possess no immunity from typhus on visiting localities in which it is prevalent. Turning our attention to the Western hemisphere, we find that typhus fever has prevailed in the United States and British North America, at various times in restricted epidemics. There is reason to believe that most of the epidemics that prevailed extensively in the United States during the early part of the present century, and were described by med- ical writers of the period under such names as " spotted fever,'''' '■'■ 2')etechial typhus^'' and '■'■typhus syncopalis,'''' consisted of cerebral spinal fever. In more recent times, typhus fever has not infrequently made its appearance in the cities of the seaboard, as a direct importation from Ireland and other transatlantic countries in which it has prevailed. Hence the pop- ular terms, "Trw/i/eyer," '■'■ emigrant fever^"* ^'^ ship fever.'''' Its importa- tion has without doubt been more frequent in recent times, in consequence of the facility and rapidity of ocean travel and the enormous immigration hitherward. The instances of its supposed autochthonous origin in the United States are readily explicable upon the theory of a prolonged latent existence of the germs, terminating in their becoming the exciting cause of the disease under favorable circumstances; that is, upon the presence and coacurrent action of the predisjDOsing causes. Thus, Hirsch states that he has been able to find but seven instances of the sponta- neous origin of typhus in the United States between the years 1817-56. The first of these broke out in the poor-house in Boston, in 1816, and extended to the inhabitants of the city. The second occurred in Phila- delphia in 1820, and was exclusively confined to the poor-house. The third, fourth, and fifth occurred in 1818, 1825, and 1837, in the prison at Bellevue, in New York, and prevailed at the same time in the crowded and destitute portions of the city. The sixth of these outbreaks was observed in Westchester County, among railroad laborers. The last occurred in the year 1836, among the most wretched, filthy, and impoverished portion. 250 THE CONTINUED FEVERS. of the population of Philadelphia, and extended over a great portion of the city. This outbreak was described by Gerhard and Pennock, in a paper that remains to this day the most important contribution to medi- cal literature upon the subject of typhus in the United States.' It is only necessary to point to the fact that all these outbreaks occurred in or near seaport cities, in direct communication with those parts of the world in which typhus fever makes its home, and that each of them arose in a local- ity in which the predisposing causes of typhus fever probably existed to a high degree, to show how unstable is the basis upon which rests the belief that the disease was, in these instances, of spontaneous origin. The ina- bility to trace the contagion in any outbreak is not a sufficient warrant for the supposition that it has spontaneously arisen. Typhus has repeatedly appeared, in consequence of direct and easily traceable importation, in New York, Philadelphia, Boston, and Baltimore. There are no records of its occurrence in the Gulf States or upon the Pacific slope; and although Drake, in his " Treatise on the Diseases of the MississijDpi Valley," treats at great length of the typhous group of fevers, it is clear from his descriptions that he refers principally to outbreaks of enteric and cerebro-spinal fever, and not to typhus fever as we know it. In fact, typhus is not a disease of North America. It occurs here only in consequence of importation, and prevails only in restricted epidemics. Among the more recent outbreaks are to be mentioned that of 1850-52, in Buffalo, described by Flint; that of 18G1-65, in New York, of which we have an account in the writings of Loomis; and that of 1SG4, in Phila- delphia, which forms the basis of the excellent paper by Da Costa. Notwithstanding the existence of typhus in several of the seaport cities of the North during the years of the American war, it is a remark- able fact that there was perhaps entire immunity from this disease in the armies both of the United States and the Confederates. Dr. Clymer ^ states that, as a result of large personal observation and diligent inquiry among the medical officers of the United States army, he is satisfied that, as an epidemic, however limited, typhus never prevailed, even at the depots for returned prisoners of war. He thinks that there is every rea- son to believe that the cases, 1,723 in number, with 57^deaths, reported to the ofiiee of the Surgeon-General of the United States, were not in- stances of true typhus. Students of medicine in American cities rarely have the opportunity of familiarizing themselves with the clinical aspects of typhus. Never- ' On the Typhus Fever which occurred at Philadelphia in the Spring and Summer of 1836 ; illustrated by Clinical Observations in the Philadelphia Hospital, etc., etc., by W. W. Gerhard, M.D.: Amer. Jour. Med. Sc, vol. xix., p. 289 et seq., and vol. xx., p. 289 et seq. Philadelphia, 1837. ^ Aitkin's Practice. Vol. i. Article Typhus. Third American edition. Philadel- phia, 1873. TYPHUS FEVER. 251 theless, occasional examples of this disease find their way into the hospi- tals of the seaboard towns. Thus, typhus showed itself in Philadelphia iu the spring of 1880, and several cases were at that time treated in the wards of the Philadelphia Hospital. During the summer the disease dis- appeared, but again made its appearance in the autumn, and is still pre- valent. The number of cases, fortunately, is extremely limited. Typhus has been observed under similar circumstances of direct im- portation in British North America, where, however, the epidemics have, in most instances, assumed more extensive proportions than with us. Etiology. i. pkedisposing causes. Climate has undoubtedly an influence upon the development and spread of typhus. As indicated in the foregoing historical sketch, its home is Europe and the British Isles. If it be endemic in India, it is so to a very limited extent. In other tropical and subtropical countries the typhus of Ireland is certainly almost unknown. It is essentially a dis- ease of cold and temperate climates. The season of the year appears to exert very little influence upon ty- phus. Epidemics arise and pursue their course irrespective of the season. It has sometimes been observed that the number of cases has diminished during the summer, and again increased in the last month or two of the year. The diminution does not begin at once upon the advent of warm weather, nor does the increase follow immediately upon cold. A contin- uance of these conditions is necessary to produce their respective influence upon epidemics. From this it would appear that the influence is due to the different mode of life incident to the seasons, and that the increase of typhus in the winter and spring months is due, not to the weather, but to the protracted overcrowding and deficient ventilation of the dwellings of the poor, and perhaps also to a greater scarcity of food, particularly in times of scarcity, in the winter. Meteorological conditions exert little or no influence upon typhus; they are by no means constant for different epidemics. Hirsch regards a low and damp situation as powerfully predisposing to the endemic and epi- demic prevalence of typhus, but insists that it is by no means a neces- sary or important factor in the production of the disease. As the result of importation, typhus may occur at a considerable height above the sea- level. In the spring of 1839, Lebert observed a considerable number of cases on the plain and in the valley of the Salvan, in the lower Valais, at a height of 4,000 feet above the sea. The disease in this case was brought from Piedmont, over the St. Bernard pass, and at least one-third of the monks at the Hospice contracted it. 252 THE CONTINUED FEVERS. Age affords no exemption from the attack of typhus. It would ap- pear, from death registers and hospital reports, that it is for the most part a disease of adult life. The mean age of 3,456 cases admitted to the London Fever Hospital during ten years (1848-57) was, according to Murchison, 29.33 years; and of 18,138 cases admitted in twenty-three years (1848-70), more than one-half (9,248) occurred between the ages of ten and thirty; the youngest was ope month, the oldest eighty-four years. The evidence furnished by data of this kind is untrustworthy as indica- ting the relative liability to typhus at different periods of life. Children, for obvious reasons, contribute a relatively smaller number of cases to hos- pital statistics than adults, and, for the reason that the disease is much less fatal in the early years of life, they contribute an actually smaller number to mortality statistics. In view of the fact that many adults are protected by previous attack, it is probable that all periods of life are alike susceptible to the exciting cause of typhus. jSex in itself has no influence. Up to thirty years of age rather more males than females contract typhus; above the age of thirty years the re- verse is true. Taking all ages together, the number of cases is about the same for each sex. Occupation, except as it involves actual exposure to the contagion, as the case of hospital attendants, physicians, clergymen, etc., does not predispose to t^^phus. Patients admitted to hospital suffering with this fever are almost always in destitute circumstances, and, if possessed of a trade, have usually been out of employment so long that it could not be regarded as exerting any influence whatever. Numerous observers have thought that butchers are less liable to typhus than those engaged in other pursuits. The fact may be accounted for by their alvvays having a good supply of food. The laboring classes are more liable than the well-to-do middle classes, probably for analogous reasons. Habitual alcoholic excesses predispose to typhus. Murchison states that a single act of intoxication may render the subject liable to it; that he has " known several instances of persons exposed for months to the poison in its most concentrated form, who were not attacked until imme- diately after a debauch." Previous illness is thought to predispose to typhus. In general hos- pitals, the convalescents from other diseases not infrequently contract typhus. Many persons, who during epidemics have long escaped the fever, are seized with it after a slight attack of sickness. In the Crimean war, scurvy was found to be a powerful predisposing cause. Phthisis, quiescent before, has frequently been observed to run a rapid course after an attack of typhus. Fatigue, both bodily and mental, want of sleep, anxiety and other de- pressing emotions, particularly a dread of the disease, increase the liability TYPHUS FEVEK. 253 to the attack. These influences have, in very many instances, appeared to determine the seizure among medical students, clinical clerks, nurses, and other attendants upon the sick. Among the predisposing influences, is to be mentioned personal idiosyncrasy. Different individuals possess for typhus, as for other contagious diseases, a varying degree of personal susceptibility independent of other circumstances of predisposition. Tlie mode of life of the individual exerts a powerful predisposing in- fluence. Typhus is a disease of the poor and underfed of large cities. With the exception of persons of the better classes who contract the dis- ease by direct exposure to the contagion, it is, under the ordinary circum- stances of its endemic or mildly epidemic prevalence, confined to the indigent classes and those just above the indigent classes of the com- munity. It is only under unusual circumstances, or in fierce epidemics, that it attacks those who are well-to-do. It was found, upon inquiring into the antecedent history of 18,268 typhus patients admitted into the London Fever Hospital during twenty-three years, that they belonged almost invariably to the lowest classes of the population, 95.76 per cent, being the inmates of workhouses or dependent upon parochial relief, whereas comparatively few of the better class of patients, who were able to pay for admission, were affected with typhus. A large proportion of the typhus patients had been on the verge of starvation for several weeks or months prior to admission (Murchison). The great epidemics of typhus, not only in Ireland and Great Britain, but also upon the Continent, have invariably occurred in times of scarcity. They have followed failure of the crops, and prevailed generally over lands visited by famine; or they have arisen in consequence of the hardships of war, sieges, commercial distress, or strikes in the manufacturing districts, and have remained to a greater or less extent circumscribed. Overcroiodmg , beyond all question, plays the most important part among the predisposing causes of typhus. The conditions which consti-. tute overcrowding are, in the words of Dr. George Buchanan,' " scarcely to be separated from each other, but may be enumerated as overcrowd- ing of dwelling-houses upon a too limited area, overcrowding of rooms by too many occupants, bad ventilation of streets and houses, domestic and personal dirtiness." To the combined influence of these conditions is due the proneness of the laboring population of great cities to typhus. Murchison found that in London the cases admitted to the Fever Hospi- tal were for the most part brought from the central and most crowded localities, and that on approaching the suburban districts their proportion gradually diminishes. In Liverpool, which has habitually more cases of typhus than any other town of England, and in which the most serious epidemics occur, the huddling together of houses with insufficient space ' Reynolds' System. Article Typhus, vol. i. 254 THE CONTIXUED FEVERS. around them is carried on to a greater degree than in any other town in the kingdom. A large number of the houses are built back to back in unventilated courts, and the population is so dense that in some districts each person only gets eight square yards of superficial space. In these parts it is that fever especially flourishes, and, in epidemic periods, passes by none but those who are protected by previous attack (Buchanan). In Edinburgh, where the overcrowded dwellings of the poor and the houses of the better classes are perhaps more widely separated than in any other city, typhus, even in the midst of the greatest epidemics, is almost re- stricted to the most crowded and wretched parts of the Old City (Mur- chison). Glasgow is another of the cities in which the houses occupied by the poor are densely crowded together. Its inhabitants have likewise been great and constant sufferers from typhus, which has been found to prevail most fiercely in the more crowded parts, and to leave the more open districts, inhabited by the opulent, almost or quite unscathed. The crowding together of many persons in small rooms with deficient ventilation is not a less potent predisposing cause. Hence, in former times, the ill-repute of the lodging-houses frequented by the poor in the large towns of Great Britain and Ireland. Of these there are great numbers, and previous to the enactment of laws regulating their management, in 1857, they were pestilential centres, perennial hot-beds of typhus, where the fever, like a spark under the ashes, forever glimmered, ready to burst forth into the flame that so often swept the land from end to end. Typhus has very frequently arisen, both in early and recent times, under circumstances of overcrowding, in hospitals, prisons, ships, and armies. Sir John Pringle in 1752 gave it the name of "Hospital Fever." The "Gaol Fever" and " Jayl Distemper" of former times was typhus. Common in the overcrowded, foul, and ill-ventilated prisons, it spread thence to the communities around them. Such is the origin of the " black assizes " already alluded to, three of which occurred in the sixteenth and three in the eighteenth century. They are of interest as showing in a remarkable manner the condition of the prisoners and the intense activity of the typhus contagion in densely crowded and unventilated rooms. They certainly do not prove the independent origin of the specific excit- ing cause. The accounts are transcribed from the pages of Murchison, by whom they were collected from the writings of "Ward, Bancroft, Hux- ham, and others. " The first occurred at Cambridge, during the Last Quarter Sessions in 1522, the thirteenth year of the reign of Henry YIII, The justices, gentlemen, bailiffs, and most of the persons present in court, were seized with a fever, which proved mortal to a considerable number. No account is preserved of the symptoms of this fever; but the circumstances were similar to those of subsequent black assizes, in which the disease was un- doubtedly typhus. TYPHUS FEVER. "200 "The year 1577, or twentieth of the reign of Queen Elizabeth, was notorious for the Oxford " black assize." This assize was held at Oxford Castle, on July 4th and two following days, for the trial of Rowland .Tencks, a bookbinder and a Roman Catholic, for treason and profanity of the Protestant religion. Jencks was not the only prisoner brought before the court, but the accounts state that, after judgment was pro- nounced against him, ' an infectious damp or breath arose among those present. Many seem to have been taken ill on the spot. Above six hundred sickened in one night, and the day after, the infectious air being carried into the next village, sickened there a hundred more.' On the 15th, IGth and 17th of July, three hundred more fell sick; and between the Gth of July and the 12th of August five hundred and ten persons perished. The following are mentioned as the symptoms: loss of appe- tite, great headache, sleeplessness, loss of memory, deafness, and delirium so that the patients would get up and walk about like madmen. The general impression at the time was that the 'infection arose from the nasty and pestilential smell of the prisoners when they came out of the jail, two or three of whom had died a few days before the assize began;' the only other explanation offered being that it resulted from the * dia- bolical machinations of the papists,' or, according to the Catholics, that it was a miraculous judgment on the cruelty of the judge for sentencing the bookbinder to lose his ears. " In 1586, another ' black assize ' occurred at Exeter. Some time be- fore, thirty-eight Portuguese seamen had been cast into ' a deep pit and stinking dungeon ' in Exeter Castle. They had no change of raiment, and were left to lie upon the bare ground. A contagious fever broke out among them, which, from Hollingshed's description, was evidently typhus. Many of them were sick during their trial, and by them the disease was communicated to those present in the court. The judge, three knights, and many others died, and the disease spread over the whole county. In this instance very few became ill until fourteen days after the trial. The fever was believed to have proceeded from ' contagion by reason of the close aire and filthie stinke of the gaole.' " There are accounts of a fourth ' black assize ' at Taunton, during Lent, in 1730. A contagious fever was communicated by the prisoners, who had been removed from Ilchester jail, to the judges and many others in the court. The Lord Chief Baron, the Sergeant-at-law, and the High Sheriffs of Somersetshire, all died of the disease, which spread widely at Taunton, and proved fatal to several hundreds. "Twelve years later there was a fifth 'black assize' at Launceston, an account of which is contained in the writings of Huxham. 'A putrid, contagious and highly pestilential fever, which had been geiierated i?i the prisons,' was widely disseminated by means of the county assize, and occasioned great mortality. Among the symptoms were great prostration 25G THE CONTINUED FEVERS. and oppression, a florid rash with petechiae, -watchfulness, delirium, tre- mors, subsultus, black, dry tongue, and fetid breath. The pulse was weak from the commencement, even in the robust, and ' bleeding killed the pa- tient, and not the disease.' "The sixth and last 'black assize ' was that of the Old Bailey, in 1750. Nearly a hundred prisoners were tried, who were all, during the sitting of the court, either placed at the bar or confined in two small rooms which opened into the court. The court was crowded to excess, and many present were 'sensibly affected with a very noisome smell.' Within a week or ten days many of those present were seized with a 'malignant fever,' among the symptoms of which were a weak pulse, de- lirium, and petechias. Its duration was a fortnight. That this was the jail distemper or typhus appears from a pamphlet published at the time by Sir John Pringle. Neither the prisoners under trial, nor any in the jail, were suffering at the time from typhus." There are many instances where typhus has attacked individuals and families or isolated bodies of men, as in jails or on shipboard, without traceable contagion. Dr. Murchison has collected a number of such ex- amples, which he adduces in support of the theory of the independent spontaneous origin of typhus by the intense action of its predisposing causes, advocated by himself and others. If the infecting principle or contagion be a minute organism capable of indefinitely reproducing itself in the human body and in other favorable localities, as has been rendered almost certain by the discovery of the parasitic exciting cause of the congener of typhus, relapsing fever, it is more in accordance with modern views to suppose a continuous latent existence of the germs, which are called into activity by overcrowding, destitution, and other predisposing causes, than to accept the theory of its independent generation de novo. The examples in question are capable of explanation quite as satisfacto- rily by the former as by the latter supposition. This brings us to the consideration of the exciting cause. n. THE EXCITING CAUSE. Typhus fever is due to an infecting principle, communicable from the sick to the well by actual contact, by means of the atmosphere, by fomites, and by drinking-water. The nature of this principle is unknown. In the words of Lebert, "when contagion plays a part so important, one is forced to admit a specific cause for a disease so absolutely defined and so well characterized. Such can only be an organic poison or an organ- ized germ. A poison may kill, but cannot infect, still less spontaneously multiply to an enormous degree; while everything in the history of this disease admits a ready explanation through organized germs." Typhus is pre-eminently contagious. When it appears in a community TYPHUS FEVER. 257 it spreads rapidly among- the susceptible persons. The rapidity and extent of its spread is proportionate to the intensity and diffusion of the conditions known as predisposing causes, but persons exposed to none of the predisposing causes contract the disease when in close attendance upon those ill of it. The prevalence of typhus in restricted localities is in proportion to the degree of intercourse between the healthy and the sick. When it breaks out in a house, those living in the same room with the person first attacked are usually the next in order to develop the disease. In hospitals the nurses and resident physicians are much more commonly attacked than the attending physicians or students. The medical assistants in the British fever hospitals rarely escape the disease. During the year 1827, in the Edinburgh Infirmary, ten clinical clerks and twenty-five nurses or servants, caught typhus; all of them had frequent and close communication with the fever-patients; whereas the clerks and nurses residing in the same building, who had no intercourse with fever-patients, almost uniformly escaped.' Instances might be mul- tiplied indefinitely in support of this statement. During twenty-three years (1848-70) 288 cases of typhus originated in the London Fever Hos- pital. Of these, 193 were nurses and other attendants in the wards, 14 were medical officers, 7 laundresses, and only 3 servants not engaged in the wards; 71 were patients admitted for other diseases (Murchison). In 1814, typhus was brought to the Salpetriere, in Paris, by some soldiers; of the persons attached to the hospital 120 were attacked and eight phy- sicians died. During two and a half months in 1856, 600 of the attend- ants in the French military hospitals in Constantinople contracted typhus, which was not then prevalent in the city itself. Typhus is, in all epidemics, imported into localities previously free from it, by infected persons. It is in this way that the disease has made its way to the seaport towns of this country. Hence its names: Irish fever, emigrant fever, and so on. Very often in general hospitals the admis- sion of a single case of typhus is followed by its spread among the attend- ants and the other patients. Tiie prompt removal of the first cases from the house or locality in which the disease has made its appearance has often arrested its spread, while the neglect of this measure has converted such house or locality into a focus of contagion. The disease may be and constantly is communicated from the sick to the well by actual contact. This, however, is by no means necessary. The infecting principle is in all probability borne in the expired air of the patients and in the exhalations from their cutaneous surfaces. It may be thus carried into the surrounding atmosphere, and so reach the blood of those quite near at hand by the channel of the breath or by the ' W. P. Alison, M. D. : Observations on the Epidemic Fever now prevalent among the Lower Orders in Edinburarh. Edinburgh Med. and Sur. Jour., xxviii. , 1837. 17 258 THE CONTINUED FEVERS. saliva wliich they swallow. But tlie distance to which it may be thus conveved cannot be great. If the room occupied by the patient be spacious, airy, and clean, the risk of contagion is very slight. Physicians who visit j)atients in such apartments with due precaution, and pass at once into the open air, incur but little liability to contract the disease; but those, on the other hand, who heedlessly inhale the atmosphere immedi- ately surrounding the patient, or incautiously perform auscultations, or who tarry in his presence, especially if the apartment be small and im- perfectly aired, incur great risk. Typhus is never communicated by means of the atmosphere from fever hospitals to the houses in their im- mediate neighborhood. Lebert states that in his wards at Breslau, during the epidemic of 1868-69, when the greatest attention was paid to ventila- tion both in winter and summer, neither typhus nor relapsing fever was propagated. The breath of typhus-patients conveys, and their bodies emit when the bed-clothes are turned down, a peculiar, strong, somewhat pungent odor, which has been regarded by many observers as characteristic of this disease. It has been thought that those in whom this fever-odor is strongest are most likely to communicate the disease to others. The fact is well attested that man}' persons, Avho, upon coming into close proximity with patients, have felt a sickening sense of the intensity of this odor, have within a very short period developed the disease. Articles of all kinds with which the patient comes in contact may become carriers of the contagion. It is probable that the germs of typhus, in a dried state, or, at all events, in a condition of diminished activity, may retain their vitality for an indefinite period, in the absence of conditions favor- able to their development or multiplication — in other words, in the absence of the predisposing causes of the disease. Not only the bedding and clothing of the patients, but also the apartment in which they have lain, may act a.s fomites. Particular houses, in this way, become hot-beds for the production of the disease; ships used for the transportation of typhus- patients, become the home of the infection, and vehicles used to convey patients to the hospital may communicate the sickness to their next oc- cupants. Those who wash the undisinfected clothing of typhus-patients are peculiarly liable to take it. Woollen substances are more apt to ab- sorb and retain the contagion than other textures, and garments of a dark than those of a light color. Not only may the disease be thus conveyed to a distance by articles of the most varied description capable of carrying the contagion, but in- dividuals not themselves sick of the fever may be the means of communi- cating the disease from the sick, or from infected localities, to the healthy at a distance. Thus, in January, 1867, a patient in a surgical ward of the Middlesex Hospital was seized with typhus. She had been in the hospi- tal four and a half months, and in bed all the time. There were no other TYPHUS FEVER. 259 leases of typhus in the same ward or on tlie same floor: but a nurse in close attendance upon a typhus-patient down-stairs, though in good health herself, had been in the habit of visiting this patient daily (Murchison). It is, however, fortunate that the contagion, in order to be conveyed by means of fomites, must be concentrated, and that habits of cleanliness and caution, and free ventilation, reduce this danger to a minimum. Drs. Gregory, Tweedie, and Murchison have separately recorded their belief that, in an attendance upon typhus-patients extending over many years, they have in no case been the means of the communication of the fever. The disease may be contracted by susceptible persons through contact with the bodies of persons who have died of it. There are no facts to prove that it is disseminated from the dejections, as is the case with en- teric fever. The period of incubation is placed by Murchison at twelve days or less, rarely longer; by Lebert at from five to seven days. There are no reliable facts in support of the statement that it sometimes exceeds three weeks. A number of cases have been recorded in which the symp- toms of the disease appeared immediately upon exposure. In these in- stances the possibility of previous unsuspected exposure is to be con- sidered. Lebert holds the opinion that the contagion of typhus and relapsing fever, as of other contagious diseases, must in many instances be dissem- inated by generally acting local causes. He regards the ground — and drinking-water as together playing an important part. This opinion is based upon the simultaneous or nearly simultaneous infection of several persons in the same house or locality at the beginning of an epidemic, a circumstance which the communication of the disease from the sick to the well cannot explain. Typhus is but little contagious during the first week; the period in which it is most likely to be communicated is from the end of the first week to convalescence. After the disappearance of the fever and the return of appetite and digestion, the danger of conta- gion is slight. It is, however, to be borne in mind that the clothing of the patient, and articles in the sick-room, may, even at this period and long afterward, unless disinfected and exposed to the air, transmit the specific cause of the disease. The contagion of typhus is destroyed by prolonged exposure to mod- erate dry heat (95.5° C. [204° F.]). Immunity from a second attack is enjoyed by a majority of the per- sons who have suffered from typhus. Nevertheless, many cases of well- marked second attacks attended by the eruption are recorded. It is probable that an abortive attack is less apt to confer immunity than the fully declared disease. The lower animals, so far as is known, do not suffer from any disease identical with human typhus, nor is it communicable to them (Murchison). The experiments of Mosler, Obermeier, and Zuelzer, upon dogs, rabbits, 2G0 THE CONTINUED FEVERS. and guinea-pigs, have yielded contradictory results. Even where these animals have died, after the intravenous injection of the blood of typhus- ]):itieiits, with the symptoms of an acute infection, it is impossible to alHrm that this disease has been typlius, for the reason that typhus pre- sents no specific lesion. At the autopsy of ten rabbits, Zuelzer found localized pneumonic patches in two; in the eight others, congestion of the lungs, the kidneys, and the liver. But, as Jaccoud ' has pointed out, this does not warrant the conclusion that they died of typhus. Clinical History. The evolution of tvphus, clinically considered, is continuous rather than by a succession of distinct stages or periods. From the onset of the at- tack, which is usually abrupt, to the defervescence, which is, in by far the greatest number of instances, critical, the march of the symptoms is pro- gressive; and if stages can be artificially established for purposes of de- scription, they are not separated in nature, but merge imperceptibly into one another. Even the appearance of the eruption cannot be said to begin a distinct period in the clinical history of typhus fever, for the other symptoms are with that event commonly not modified; they are only deepened. The attack is occasionally preceded by prodromes of a few days' dura- tion. They consist of a general feeling of weakness and indisposition, with headache, loss of appetite, nausea, and restlessness at night. These prodromic symptoms are not, as a rule, so severe as to compel the patient to abandon at once his usual occupations; in some instances, however, he feels so dispirited and his sense of fatigue is so great, that even in this stage he promptly betakes himself to his bed. Ill the greater number of cases, and especially in those cases where the development of the fever is rapid and the symptoms are severe, prodromes are wholly absent. A chill or chilliness marks the invasion of the disease, which is gener- ally so sudden that the patient or his friends are able to designate the day on which the attack began. The chill or chilly sensations are in many cases repeated at irregular intervals during the first two or three days, and, being followed by perspiration, may present a superficial like- ness to intermittent feyer. In children not infrequently, but rarely in adults, vomiting, often repeated during the first few days, attends the onset. At the same time there is fever, which rapidly augments; the skin is hot, the face flushed, the eyes injected; headache is constant and se- vere, and a feeling of dulness and confusion, with vertigo upon assuming the upright posture, and noises in the head, distress the patient. He Traite de pathologic interne. Tome ii. Paris, 1877. TYPHUS FEVEK. 261 complains also of some pain in the back, and dull, sore pains in his limbs and joints. Catarrhal symptoms are common, such as slightly hurried respiration, a little cough, sore throat, swelling of the edges of the eye- lids, and lachrymation. Muscular weakness and an extreme sense of prostration appear early. The patient's face at first wears an expression of weariness, but soon be- comes dull and stupid. He falls into a drows}^ state, but passes uncom- fortable, restless nig'hts. Wakefulness alternates with brief periods of sleep, disturbed by painful dreams and startings; after three or four da^'s he begins to talk and mutter in his sleep, and between sleep and waking there is slight delirium. When awake, the patient is still conscious and answers questions slowly, but generalh' with correctness, although there is confusion of mind and memory. Already he requires close watching, especially at night, when in his delirium he may leave his bed and wander from the room. In severe cases muscular movements are early unsteady and tremulous, the tongue trembles as it is protruded, and speech is feeble and hesitating. From the beginning the tongue is large, pale, and coated at first with a white, later with a thick, yellowish brown fur; it speedily shows a ten- dency to become brown and dry; appetite is lost, there is thirst, the se- cretion of saliva is diminished, taste is perverted, and a stale, unpleasant odor loads the breath. Nausea is occasionally present, but vomiting is rare. There is constipation as a rule, but in some instances slight diar- rhoea occurs. The abdomen is soft and painless, with the exception of slight tenderness in the region of the liver and the spleen. Enlargement of the spleen may be early detected on percussion. The pulse is increased in frequency from the beginning of the attack; it soon reaches the neighborhood of 110 in the morning and runs up to 130 — 130, or even higher in the evening, with a much higher rate in chil- dren. It is full at first, but compressible — rarely firm or tense; it soon grows feeble, but dicrotism is uncommon. As a rule the temperature rises rapidly, attaining 39.4° — 40° C (103° — 104° F.) by the morning of the third or fourth day, and 40°— 41° C. (104°— 105.8° F.) the same evening, and remaining nearly stationary at these points until some time in the second week. The high temperatures of relapsing fever are very rare in typhus. ' An evening temperature of 42° C. (107,6° F.) is seldom observed. A decided difference between the morning and even- ing temperature is more favorable, even when the evening increase is con- siderable, than a continuously high temperature range in which the morn- ing remission fails. On the fourth or fifth da}', as a rule, less often at the end of the first week, the characteristic eruption appears. It consists of numerous rose- ola-like spots of irregular outline and varying in measurement from a line to three or four lines across, scattered singly, like the spots of enteric 2(32 THE CONTINUED FEVERS. fever, or, as is by far more common, arranged in irregular groups, like the rash of measles. At first these spots are of a dirty rose-color, very sliohtly raised above the surface of the surrounding skin, and upon pres- sure thev momentarily disappear. AVithin the course of a day or two they become darker from the escape of the coloring matter of the blood into the tissues; they are no longer elevated, but appear as faint, dirty brown stains, without defined margin, and fading, not disappearing, upon pressure. Not infrequently, at a later period of the fever, petechias show themselves at the centre of many of these spots, while others, espe- cially in grave cases, are converted into dark red stains; yet they cannot be regarded as being in themselves at any period of their course true petechia^. They closely resemble the rose-rash of enteric fever, differing principally in their numbers and grouping, and in the fact that they ap- pear once for all, and not in successive crops. Their course is typical. They fade during the first half of the second week, and disappear with or without desquamation toward its close. The true petechise appear as such about the time the typical rash begins to fade, that is to say, about the eighth or tenth day; they remain longer and disappear more slowly. A faintly reddish, ill-defined mottling or marbling of the skin between the spots or groups of spots, which form the characteristic rash, also oc- curs to a greater or less extent. It is this that has been described, from its appearing to lie beneath the surface, as the "subcuticular" eruption of typhus. The appearance of the rash varies greatly, and the variation is determined by the general abundance of the two eruptions, by the relative preponderance of one or the other, and, in certain cases, by the extent of the true petechiae, which are, however, frequently absent alto- gether. The spots and the mottlings together constitute the " mulberry rash " of Jeuner. The distribution of the typhus eruption is irregular: appearing usually first on the sides of the chest or abdomen, it spreads in a brief time over the chest, abdomen, back, and limbs. It rarely appears upon the neck or face. It has in some instances been observed to first appear upon the backs of the Jiunds. In some cases the roseola-like rash is absent altogether, the faint, subcuticular mottling alone being present. An entire absence of erup- tion is very rare. About the end of the first week the depression becomes profound, headache passes into delirium, and the impairment of the mental powers is extreme. The patient is dull of hearing; he answers questions very slowly and vaguely; drowsiness and stupor are marked, and in severe cases there is a tendency to coma. The character of the delirium is vari- able. It is commonly low, wandering, muttering; occasionally it is at first acute, severe, boisterous. This violence usually soon passes away, leaving the patient in a state of the most profound exhaustion, or it grad- ually subsides into dulness with muttering. With both forms of delirium TYPHUS FEVER. 2 Go there is sleeplessness. The tongue is now dry, fissured, and crusted, sordes collect upon the teeth and lips, the conjunctivse are deeply in- jected, the flushing of the face gives place to a dusky pallor most marked about the nostrils and lips, and emaciation progresses. The breath and the skin exhale a peculiar foetor, there is annoying cough with mucous expectoration, and, upon auscultation, rules are heard in all parts of the chest. Tlie heart-sounds and the impulse are faint and indistinct. The area of splenic dulness is considerably extended. The state of the bow- els varies from constipation to irregular, scanty dejections, or a moderate intestinal catarrh; the urine is scanty, opaque, high-colored, and very fre- quently contains albumen. In severe cases the discharges are passed in- voluntarily, or there is retention of urine. The symptoms deepen. The patient utters no complaint. Neither pain nor headache are felt. Appetite is completely lost, thirst no longer distresses him, although he swallows with difficulty, owing to the dryness of his throat. He lies upon his back, stupid, lost, utterly indifferent to everything around him, sometimes moaning or muttering incoherently, sometimes quiet. The eyelids are partly closed, the pupils contracted. Deafness is often present. When spoken to loudly, he stares vacantly without attempting a reply. If asked to put out his tongue, he opens his mouth and leaves it open till reminded to close it. He is unable to raise himself, or even to turn from side to side; from muscular weakness he is continually sliding down in the bed; his hands tremble, he picks at the bed-clothes and feebly grasps at unseen objects in the air; there is subsul- tus. The pulse is small and weak, often difficult to count, less commonly irregular or intermittent. It ranges from 112 to 140 or over. The por- tions of the skin subjected to pressure show a tendency to slough. The surface now becomes cooler and is often moist. If petechiie are present they become more numerous. Death may take place at any time after a condition such as has been described becomes fully developed. In very severe cases it may occur in the course of a few days or before the end of the first week. More com- monly the fatal termination takes place between the tenth and the seven- teenth days. Death at a later period is uncommon, except as a conse- quence of complications. The mode of death is by coma, or by asphyxia in consequence of sudden pulmonary enlargement, or by failure of the heart, the pulse becoming imperceptible, the surfaces cold, livid, and bathed in sweat. In abortive cases a favorable termination may take place by critical de- fervescence at the end of the first or the beginning of the second week. In average cases the fever comes to an end about the fourteenth day— sometimes as early as the tenth day, sometimes as late as the middle of the third week. The amendment is more or less sudden. The tempera- ture, which in many cases shows a little abatement for some days before 204 THE CONTINUED FEVERS. tlie crisis, falls iu a single niglit, uv in the course of twenty-four or forty- eight hours, to the normal or even a little below it; the pulse beqpmes much slower and its character improves; the stupor and coma immediately disappear after a prolonged, refreshing sleep, out of which the patient awakes as from an oppressive dream — conscious, but at first bewildered and confused. The eruption fades and gradually disappears, the tongue cleans and becomes moist at its edges, the appetite returns. The crisis is often attended by moderate sweating or diarrhoea, or both, and by an in- crease in the amount of urine, with a copious deposit of urates and the disappearance of albumen. In the course of a few days the tongue is moist, the appetite eager, strength begins to return, and the convalescence progresses rapidly, so that many patients are able to resume their work within a month from the beginning of the attack. Temporary loss of hair not infrequently occurs during convalescence, and in many cases a considerable length of time ensues before the body- weight and the original vigor of mind are regained. The deafness in al- most all cases gradually passes away. Relapses occur, but they are much less common in typhus than in enteric fever. Analysis of the Principal Symptoms, symptoms eeferable to the nekvous system. A chill or chilliness is, in many cases, the initial symptom. It is, how- ever, often absent. Headache is among the earlier and more constant symptoms of typhus. When prodromes are present, headache is usually among the number. In most cases it is present from the onset; it is most severe during the first week; it often lasts only a few days, and, as a very general rule, terminates early iu the second week, upon the advent of delirium. Its seat is most frequently in the forehead or temples; it is rarely con- fined to the vertex or occiput; in a majority of cases it is general. It is usually dull or heavy, often moderately intense, and for a few days the most prominent symptom of the disease, but rarely acute or paroxysmal. Sometimes it is slight. Vertigo, increased upon assuming the upright posture and becoming more marked with the progress of the disease, is usually associated with the headache. Pains in the back and limbs are prominent symptoms during the earl^ days of the attack. The pain in the back is dull and heavy, but less dis- tressing than the headache or the pains in the extremities. The last ar(v described as of a sore character, as if from severe bruises; they outlast both the headache and back-pains, and often recur during convalescence. They not infrequently implicate the joints as well as the muscular masses. TYPHUS FEVKli. 265 Dellriuin is common. Some impairment of the mental faculties is constant ; hence the synonym " brain fever." In the latter part of the iirst week, as a general rule, sluggishness of mind becomes apparent; tlie perceptions are blunted, mind and memory are confused; the patient can- not tell how long he has been sick, nor the day of the week ; he is indif- ferent to what goes on around him, and annoyed at being spoken to or questioned. This mental dulness alternates with drowsiness, which lacks the refreshing attributes of sleep and scarcely deserves the name. He becomes more and more dull, and, although this degree of mental dis- turbance may not be exceeded in mild cases, in most instances the stupor passes into delirium. The period at which delirium supervenes is variable. It commonly appears as the headache subsides — about the end of the first or the begin- ning of the second week. It may occur much earlier. In rare instances it has been observed from the first night of the attack; on the other hand, it may not appear till shortly before the critical defervescence, toward the close of the second, or in the early part of the third week in protracted cases. At first the delirium occurs only during some part or the Avhole of the night, and is absent during the day, to return again at nightfall. After a time, it becomes present during the day also, and is then worse by night. It is common for patients to be drowsy and stupid in the daytime, wake- ful and delirious at night. It usually ceases after the crisis, but in rare cases continues to occur at nig-ht for some time into the convalescence, even after the general condition has begun to show a decided improve- ment. The character of the delirium presents the widest range of variation. This phenomenon, as well as the other symptoms of mental disturbance, are greatly modified by the mental temperament of the individual, his intelligence and education, previous habits of intemperance and the like, and Ijy the amount of anxiety and fatigue that have preceded the attack. In uncomplicated cases the severity of the attack may be measured by the degree of mental aberration and delirium (Murcliison). The delirium is generally quiet; the patient moans and mutters inco- herently, or he is restless, irritable, and easily disturbed. At first, he replies coherently to questions when aroused, or his answers are rambling and inconsequent; after a time he falls into a state of more or less com- plete unconsciousness. It is less frequently, but in no small proportion of cases, much like tliat of chronic alcoholism — a form of delirium tremens. In spite of his extreme prostration, the patient is restless and fidgety; he sleeps little or not at all; he glances furtively from side to side, and makes eager but ]>.!rposeless attempts to leave his bed ; his tongue is protruded trem- blingly, and there are muscular tremors of his limbs. The pulse is weak 266 THE CONTINUED FEVERS. and frequent, the impulse and first heart-sound impaired, and the skin lealvV. Again, the delirium may be active and noisy. The patient shouts and screams. lie tosses about and seeks with violent efforts to get out of bed. His strenirth is surprising. He has to be controlled Ijy force, for which stout attendants are sometimes necessary. In this state tlie patients often show a suicidal disposition, and require careful watching-, especially at night. Indeed, the mental state in typhus fever is so pecu- liar, that it is in no case safe to leave tlie patient alone. Patients who are quite rational to all appearances during the day, rnay wander about in delirium at night, and the semblance of reason at one period of the day may be followed by suicidal mania in the course of a few hours. The last form of delirium is called delirium ferox j it is much less common in typhus than the low, wandering form which has been called " typho- mania," and is apt to be more or less transient and to terminate in pro- found exhaustion or even fatal collapse; in other cases it subsides into typhomania. The mental state is peculiar, but that it difiers essentially from that of the delirium in other fevers or acute diseases is not apparent. Dr. Murchison has collected, in " The Continued Fevers," an interesting ac- count of the delusions and fancies of patients in the delirium of typhus, to which the reader interested in this branch of the subject is referred. The instances cited bear out the statement of Griesinger,' that the mind in the delirium of typhus is very often concerned with a limited number of constantly recurring alarming fancies. Da Costa observed a fatal case in the wards of the Pennsylvania Hos- pital, in which delirium was absent altogether. The patient's mind re- mained clear to the last hours of life. IVakefuhiess, drowsiness. — During the first two or three days the patient may be dull and inclined to sleep, but wakefulness is a j^rominent and distressing symptom in most cases until the beginning or middle of the first week, particularly at night. Inability to sleep and restlessness are also common in children. It is a curious fact, noted by many ob- servers, that patients who sleep sometimes for several hours together, will often insist that they have not closed their eyes, although in all other respects rational. To this sleeping, without being aware of it afterward, has been ap- plied the awkward and useless term coma vigil. This term has also been applied, perhaps more correctly, to a condition of great gravity, " in which the patient lies with his eyes wide open, g-azing- into vacuity, his mouth partially open, his face pale and devoid of expression ; the pulse rapid and feeble, or imperceptible; the breathing- scarcely perceptible; and the skin ' Virchow's Handbuch. P.and II., Abtheil. 2. Erlangen, 1804. TYPHUS FEVER. 267 cold and bathed in perspiration. He is evidently awake, but he is indif- ferent and absolutely insensible to all that is going' on about him." The condition so graphically described by Jenner is not infrequently observed shortly before the fatal issue in typhus. The term coma vigil is not sufficiently significant to describe it, nor is it sufficiently explicit, being indiscriminately applied to two widely different states, to designate either the one or the other. It belongs to a larg-e class of meaninsjless words which, being neither descriptive nor explicit, nor generally understood or understandable, might well be sj^ared out of medical literature, which they cumber. J)roicsiness, more or less marked, not infrequently alternates with wakefulness and delirium; bvit about the middle of the second week that indeterminate condition between sleep and waking, to which the term somnolence has been a2:)plied, commonly supervenes. It may follow pro- longed wakefulness and mental excitement, or may occur without them.. It is more or less profound according to the gravity of the case, and deepens by imperceptible gradations; first into stupor, then to coma. Debility is one of the most characteristic features of typhus. It comes on early, and is in all cases marked. The patients are obliged to- take to their beds from sheer weakness within the first day or two of their illness. So great is the loss of muscular power that the patients are un- able to walk or rise without assistance, or, in many cases, even to turn in bed. As a general rule, the prostration increases till the ninth or twelfth day, when it is often complete. The excessive effort of the maniacal paroxysms in the acute form of delirium is apt to be followed by a corresponding prostration, so great in some instances as to prove rapidly fatal. The loss of strength sometimes is not very great until the beginning of the second week of the disease, when it develops suddenly with dangerous symptoms of extreme debility. This class of cases is rare. Except when changed by restlessness or delirium, the attitude of the patient is, by reason of the loss of muscular power, that which is described as the dorsal decubitus. With increasing weakness he tends to sink toward the foot of the bed. Paralyses of certain groups of muscles occur; hence the involun- tary discharges and the retention of urine that so often attend the height of the disease. Dribbling of urine may result not only from paralysis of the neck of the bladder, but it may also arise as a consequence of over- distention of the bladder from paralysis of its muscular coat. In typhus and in all low fevers, the routine exploration of the suprapubic region by palpation and percussion is imperative, as in this way retention of urine, that by reason of the dribbling might be otherwise overlooked, is often detected, and may be relieved by the use of the catheter. Neglect of this precaution is apt to result in ura?mia with coma and convulsions, or. 208 THE CONTINUED FEVEKS. more remotely, in catarrh of the bladder or ulceration of its mucous mem- brane. Murchison states that there is occasional paralysis of the orbiculares muscles, and that, in consequence of the inability to close the eyes, vilcer- ation and sloughing- of the cornea may take place. Among the disturbances of the functions of the nervous system is tremulousness. In few severe cases is trembling of the hands and tongue wholly absent during the period preceding the crisis or the fatal issue. In some cases — especially in those who have habitually indulged too freely in the abuse of alcohol, the aged and the very infirm, the whole body is observed to be in a state of tremor. Oscillatory motions of the eyeballs (nystagmus) and choreic movements of the limbs have been recorded. Subsultus tendinum, spasmodic twitchings of the muscles of the face, carphology or grasping in the air, and picking at the bed-clothes, also belong to the motor disturbances of the gravest cases of typhus. Hic- cough occasionally occurs. Much more rarely, and in grave cases only, tense contractions of groups of muscles are met with. The flexors of the forearm, and of the thighs and legs, are among the groups apt to be thus affected. Trismus, strabismus, and, in very rare instances, opisthotonus, have been seen. General eonvrdslons are met with, according to Murchison, about once in one hundred cases. They are due to uraemia in the vast majority of cases, and rarely appear earlier than the middle or end of the second week. An unusual tendency to stupor, and a marked diminution in the quantity of urine secreted, as a rule, precede for three or four days the fit, which is apt to be followed by death, or by coma that continues till death occurs. Life is rarely jDrolonged beyond three or four days after the occurrence of general convulsions. Fatal ur^emic convulsions mav, however, occur in cases that have apparently pursued a mild course, or even after the patient has entered the stage of convalescence. The organs of special sense are to some extent implicated in the processes of typhus. During the first week the eyes are watery; later in the course of the attack they are dry. The conjunctivae are commonly deeply injected from the earliest days of the attack. Most observers in- sist upon the fact that the discoloration of the conjunctiva is of a darker hue in typhus than in ordinary inflammations of the eye. The pupils are commonly contracted, sometimes in grave cases to a mere point, and are not infrequently insensible to the stimulus of light. Dilatation of the pupils, with failure to respond to light, is very rare, and occurs only in the most profound stupor or coma. Intolerance of bright light is common. During the first four or five days, patients very often complain of noises in the head, and associate them with dizziness. After the fourth or fifth day, decided or even complete deafness is common; it often ex- tends into the convalescence, but is not persistent. It was regarded as a TYPHUS FEVEK. 269 favorable symptom by the earlier observers. This opinion is not borne out by recent observations. It is not a nervous symptom, but is probably due to catarrhal processes in the middle (or external) ear. Intolerance of sound is far less common. Coryza forms part of the general catarrhal disturbance which attends the development of typhus. Epistaxis is very rare in most epidemics of typhus. Most writers do not allude to it. Murchison met with it in about a dozen instances out of seven thousand cases; Barrallier 97 times in 1,302 cases, and Jacquot in about one-fourth the cases among the troops in the Crimea, where, however, typhus was very often complicated with scurvy. On the other hand, it was present in one-fourth the cases observed in Philadelphia by Da Costa, who states that hemorrhages from other sources, as the gums or bowels, did not occur in his cases, and that sordes were not unusually common. When epistaxis is present, it comes on early, and the cases in which it oc curs are, for the most part, severe. The taste, as in all fevers, is perverted. Sweet things are disliked; acids are often grateful. The general sensibility of the surface is not infrequently increased. It is important to distinguish between hypersesthesia of the surface of the abdomen and tenderness of the internal organs upon pressure. Toward the close of grave cases, general anaesthesia is said to be some- times present. The mental state of such patients renders this observation in most cases doubtful. THE PHENOMENA OF THE FEVEB. The tem'perature range of typhus, as Lebert has pointed out, lies mid- way between that of enteric and that of relapsing fever. With the former it shows a rapid, progressive increase of body-heat during the first days of the attack, and a continuous high range marked by moderate morning remissions. The range of typhus, however, differs from that of enteric fever in the much more rapid rise to its maximum, the shorter duration of high temperature, the marked fluctuations early in the second week, and its critical termination. The curve of typhus resembles that of relapsing fever in that both rise rai:)idly to the maximum at the outset, remain continuously high, and ter- minate abruptly. The rise in relapsing fever is, however, much more abrupt, the range higher, the course shorter, and the crisis on the fifth or seventh day more precipitous. In no case does typhus show, after an in- termission of several days, the sudden, intense, febrile relapse Avhich is characteristic of relapsing fever. Considerable discrepancies are apparent upon an examination of the records of the studies made by many competent observers on the tempera- 270 THE CONTINUED FEVEKS. tare of typhus. Doubtless some of the statements made are based upon too limited a number of observations, possibly others are the result of tlie investigation of cases in which the typhus temperature has been modi- fied by complications, or other sources of error may have been overlooked. It is, however, probable that the discrepancies in the records of different observers are due in great part to differences in the temperature range of typhus in different epidemics. Without going into a detailed comparison of the recorded observa- tions, we may regard the following statements as representing the main facts. The temperature rises rapidly from the onset of the disease, and in average cases reaches its maximum at from the fourth to the seventh day, or about the period of the appearance of the eruption. Occasionally, the maximum is attained as early as the third day, or, and this is especially so in very severe cases, not until the ninth or tenth day. The maximum is commonly between 40°— 41° C. (104°— 105.8° F.); it rarely reaches 41.5° C. (106.7° F.), except in children, and it may not exceed 39.5° C. <103.1° F.) Even on the l^rst evening it may reach 40°— 40.5° C. (104°— 104.9° F.). On the evening of the fourth day it is seldom below 40.5° C. (104.9° F.), much more commonly 41° C. (105.8° F.), and not rarely higher, while the average morning temperature at this period is 39.5° — 40° C. (103.1° — 104° F.). Exceptionally, an evening temperature of 39° C. (102° F.) has been encountered on the third day; but this is not of itself, by any means, of favorable prognostic import. After reaching its maximum, the temperature falls off* to a very slight •extent in about two-thirds the cases, but remains about the same in the rest, and there is otherwise little change for several days, until about the seventh or eighth day — more rarely, as late as the tenth, when there is ■commonly, except in the severe cases, a slight remission, which, in the very mild cases, may be followed by complete defervescence, but after which the temperature commonly rises again, and then gradually but slowly falls until the twelfth or fourteenth day, when it rapidly subsides to the nor- mal, or in many instances even slightly below it. The morning remissions are less marked than in enteric fever; they vary from one day to the next, but the usual difference is 0.5° — 1° C. (0.9" — 1.8° F.) for the second week, though the same curve may show greater or less variations, especially as the period of the crisis draws near. Ex- cept during defervescence, a higher morning than evening temperature is very rare. A curve in which the morning fall is absent may be looked upon as an unfavorable indication, and the same may be said of a sudden fall of temperature, with arise in the pulse or without improvement in the •other symptoms. A high range of temperature in the first week is apt to be followed by severe cerebral symptoms in the second. The absence ■■ millllllllllHIIIIIIIIUIIIIIIIIBUIKSilll yimmmimi mmiimMME Sagwmiia MinnniiimiiiiiiiiiiBiiniiiiSiiglsSB MiiiHi MH mimmHiHBHiBigBiaiiM niiiiiimiiniiiiiiiiiniiiiniEaiinniH !!!!!!!!!!!!!!!!"H™iHHniiiinii«ii H!n!!!!!!!!!!!!!||||||!ii!iiH||iiH€bn isa! nnHniiHiiiiiiilliiinill^ miEiiaiim iHimSimiyHiifiHiiiBH MBHHMUBsaaiamiimMnmimiuiMM a a ■■■■■ggiHiiiiiiiiiijiiiiimiiiimiiiiii H!!!iis iiHMBmMm i MiH mmS8iiaHii llllcglHm mMmMHMiHm mmMHM SiSITiasiiPiiiiiiiiniiiiiiiniiiiiiiBiiu a 9 in nHSaWM MBinmiiiBliiiiiliiiiiiiiiia ■S^EBBIBIBIRBinia a a a jniinca||gMinnHiiiiiiHHiiiii8S!iiiii !!!!!P!SllH!!HnBiiiiiiiiiniiiifliniiifl liBBfcaiMMHiaMMimwnmHMimMM nHinE^iiiiumniiiiiHiiiiiiiiiiiiiliii. BBBIB i—BMIIBi E!l!!P!!iaaSsSHniiiiuiiiiiHiiniiHiiii ""*"— ^■ ^■■■— ■■■■■■■■■■■■■■■■■■8i888i888888 a a a a a LM' THE CONTINUED l-'EVEKS. oE a distinct, tlioug-li slight n^inission, about the seventh or eighth day, is of unfavorable prognosis. A fall of temperature before the crisis is common. This fall usually oc- curs in the morning of the day preceding the crisis. It may amount to 1.5'' —3° C. (2.7°— 3.0° F.), or even to 2.5° C. (4.5° F.), but the temperature rises again in the evening, to fall permanently on the following, the critical day. In rarer cases a decided rise, amounting to 2° — 2.5° C. (3.0° — 4.5° F.) pre- cedes the crisis, and there are cases in which a gradual abatement, with a progressively lower morning and evening temperature from day to day, occurs. Finally, there are cases in which no change in temperature, pre- cedes the crisis, which sets in suddenly and progresses with rapidity. The critical defervescence may' be completed within twelve hours. Much more commonly it occupies one, two, or even three days. It usually begins in the evening, only exceptionally during the course of the day'- The fall in temperature amounts to 2°— 4° C. (3.0°— 7.2° F.). Recovery commonly takes place after the crisis; but in some instances the patients have fallen into fatal collapse after it, or death may occur in consequence of some complication. The fall is usually to the normal, but not infrequently to a point a little below it, 36.5°— 30° C. (97.7°— 90.8° F.). The evening after the lowest point is reached there is usually a slight rise, to be followed by a fall to below the normal the following day', and a subnormal temperature is often present for several days in the convalescence, liable, however, to occasional transient subfebrile exacerbations in consequence of complica- tions, or without assig-nable cause. In very rare instances an attack of typhus has been protracted into the third or fourth week, coming slowly to an end by true lysis. A rise in temperature of from 1,5° — 3.0° 0, (2,7° — 0,4° F.) takes j)lace just previous to, or at the time of death, in uncomplicated cases. The pulse from the beginning of the attack is frequent, varying be- tween 110 and 130, and keeping pace with the severity of the general symptoms, and in the main with the temperature range. The evening rate is usually slightly in excess of the morning, and the daily' variations are inconsiderable. Sometimes it increases from day to day until death or recovery. Although a rapid pulse is commonly present in severe cases, a slow pvilseis by no means invariably the indication of a mild case. The pulse is sometimes slow in cases characterized by extreme prostration, and death has taken jiluce in cases in which the pulse at no time exceeded 100 (Murchison), A gradual at first, but toward the end of the defervescence a rapid fall in the pulse-rate, is commonly the attendant sy^mptom of improvement. With a temperature below the normal, in the first days of convalescence, there is usually a pulse lower than normal in frequency (50 — 70). If it remain frequent, particularly while the patient is in bed and quiet, this TYPHUS FEVEE. 273 BHUB aiiiiiiiiiiiiiii|iiiHi|iilll|lllliilini aiHiinnHniHiiiiiiHiiM nniiiniiiiniiiHiiiiiiiiiiiiKaiiiii Biniiiinil niiiiimi iinniiiiHir niiiiiiiiiiiii B y i y i iiii^j— — BIIBiiiiiiiiisiinnniiniiiinii^ imiiiiliKEiHiiniiriiimiiil ■ Hmmm\ , _iiiiiaiiisnniiiiiniiHiiiini^^ssseii iHilll^ifiSElllllllinimiBil mwmms mHHUum anuwHMWHMWu Hlllllg||IR£sSllliHllllllllllllllllill i mw iHgS^asimiyMMWMi iHiiiiiialf=i!:s^9nniiiiiiiiiE3SEsass] HiiiiiiiiniiisaBsiii iiiliiifaiiiiiiiissi g BIIIUHII|II iSMHES^ma -■HiiminMliiiiinUMiiiiisiiin ■■■ 18 274 THE CONTINUED FEVERS. may be in consequence of some complication; and a decided rise, after it has fallen with the temperature, is almost always indicative of a compli- cation, which is often pulmonary. During the second week, if the depression be very great, the frequency of the pulse may be accelerated, while the temperature is slightly lowered; but, upon the Avhole, the pulse increases in frequency as the temperature rises, and falls with the defervescence. In the beginning of the attack the pulse is full, soft, and compressible ; in young and vigorous persons it may for a time be somewhat tense, as ■well as full, but this is highly uncommon. As the disease progresses and the strength of the patient becomes from day to day more impaired, the pulse diminishes in force as it rises in frequency, becoming smaller and weaker, until at length it is perceived with difficulty, or not at all. This feeble pulse of typhus is not only greatly modified in frequency, but also in force by changes from the horizontal to the semi-erect or erect posi- tion, both during the fever and in the convalescence. It is not rarely irregular or intermitting, often undulatory, but less commonly dicrotous in typhus than in enteric fever. The impulse of the heart is almost invariably, except in the mildest cases, enfeebled from the fifth or sixth day of the disease. This enfeeble- ment is progressive, and for several days during the height of the disease the impulse is not infrequently absent altogether. Coincidently with the diminution of the impulse, the first sound becomes progressively less dis- tinct, and may at last be inaudible. It is occasionally replaced by a soft, systolic murmur of ha?mic origin. The second sound remains distinct. With convalescence, the impulse and the cardiac first sound only gradually regain their normal character. The radial pulse is not always in correspondence with the impulse of the heart as regards force. The former may be small, weak, or even im- perceptible, while the cardiac impulse is excited and so strong as to dis- tress the patient, and the systolic sound but little enfeebled. These phenomena relating to the heart are due in part to impaired innervation, and in part to the degenerative changes that take place in the muscular tissue of the organ. They are of the utmost importance clinically, as affording the most reliable guide to the administration of stimulants, both as regards the time and the amount. To the enfeeblement of the circulation so characteristic of typhus are to be referred the duskiness and lividity of the face and extremi- ties, often seen in the fully developed disease, the tendency to venous and arterial thrombosis described in rare instances, and the occurrence of embolism of the larger arteries, with resulting gangrene of an ex- tremity. Theurlne varies in quantity with the amount of fluids taken. During the first week, it is often reduced from twenty-five to fifty per cent. In TYPHUS FEYEU 275 In the later periods of the disease it is not infrequently increased severe cases partial or total suppression may occur. Notwithstanding the large amount of water drunk, and the dryness of the skin and absence of diarrhcEa, the amount of urine in the whole ■inBHBBBIHHBHBHHBHB IBBBBBIBBBBIBI I ^Slll llllllllissiiiill m ^■■■■■■■■■■■■■ ■■■■■■■■■iiiggaaaB gwMH B B B B B B B B MIIIIIIIIIIIIIIIES!|||!||||||||!!I|||!!! B BBBiiiiiiniHiinanHiB!!!!!!!!! ■HlfliBBIBBIIBIBIIIIIIIIIiamii! course of the disease is in most cases decreased. There appears to be a retention of water in the system. At the commencement of convales- cence the secretion is often greatly augmented. It is commonly high-colored at first; it may remain so until the crisis. 276 TllK CONTINUED FEVKi:S. As lliu quantity increases, either jit the lieig'ht of tlie attack or upon the beginning- of convalescence, the urine may become very pale. When partial suppression occurs, it is often of a dirty brown color like porter, M'lth a copious deposit of renal epithelium and blood-elements. The specific gravity is usually high in the beginning of the attack, and lower later In its course and in convalescence, varying with the amount of iirine passed. Tlie reaction Is at first decidedly acid; later it is often neutral, or even alkaline, when freshly passed, and dej^oslts an abundance of urates and l)hosphates. The chlorides gradually lessen; at the beginning of the second week they are reduced to a trace, or, in severe cases, are altogether absent. This Is not wholly due to the non-ingestlon of salt, since in health all chlorides may be withheld, yet for a considerable time, the urine will con- tinue to contain them. With the approach of convalescence they reappear in some quantity in the urine without change in the diet, and gradually increase from day to day. Their disappearance is due to the processes of the fever, and takes place in cases uncomplicated by diarrhcea or by pneumonia. The daily excretion of urea is at first considerably above the normal amount, notwithstanding the decrease in the quantity of food, and this increase is proportionate to the intensity of the fever and the consequent tissue-waste. The increase has been present in the earliest days upon which the urine has been examined. The daily excretion is very variable in the second week. In some cases it gradually diminishes, in others it remains lilgli until the crisis. During the early days of convalescence the quantity of urea falls below the physiological standard, notwithstand- ing a generous diet, and gradually I'lses again as health and strength are regained. Urea has been repeatedly found In the blood of persons who have died of typhus, with marked cerebral symptoms, even although there have been no disease of the kidneys and no diminution in the amount of urine (Murchison). TJric acid is usually increased. Alhuinen has been found to be present in the urine in a considerable proportion of cases, by all observers who have made it the subject of in- vestigation. This proportion has greatly varied in different epidemics; sometimes constituting the greater number or even nearly all of the cases examined, at other times amounting to a very small percentage of them. The albumen varies In amount from a mere trace to an abundant deposit; it may appear early In the attack, or not until a day or two before the crisis; and finally, it is often transient, lasting at the most three or four days, sometimes persistent from the day of its first appearance, commonly the sixth or seventh day of the disease, until death or recovery. The TYPHUS FJ<:VER. 277 cases in wliich albuminuria is early, or copious and persistent, arc almost always severe. At the same time it does not arise as a symptom in xo.vy many severe or even fatal cases. The albuminuria of typhus is due to the altered condition of the blood, which induces hypentunia of the kid- neys, that may proceed to actual inflammation of their stnuiture. With the albumen, and in many cases when its presence cannot be detected, renal epithelium, and hyaline, granular and epithelial casts are found. Casts are more frequently jjresent than absent in the urine of severe cases (Da Costa). In cases of gi-eat severity, blood and blood-casts are met Avitli. After death the kidneys have frequently presented the ap- pearances of acute nephritis, where no history of previous reiuil disease existed. Previously existing nephritis, in a limited i^ropcu'tion of the cases, will account for the albuminuria. Sugar was found in minute amounts in the urine of nine out of four- teen typhus cases, in which it was soug'ht for by Dr. George Buchanan, who states that it appeared at any period between the sixth and twenty- seventh days, and only lasted a day or two. It was of no clinical signi- ficance. SYMPTOJIS MANIFESTED UY THE SKTN. 71ie eru.ptio)i of typhus is prominent among the clinical phenomena of the disease. It is very rarely absent. The statistics of the London Fever Hospital show that, of 18,268 cases admitted to that institutioii in twenty- three years, the eruption was noted in 17,025, or in 9-3.2 per cent.; and Dr. Murchison informs us that these figui'es exaggerate the proportion of the cases in which it was absent, it being, in certain cases where it was pres- ent, noted as absent by resident medical officers, who were not suffi- ciently vigilant, or were new to their work. He further states that in the year 1804, when the records were kept with unusual care, the eruption was noted as present in all but 55 out of 2,-4:93 cases, or in 97.77 per cent., and that some of the cases in which it was not found were admitted after the patient had passed through the attack, so that the probability that the eruption had been present and had disappeared is to be re- gai'ded. All observers agree that the eruption is absent in a very small propor- tion of the cases, and that it is of diagnostic importance. Both the mottling, or subcutaneous rash, and the distinct measly eruption, are darker and more distinct upon the dependent parts of the body. The back should, therefore, always be carefully examined in case of doubt. The character of the eruption has already been described in the con- sideration of the clinical history of this fever. The mottling and the dis- tinct rash usually exist together; but in the lighter cases, and particularly in children, the former mainly constitutes the eruption, while in older persons the distinct rash is very prominent. The proportion of cases in 278 THE CONTINUED FEVERS. Avhicli the eruption is altogether absent is much greater under the age of fifteen than over it. In children true petechi;e rarely appear; but they have been observed at all periods of life, from earliest infancy to extreme old age. A copious eruption, deep in color and early becoming livid or pete- chial, generally accompanies the severe cases of the disease. The extent and distinctness of the eruption, and in particular its lividity and the abundance of the petechias, have been regarded in all times as proportion- ate to the general severity of the case. The absence of the eruption, in the rare cases in which it is wholly ab- sent, is not always of itself of favorable import. Lebert states that in his experience such cases liave proved very serious, and in several in- stances have terminated fatally. On the other hand, Murchisou lias found the cases without any eruption mostly mild. The eruption shows itself on the fourth or fifth day, as a general rule; i: may, however, appear aipoii the third day, or not until the end of the first week after the beginning of the fever. The cases in which it appears later than the sixth dav are extremely rare. It is first seen upon the sides of the chest or abdomen, or in rarer cases upon the backs of the hands or the wi-ists, and spreads rapidly over the trunk and extremities, respecting only the neck, face, the hairy scalp, and tlie palms of the hands and soles of the feet; but even these exceptions are not constant, and cases are not very rarely observed, especially in childhood, in which the distribution of the typhus-eruption is not less extensive than that of measles. A diffuse, erythematous blush is not infrequent during the first day or two after the appearance of the eruption. If the spots are faintly raised above the surface of the skin, their grouping presents a close resem- blance to measles — a resemblance heightened by the conjunctival injec- tion, and the nasal and pulmonary catarrh, which are also at this time well developed. The eruption of typhus never ai:)pears, as does that of enteric fever, in successive crops. It requires in most instances, apparently from its very abundance, a variable time, often forty-eight or even sixty hours, for its full development; but the spots that appear upon the second or third day ai'e superadded to those first seen, and are due to the same cause. After the rash is completely established, it is permanent, no new spots of the same kind appearing. Its average duration is from eight to eleven days; it disappears, as a rule, with the defervescence. In some cases, and particularly Avhen it has consisted only of a faint mottling, it lasts but a brief time — from a few hours to a day or two — and wholly A'anishes several days before the termination of the fever. Where the eruption is very dark, and where true petechiae are abundant, the discoloration of the skin ])ersists for some days into the convalescence, and only gradually fades. TYPHUS FEVEll. 279 The course of the typlius-eruption is as follows: at first the lesion consists of a hyperjemia of tlie cutaneous capillaries, which, bein"- in ])art diffuse, is manifested by that mottling or marbling of the surface, described as the subcuticular rash; and being in part localized, shows itself in the pale, dirty pink or florid spots, faintly raised above the sur- face, disappearing upon pressure, and variously grouped, Avhich have al- ready been described as the rubeoloid or measly eruption. In the course of two or three days these spots are found to be no longer elevated; they have lost the brightness of their color, and, in consequence of the transu- dation of blood-coloring matter from the vessels, appear as i-eddish brown or rust-colored stains in the skin, not distinctly marginate, but fadino- ob- scurely into the tint of the surrounding surface. The hyperjemia has now given place to pigmentation, which cannot, however, be called petechial. The spots no longer disappear, although they grow less distinct under pressure. This change does not usually affect all the spots. Manv of them, under ordinary circumstances, gradually disappear about the middle of the second week of the fever, or at the approach of the crisis. In tlie second week a minute extravasation of blood appears at the centre of some of the pigmented spots, and in certain cases petechiie appear, not as a step in the evolution of the typhus-eruption, but as such from the beginning. The blood-stainings in the site of the spots, and the true })etechi8e, are alike uninfluenced by pressure. The duration of the vari- ous stages of the eruption is by no means constant. In truth, it may come to an end without passing into the rusty color; still less before the appearance of petechias. In some cases the eruption is rusty, or livid and petechial, from a very early stage, or, in fact, from its beginnino-. If death occur while the eruption is pinkish or florid and disappears on pressure, no trace of it is seen in the dead body; but if it has become rusty, or if petechia^ have developed, the eruption is persistent, and upon examination of sections of the skin it is found to be stained by the color- ing-matter of the blood. The subcuticular mottling usually disapDears after a few days, while the spots grow darker and more distinct. Hence, as Murchison has pointed out, the eruption of typhus is pale and blended in the early stages, darker and more spotted in the later periods. True petechia? are neither essential nor peculiar to typhus. In many cases they do not occur at all — in few before the last stages. The erythematous blush which attends the outbreak of the eruption usually quickly subsides. In the later periods of grave cases the. skin grows dusky or livid, especially in the dependent portions of the body. Vibices and larger transudations of blood beneath the skin (ecchj/mo- ses) also occur in grave cases, and especially where scurvy exists as a com- plication, as it did in the war of the Crimea. 280 TllK CONTINUKU FKVKKS. -Murchi.son uunilions "' taelies bhiudtres '"' as occasionally occurring. Snda)ni)ia are occasionally met witli. They are more common before than after the fortieth year of age, and may occur eitlicr Avith or Avithout marked sweating. Desquamation follows the disappearance of the eruption in a limited number of cases. It is fine and bran-like, and proceeds from above down- wanl, but may become coarse or membranous on the hands and feet. The nails show a white band and a furrow as the result of the disturb- ance of nutrition Avliich attends the fever. There is in most instances more or less falling' of the liair during the convalescence. Tl'tlcaria occasionally makes its appearance in young persons about the time of the crisis, or early in the convalescence. JTerpes occurs exceptionally. It may precede the orujition and give rise to brief confusion of diagnosis. It also occasionally appears towani the termination of the disease. Erysipelas has occurred with frequency in the wards of certain hos- pitals, and is due to hospital influence rather than to the processes of ty- phus. It is a serious complication, but not necessarily fatal. It appears usuallv upon the approach of or during convalescence, and is usually con- fined to the face and head. These eruptions are accidental. 77ie general appearance of the patient ill of t^-phus fever is peculiar. It is often of Itself so striking as to Indicate, even to a person of limited experience, the nature of the disease, and in cases of doubt it Is of diag- nostic value. The expression of the countenance, the appearance of the skin, the attitude, considered together, constitute what may be called the ])hysIognomy of the disease. From the first the face Is the index of the grave derangement of the functions of the nervous system that are so ]iroininent. The look is dull and heavy; as Da Costa has well said, it is '"coarser" than in health. It is also most weary. As the case pro- gresses the expression becomes blank and stupid, the eyes are half- closed, or widely open and staring at nothing, and the lips relaxed, l^arted, the lines indicating thought and emotion blurred or altogether blotted out. The facial expression varies with the form of the delirium. In typhomania It Is feeble, fatuous, or silly; In the trembling, which so closely resembles the delirium tremens of alcoholism. It Is eager, rest- less, suspicious, and when the delirium Is active or acute, the expres- sion is often bold and defiant. If it Is at all anxious, it betrays the terror or anxiety due to some fixed, distressing- Idea with which the delirious brain busies Itself, not the anxiety of suffering or suspense met with In many acute diseases, for the pains of typhus are not commonly acute, and it Is rare for the patient to manifest concern as to the Issue of his slcktiess. A uniform general flushing of the face or cheeks Is generally j)resent. 'IVPHUS FKVEK. 281 It may be deepest over tlie cheek-bones, but it is never circumscribed. It is not pink or florid, but of a dull, dusky-red color, or it may be of an earthy or leaden hue. In the advanced stage of grave cases the face is often livid, pai'ticularly about the mouth and nostrils. The eyes are suf- fused and the conjunctivae injected ; sordes collect upon the lips and teeth. The patient lies most veearily upon his back. In the graver cases he is unable to move in bed, or to help himself. He lies with his hands crossed upon his abdomen or extended at his sides, unconscious of or in- different to what ffoes on about him. SYMPTOMS REFERABLE TO THE RESPIRATORY SYSTEM. The respiratory nwveineNts are moderately accelerated during the first week, ranging from twenty to twenty-four per minute in uncomplicated cases. With the advent of delirium and the increased frequency of the pulse which attends the developing prostration, the respiration becomes more hurried and shallower. In grave cases, in which the disturbance of the nervous system is profound, the respiration is sometimes abnormally slow. It is more commonly hurried, aiid may without pulmonary com- plication be irregular, sighing, or jerky. Affections of the lungs, as in enteric fever, are very common. Of these, the most are to be regarded as complications, and will be consid- ered under that heading. But the bronchitis, which is usually present in the first week, appearing coincidently with the nasal and conjunctival catarrh, seems worthy to be regarded as a symptom. It is at first at- tended with but slight cough ; little expectoration, or none at all ; no difficulty and but little quickening of the movements of respiration, and there are detected upon auscultation a few scattered, subcrepitant, sono- rous or sibilant rales. During the second week the bronchitis may become diffuse, and extend to the capillary tubes. This it may do in an insid- ious manner, without much cough or other danger-symptoms except quickening of the breathing. In other cases the pulmonary symj^toms become grave, or they may even predominate so that the case may assume the form that has been described as bronchial typhus. Physical explora- tion reveals subcrepitant rules in all parts of the chest, localized bronchial breathing with dulness, areas of very faint respiratory sounds, or exten- sive hypostatic congestions, or the signs of lobar pneumonia. SYMPTOMS REFERABLE TO THE DIGESTHE SYSTEM. The affections of the digestive tract consist chiefly of perverted func- tions and of catarrlial conditions of the mucous membrane of the mouth, pharynx, stomach, and intestines. 282 THE CONTINUED FEVEKS. Tlic tongue is at first covered with a thick wliitisli or yellowish-white fur. It may remain thus furred and moist throughout the attack in mild cases; but, as a rule, it becomes, at the end of the first or the beginning of the second week, dry and brown or brownish along its middle. In severe cases it is very dry, often retracted into a globular mass, and is coated with a dry, dark crust, which sometimes cracks at several places. In severe cases attended with j^rofound asthenia the tongue is sometimes moist throughout. The tip and edges are usually pale. The deep fis- sures so often met with in enteric fever, and occasionally in relapsing fever, are rare in typhus. The tongue is protruded tremulously, espe- cially in the second week of the disease. It is sometimes protruded with difficulty, or not at all; apparently in some cases from sheer weakness, in others from dulness of intellect, and yet in others on account of its dry and firmly contracted state, Sordes begin to collect upon the gums and teeth, and even upon the lips, about the beginning of the second week. The gums also bleed at times, but this phenomenon is usually associated with a scorbutic tendency. Loss of a2)2>Gtite is complete throughout the attack. A desire for food is very often expressed immediately upon awaking from the sleep that marks the crisis, and it is not a very unusual circumstance for patients to ask for food shortly before the crisis, before any indication of improve- ment as regards the general symptoms is apparent. Thirst is a constant symptom. It varies greatly in urgency, and is excessive in about one-fourth the cases. It is most prominent during the first week, and diminishes or altogether ceases upon the advent of the graver nervous symptoms that set in with the second Aveek. Difficulty in sicallowing occurs in a small proportion of the severer cases. It first appears in the later periods of the disease, and may be due to the extreme dryness of the mouth and throat, or to spasm or paralv- sis of the muscles concerned in deglutition. y^iiusea and vomiting are not common in typhus. Vomiting has been noted in from six to ten per cent, of the cases in some epidemics in which it was made the subject of special investigation. It is in most instances an early symptom, but may recur for a day or two preceding the crisis, and in some cases is confined to the period of convalescence. In dys- peptic persons it may continue throughout the attack. The matters ejected usually consist of thin, gastric mucus tinged with bile. Vomiting may be the forerunner of the symptoms of uraemic toxici- tion, such as general convulsions and coma. Occurring toward the end of the first or th^ beginning of the second week, it thus becomes a symp- tom of the gravest significance, and should direct the attention of the physician to the closest scrutiny of the amount and character of the urine, and particularly to the absence or presence of albumen, if these TYPHUS FEVEK. 283 matters have not already been made, as they invariably should be, the subject of routine examination. Tympany is rare in typhus. In those cases in which it occurs it is a later symptom, and is associated with grave depression of the nervous system. It may so distend the belly and interfere with the descent of the diaphragm as to seriously embarrass respiration. Abdominal ixAin arid tenderness 2.\(i not common. Slight colicky pains may occur during tlie first week, and there is usually a little obscure tenderness in the hepatic region. Pain or deep tenderness localized in the area corresponding to the ilio-cajcal region of the gut does not occur. Hie liver is slightly enlarged in rather less than one-third of the cases. Enlargement of the spleen is discovered in the greater number of cases of typhus by physical examination during life, and this organ is found to be enlarged and softened in about three-fourths the cases examined after death. The enlargement is acute, and may be made out by tlie fifth day. It is less common than in enteric fever, and does not attain the limits common in relapsing and malarious fevers. Co)istipatio}i is very common in typhus. In many cases, however, the bowels are moved regularly, and exceptionally there is diarrhoea. The state of the bowels varies in diiferent epidemics. Lebert mentions that diarrJicea was frequent in tiie typhus epidemics observed by him at Breslau, and ])a Costa and other observers of typhus in the United States luive noted it as a frequent symptom. Spontaneous diurrlicBa is not com- mon in the lighter cases. Of 31 cases noted by Da Costa at Philadelphia, this symptom was present to a marked degree in 13, or 41.9 per cent. Murcliison, on the other hand, informs us that, of 1,782 cases collected from various sources, diarrhoea occurred in only 184, or in 10.32 per cent., while in 059 of 1,739 cases, or 55.14 per cent., there was obstinate con- stipation; and of 14,589 cases admitted to the London Fever Hospital during nine years (1803-70), only 734, or 5 per cent., suffered from diar- rhoea. Of the 734 patients in whom diarrhoea occurred, 178, or 24.25 })er cent., died, while the death-rate of patients in whom diarrhoea did not occur was only 18.14 per cent. Diarrhoea may be present in the early days of the attack, or may occur at any time during its course, either spontaneously or as a result of purgative medicines. It is also observed at the crisis. It is usually mild, but may in rare cases be very trouble- some, or even so excessive as to endanger the life of the patient by the increased prostration to which it gives rise. Involuntary discharges oc- cur in cases of the most serious kind, and commonly upon the approach of death. The stools, when there is diarrlioea, are usually of a dark, greenish brown color, and of a less fluid consistency than in enteric fever; in some cases they are of a light color and watery. In Da Costa's cases the stools were small, thin, and feculent, often offensive, and of a yellowish color. They 284 THE CONTINUED FEVERS. are not coininonly attended by pain or tenderness, altliou«r}i iu rare in- stances the movements are preceded by colicky pains. Complications axd Sequkls. The complications of typhus are numerous. They vary in different epidemics, but sometimes appear to be determined by individual peculi- arities, different members of the sam>e family presenting, when attacked by the disease, the same complications, such as convulsions, iialsies, gan- grene, and the like. The fatal termination is not infrequently due to some complication; and the occurrence of a complication may postpone the critical defervescence or arrest it altogether, and thus prolong the attack to an unusual length, and cause it to end, in cases ultimately fa- vorable, by a gradual defervescence (lysis). The convalescence may be interrupted and greatly prolonged by the development of sequels. Affections of the respiratory tract are common and serious in typhus. A^cute laryngitis, leading speedily to oedema of the glottis, is of occa- sional occurrence. This may occur of itself as a secondary affection, or it may be led in by ulceration of the larynx, by a post-pharyiigeal abscess, by enlargement and suppviration of the parotid or submaxillary glands, or it may occur in consequence of erysipelas. Its advent, either with or without preceding inflammatory processes in contiguous structures, is in- sidious. Slight huskiness may be quickly followed, after a brief period, by laryngeal breathing and the signs of impending asphyxia, rendering prompt larj'ngotomy or tracheotomy necessary to save life. The laryngitis is sometimes croupous, and diphtheria of the larynx and pharynx occur. Laryngeal ulceration is less common than in enteric fever. The obscure onset of the pulmonary complications of typhus has al- ready been alluded to. It is of the utmost importance that systematic physical exploration of the chest be made from day to day. The gravest chest-complications may be developed with but little cough, little or no expectoration, and no complaint of pain whatever. The debility of the patient and his blunted perception serve to mask the special symptoms of lung-trouble. Hurried respiration and increased duskiness of the face are the danger-signals. Bronchitis has already been spoken of. It is, in fact, a symptom rather than a complication. The great danger lies in its tendency to become diffuse and to extend into the finer tubes, and thus, leading to atelectasis and secondary lobular pneumonia, to destroy the patient by cutting off extensive areas of breathing surface. True lobar pneumonia is infrequent in typhus. It is manifested by the usual signs, dulness — crepitus, bronchial respiration, and rusty sputa. TYPHUS FEVER. 285 Gangrene of the Ikhc/ also occasionally occurs; it is manifested by the peculiar and horrible fcetor, supervening' upon the signs of acute inflammatory processes affecting the lungs, the altered look of the pa- tient, and a simultaneous agg'ravation of all the symptoms. It is usually fatal. Pleural ej^'i(siu?is, both serous and purulent, occur in rare instances. Unless the chest be systematically explored they are apt to be overlooked, as they come on insidiously, without pain, and do not greatly embarrass the respiration until they have attained considerable volume. Phthisis is sometimes lighted up during the attack of typhus or in the convalescence. The catarrhal pneumonia persists, and rapid emacia- tion, night-sweats, and muco-purulent sj^uta occur. Jilood-sjyitting is a very rare occurrence in typhus fever. Murchison points out the fact that it may occur in consequence of the pulmonary hyperfemia in a previously diseased lung, or by reason of the existence of the hemorrhagic diathesis. Other hemorrhages are not uncommon in grave cases — not alone when, as so often has happened in camps and armies and in times of protracted scarcity of food, scurvy complicates the disease, but also when no such predisposing cause is present. Bleeding from the nose, the gums, the bowel, the urinary passages, and the vagina, as well as the spitting and vomiting of blood, have been observed. Slight wounds and superficial ex- coriations may give rise to serious or even fatal hemorrhage. These events are unusual. But, in many epidemics, large subcutaneous extrava- sations of blood are common, and after death similar effusions are found beneath the mucous and serous membranes, in the intermuscular planes, and within the substance of the muscles. Polls occasionally break out in numbers during the convalescence. They constitvite a troublesome sequel. Among the rarer complications of typhus is lyymmia with inirulent deposit in the joints. It begins with severe chills, followed by great pros- tration, rapid and feeble pulse, and acute swelling of the joints with ten- derness and redness. There is commonly jaundice and sweating. The smaller joints also, are often implicated. After death the joints are found to contain pus, but abscesses in the internal organs are rare. This com- plication usually apjDears at the time of the crisis, or early in the conva- lescence. Phlegmasia dolens was noted as of common occurrence in the conva- lescence in those epidemics in which bleeding entered largely into the treatment. This complication has been very rare in recent epidemics. When erysipelas occurs, it usually comes on late in the fever or early in the convalescence. Much more rarely it occurs shortly after the begin- ning of the disease. It commonly commences about the root of the nose or the lobe of one ear, and spreads over the face and scalp, sometimes ,286 THE CUJMTINUKD FEVERS. leading to the formation of abscesses of the eyelids and of the integuments elsewhere. The pharynx and larynx are very often implicated in the erysipelatous process, and cedenia of the glottis sometimes results. Ery- sipelas occurs less frequently in other parts of the body. Many cases of er^'sipelas arising at the same time, where typhus fever patients are crowded together in a hospital ward, are to be attributed rather to bad hygienic influences than to the typhus processes. iJiffiise mjiamrnatlou of the subcutaneous tissues, resulting in purulent infiltration, occasionally occurs, most commonly in the lower extremities. It is attended by the symptoms of serious constitutional disturbance and pain in the affected part. Enlargement and suppuration of the parotid gland occur early in many epidemics. Sometimes, however, they are met with about the time of the crisis, and again they may not be developed until convalescence. They occur at all periods of life, but are proportionately more common after the thirtieth year. The tumefaction forms rapidly and suppuration speedily follows. Resolution, however, may occur without the formation of matter. The connective tissue overlying the glands is largely involved in the suppurative process. The parotitis is often associated with facial erysipelas or with extensive inflammatory cedema of the neck. This is a very dangerous complication. These inflammatory swellings occur also in the submaxillary glands, in the mammae, the glands of the axilla and groin, and less frequently in the extremities. Their number is sometimes limited to one or two; sometimes they are numerous. They occasionally result in extensive gangrenous ulcers. In many epidemics they are absent. Parotid buboes and other inflammatory swellings occurring in typhus, sug- gest a relationship between this disease and the true plague. Murchison suggests that typhus is probably the plague of modern times. JBed-sores are not very frequent in uncomplicated typhus. They are apt, however, to occur in cases protracted by other complications. They appear in those parts of the body subjected to pressure, the most common situation being over the sacrum. They also occur in the heels, upon the back of the head, at the trochanters, and over the vertebra prominens. They protract the duration of the illness, and may bring about a fatal termination of the case by exhaustion or b}'' septicaemia. Parts not subjected to pressure may become gangrenous in conse- quence of arterial thrombosis. The death of the tissues is usually preceded by darting pains and the signs of arrested circulation in the part, namely, numbness, coldness, and livid discoloration. The feet and ankles are apt to be involved, less frequently the nose, the penis and scrotum, and the external genitalia in the female. In severe epidemics many observers have noted the tendency of wounds and ulcerated surfaces to become gangrenous in typhus-patients and even in those not suffering from the disease. Under such circum- TYPHUS FEVER. 287 Stances gangrene has resulted from the application of blistei'S and sina- pisms. Perforating ulceration of both corneje occasionally occurs, in conse- quence of the exposure of the globe from the eyelids being kept con- stantly open. JVojna or cancrum oris occurs in some epidemics. It is fortunately a very rare complication, but is fatal in most instances. It is more fre- quent in children than in adults. JVeci'osis is a rare result of typhus, as of other severe fevers. Murchi- son saw in one instance extensive necrosis of the fibula follow an attack of typhus. It is probably secondary to arterial thrombosis. Pericarditis and endocarditis are extremely rare. In rare instances mental feebleness follows the attack; but, as a rule, the intellectual faculties are restored shortly after the crisis. Maniacal attacks sometimes occur during the convalescence. They are usually transient. Palsy may occur as a sequel of typhus fever. It may involve both lower extremities or one-half the body. Numerous examples of hemi- plegia are recorded, and there are not a few cases of right hemiplegia with aphasia to be found in the literature of the subject. In other cases the palsy is restricted to individual muscles or groups of muscles. In very rare instances paralysis of one side of the face has been observed. The paralysis following typhus usually terminates, in the course of some days or weeks, in recovery. It may, however, be persistent. The deafness which so frequently attends the fever usually passes away in the early days of convalescence. Inflammation of the external auditory meatus, or of the middle ear, may give rise to permanent impair- ment of hearing upon one or both sides, and suppurative inflammation of the ear may be remotely followed by secondary inflammation of the men- inges, as in scarlet fever. Transient dimness of vision is occasionally noticed after severe at- tacks (Murchison). It remains to notice some of the comjjlications due to derangements of the digestive tract. Murchison saw one case of acute glossitis in his great experience. The patient recovered after free incision of the tongue. The occurrence of diarrhoea has already been spoken of. (See p. 383.) Dysentery has prevailed in some epidemics, side by side with typhus, and especially in many outbreaks in camps and besieged cities, and has, under such circumstances, become a frequent complication. Jaundice, a frequent symptom in relapsing fever, is very rare in ty- phus. When it arises, it is due either to congestion of the liver, or to gas- tro-duodenal catarrh occurring as complications; or it may be one of the group of symptoms belonging to pyaemia; or, finally, it may appear about the time of the manifestation of the typhus-rash, as one of the expres- 288 THE CONTINUED FEVERS. sions of the overwhelming- action of the poison upon the blood. It is then to be regarded as an ominous indication. If ■)nenstr nation occur during the course of typhus, it may be profuse and even endanger life. Murchison states that he knew of one case in which death was due to flooding. Prereparations for a long time (nine months or longer), and that they may be recognized in the blood thirty-six hours after death. Up to the pres- ent time all attempts to cultivate the spirilli outside the human body have been unsuccessful. Dr. Guttman also describes very minute moving corpuscles, which arc ' Zur Histologie des Blutes bei Febris Recurrens. Virchow's Archiv, LXXX. , 1880. . RELAPSING FEVEE. 313 found in the blood of relapsing fever patients both during and between the paroxysms, but in rather greater numbers during the febrile periods. They are from one-thirtieth to one-twentieth the size of a red corpuscle, and of a round or oval shape. They are not peculiar to the blood of re- lapsing fever, but occur also in that of patients suffering from other acute febrile diseases, as pneumonia, scarlet fever, measles, enteric fever, typhus, dij^litheria, and erysipelas, and in smaller numbers even in the blood of persons in health. They were successfully cultivated in Pas- teur's fluid, and appear to be micro-organisms (mikroparasiten) derived from the atmosphere. Lebert describes the spirilli as follows: "They are exceedingly slen- der, never exceeding in diameter 0.001 mm., and in length, 0.15 to 0.2 mm. Their form is spiral. In their interior I have been unable to make out either fat-particles, sheaths, or structure of any kind. Their motion is very lively, rotary, twisting and rapidly progressive, but soon ceases under the ordinary conditions of microscopic examination Thus far we have sought in vain for this organism in the secretions and excretions, as well as in the internal organs; it is probable, however, that in the future it may also be found in these localities." Up to the present time this variety of protoniycetes has never been found in any other disease. The conclusion that this parasite has to do with the causation and development of relapsing fever is inevitable. It constitutes the conta- gium. These spiral filaments, communicated from individual to individ- ual, spread the disease. Finding in the human body the conditions favorable to their development, they multiply indefinitely. The functional perturbations to which their presence gives rise constitute the phenomena of the fever. It is probable that, under favorable circumstances outside the body, their existence may be prolonged through a considerable length of time. This existence may be latent, yet capable of assuming the most energetic activity when introduced into the human body. Such being the case, the possibility of transmission to remote points follows, and the rise of epidemics at considerable intervals of time and at points far dis- tant from each other is comprehensible without the assumption of the independent origin of the germs of disease, or the new development of an old poison. It is much more in accordance with the general laws of or- ganic development to accept a continuous concealed existence of the germs, than to have recourse to spontaneous generation to account for their development (Lebert). The origin of an epidemic is due to the importation of the materies morbi in the person and belongings of a patient, or in other materials from an infected localitv, or else to circumstances calling into activity germs that have maintained a latent and harmless existence during a more or less extended lapse of time. The history of relapsing fever in all great 314 THE CONTINUED FEVERS. epidemics points to scarcity of food and its attendant evils as the condi- tions favoring the activity of relapsing fever germs. When the disease has appeared in any locality it spreads with great rapidity by contagion, but in every community it forms centres of great- est prevalence. These foci are determined by the dense crowding to- gether of the poor in the most wretched quarters of cities, and by impure drinking-water and stagnant water in the neighborhood of dwelling- houses. The rapidity of the spread of relapsing fever in single houses, or within limited districts, is in proportion to the number of the inhabitants and the amount of intercourse between the sick and those surrounding them. It has been a matter of common observation that when the disease has made its appearance in a house inhabited by several families, the occu- pants of one apartment have been seized one after another, or nearly at tlie same time, that those dwelling upon the same floor have been next attacked, and afterward the neighbors upon the other floors in the order of the intimacy of the intercourse between families. Reid,* of Glasgow, has placed upon record two observations which illustrate the above state- ment. The first is the account of the introduction and spread of the disease at the Dalmarnock colliery in 1843. The colliers, comprising forty different families, occupied a large tenement standing alone in the midst of open fields. It consisted of three stories, entered by three sepa- rate stairways. In May an Irish family took possession of a single apartment on the uppermost story, the youngest child being at the time sick of the fever. On the sec- ond of June the father sickened, and afterward successively every member of the fam- ily. The fever then spread from room to room, and in the space of two months attacked twenty-two persons on this story, the other inhabitants remaining all this time exempt. In the second instance the disease was introduced from a neighboring village into a house of two apartments occupied by eleven persons. All of these were attacked, and every one suffered the relapse ; but in the adjoining house, with a similar entry and separated only by a brick partition, where the occupants were nearly equally nu- merous, and from their circumstances and habits equally susceptible, all escaped. In this connection it is proper to call the attention of the reader to the statement already made, that the attendants upon the sick are very liable to contract the disease. This liability increases in proportion to the closeness of the association between the attendant and the patients, re- quired by the duties of the former. Thus, male and female nurses, and the resident physicians in hospitals, are much more frequently attacked than the visiting physicians. In fact, in general hospitals it is only those who are brought into close relation with relapsing fever cases, or who wash ' The New Form of Fever at present Prevalent in Scotland. By W. Reid, M.D., London Medical Gazette, vol. xxxiii , 1843. BELAPSING FEVER. 315 their clothes or bedding, that contract the disease. Nurses in the medi- cal wards into which fever cases are not admitted, and those in the surgi- cal wards, as a rule escape. My colleague, Dr. Morris Longstreth, at the time when, as residents in the Pennsylvania Hospital, we had the opportunity of observing re- lapsing fever in the wards during the epidemic of 18G9-71, contracted the disease. The records of every epidemic abound in instances of the communication of the fever from patients to their attendants. Dr. Welsh' wrote in 1819, as follows: " When acting as clerk to Dr. Hamilton, in the Royal Infirmary, in the course of four months my three colleagues, two of the young men in the apothecary's shop, two housemaids and thirteen or fourteen nurses, caught the disease, and the matron and one of the dressers died of it. Since I left the infirmary, three more of the gentlemen acting as clerks, one of the young men in the shop, and many more of the nurses, have caught the infection, but the number I do not know. Since Queensbury House was opened, on February 23, 1818, my friends, Messrs. Stephenson and Christison, the matron, two apothecaries in suc- cession, the shop-boy, washer-woman and thirty-eight nurses, have been infected; four of the nurses have died. With the exception of two or three nurses, who have been but a short time in the hospital, I am now the only person in this house who has not caught the disease within the last eight or ten months. Several students, whom curiosity led too near the persons of the patients, might be adduced as additional evidence. When it begins in a family, we always expect more than one of them to be affected. I could mention instances of four, five, six and seven being sent to the hospital out of one family; eight, nine and ten out of one room; twenty and thirty out of one stair; and thirty and forty out of one close; and this all in the course of a few months." Writing of the fever of 1843-44, Dr. Wardell " states that " most of the medical officers con- nected with the Edinburgh Royal Infirmary and additional fever hospitals were seized with it; eight of the resident and clinical clerks in quick suc- cession became aftected, and out of that number no less than six were yellow cases, and thus obviously in danger of their lives. The majority of the nurses and domestics took the disease, and of the former, at one time no less than nineteen were laboring under it. Some of the dispens- ing physicians and other practitioners took the disorder, as also several of the clergy and visitors of the sick, whose duties brought them to the bedsides of the patients. The few cases occurring among the higher classes resident in the new town were generally to be traced to the in- ' A Practical Treatise on the Effiracy of Bloodletting in the Epidemic Fever of Edinburgh, illustrated by Numerous Cases and Tables, extracted from the Journals of the Queensbury House Fever Hospital. By Benjamin Welsh, M. D. Edinburgh, 1819. * The Scotch Epidemic Fever of 1843-44. London Medical Gazette, xxxvL-xl. 1&46-47. 31G THE CONTINUED FEVERS. lluence of contagion, the parties affected having had either immediate or indirect coniinunication with th'ose sufEering under the disease." Cor- mack,' in his account of the same epidemic observed: "Almost all the clerks and others exposed to the contagion have been seized. Dr. Heude, and his successor Mr. Reid, in the ISew Fever Hospital, Dr. Bennett, my successor there, Mr. Cameron and his successor, Mr. Balfour, in the adjoin- ing fever-house, as well as most of the resident and clinical clerks in the Royal Infirmary, have gone through severe attacks during the past summer and autumn. Hardly any of the nurses, laundry-women, or others com- ing in contact either with the patients or their clothes, have escaped; at one time there were eighteen nurses off duty from the fever; and of those who have recently been engaged for the first time, or of those who have hitherto escaped, one and another is from time to time being laid up." Murchison informs us that, " in the London Fever Hospital, during the years 1869-70, twenty-seven of the nurses and officers, and five patients contracted relapsing fever. One nurse, who had been in the hospital for nearly twenty years, and had passed through typhus, had a severe attack of relapsing fever shortly after the first cases of the disease were ad- mitted." Persons in health, from localities where the disease is unknown, are attacked upon coming in contact with the sick in an infected community at a distance. The pestilential centres of relapsing fever are in all in- stances limited to the quarters of cities and like districts inhabited by the poor, while persons living in easy circumstances and in opulent neighborhoods, under favorable conditions of public and personal hygiene, as a rule wholly escape. This immunity ceases, however, upon their vis- iting the sick. On the other hand, relapsing fever is, in every epidemic, liable to be imported by infected persons into localities before exempt. The history of the march of the disease in the epidemics of Great Britain sufficiently illustrate this statement. It is also stated that it was carried in this way from St. Petersburg to other cities in Russia, and most writers are agreed that the American outbreaks were due to importation from the other shores of the Atlantic, although it was not possible to trace its route. It is certain, however, that in several of the local epidemics out- side of Philadelphia and New York the disease was brought from those cities by persons who had been in contact with the sick. The following striking example of the contagion is narrated by Parry : " A man left Philadelphia about February 1st. remaining for two months in West- em Pennsylvania. During his absence his health was good, and he had no known opportunity to take any disease. On returning home he spent several days with a ' Natural History, Pathology and Treatment of the Epidemic Fever at present pre- vailing in Edinburgh and other Towns. By J. Rose Cormack, M.D. London, 1843. RELAPSING FEVER. 317 friend in the. second paroxysm of relapsing fever. He then went to his brother's, and ten days after reaching the city was seized with mild relapsing fever, and was sick five days. In about two weeks his brother's wife was taken and had it se- verely. Subsequently another case occurred in the same family. During the re- mission this same man went to his brother-in-law's in a distant portion of the city. Here he had the relapse, which lasted four days. This family consisted of six per- sons, four of whom were children. Only one of the six, the mother, escaped. It ia worthy of note that the youngest children, who were most exposed by being with their uncle, and who were aged respectively four and six years, were taken first on, the eleventh and twelfth days after their relative reached the house. The older ones, who were nearly grown up and engaged at work during the day, did not take sick until the younger ones were in the relapse." Ill hospitals the nurses and attendants have never contracted the dis- ease until after the admission of relapsing fever patients. Without doubt it is in many instances communicated from the sick to the well by direct contagion, that is, by actual contact. Hence, it spreads rapidly in chambers and iiouses occupied by large numbers of destitute persons, and in the lodging-houses frequented by the vagabond poor. But it is also largely communicated by fomites. In this way only can be explained the great liability of the laundry- women in hospitals to con- tract the disease without direct contact with the sick, and under circum- stances that render it in the highest degree improbable that the poison reaches them either by means of the atmosphere or of drinking-water. Parry relates the following instances in which relapsing fever was trans- ported to a distance by infected clothing: " A family lived in a healthy neighborhood and were in comfortablG circumstances. One of the eons was employed in a factory, where they procured a new hand, who, it was afterward learned, had just left a hospital where he had been ill with relapsing fever. From him the son purchased a pair of overalls and carried them home. On April 19 th one of the sisters washed them. She was taken ill with the fever on May Ist. At the same time this garment was handled by two other sisters, who fell sick on the 2d and 3d of May, respectively." " A woman learned through the newspapers that her husband had been picked up ill in the street and taken to the Philadelphia Hospital. He had not been home for some time before. On March 21st or 22d she sent a friend to the hospital to learn his condition. She found him dead, it was stated, from relapsing fever. She went to the dead-room and identified his body, which was not brought away for burial. She carried his clothing to her own home and placed it in a room next to her chil- dren's bed-room, with an open door between them. Four cases of the disease afterward occurred in the family. On April 7th, a boy was taken, April 25th a girl, April 29th another girl, and on May 3d her husband. There had certainly been no cases in the immediate neighborhood before that time." It is in the highest degree probable that the disease can be communi- cated by means of the atmosphere. But the distance to which the poison can be transported in this way in sufficient concentration to produce the 318 THE CONTINUED FEVERS. disease cannot be very great. Those only who are in close communica- tion with the sick, or who visit them in their ill-ventilated quarters, or who reside near at hand, suffer. With free ventilation the disease almost ceases to be communicable (Murchison). Lebert deems it worthy of re- mark that in all epidemics occurring in his wards, in which thorough ventilation is maintained summer and wdnter, cases of contagion have been exceedingly rare. The danger of contracting the disease through the atmosphere appears to increase with the length of the exposure. In a few instances the dis- ease has seemed to follow promptly upon exposure. The poison in these cases must have been very concentrated. As a rule, the resident physi- cians in hospitals are more apt to contract relapsing fever than dispensary physicians who visit their patients in their badly ventilated houses, and, remaining but a short time, have constant opportunities to breathe an un- contaminated air in passing from house to house. The length of time necessary to contract relapsing fever by exposure to the atmosphere of the sick-room without actual contact is longer than in the case of typhus. Finally, Lebert ascribes great importance to drinking-water as a carrier of the infecting principle. The pathogenetic protomycetes thriving in it may infect many persons in the same house at the same time, or in rapid succession, as is seen in cholera. The researches of this observer, in 1868 and 1869, show that in 27 per cent, the interval between new cases in the same house was only 1 day; in 16 percent., 2 days; in 11 per cent., 3; in 5 per cent., 4; in something over 6 per cent., 5; in 6 per cent., 6; and in 4 per cent., T days. In other words, 75 per cent, occurred within the first week, and 54 per cent, within the first three days. It follows from these figures, he adds, that too much stress must not be laid upon the transmission of the disease from individual to individual by direct con- tagion, and he regards the simultaneous or nearly simultaneous infection of several persons by means of drinking-water as the most probable expla- nation of the facts. He informs us that the nidus of typhus and relapsing fever in Breslau was in a quarter of the city supplied by such impure drinking-water that a whole fauna and flora might be found in it. TTie period of incubation of relapsing fever is variable. In some rare instances it has been absent, the symptoms following immediately upon the first exposure to the contagion. According to Murchison, it varies from five to sixteen days. Parry estimates it to be from seven to fifteen days. Lebert states that it is from five to seven days. The number of accurate observations bearing upon this point is limited. Ao immunity from subsequent attacks is experienced by those who have suffered from relapsing fever. Observers have recorded the occur- rence of second and even third attacks in the same individual, within the course of several months, in almost all epidemics. In this respect relaps- ing fever presents a striking contrast to typhus, and, in fact, to most of RELAPSING FEVER. 319 the other infectious fevers. Dr. Christison' remarks that, during the epi- demic of 1817-19, he experienced no fewer than three separate attacks in his own person, within fifteen months. As has been already pointed out, there exists a remarkable association of relapsing fever with typhus in epidemics. Prior to 1843, the former fever was looked upon as a mild form of the latter. To Dr. Henderson,' of Edinburgh, is due the credit of having first pointed out their essential difference. He showed that they were characterized by different symp- toms, and stated his belief that they arose from different poisons. His views, which were confirmed by many other observers at that period and since, were based upon the two-fold proposition that, first, the one fever under no circumstances gave rise by communication to the other; and secondly, that an attack of typhus never conferred immunity from relaps- ing fever, any more than the latter afforded protection from typhus. Henderson and others found that only in the rarest instances, cases of relapsing fever and of typhus fever occurred at the same time in the same house. On the other hand, numerous excellent observers have re- corded instances of the association of the two fevers in the same house and even in the same room. This discrepancy is to be readily explained by the manner in which the two diseases are associated in most epidemics. In circumscribed localities there was the same sequence of the two fevers as was found in studying the history of wide-spread epidemics: at first, relaps- ing fever only; then relapsing fever and typhus together; and, last of all, typhus alone (Murchison). Cases in which relapsing fever follows upon typhus in the same indi- vidual are rare; but the instances in which the order of events has been reversed, and the latter has followed relapsing fever in the course of a few weeks or months, have been so numerous as to attract the attention of most observers. Lebert collected accurate statistics of fifty-three cases of relapsing fever in which an attack of typhus occurred at an interval of from several weeks to a few months later. The subjects were mostly be- tween fifteen and sixty years of age. The mortality of typhus in those cases was 7.55 per cent., half the death-rate of the other typhus cases. Whether this lowered death-rate was the result of the chance association of favorable cases, or of an influence on the part of the forerunning relaps- ing fever poison, which rendered that of typhus less dangerous, remains unsettled. The peculiar relationship of relapsing and typhus fevers, both as re- gards the individual and as regards the community, point to an affinity ' On the Changes whicli have Taken Place in the Constitution of Fevers and In- flammations in Edinburgh duriug the Last Forty Years. Edia. Med. Journ., Jan., 1858. - On Some of the Characters which Distinguish the Present Epidemic Fever from Typhus. Edin. Med. and Surg. Journ., vol. xli., 1844. 320 THE CONTINUED FEVERS. between them that, in spite of their essential difference, cannot be acci- dental. Clinical History. Relapsing fever is divisible into four distinct stages. These are, in ordinary cases : the primary paroxysm, the intermission, the relapse, and * convalescence. The attack begins abruptly — a prodromic stage being, as a rule, absent. If prodromes occur at all, they are of short duration, and consist of general malaise, dull pains in the head, wakefulness, loss of appetite, and the like. The speedy onset of the disease is characteristic. On waking in the morning, or in the middle of the day while engaged in their ordinary pursuits, more rarely later in the course of the day, or at night, the pa- tients are seized with high fever, ushered in with a sense of chilliness in about half the cases, and with a decided chill in a much smaller propor- tion of them. When the disease begins with a rigor, it recurs in some instances irregularly during the first two or three days; and, as sweating is often, though by no means in all the cases, present during this period, a superficial resemblance to the paroxysms of intermittent fever may arise. The sweating usually breaks out upon the face and upper parts of the body, while the rigor continues without the intervention of a distinct hot stage. In other instances sweating does not occur till the second or third day, when it may be profuse and continue for several hours, without re- lief to the headache or other symptoms. The skin is, during the paroxysm, frequently bathed in sweat, while the temperature remains high. There is debility from the onset, and this, with the giddiness, headache, and pains in the joints and muscles, compels the patient to betake himself to bed at once. In the lightest cases he is able for a time, or even through- out the attack, to continue his avocation. In a little time after the initial symptom the skin becomes dry and very hot ; there is intense thirst and great aggravation of the pains ; appe- tite is lost, and nausea and vomiting are common, sometimes persistent. The vomited matters consist of a greenish fluid. The temperature rises rapidly. The morning following the onset it may exceed 39° — iO° C. (103.2° — 104° F.), and, assuming an irregular and faintly marked inter- mittent type, it mounts, in the course of a few days, some degrees higher — 4i°— 42° C. (105.8°— 107.6° F.). The pulse is frequent, usually exceeding 110, often 120, and occasionally beating as often as 140 — IGO per minute. The difference in the frequency of the pulse in the morning and in the evening is but slight. It is of moderate fulness and tension, often quick, sometimes dicrotic. The tongue is usually moist, and covered with a white or yellowish — IIELAPSINO FEVER. 321 white fur of varying thickness ; it is apt to continue thus coatedthrough- out the paroxysm ; in a small proportion of the cases it becomes dry, or shows a dry, brownish streak in the middle. The bowels are constipated, or rarely there is slight and somewhat persistent intestinal catarrh. In a varying proportion of cases, but without great frequency, jaun- dice appears during the course of the first paroxysm. There is no char- acteristic eruption ; sudamina appear late ; herpes facialis occasionallv occurs. The skin is, as a rule, moist after the first few days. In many cases it remains dry until the crisis. As early as the second day a feeling of distress in the upper part of the abdomen is complained of. This approaches more nearly to actual pain in the left hypochrondium than in the right (Lebert). Physical ex- amination reveals enlargement of the liver and a rapidly progressive in- crease in the size of the spleen, which not infrequently reaches below the ribs. There is marked tenderness in the epigastrium and in the splenic and hepatic areas. At the commencement of the attack, pains in the back and joint-pains are marked. To these are speedily added distressing muscle-pains in all parts of the body, as well as in the upper and lower extremities — but most severe, as a rule, in the calves of the legs. These pains are described by the patients as stabbing, burning, grinding. They are present when the body is in repose, but are aggravated both by movement and by pressure. After the first days the headache lessens, but the muscular pains persist. The patients lie motionless to avoid the increase of pain which change of position induces. Sleeplessness is a distressing symptom. Pain prevents sleep. The mind is clear. The expression lacks the dulness of typhus and enteric fevers ; delirium is rare. Epistaxis occurs, but with no great frequency. It is more common iu childhood than in adult life (Parry). The urine presents the characters of febrile urine in general. It more- over not infrequently contains albumen. When jaundice is present, it contains bile-pigment. Upon the fifth, sixth, or seventh day, as a rule, but sometimes as early as the third, very rarely as late as the tenth, the sickness apparently comes to an abrupt end. The symptoms, in some instances having even augmented in severity, suddenly cease. The change is mostly attended by a critical discharge, usually by a profuse sweat, sometimes by diar- rhoea, more rarely by bleeding from the nose, rectum, or vagina. In rare instances the crisis is preceded by a brief, violent delirium. The tempera- ture, usually during the course of the night, falls to a point below the nor- mal standard, the pulse becomes much less frequent, the skin cool. The breathing, which has been hurried, becomes normal, the pains in the muscles, and the headache lessen greatly, or cease altogether. Thirst no longer 21 322 THE CONTINUED FEVERS. torments the patient, the tongue cleans, appetite returns, the liver de- creases in size, and the spleen contracts almost as rapidly as it augmented in volume; epigastric tenderness disappears, and jaundice, if present, be- criiis to fade. To all the evidences of a severe, even alarming illness, have rapidly supervened a condition of comfort and apparently almost com- plete convalescence. But for a feeling of weakness, the patient regards himself as well. His strength augments from day to day, and he arises and moves about — often, if in hospital, insisting upon going to his home, in disregard of the warnings that he will suffer a relapse. During the intermission, in most cases, the convalescence is rapid and the patient in truth resumes the appearance of health. The appetite is usually excellent. In many cases, however, there is a notable slowness of the pulse — 40 to G8; in not a few the first sound of the heart is" faint, sometimes almost inaudible, while the second is relatively intensified. Great muscular weakness, and even paresis of the lower extremities, have been observed at this period. The spirilli of Obermeier, constant during the periods of pyrexia, are not now found upon microscopic examination. The jDeriod just described usually lasts about a week. In some in- stances it does not exceed four or five days; in others, it may extend to two weeks, and in very rare cases the first paroxysm has comprised the whole of the attack, not being followed at all by a second pyretic period. Between the twelfth and twentieth days from the beginning of the at- tack, but in by far the greatest number of cases, on or about the four- teenth day, the patient, unexpectedly to himself and with the same sudden- ness as before, again falls ill. Commonly in the night, biit sometimes during the day, the relapse sets in. Its advent is attended by chilliness or a decided riofor, or it may be marked by fever without either. The symptoms are a repetition of those of the primary paroxysm. There are the headache, the pains in the back and limbs, the hot skin, the abrupt high fever, the rapid action of the heart, the furred tongue, vomiting, con- stipation, tenderness in the epigastric zone, that characterize the earlier sickness. The liver and spleen again undergo rapid augmentation in volume, and upon microscopic examination the spirilli are found in num- bers not less than before. ^Yith the approach of convalescence their num- ber again diminishes and they finally disappear. It may be stated that, as a general rule, the symptoms of the relapse are less severe than those of the first febrile period; exceptionally tiiey are more so. The tvpe of the fever of the second paroxysm is more dis- tinctly remittent than that of the first, marked remissions occurring in the morninof, decided exacerbations toward niofht. The length of the relapse is usually about three days; it is occasionally almost abortive, not exceeding a day; at other times it may be extended to five davs or more. RELAPSING FEVEK, 323 The second crisis, like the first, commonly sets in during- the night, and is attended by abundant sweating and a fall of the temperature below the normal, with a corresponding decrease in the frequency of the pulse. The second defervescence is in some cases also preceded by a brief but marked intensification of all the symptoms. Occasionally a second relapse, attended with symptoms similar to those of the first and lasting two or three days, occurs on or about the twenty- first day. Less frequently a third, and still less frequently a fourth re- lapse, has been observed. x\t the termination of the disease the condition of the patient is com- paratively comfortable. The fever ceases, the pains disappear, appetite is, in most cases, speedily regained; but the loss of strength and the ema- ciation are such that a number of weeks must elapse before the sufPei-er is suflSciently restored to health to resume his ordinary avocations. The whole period, from the beginning of the sickness till complete convales- cence, is, upon an average, six weeks. Anaimic murmurs often jjei'sist for a still longer period. The death-rate varies between two and four per cent., differing in dif- ferent epidemics. Death may occur from the intensity of the fever and the consequent exhaustion, usually at the close of the relapse, or by pro- gressive exhaustion, after several relapses. Occasionally a sudden fatal termination takes place at the crisis, by failure of the heart. Death is due, in some instances, to suppression of urine, with coma and convul- sions. It may also result from pyaemia following softening and abscesses of the spleen, and the last-named lesions have by rupture caused fatal peritonitis. Pregnant women almost invariably abort or miscarry during the course of relapsing fever. This accident exceptionally occurs in the first par- oxysm, commonly in the second. The foetus, even at the approach of term, perishes, and the life of the mother is often, though not invariably, lost. Death is frequently the result of this and other complications, par- ticularly pneumonia, or of the aggravation of previously existing severe disease. In relapsing fever, as in other epidemic diseases, abortive cases are not infrequently encountered. Cases of this kind may terminate with a single febrile paroxysm, attended with symptoms of moderate intensity, sometimes indeed so light as not to compel the patient to take to his bed, or a second paroxysm of short duration and little severity occurs. In view of the protomycetic basis of the disease, it is difficult to com- prehend the varying intensity of the attack. The numbers of spirilli dis- coverable in the blood have not always been proportionate to the severity of the symptoms. There is, doubtless, a different degree of tolerance of the presence of this particular parasite in different individuals. In the words of Lebert, " it is possible that, according to the predisposition, a grave difference may result as regards the pyrogenetic products." 324 THE CONTINUED FEVEKS. Cormack,' iu his description of the epidemic of relapsing fever in 1S43, referred the cases to two general groups. Of these, the first he called the ordinary or moderately congestive form. This included the common, mild, and average cases, which were rarely fatal except in consequence of some complication. The second he termed the Juyhly cony estive form. In tliis form a deep, persistent, purple color of the face, intense jaundice, marked enlargement of the liver and spleen, hemorrhages from the mucous tracts, drowsiness, delirium, aiid subsultus were prominent symptoms. The paroxysms in the graver form were separated by a period of remission rather than by a distinct intermission. These cases were rare, but often fatal, the patient falling into a condition of collapse, which often lasted for some days before death occurred. This form corresponds with that which has been described by recent observers as " bilious typhoid.''^ It has occurred with varying frequency in many of the epidemics of relaps- ing fever, and has had much to do in determining the high death-rate in some of them, notably in the Russian epidemic of 1864-65. Bilious ty- phoid, which has not occurred in any of the outbreaks of relapsing fever in America, was first fully described by Griesinger,^ who observed it at Cairo in 1851, and gave it this name. ANALYSIS OF THE PrIXCIPAL SyMPTOMS. SYMPTOMS REFEBABLE TO THE NERVOUS SYSTEM. Headache is an early and persistent symptom. It subsides with the cri- sis only to recur with the relapse, in which it is, however, often somewhat less intense. It is commonly frontal, sometimes general, and is throbbing or darting in character. In rare instances it is mild, and ceases after a day or two. Vertigo is very common. It occurs as an early symptom, and patients often declare that it is the giddiness rather than the fever that forces them to take to bed speedily -after the onset of their illness. This symp- tom continues throughout the primary paroxysm, and returns in the re- lapse; it causes the patients to stagger like drunken persons when they attempt to stand or walk. Delirium is rare. When it exists it is transitory, but is apt to be ac- tive and noisy. It occurs for the most part in hysterical or intemperate persons. In most cases the mind is unclouded throughout the attack. Stupor and coma occasionally come on rather suddenly at or soon ' J. Rose Cormack, M.D. : The Natural History, Pathology, and Treatment of the Epidemic Fever at present prevailing in Edinburgh. Edinb. , 1843. - See Yirchow's Ilandbucli der speciellen Path, und Therap. Band II., Zweite Abtheil. ; also Dr. Van Ilarlingen's translation in Lebert's article in Ziemssen'e Cyclo- paKlia, vol. i. liELAPSING FEVER. 325 after the crisis, in consequence of suppression of urine. They may be attended with general convulsions. The patient may sink into persistent stupor, with dry, brown tongue, muttering delirium, and the attendant symptoms that make up that condition known as the " typhoid state," in consequence of the intensity of the fever. This is rare, but v?hen it takes place the crisis does not occur, and the condition is one of the greatest danger. Insomnia is often marked, and occasions great distress; it is in large measure due to the pains. In the cases observed by Dr. Parry it was a much more prominent symptom in the early than in the later months of the epidemic. Sleeplessness attended in many of his cases the primary paroxysm, the remission, the relapse, and the period of convalescence; it did not yield to the administration of hypnotics. Toward the end of the outbreak it was a less gi-ievous symptom, and was easily controlled by lemedies. Debility is an early symptom. That it should become marked toward the end of the sickness is apparent from a consideration of the symptoms that attend the attack. In most instances, however, the patient is able to get out of and into bed again, and to help himself. Pain. — Among the more characteristic and distressing symptoms of relapsing fever are the severe joains in the muscles and joints complained of by almost all the patients. Pain in the back is severe during the first few days. The other pains are also present from the beginning; they continue throughout the paroxysm and the relapse. In many cases they are also present during the intermission; at this period they are apt to be more distinctly articular, but are unattended by swelling or by any grave difficulty of treatment. The muscle-pains are seated in the neck, chest, and abdomen, as well as in the extremities; they are usually most severe in the lower limbs, and in particular in the calves of the legs. They arise spontaneously, but are also excited by pressure and by volun- tary movement, and compel the patient to preserve as nearly as possible a motionless attitude in bed. They are described as resembling the neu- ralgic pains that follow unaccustomed or over-prolonged use of certain groups of muscles. Subsiding during convalescence, they leave behind them marked muscular weakness. Muscular palsies will be considered among the sequels. Retention of urine and involuntary evacuations are very rare. When they occur, it is in consequence of sudden syncope or cerebral complications attendant upon urasmia. Involuntary fecal discharges are sometimes due to ex- treme diarrhoea in grave cases. Tremors are not observed except in the subjects of previous alcoholism. 326 THE CONTINUED FEVERS. THB PHENOMENA OF THE FEVEB. The temperature rises with great rapidity, and attains a height infre- quent in the other fevers. Its course is characteristic of the disease. During the initial rigor it is often as high as 39° C. (102.2° F.), and within twenty-four hours it attains 40°— 41° C. (104°— 105.8° F.). The maximum of temperature may be attained upon the first day, during the mid-course of the paroxysm or shortly before the crisis; the last is the most frequent, and at this period the temperature occasionally runs up rapidly in the course of a few hours. The curve is irregularly remittent, the morning temperature being from 1° to 1.5° C. (1.8° — 2.7° F.) lower than that of the midday or evening. Occasionally the remissions are much more marked, but the variations are neither constant for different days nor for the same hour of successive days; in some cases they do not amount to more than a few tenths of a degree, and it is not uncommon to note a higher temperature about noon, or early in the afternoon, than in the evening. In rare cases the diurnal curve shows no remission what- ever, the evening and the morning temperature being alike. The remit- tent type is most constantly present, and is most distinctly marked in children. In no other disease is so decided and so rapid a critical defervescence met with as in relapsing fever. It is always sudden, very frequently preceded by an increase in the severity of the symptoms, and sometimes ushered in Avith a chill. It commonly occurs in the evening or toward morning, and is complete as a rule in the course of a few hours. The temperature falls from 3° — G° C. (5.4° — 10.8° F.) in cases that may be spoken of as average instances, and it is not uncommon to observe a fall of even 7° C. (12.G° F.) within a short time. Murchison informs us that falls of 13° F. in six, and 14.4° F. in twelve hours, have been noted. A comparison of the temperatures of the febrile paroxysm and the fall during the defervescence, indicates a subnormal temperature as almost constant at the termination of the crisis. This is found to be the case. It is not rare to find the temperature at this period as low as 36° — 35° C. (9G.8° — 95° F.), or even much lower. According to the author last re- ferred to, 94° F. and even 92° F. have been recorded, and, in one instance where collapse supervened, a rectal temperature of 90.6° F. was observed. After two or three days it rises to the normal in the morning, and becomes subfebrile in the evening, and then, becoming that of health for a time, it again rises slightly upon the approach of the relapse. A temperature of 39° C. (102.2° F.) or more, attends the onset of the relapse, in which the same rapid rise to a great height, and an even more rapid fall to below the normal standard than in the primary paroxysm, are encountered. The maximum tempei-ature of the whole attack is not in' RELAPSING FEVER. 327 IIIIIIIIIIIIIIIIIIIBIIIIIIIIIIIINIIIII wsassmmtmmm iinniiiiiiiiiiiiilillliiiiiiiiiiiiiniis ■■■■■■■■■■■■■■■■ ■— ———asBsssBagga a ■■gailllllllMMWiMmiiiiilUBiffiBI ■linisiiiHiiiiiiiiiiUHliiiiiiiiiiiiiii ■ ■III ■III ■nBH ■inniiHniiiniiiiiiiniiiiiiiiSiiinii HiHumiiiiiiiiiiiiiliiHiiiiKSiiiiin BininuHnniiiiiiiniimiiiiK!^ iMiiniiiiniiiniinp""""""'" linnHiiiiHimiii! iiiiiininiiiiiHiiii HinillllHinniMnBHEisSSSiSninH I 3 28 THE CONTINUKD FEVEKS. frequently met with in the ruhipbc. The crisis is acconi})anied by free perspiration. If other relapses follow, the temperature curve attending^ them is the same, but the fever is of shorter duration. The maximum temperature of relapsing fever varies from 41° to 42" C. (105.8° — 107.G° F.) in cases that cannot be looked upon as exceptional. A temperature of even 42.5° C. (108.5° F.) has been observed. These ex- cessively high temperatures, if not long continued, are not attended with great danger to the patients, nor do they give rise to cerebral symptoms. In this respect relapsing fever differs from other diseases characterized by intense pyrexia. The foregoing statements are based upon observations of temperatures taken in the axilla. The pulse is always frequent. It is commonly above 112, but may vary from 90 to 120, or even beat as rapidly as 160 or 170 per minute. It is more frequent by 20 or 30 beats in childhood than in adult life. This frequency is attained very early in the course of the disease. It is not of unfavorable prognostic omen. The number of beats per minute in- creases toward evening and with a rising temperature. A gradual or progressive increase does not occur with the progress of the attack, al- though it is not uncommon to find a sudden increase in pulse-rapidity, as well as a decided sudden rise in temperature, immediately preceding the crisis. With the defervescence there is a sudden fall in the pulse-rate to the normal, and often below it. In a few hours, declining a little before the temperature begins to fall, it may change from 140 to 48 — 54. During the intermission it is often abnormally slow, 40 — GO; but if the patient leave his bed it becomes more rapid, 100 or more upon his assuming the upright posture, and continues to beat rapidly. There is no constant ratio be- tween the rate of the pulse and the temperature. Murchison states that there is less correspondence between them in the relapse than in the pri- mary paroxysm, a pulse not exceeding 90 being sometimes met with where the thermometer marks a temperature of 106° F. The pulse during the febrile paroxysms is often at first full and tense, but with the crisis it becomes small and feeble, and is often jerking and irregular; after the crisis it is compressible, and not seldom dicrotic. With convalescence, as the patient gains strength, the pulse resumes its normal character. About the time of the crisis, and in particular immediately after it, the impulse and first sound of the heart are often very greatly impaired, and sudden death from syncope may take place. Within the course of a few days, and with the use of stimulants, the heart regains its power. A soft systolic murmur is heard over the cardiac region during both paroxysms in frequent cases and sometimes in the intermission. Its area of greatest intensity is at the base; it is propagated in the course of RELAPSING FEVER. 329 ^liliiyHMiBHiillH tllW— MmitimiHMmMii amisinaisissssiimiuiBssgSiHBHassHHs e§iaissii»isiis8sa88iissiisiismsi8is p^SKHssssanuaigsiKssBssssiiBsAiiis KsmiMESraHinninnnniinpniiiiiiiiiiiiiiiiiEi iaailiHiUHinimiiniiHiniiiinniniiSBiKiniii ^■■■■■■■■■■■■■ii III IIUIIIIIIIliL iHiiiHiiiiiinii iiiiii|Hir mil iiiiiniiiu ^nu^miiiiiiiiiiii iiniijiaiinspiiiiiiiiHii riljiiiniiiiEriiiiiiHiHii duiiisSsKSiMiiiiiuiiiiiiiiiiiii mniiiiiii ^^iniiliiiniiiiiiiiiiii HIHHMKSaZgggggiiMllMMHimWHHlHmHHHiM ■■liiiiHiiiiiiHiiiiiiimBiiiissliiiiiiHiiiiiiiiiii ^ Ol MiiinnBnraifasisnmsssga^^^^ lama III! miiiiiii MB ^liiiiiiiiiniiiii inii^HHiiiiiiiiii ■■MlMMHIMHliniliiMMlMliiHiiiiiB>gs==B=M IIII«fi5ss=s«wwii||i!ailllllHllinilllllllll|llll| iHiiihiiuisliiiiiliiiiiiiiiiiiiiiuiiiiiiniiiiiiifi IininiiKiiiiii!! iiBinniiissES! ■■■■■^■■■■■■MMIMHlWHHMIMMIHIHmWWBWB iniiiiiiiiiiiiiHiiiiiiiiiiiiiiiiiiiiiniiiiiiainiiM IHl 330 THE CONTINUED 1-EVEKS. the great vessels, and becomes faint or is lost entirely in the erect po- sition. The urine presents the characteristics of febrile urine in general. Its amount varies with the quantity of fluids ingested, and is influenced by the abundant sweating that occurs at the crisis, and, in many cases, during the progress of the febrile paroxysms. As a rule, it is diminished in quantity during the febrile stages, and of darker color and higher specific gravity than normal, and becomes normal or even increased in quantity shortly after the crisis. It is frequently cloudy, and deposits a sediment consisting of the urates; less often uric acid is present, and crystals of the oxalate of lime. It is commonly acid in reaction, but occasionally alka- line when passed. The triple phosphates are present in the latter case. In some cases the amount is greatly reduced immediately after the crisis, the patients being exceedingly weak and sweating profusely. Two cases under Parry's observation did not void more than an ounce in twenty- four hours for several days, yet there was no evidence of uraemia. Albumen in small amounts is often present in the urine during the primary paroxysm, and Murchison reports a case in which copious h.nema- turia occurred in both paroxysms, although the urine during the interval contained no trace of albumen. Recovery took place. Tube-casts are found along with the albumen. In the first paroxysm they are usually hyaline, in the relapse they contain granular matter and oil-particles. If pre-existing Bright's disease complicate the case, the character of the urine, especially as regards the quantity of albumen and the nature and abundance of the renal casts, will be modified. The opinion of Obermeier,* that acute desquamative nephritis is one of the ordinary phenomena of relapsing fever, calls for a closer examination into this point in future epidemics. It is not confirmed by other recent observers. In cases com- plicated with disease of the kidneys, and under other circumstances, marked diminution or suppression of urine has been followed by ursemic symptoms, such as delirium, stupor, coma, and convulsions. This con- dition is apt to supervene at or about the time of the crisis. Such pa- tients have in many instances recovered after a copious discbarge from the kidneys. Murchison states that he " has never known typhoid symp- toms in relapsing fever Avithout albuminuria or some other evidence of retarded elimination by the kidneys. In those cases marked by jaundice, bile-pigments are found in the urine; the biliary acids have also been detected. TTie s/chi in relapsing fever shows no characteristic eruption. The abundant perspiration gives rise to plentiful crops of sudamina. Herpes facialis occurs, but not frequently. Minute petechise are occasionally observed in delicate persons, and are apt to be most abundant upon the ' Quoted by Murchison. RELAPSING FEVER. 331 lower extremities. Extensive desquamation sometimes occurs, and durimr the pyrexia the nutrition of the nails is impaired, as is shown by the de- velopment upon them of white transverse lines. SYMPTOMS DUE TO DISTUBBANf'E OF THE DIGESTrSTE ORGANS. Thirst and loss of appetite are due to the fever; upon the defervescence the former, which is often excessive, ceases, and desire for food returns; with the relapse the thirst and anorexia reappear. In some instances au inordinate desire for food during the febrile paroxysms, and especially iu the relapse, has constituted a remarkable feature of the disease. Patients with a temperature of 40° C. (104° F.) or higher, have, in some instances, begged for solid food and eaten it eagerly iu considerable quantities without apparent injury — a statement attested by numerous competent observers. The tongue is usually indented at its edges by the teeth, and covered with a whitish or yellowish-white fur of varying thickness. In other in- stances the fur is of a brownish color from the beginning. The edges and a triangular space at the tip are sometimes clear and of a brighter red than normal. The papillae are enlarged in some instances, so that the tongue may be likened to that of scarlet fever ; less commonly the organ is red and glazed, especially in the relapse. As a rule, it is moist through- out the sickness; but it may show a dry, brownish streak down the middle about the third or fourth day. It sometimes becomes deeply fissured — a very painful symptom. In very severe and in fatal cases it becomes dry, brown, and crusted, and sordes collect upon the teeth and lips. The fore- going facts being considered, it may be stated that the tongue iu re- lapsing fever presents no constant characteristic appearance. JVhusea and vomiting are common symptoms. They appear early and soon subside. In some cases, however, the vomiting persists to the end of the paroxysm, ceasing with the crisis, but returns with the relapse iu some few instances. The vomited matters consist of the substances taken into the stomach, of gastric mucus, and of bile. They are of a greenish or yellowish color, and are usually scanty. " Black vomit " was, in rare cases, observed in some of the earlier epidemics. Hsematemesis has also been noted. Pain and tenderness in the epigastrium are present in a large propor- tion of the cases. They are frequently associated with vomiting, but are by no means proportionate to its urgency. The pain is usually slight ; it may, however, be so severe as to interfere with respiration (Murchison). It may be limited to the epigastrium, or extend across the epigastric zone. In the latter case it is most severe in the left hypochondrium, and is patho- logically referable to the acute enlargement of the spleen. Enlargement of the liver occurs iu most of the cases. It appears later 3;}2 THE CONTINUED FEVERS. than the enlargement of the spleen, and is much less marked. It is at tended with pain upon pressure in the hepatic region. Jaundice appears in varj-ing frequency in different epidemics. It has seldom been observed in more than twenty per cent, of all cases, and is, as a rule, still less frequent. It rarely appears earlier than the third or fourth day of the primary paroxysm, and in some instances not until the crisis. If it comes on in the first paroxysm, it usually fades rapidly during the intermission. With the relapse it may again deepen; it sometimes does not appear before this stage of the fever. It is usually slight and disappears in the course of a few days; in some cases, however, it is intense and per- sistent. It occurs in all ages, but is most frequent in the middle periods of life. Its presence imparts to the physiognomy an appearance not com- mon in the fevers of temperate climates. Jaundice is not in itself a dangerous symptom. In severe cases it is sometimes associated with albuminuria. Enlargement of the spleen is a constant symptom. So rapid is the alteration in the volume of this viscus that the enlargement may often be detected within twenty-four hours of the beginning of the attack, and it not infrequently amounts to two or three times its normal bulk. It pro- jects below the margin of the ribs, and may, even at its maximum, which is attained about the close of the primary paroxysm, give rise to visible bulging of the surface of the abdomen. It rapidly decreases during the apyretic period, but again enlarges in the relapse. During the con- valescence it rapidly diminishes in size, but more or less enlargement may often be detected for a long time after the attack. Tlie stools may retain their normal color and consistence, but not in- frequently they are darker than in health. Intestinal catarrh sometimes gives rise to more or less persistent diarrhoea. Hemorrhages are met with. Epistaxis is not infrequent. It has been observed oftener in childhood than in adult life. It is sometimes so severe -as to require plugging of the nares. Hasmaturia has already been alluded to. Intestinal bleeding may also occur, but is not a common accident of this disease. The catamenia occurring during the progress of relapsing fever are apt to be profuse. Severe uterine hemorrhage may occur in ■connection with abortion. Complications and Sequels. Mild bronchitis is not uncommon. It usually requires no treat- ment, and interferes but little with the progress of the case or with recovery. Pneumonia occurs as a complication in some epidemics. It usually appears in the course of the primary paroxysm or in the relapse. In the <5ases observed by Lebert in the epidemic of 1868-69, in IBreslau, it showed I RELAPSING FEVER. 333 a strong tendency to become double, and was in severe cases the cause of deatli. In rare cases pneumonia terminates in gangrene. Pleurisy occasionally occurs. On the left side it may arise as a sec- ondary lesion to splenic abscess. Chronic indmonary affections appear to be but little influenced by the disease. When the subjects oi fatty degeneration of the heart are attacked by relapsing fever, there is danger of sudden death from syncope. This un- toward accident may take place in the first paroxysm, in the intermission,, or in the relapse. It has been perhaps more frequently noted at or about the time of the first crisis. Sudden collapse and death from heart-failure may also occur in consequence of other forms of organic disease, and cases have been observed in which sudden death has occurred shortly after the patient has appeared to be doing well and the disease seemingly run- ning a mild course, without the post-mortem discovery of any lesion ade- quate to account for it. Acute laryngitis, with oedema, has in more than one instance neces- sitated the performance of tracheotoni}'^ in the course of relapsing fever. Dr. Begbie* mentions a case of this kind, in which the complication was ascribed to peculiar exposure to cold during the fever. Gangrene of the feet, nose, ears, and lips have, in rare instances, oc- curred, in consequence of arterial thrombosis. Splenic enlargement may persist for a considerable time after the at- tack, and is in such cases to be regarded as a sequel. It is of two kinds: first, painless and associated with profound anasmia; and second, tender upon pressure, and accompanied by fever of remittent type. Abscesses of the spleen occur in rare instances. They give rise to pyse- mic symptoms, and may be the cause of acute peritonitis or left pleurisy, or they may burst into the descending colon. The softened spleen may rupture during the paroxysm, and cause death by hemorrhage into the peritoneum. In view of the possibility of this accident, palpation of the splenic area is to be performed with great circumspection. Anaemia is very commonly a sequel of relapsing fever. It is usually marked, sometimes attended with puffy eyelids and oedema of the lower extremities. It gradually amends, but in some cases is persistent. Antemic murmurs are common. Subcutaneous abscesses, parotid swelling, and buboes, occur, in very rare instances, during the convalescence. JErysijjelas also occurs, and is sometimes fatal. Diarrhoea is not an uncommon complication and sequel. In some epidemics it has been the cause of a considerable proportion of the deaths. It is occasionally critical, ' Reynolds' System, vol. i., article Relapsing Fever. By J. Warburton Begbie, M.D. 334 THE CONTINUED FEVERS. Dysentery is also mentioned as a sequel. It is, in rare instances, tlie cause of peritonitis. Pains hi the muscles and Joints, and various neuralgias, are very con- stantly annoying symptoms during the early days of the convalescence. With regaining strength and improved nutrition they pass awa\\ Local palsies are infrequent after relapsing fever. Paralysis of the deltoids, and the flexors of one or both forearms, has been observed. Paresis of the muscles of the uj^per and lower extremities has been noted witli greater frequency. The loss of power comes on suddenly in the early days of convalescence, and is accompanied by numbness. It is transient, And disappears in the course of a week or ten days. Lebert alludes to hceniorrhagic 2)achy)/ieninyitis as a sequel, and states that it was frequently encountered in the St. Petersburg epidemic. Inflammatory affections of the internal structures of the eye, such as iritis, choroiditis, and retinitis, have occurred with considerable frequency ■during the late convalescence in some of the epidemics. These affections never occur as sequels of typhus or enteric fever. They have been described by various authors under the name of "post- febrile ophthalmia," and, in particular, the accounts given by Macken- zie ' and Dubois "^ are of interest among the earlier descriptions. Quite recently, Dr. Julius Trompetter "' reported that, in three hundred and twenty- five cases of relapsing fever in Breslau, twenty-one cases of choroiditis were observed ; they were nearly all of the acute form. On admission to hospital, the patients mostly presented the characters of well-marked choroiditis in the fonn of cyclitis. Very fre- quently hypopyon appeared, without inflammatory phenomena on the part of the iris. Turbidity of the vitreous humor was ascertained to be present in all the cases, and the visual acuity was always considerably impaired at the commencement of the ill- ness. The field of vision showed a limitation of the periphery in all directions. The course of the choroiditis was in general favorable ; its average duration was from a month to six weeks. In two cases both eyes were affected. Dr. Trompetter believes that the affections of the eye in relapsing fever are due to embolism arising from par- tial necrosis and abscess of the .spleen. In a recent epidemic of relapsing fever, at Konigsberg, Dr. Luchhau has also in- vestigated the frequency of ear and eye complications. No less than three hundred cases were treated in the town hospital. Of this number only one hundred and eighty cases were, however, specially examined as to the existence of ear complications, and these were found in fifteen only, and in all the middle ear was the part affected. In most cases there was suppuration, and the pus was evacuated through the tympanic membrane. In most cases of disease of the middle ear in acute maladies the inflamma- tion appears to arise by extension from the throat; but it was found that, in re- lapsing fever, pharyngeal catarrh is absent, as a rule, in the cases in which the middle 'W.Mackenzie, M.D. : Account of the Epidemic Remittent Fever at Glasgow in 1843, and of the Post-febrile Ophthalmitis. London Medical Gazette, vol. xxiii., 18-48. - Relapsing Fever and Ophthalmitis Post-febrilis in Xew York : Trans. American Med. Assn., 1848. ^ Klinische Monatsbliitter f iir Augenheilk. , January, 1880. KELAPSING FEVER. 335 •ear suffers, and there was no evidence of disease of the Eustachian tubes. The progno- sis is not unfavorable if prompt treatment is adopted. Only six cases presented e^'e symptoms out of the hundred and ei^jhty examined (three and a half per cent.). In three there was iritis, which was unilateral in every ca.se. All these cases did well. In one case, however, some weeks later, the patient complained of failure of sight, and opacities were discovered in the vitreous. In two other cases optic neuritis occurred. In one the affection was discovered in the first relapse. The second relajjse was severe, and some time afterward there was atrophy of the optic nerves, and vision was reduced to one-tenth. In the other case, the neuritis also occurred during the second febrile attack ; a few days after it had ceased, the swelling of the optic papilla was discovered, dirty red in color, with arteries narrowed and veins d.steiided and somewhat tortuous. Vision was reduced to one-third in one eye, and one- tifth in the other. Another patient came into the hospital during the first relapse with iritis and hypopion. The ocular trouble healed completely, but after the relapse the patient insisted on leaving the hospital and passed through the second relapse at home, under very unfavorable conditions. When it was over he returned to the ho.spital with doable irido-cyclitis. Numerous thick tlakes were seen in the vitreous, the fundus was very indistinct, but the papillae were seen to be red and swollen, and there were numerous retinal hemorrhages. The account of these cases is published in the October number of Virchow's Archie. ' Prognosis and Mortality. Ill general terms the prognosis in relapsing fever is favorable, the death-rate being low. Death occurs, not directly in consequence of the fever, except in rare instances, but by reason of some complication, as feebleness of the heart, urfemia, peritonitis, pneumonia, or abortion. It may take place during the paroxysm, the intermission, the relapse, or after the second critical defervescence. Of 2,115 cases admitted to the London Fever Hospital from 1847 to 1870, according ■ to Murchison, 39, or 1.84 per cent., or about 1 in 54, proved fatal. Deducting from this number 10 cases fatal within forty- ■eight hours after admission, the death-rate was only 1.38 per cent., or less than 1 in 73. An analysis of the statistics of the Scotch epidemics made by the same author, give for one series of G,300 cases a mortality of 260, or 4.12 per cent., or 1 in 24.23 ; and for a second series of 10,444 cases, 462 deaths, or 4.42 per cent., or 1 in 22.6. These two series of cases, taken in connection with the statistics of the London Fever Hospital for the period mentioned, give, in a total of 18,859 cases, 761 deaths, a mortality in England and Scotland of 4.03 percent., or 1 in 24.78. Lebert informs us that in three epidemics in Breslau the mortality did not rise above two to three per cent. In the Russian epidemic of 1864-65, of 12,382 cases, 1,574 terminated ' Lancet, Dec. 11, 1880. 30 40 40 50 50 GO GO 70 70 80 Age doubtful 1, 336 THE COJ!iTINUED FEVERS. fatally, being 12.7 percent., or 1 in 7.8G — the highest recorded death-rate in any epidemic. The death-rate increases, in adult life, progressively with the age of the patient. During childhood and adolescence, relapsing fever is scarcely ever fatal. Reverting again to the statistics of the London Fever Hospital, we find that, of the 2,115 cases admitted, there were: Under 20 years, 804 cases, 3 deaths, or 0.37 per cent. Between 20 and 30 " 5G2 " 4 " 0.71 " ' 322 " 8 " 2.48 ' 232 " G " 2.58 " ' 119 " " 7.56 ' 6G " 7 " 10.60 " ' 6 " 2 " 33.33 " 4 " The death-rate is, according to almost all published statistics, a little higher in the male than in the female sex. This is due to incidental cir- cumstances. As in other epidemic diseases, the mortality is greatest at the outbreak and during the height of epidemics. AxATOMiCAL Lesions. No constant anatomical lesion is found after death. The spirilli are discoverable, in some instances, in the blood, if deatli takes place during the pyretic stages (Guttmann). But they have been sought for in vain in the spleen, lungs, and other organs, although the possibility of their existence can by no means be denied (Lebert). The body is often emaciated; the skin, in addition to the cadaveric discolorations common after the infectious diseases, shows petechife, if they were present during life; the jaundice persists, and even deepens (Murchison). The color and texture of the muscles is unchanged; but, upon microscopic examination, there is not infrequently found, especially when death has taken place after a protracted illness, granular infiltration of the muscular fibres, amounting sometimes to fatty deg'eneration. Cadaveric rigidity appears early, and continues for a considerable time. The stomach is usually normal, but small extravasations of blood are met with in the mucous membrane of this viscus, and in other mucous and serous membranes. This has been particularly observed in those cases in which urgent vomiting has preceded death, or in those charac- terized by black vomit. T7i,e intestines are normal, except in cases in which diarrhoea or dys- entery has occurred. After the former, injection of the mucous mem- brane, particularly toward the lower end of the ileum, is seen; after dys' entery, the lesions peculiar to that affection are met with. EELAPSING FEVEE. 337 The solitary follicles are sometimes slightly enlarged. They are never ulcerated, nor are the agminate glands of the small intestine. Slight swelling of the mesenteric glands is sometimes found. The liver is slightly or moderately enlarged, and deeply congested, especially when death occurs during the pyrexia. In rare instances, it is the seat of small deposits of a dull yellow color, softened in the centre. The gall-bladder is generally filled with a clear, viscid, yellow, or brown- ish bile. The spleen is enlarged, sometimes to two- or three-fold its normal size. This change, except in cases that have resulted fatally at a late period, after the second defervescence, is met with in all cases. Its capsule is smooth, very tense, and clouded. Upon section the parenchyma is soft, in many cases almost diffluent. It may present a homogeneous appear- ance, or the Malpighian corpuscles may be seen with unusual distinctness. Minute roundish or irregular deposits of a dull yellow color, similar to those found in the liver, are frequently met with. They contain granular detritus, with cell-elements and free nuclei. These are also found in the lymph-follicles, and may be observed in different sections, in all stages, from simple follicular enlargement to the aggregations of detritus (Lebert). Wedge-shaped infarctions are occasionally met with, either firm or break- ing down, but without demonstrable embolic origin. If the spleen be greatly softened, no decided structure can be recognized. If death take place some time after the termination of the relapse, in consequence of any complication, the spleen is found to be reduced in size, and its cap- sule shrivelled. In rare instances abscesses, due to the breaking down of the infarcts mentioned above, are found underlying the capsule and still more rarely the spleen is found to be ruptured. The heart presents no change consequent upon the processes of relaps- ing fever, except, in some instances, after protracted illness, slight gran- ular infiltration of the muscular fibres. Fibrinous coagula are found in the heart and great vessels, together with fluid blood. The lungs show only those changes which attend the various pulmo- nary complications of relapsing fever. These are chiefly bronchitis and pneumonia. The latter is often double, and may in rare cases result in gangrene. The signs of recent pleural inflammation are rarely encoun- tered. Hypostatic congestion is rare as compared with typhus or enteric fever. Diagnosis. If regard be had to the temperature, but little difficulty can attend the diagnosis of relapsing fever, even in the beginning of epidemics. The abrupt and unusual rise in temperature, the slight and inconstant morning remissions and frequent midday rather than evening exacerba- tions, the critical defervescence at the expiration of five or seven days, 338 THE CONTINUED FEVEKS. and the rapid decline of the temperature to a point below the normal, con- stitute a group of phenomena characteristic of this, and met with in no other disease. The acute, progressive, and extreme enlargement of the spleen, the coincident, but less marked increase in the size of the liver, the tenderness in the region of both these organs and in the epigastrium, and the muscular pains, are also diagnostic. Equally characteristic is the abrupt relapse, after an apyretic period of several days, with its repe- tition of the symptoms of the primary paroxysm and the extraordinary rise, high range and sudden fall of the temperature to a point below the normal. Clinically, relapsing fever and typhus are widely unlike. "Whether they are equally unlike etiologically, speaking in general terms, remains for future investigations to decide. The striking fact that the former, in all its great epidemics, has prevailed in connection with typhus, and commonly in a definite relation with it as regards the progress of the epidemic, being proportionately most common at the beginning of the outbreak, less so as the epidemic advances, and giving place wholly to typhus at its close — this fact, coupled with the well-established observa- tion that relapsing fever patients are prone to typhus after convalescence, while typhus fever patients are little liable to suffer from relapsing fever within a short time, makes it appear most possible that in a broad sense these two fevers are due to closely associated causes. Prevailing, as they so constantly did in the early epidemics, together as a pestilence — known by the simple designation of " fever," or " the fever," it was natural to regard relapsing as a mild form of typhus fever. The error, once established, was overthrown with difficulty — a difficulty to which the nosological method of the continental Avriters has contributed not a little. By this method the typhus, enteric, and relapsing fevers, and sometimes others — for the designation is an elastic one — are classed together as the common group of so-called " typhus " diseases, the first being regarded as " exanthematous typhus," the second as " abdominal typhus," and the last as " recurrent typhus." The following tabular ar- rangement of the principal phenomena of the three fevers just named, will serve to show how unlike they are in their clinical aspects, and, at the same time, to present in the most concise manner their more important points of differential diagnosis: TYPHDS. Essentially an epidemic disease, although endemic in certain localities. Highly contagious. Attack sudden, often without prodromes. Course continuous. An endemic disease, often sporadic, but occasionally appearing in circumscribed epidemics. Not directly contagious. Attack generally insidi- ous. Continuous. EEIiAPSING. An epidemic disease, often the congener of typhus. Contagious. Attack sudden. Broken by a period of complete apyrexia. EELAPSING FEVEH. 339 TYPHUS. Duration about fourteen days ; rarely exceeds twenty days. Defervescence critical, or by very rapid lysis. True relapse so rare as to be almost unknown. Face deeply flushed, dusky. Conjunctivas deeply in- jected ; pupils contracted. Delirium and stupor ear- ly and prominent. Abdominal symptoms ab- sent ; constipation the rule ; meteorismrave. Intestinal hemorrhage ex- tremely rare. Acute dysen- tery may occur dviring con- valescence. Epistaxis does not occur. Skin pungently hot, sometimes emitting a pecu- liar odor. Eruption deep in color, copious, general in its dis- tribution. Emaciation slight. Pneumonia and bronchitis of finer tubes. Death not infrequent at end of first week, and often before the conclusion of the second. No characteristic lesions found in the body after death. From three to four weeks. Terminates by prolonged lysis. Relapses occasionally oc- cur ; they are irregular, in- constant, and accidental. Face pale ; if there is flushing, it is confined to the region of the cheek-bones, and is circumscribed. Eyes clear ; pupils often dilated. Less constant, more grad- ual in development, and of longer duration. Abdominal symptoms prominent. Diarrhoea and meteorism the rule. Intestinal hemorrhage not unusual. Epistaxis common. Skin hot ; sometimes bathed in acid perspiration. Eruption light red, sparse, discrete, commonly confined to particular regions of the trunk. Emaciation great. Bronchitis and pleurisy. Death usually takes place in or after the third week. Constant lesions of the ileum and the mesenteric glands. RELAPSING. Duration of primary par- oxysm from five to seven days ; of the relapse, about three. Ends abruptly by crisis. Relapse constant and an integral factor of the at- tack. Face often flushed; the color lacks the duskiness of typhus, and is not circum- scribed, as in enteric fever. Conjunctivaj slightly in- jected ; pupils natural. Mind commonly clear throughout. Pain and tenderness in the epigastric zone. Con- stipation the rule ; occasion- ally diarrhcea sets in at the crisis. Epistaxis occasionally oc- curs, especially at the time of the crisis. Skin hot ; profuse sweat- ing at crisis. No definite eruption. Emaciation not marked, save when the patient has suffered from insufl[icient food prior to his illness. Bronchitis common, but rarely severe. Pneumonia occurs. A fatal issue rare, except in consequence of complica- tions. Post-mortem appearances not characteristic. JRemittent fever is to be diagnosticated from relapsing fever by the marked differences in the range of temperature, the duration of the at- tack, the character of the crisis, the length of the intermission, the relapse, and the great contagiousness of the latter. Moreover, the circiamstances under which the diseases appear and prevail in the community are of diag- nostic value. 340 THE CONTINUED FEVERS. Treatment. Prophylactic treatment must be based upon our knowledge of the pre- disposing as well as of the exciting causes of the disease. Upon the ap- pearance of relapsing fever, renewed efforts must be made to relieve the sufferings of the poor, and chiefly to provide them with a sufficient quan- tity of wholesome food. As far as is possible, overcrowding must be di- minished in the districts most liable to become pestilential centres of the disease. The drainage is to be looked to, and, if defective, temporary measures to drain away stagnant water must be immediately resorted to. All accumulations of filth and garbage must be at once removed. The system of visitation among the healthy, by laymen competent to instruct them as to the measures proper to be taken with the view of avoiding the disease, that w^as instituted in Paris during the cholera epidemic of 1849, is suggested by Lebert. In view of the possibility of the introduction of the protomycetes by drinking-water, it should be subjected to boiling. Abundant ventilation is of the first importance. Contagious as relapsing fever is, it does not spread, even when cases occur, in the large and well-ventilated houses of the opulent, nor to any great extent in the roomy and properly aired wards of well-managed hospitals, except to those whose vocations bring them into close contact with the sick. As has already been stated, phy- sicians visiting from house to house among the poor, remaining only a short time in the presence of the patients, and passing quickly again into the open air, are less liable to contract the fever than the resident physi- cians of hospitals, who pass from bedside to bedside, without the opportu- nity, for several hours at a time, of breathing an uncontaminated atmos- phere. Cleanliness of the abode and of the person is scarcely second in import- ance to abundant ventilation. The contagium is readily transmitted by means of the clothing and bedding of the sick. Soiled clothes should be thrown into boiling water as soon as taken off, and carbolic acid, or car- bolic acid soap, used in the water with which they are washed. If patients be removed to a hospital, or after convalescence has set in, the apartment should be fumigated by burning sulphur, thoroughly aired, cleansed, and whitewashed. It is obviously impossible to treat all the rooms in the densely crowded districts of cities in this manner, but, in proportion as these measures are promptly and generally carried into ef- fect, will the spread of the disease be retarded. The bedding should also be subjected to the sun and air, and, if possible, fumigated; the cheaper materials used in filling mattresses, as straw, moss, fine shavings, and husks, should be burned. As the result of the experience of all observers upon an extended RELAPSING FEVER. 341 scale, it may be stated that up to the present time no drug or method of treatment has been found to exercise any decided influence upon the course of the disease. It is scarcely necessary to allude to hloodletting. From the day that relapsing fever was distinguished from typhus, it was clear that the criti- cal defervescence on the fifth or seventh day of the short fever, ascribed to depletion, was, in fact, not the result of treatment at all, but an event of the natural course of the disease. Repeated cold baths and large doses of quinia reduce the temperature, but neither aifect the duration of the paroxysm nor prevent the relapse. Quinia has been tried in vain, in moderate and large doses, both during the pyretic period and in the intermission, ArseniG\?> likewise ineffectual. The observations of Dr. Riess,' of Berlin, are of great interest. Her found sodium salicylate very effective in reducing the temperature, and, given in large doses during the intermission, in lessening the severity of, and apparently even sometimes preventing, the relapse. These observa- tions are to be tested by a more extended investigation of the value of this drug in future epidemics. It has been suggested that the enormous development of the proto- mycetes in the blood during the paroxysm, and their disappearance during the intermission, are strong arguments in favor of the administration of parasiticides; that, with this view, a more systematic administration of the sulphites, and the disengagement of sulphurous acid gas in the air of the sick-apartment, should be attempted. Remedies of this kind had been tried without success before Obermeier's discovery. Parry, in 1870, administered, without in the least abating the violence of the course of the disease, the sulphites, the hyposulphites, and the preparations of chlorine. The destruction in the blood of enormous numbers of disease- producing parasites — so low in the scale of existence as to lie upon the most distant borders of independent life — so minute that they dwell in the ultima Thule of microscopic vision — by means of parasiticides administered in any amount short of compromising the integrity of the blood itself, is highly problematical. Meanwhile, relapsing fever must be treated on the expectant plan. Rest in bed, quietude, abundance of fresh air, cleanliness, a carefully regulated diet consisting of milk, broths, meat-jellies, light farinaceous foods, or, if the patient craves them and can digest them, even the stronger soups, meat and vegetables, but always plenty of cooling drink, will in many cases suffice. The tendency of the disease is to recovery. The patient must not be allowed to suffer from thirst. Let him drink freely. The best beverages are pure water, carbonated water, seltzer water, or milk diluted with any of these. If he prefer it, let him drink 'Berlin, klinische Wochenschrift, iii., 1S79. 342 THE CONTINUED FEVERS. water acidulated with the juice of lemons or limes, or let him take ten or fifteen drops of dilute phosphoric or muriatic acid every three hours, in a wineglassful of water slightly sweetened, rinsing his mouth and teeth afterward. Cold aj)pllcations to the head, by means of ice and bran in bladders or caps of india-rubber, are useful in mitigating the headache. They should be applied only during the paroxysms of pain. The frequent resort to friction, with anodyne linhnents will give relief to the muscle-pains. For this purpose — Yf.. Chloral hydrate 16 — 32.00 gm. \ ss. — j. Lin. saponis camph 200.00 c.c. fl. % vj. M. or a lotion consisting of equal parts of chloroform and olive oil, may be employed. If the pains be very severe, the hyiyodermic xise of vxorphia, alone or with atropia, will be required to relieve them. Opium and its derivatives, by the stomach, appear to have in very many cases but little effect, either in relieving pain or producing sleep, in relaps- ing fever. Parry and other observers state that a remarkable tolerance for this druff was established during the attack. J^otassium bromide is useless. Sleeplessness will yield to the administration of chloral hydrate in moderate doses. This drug is to be given with caution where the action of the heart is enfeebled. An eynetic, followed by mild purgatives, is of use in relieving the vomiting and pains in the epigastric zone. At the same time sinapisms, hot fomentations, or small blisters, should be applied. Carbolic acid may also be given for the nausea and vomiting. If the pain in the region of the spleen is very great, poultices should be applied, or frequently re- newed cold-water applications may afford relief. Alcoholic stimulants are to be given, not as a part of a general routine treatment, but as called for by the weakness of the patient and the char- acter of the pulse, the impulse of and the first sound of the heart. At the time of the crisis they are of great benefit, and must be given during the first days of the remission, and again in the early convalescence. If collapse threaten, it must be treated by prompt stimulation by alco- hol, spirits of chloroform, ammonium carbonate, artificial heat, and so on. Diarrhoea calls for the employment of astringents and opium. Bronchitis, occurring as a complication of relapsing fever, is usually of a mild form, and does not require especial therapeutic intervention. Pneumonia is to be treated upon general principles. It may be said that, almost without exception, intercurrent pneumonias call for increased stimulation. EELAPSING FEVER. 343 Parry, after trying various drugs, found that quinia in combination with camphor was most useful, during the intermission and in the early convalescence, in relieving the patient's sense of prostration and inducing sleep. The anaemia of convalescence from relapsing fever urgently demands an abundance of wholesome, nutritious food, the vegetable tonics, such as the best preparations of cinchona and nux vomica, the best-borne preparations of iron, and, if the pallor be protracted and the patient take it well, cod-liver oil. Chronic enlargement of the spleen should be treated by quinia and iron, and externally by inunctions of the red iodide of mercury oint- ment. VII. DENGUE. Definition. — An acute, febrile affection, of short duration, due to an un- known external specific cause, and prevailing in extensive epidemics, which are chiefly confined to warm climates; it consists of two dis- tinct, brief, febrile paroxysms, each attended by a different group of symptoms, and separated by an intermission lasting from a few hours to several days. The first is characterized by continuous high fever, distressing pains in the joints and muscles, interfering with motion, and occasionally by a cutaneous efflorescence; it usually terminates suddenly with some critical discharge; the second paroxysm is marked by a milder fever of remittent type, an eruption of different charac- ter, which is attended with intense itching and followed by desqua- mation, by some recurrence of the joint-pains, and by debility; it gradually subsides. The disease is extremely painful, but very rarely fatal; its morbid anatomy is therefore unknown. Synonyms. — Febris exanthematica articularis; Exanthesis arthrosia; Exanthesis rosalia arthrodynia; Scarlatina rheumatica; Scarlatina mitis; Eruptive articular fever; Eruptive rheumatic fever; Rheu- matic fever with gastric irritation and eruption; Eruptive epidemic fever of India; Epidemic inflammatory fever of Calcutta; Epidemic anomalous disease; Peculiar epidemic fever. Dandy fever; Polka fever; La Piadosa; La Pantomina; Colorado; Bouquet; Bucket; Giraffe; Stiff-necked fever; Broken-wing fever; Break-bone fever; Toohutia; Three-day fever; Knockel Koorts; Aburuka-Bah (Father of the Knee) ; Date fever. Dengue, pronounced dangay. " This disease, wheii it first appeared in the British West India Islands, was called the dandy fever, from the stiffness and constraint which it gave to the limbs and body. The Spaniards of the neighboring islands mistook the term for their word dengue, de- noting prudery, which might also well express stiffness, and hence the term dengue Decame at last the name of the disease." This term, begotten of a misapprehension of a word applied to it in jest, has become the generally accepted designation of the disease. DENGUE. 345 To a similar origin are due many of the popular names by which it is known in the countries where it has prevailed. The people are often dis- posed to make a jest of epidemics not attended by danger to life, the more perhaps when the sufferers present an absurd appearance. The Brazilians called this disease \X\Q])olka fever ; the Spanish, /apaw^omma/ the French, bouquet and giraffe, the latter because of the stiff manner in which those affected often carry the head. Stiff-necked fever and broken-wing fever are likewise terms suggested by the posture of the convalescent; while break- bone fever, and the Batavian designation, Knockel Koorts (bone fever), refer to the torturing joint-pains that attend it. In Spanish-American countries it has been known as Colorado, on account of the red color of the eruptions. It is probable that this is also the derivation of the French term bouquet. Toorhutia and three-day fever are East Indian names for it; and aburuka-baJi and date fever — the latter because it has been observed to prevail during the date-harvest, are Arabian folk-terms. Medical observers have designated it by various terms of classical derivation, according to the views which they have entertained concern- ing its nature. Of such terms, those based upon its fancied relationship to other well-known affections, as scarlet fever and rheumatism, are inap- plicable now that it is known to be a distinct affection; others fall to the ground, because they are based upon the assumption that the disease is peculiar to a country or locality, now that it has become known as pan- demic in tropical and subtropical climates; while others still fail of ac- ceptation because they are not suflBciently distinctive. Historical Sketch. Dengue first excited general attention by its epidemic prevalence in the West India Islands in 1827. Previous to that date, however, it had occurred in less extended outbreaks in tropical countries and elsewhere. The earliest account of the disease, according to De Wilde,' dates from the year 1779. David Brylon, the chief physician of Java at that time, briefly describes, under the name of Knockel Koorts, an epidemic disease which prevailed among the natives and colonists. Rush ' published an account of an epidemic which occurred in Philadelphia in the following year, 1780. The disease was then, as now, described in North America as break-bone fever. At the same time it was observed by the missionary Wise, according to an anonymous French writer,' on the coasts of Coro- mandel, Africa, Arabia, Persia, and Thibet. It is said also to have oc- ' J. J. de Wilde : Dengue in Fort William I., in Java. Niedl. Tijdschr., 1873, quo- ted by Zuelzer. - Medical Enquirer and Observer, 1789. 2 Zuelzer : Ziemssen's Cyclopedia, vol. ii. 346 THE CONTINUED FEVERS. curreJ at Lima, in January, 1818, and in the United States, at Savannah, in 182G. Previous to the general epidemic which made its appearance first in September, 1827, at St. Thomas, there exists not the slightest trace in medical literature of this disease in the West Indies/ From the Island of St. Thomas it spread in October to St. Croix. In these islands almost every inhabitant in a population of 13,000 suffered. It passed thence toward the northwest, over the great Antilles to the main-land of North America, and southward over the Caribbean Islands to Columbia, Following its course toward our own country, we find that in the spring of 1828 it had reached Pensacola, and that it spread thence in June to Charleston in one direction, and in the other, to Mobile and New Or- leans, where it prevailed early in the summer. It made its appearance in Savannah in September. In the same year sporadic cases were observed iu Boston, New York, and Philadelphia, and, according to some accounts, in some of the cities of the West, although the evidence in regard to the last statement is not conclusive. In the beginning of the year 1828, the disease prevailed in Columbia, and nearly at the same time in Porto Rico, Hayti, and Jamaica. It broke out in Cuba in March. In these islands and in Columbia it continued till September of the same year. Two decades now passed without the occurrence of dengue in extended epidemics. It is true that in 1839 an outbreak took place at Iberville, in Louisiana, and one in 1844 at Mobile, but they appear to have been con- fined to the localities in which they first appeared. In the summer of 1848, it again showed itself in New Orleans, and less extensively in Vicksburg and Natchez. In these outbreaks, dengue appeared simultaneously with the yellow fever. In the autumn of the same year it was again observed in Mobile. Cases occurred during the next two years, from time to time, in the cities along the Gulf Coast. In 1850, a wide-spread epidemic visited the Southern States. Appear- ing in Charleston toward the end of July, it spread successively to Sa- vannah, Augusta, Mobile, New Orleans, and intermediate points, and into Texas, in which state it became epidemic in October. The extent of prevalence of this disease in some of the localities visited by this epi- demic is remarkable. Dickson informs us that, in Charleston, all the members of large households were attacked, without a single exception, and that of his own family, numbering eleven persons, he alone escaped. It is computed that ten thousand persons were ill in Charleston at one period, and that between seventy and eighty per cent, of the population suffered during the epidemic. The number of inhabitants in the town of New Iberia, Louisiana, in 1857, did not exceed two hundred and fifty; ' Hirsch : Handbuch der historisch-geographische Pathologie. Erlangen, 1860. DENGUE. 347 of these, two hundred and ten contracted the disease during a period of six weeks. Less-extended epidemics occurred at various points in the same belt of country in 1861, and again in 1866. In the summer of 18-46, dengue appeared in Brazil, and prevailed widely. It reappeared, at the same season of the year, in the three fol- lowing years. In 1852 it visited Peru. This visitation was followed by yellow fever. In the eastern hemisphere, from the time of the epidemic reported by Wise, already alluded to, no outbreak is mentioned till 1799, when it broke out in Lower Egypt, and prevailed extensively in and around Cairo, under the name of the "knee eviL" Pruner, who had seen the affliction on the coast of Arabia in 1835, again encountered it at Cairo, in August, 1845, and a little later in Alexandria. No further accounts are met with concerning the existence of the disease in tropical Africa until 1871. It has, at various periods, prevailed very extensively in India; in the year 1824, dengue made its appearance as an unknown disease, both to the physicians and the public, in the southern parts; it spread, in the rainy season, to Calcutta, and from there, along the Ganges, to Berhampoor, whence it extended over the southern portion of Bengal and a part of Madras. In March, 1825, it reappeared at Berhampoor, and became epidemic in the surrounding country in the rainy season. Again, in 1836, the disease visited Calcutta, and Pruner states that travellers, who came from India to Cairo in 1845, told of its epidemic prevalence in that country and along the borders of the Red Sea. In 1860, it appeared among the ships at Martinique, and spread later to the garrison. Balbot states that, of four hundred men constituting the garrison, one hundred and twelve suffered from the disease. The dengue prevailed in Spain from 1864 to 1868. It appeared in Arabia in 1871, and was observed by Read, especially in Mecca, Medina, and Aden. In the last of these cities it was epidemic during a period of more than seven months; of the garrison of nine hun- dred men, seven hundred had the disease. Following the line of travel, it spread, in 1871, to Zanzibar and other points on the African coast. It was observed in the same year at Port Said, where it is said to have pre- vailed every year at the season of the date-harvest. In November, 1871, it broke out in Java. In 1872, it spread through all India, starting from Bombay and Cananore, and following, at first, the line of the railroads. Cases appeared at the same period in the English stations of China, Bur- mah, and NepauL This epidemic was as intense as it was wide-spread. In some localities scarcely an individual escaped. In Madras it prevailed so violently that not a house escaped. The epidemic reached its height in September and October, and subsided suddenly, after a heavy rain, about the middle of the latter month. 348 THE CONTINUED FEVERS. A mild epidemic of dengue prevailed at Charleston and in some of the neighboring localities, and at various points along the Gulf Coast, during the summer and autumn of 1880. It ceased with the advent of cold weather and frost. At the same time this disease was extensively prevalent in Northern Egypt. Etiology. I. PREDISPOSING CAUSES. There can be no doubt whatever that climate has a large influence in. the development of dengue. It is a disease of tropical and subtropical lands. When it has occurred in colder countries, it has made its appear- ance almost exclusively in the summer or autumn, and upon the advent of cold weather has promptly disappeared. Its prevalence has also been restricted to sporadic cases or to circumscribed local epidemics. Arnold ' declares that " this disease is undoubtedly affected by frost. The diminu- tion of cases after a frost last fall, was as marked as the diminution of cases in our endemic climate fever usually is." With this exception the concUtioti of the weather has no direct influ- ence either upon the origin or upon the epidemic spread of the disease. Within the tropics it has occurred alike in the hot, the cool and the rainy season of the year. In our Southern States it has prevailed in wet and dry, in cool and warm weather, indifferently, though it is to be re- marked that it has almost always first broken out in summer and disap- peared to a great extent, if not wholly, in the winter months. In the W^est Indies it prevailed continuously for a period of "nearly twelve months through a variety of seasons, and was neither perceptibly influenced by vernal nor autumnal equinoxes, by our strong, wintry north wind, nor by the scorching, fiery sea-breezes of June and July " (Maxwell). The supposition that a peculiar condition of the atmosphere, combining a high degree of moisture and " stagnation of the air " with prolonged and very intense heat, are necessarily associated with the origin and trans- mission of the disease, or that its appearance as an epidemic is necessarily preceded by prolonged, heavy rains, falls to the ground, in view of the recorded fact of its prevalence at all seasons of the year in tropical regions, and its steady advance in the direction of the lines of human intercourse without regard to the dryness or moisture of the weather. Dengue is in the strictest sense a pandemic disease. With the excep- tion of influenza, no other disease has prevailed over so wide an extent of the surface of the globe, or attacked with such impartiality the inhabitants of the countries over which it has passed. ' Charleston Medical Journal, May, 1851. DENGUE. 349 Hace and nationality hare but little influence upon this disease. Ob- servers in all countries where it has prevailed agree in the statement that it spreads equally among the white and colored of all nations. To this general remark must be made the exceptions, that in the South the negro race is attacked a little later and suffers less generally than the whites, and that, in the last epidemic in India, Europeans recently arrived ap- peared to suffer from the disease in a milder form than residents already acclimated. The disease spares neither age, sex, nor occupation. Infants in arms and octogenarians are equally prone to it. All classes of society alike suffer. The physician enjoys no immunity. He is almost invariably at- tacked. Aitken suggests that this is the reason that the details of symp- toms in epidemics of this disease are so minute. It prevails, as a rule, chiefly in cities, less generally in the open coun- try. To this there have been, however, notable exceptions. n. THE KxcrriNG cause. The exciting cause of the disease is unknown. That it is specific is no longer open to doubt. Whether it is strictly a contagium or a miasm is still undecided. It is capable of being conveyed by human intercourse, and in most instances has spread by a steady progress, in direct lines from the points of early infection. Dickson and some of the observers of the later Indian epidemic look upon the disease as contagious, but adduce no direct proofs; others strongly oppose this view. Most physicians who have had the opportunity of personally observing the disease express no opinion upon this point. It is not generally regarded as contagious. Its mode of invasion, its rapid march, the unsparing manner in which it attacks entire families, cities, and even districts within a brief space of time, are opposed to the assumption that it is propagated by contagion alone. In some of the outbreaks, dengue has preceded or followed yellow fever. But it has so often occurred independently of any association with that disease, that the existence of any pathological relationship is in the highest degree improbable. Dengue has not only prevailed in the mari- time countries subject to yellow fever, but it has extended to the moun- tainous back-country, in which the latter fever is unknown. The occasional association of dengue with scarlet fever and whooping-cough in epidemics is accidental, not causal. No hypothesis adequate to explain the fierce epidemic outbreak of this disease in widely separated localities, and at long intervals of time, has yet been advanced. 350 THE CONTINUED FEVERS. Clinical History. The period of incubation in about lialf the cases is extremely brief. At the commencement and at the maximum of an epidemic, the attack may follow exposure in a few hours, occurring without preliminary symptoms. Toward the close of an epidemic, the period which elapses between the exposure and the onset of the attack may be lengthened to several days. The invasion of the disease is generally abrupt; there may in some cases, however, be a prodromal stage of from one to three days, charac- terized by lassitude, headache, a furred tongue, loss of appetite, muscular soreness, and chilliness. Usually, however, the patient is seized, upon waking, with intense headache, burning pain in the temples, backache, and severe pain in the joints. Sometimes the first symptom is an acute pain in one of the joints — for example, one of the joints of the hand or foot; this may come on while the patient is engaged at his ordinary occupation, and apparently in full health. The affected joints rapidly become swollen, and the skin of the face and neck is flushed and turgid. Painful stiffness of the muscles fol- lows; the affected members are moved with great difficulty and suffer- ing. The muscles of the eyes sometimes become stiff and immovable, the conjunctiva reddened, the eyelids swollen, so that the patient wears a staring expression, while the eyeballs feel too large for the sockets. There is intolerance of light and sound. At the same time symptoms of gastric disturbance occur; the tongue is coated; a burning pain is felt in the epigastrium, and there is nausea, followed by bilious vomiting. The irritability of the stomach is often so great that scarcely anything is retained. In most cases desire for food is wholly lost; but not infre- quently, especially in children, the appetite is retained; thirst is not ur- gent; the bowels are constipated. Fever makes its appearance at the onset of the attack, and reaches its height within the first twenty-four hours. A temperature of 41.5° C. or 42° C. (106.7° F. or 107.G° F.) is not infrequently observed in the axilla. The fever is now continuous ; the pulse is full, hard, strong and exceedingly frequent, beating from 120 to 140, and even higher in children. The breathing is quickened, the skin hot and dry. Confu- sion of thought, and even delirium, particularly in children, also occur, and in j^oung children the disease sometimes commences with convul- sions. There are no other symptoms primarily referable to the nervous system. In a great majority of the cases, an exanthem of variable character now shovFS itself. This eruption most frequently resembles the efflorescence DENGUE. 351 of scarlatina, and for this reason dengue was regarded by many of the older observers as an epidemic scarlatinal rheumatism. The duration of the first febrile paroxysm is variable, lasting from a few hours to several days. Its average duration is from two to three days. The fever generally abates suddenly, often with the occurrence of critical discharges, such as profuse sweats, epistaxis, or diarrhoea, the evacuations being dark, greenish, tawny, and foul-smelling. Exceptionally the fever subsides slowly by lysis. The subsidence of the fever is marked by the disappearance of the eruption, if any be pres- ent, by the appearance of moisture on the skin, and an amelioration of the pains in the muscles and joints. In most cases the patient, although much relieved, is unable to leave his bed by reason of the great prostration fol- lowing the fever. In other cases the relief is so great and the strength so well preserved, that the patients do not hesitate to arise from bed and even to leave the chamber. This stage of the disease, which is analogous to the intermission of relapsing fever, is thought by recent observers to be in most cases a very marked remission, in Avhich the temperature closely approaches, but does not reach, the normal; in others it amounts to a period of complete apy- rexia. Its duration is from two to three days. In some cases it is wanting altogether, or of so short duration that it is overlooked. Notwithstanding the great amelioration of all the symptoms during this period, some head- ache, and more or less of the stiffness of the joints and muscles, remain. At the expiration of some hours, or of two or three days, as the case may be, acute symptoms reappear and the second febrile paroxysm sets in. Fever again arises, but it is not so intense as before, and its type is re- mittent rather than continued. The tongue again becomes coated, appe- tite is lost, nausea distresses the patient, but vomiting at this stage is rare. Headache attends it, and in many cases there is an exacerbation of the pains in the joints and some increase in the stiffness of the muscles, both these symptoms having continued in some degree throughout the re- mission. Coincidently with the reappearance of the fever, an eruption shows itself. This eruption, which may be looked upon as the distin- guishing feature of the second paroxysm of the disease, has been variously described by different observers as erythematous, reseola-like, rubeolous, or as resembling urticaria. Appearing in many instances, first upon the palms of the hands or upon the soles of the feet, it extends over the greater part of the surface of the body. Or it may be localized in certain regions. It is attended by annoying itching, and, after an existence vary- ing from some hours to two or three days, it vanishes and is followed by furfuraceous desquamation. The duration of these symptoms is usually about two or three days. The fever gradually subsides, and the acute symptoms disappear, leaving the patient in an enfeebled state, often requiring months for the re-estab- 352 THE CONTINUED FEVERS. lishment of health. Besides the debility, which is often very great, emaciation, diarrlioea, and painful stiffness and swellings of the joints, pro- tract the convalescence. Complications do not occur, and there are no sequels. Relapses often take place, and occasionally repeated relapses befall the same patient. They run a milder course than the primary attack. The affection is scarcely ever fatal. Convulsions may occasion an unfavorable termination in infants. On the other hand, it is among the most painful of the epidemic diseases, and not seldom gives rise to serious impairment of health by the exhaustion which follows the high fever, the prolonged, severe pains, the sleeplessness, the inability to retain food, and the abundant critical discharges. The course of the disease may be divided according to recent ob- servers into — a, the period of first febrile access, two to three days. h, the intermission, some hours to two or three days. c, the second febrile stage, two to three days. Whole duration of the acute symptoms, about eight days. The intermission may be altogether absent. The duration of epidemics varies from two to seven months. It remains to consider more in detail some of the prominent symp- toms. Tlie affection of the joints and limbs, which accompanies the first paroxysm, gives rise to the peculiarities of gait and attitude which are expressed in so many of tlie popular names of the disease. It attacks large and small joints alike, often six or eight being affected at once. The joints of the hand, foot, and knee, the spine, the fingers, the toes, the elbow and shoulder, are ofttimes involved successively in the order given. In severe cases all the joints are implicated (Zuelzer), The joints are swollen, red, immobile, painful, and often exquisitely sensitive to the touch. The stiffness of the affected limbs is not Avholly due to the condi- tion of the joints. The muscles are likewise stiffened and sore, and there is an effusion of serum in the connective tissue surrounding certain of the tendons. The finsrers are often stiff, and the hand cannot be closed. This is particularly the case in the morning, and constitutes an annoying cir- cumstance of the convalescence. The pains are described as rheumatic or rheumatoid, by most writers. De Wilde observed isolated painful spots in several instances, and in others found a single nerve-trunk, as the ulnar, to be affected. The pains in this disease, as in acute articular rheumatism, pass from one set of joints to another with remarkable rapidity. At the onset of the attack, only severe headache and pain in the hands may be complained of, yet in a few hours the joints of the feet and the knees may have become in- volved. Each new invasion of a part is accompanied in such instances DENGUE. 353 by twitching of the muscles in the neighborhood of the joint affected (Aitken).' Patients describe the pains as of exceeding severity ; they express them by such terms as " boring " and " breaking." Few can en- dure them without complaining. This affection, much less prominent during the second paroxysm of the fever than in the first, gradually disap- pears; but it may persist for several weeks, or even for some months, becoming fixed in one or more joints. In three cases examined after death, serous infiltration of the connec- tive tissue in the neighborhood of affected joints was found twice, and reddening of the crucial ligament of the knee once (Hirsch). As has already been pointed out in the definition of the disease, z. pri- mary and a secondary exanthem, corresponding respectively to the first and second febrile paroxysms, occur in a majority of the cases. The first, though present in a large proportion of the cases, is by no means constant. When present it appears and disappears coincidently with the fever. The latter is, as a rule, always encountered. Much diversity of vie-w as to the character of this eruption is found in the writings of those who have recorded their personal observations of the disease. The forms com- monly assumed by the eruption have already been indicated. In some in- stances they are mixed, as, for example, erythema and urticaria may be present at the same time. Urticaria is common in children. Consider- able swelling of the skin attends the appearance of this eruption in some regions, especially upon the palms and soles, at the lobe of the ear, and about the eyes, where it induces conjunctivitis and lachrymation. In se- vere cases the mucous m,embrane of the mouth and throat, and that of the nostrils, is inflamed. Aphthous ulcerations occur upon the tongue and buccal mucous membrane. The secretion of saliva is sometimes increased, and the salivary glands, and in particular the parotids, are swollen. The superficial lymphatics, about the angle of the jaw and in the groin, are also in some instances transiently enlarged. Less commonly, boils oc- cur during the convalescence, and some observers have recorded the occa- sional occurrence of extensive subcutaneous abscesses. The desquamation is usually bran-like, but this is not always the case. The epidermis has been observed to peel off in large flakes, leaving a denuded, painful surface, which has sometimes resulted in superficial ul- cerations. The urine during the access of fever is scanty and of dark color; its specific gravity is high; albumen has not been observed. With the crisis its quantity is augmented. Restlessness, sleeplessness, headache, especially involving the forehead and temples, and sometimes nocturnal delirium, attend the fever. ' Reynolds' System of Medicine. Article on Dengue. Vol. i., 1868. 354 THE CONTINUED FEVERS. In children the fever is of shorter duration, and the course of the dis- ease is modilied by the convulsions by which its advent is not seldom heralded, and which sometimes persist, and even lead to a fatal issue. Hapid emaciation, and, as has been pointed out, an extreme debility, attend this disease. Weakness and loss of muscular power, in the legs especially, often continue far into the convalescence. Hirsch informs us that affections of the heart appear to have been in no case encountered. His opinion is the result of a study of the histories of the epidemics prevailing previous to 1860. In the recent epidemics in India, M. Sheriff and Dunkley not seldom observed, after the fever, an affection of the heart, which was considered to be pericarditis. In no case did it, however, result in death, and after a time it disappeared (Zuelzer). The respiratory organs are not implicated in the disease. In very rare instances pleurisy has been noted. It is probable that its association with dengue in such cases was accidental. It is stated by observers of the West Indian epidemics, that females at various periods of pregnancy suffered the severer forms of the fever without any tendency to abortion. But, in the visitation in India in 1872, this accident not infrequently took place. Dr. F. P. Porcher furnished to the National Hoard of Health Bul- letin, September 25, 1880, the following account of the mild epidemic of break-bone fever which prevailed during the past summer at Charleston: " It began, it appears, in the extreme northwestern portion of the city, above Calhoun, near Line and Columbus streets, in what was formerly called the ' Neck.' Afterward it seemed to progress into the lower or oldest part, and there is every indication that it is now diminishing. " The earth had been disturbed in the paving of King street, an exten» sive thoroughfare running north and south the entire length of the city, and the special section of the city where the first cases were noticed was not in as good a condition as others, being near the marshes, and new streets having been opened there; but, though we were at first inclined to search for the causes of disease in these conditions, the simultaneous appearance of the fever in the West, and, as we learn, in Savannah and Augusta, must exclude such a supposition, and refer it to general and wide-prevailing atmospheric influences. "Besides our own experience, which has been limited on account of temporary absence, we have made diligent inquiries of many persons, of physicians as well as the laity, and learn the following particulars, which we present in default of a more complete report, which will doubtless be made in the future. " The symptoms vary exceedingly — some being present and some ab- sent — as follows: the disease generally begins with a feeling of coldness, or by a chill, followed by fever; this, with a temperature ranging from 100° to 105°, lasts generally from twenty-four to forty-eight hours, occa- DENGUE. 355 sionally extending' to four or five days, and even In rare cases to seven. Relapses occasional, especially in those who have gone out too early. Headache frequent, generally frontal, from the beginning. Miliary erup- tions, sometimes elevated and red, like measles, and the occasional pres- ence of sudamina over the face, neck, aixdhody ; sometimes the eruptions were confined to the body, and endured for days after recovery. We have seen some examples of slight desquamation — furfuraceous or branny in character. Sweating profuse in many persons, though often absent. Hence, some physicians are inclined to consider the disease to be suette miliare of a mild form. ' Break-bone ' is the best name, because pain in the bones and limbs is the most constant symptom. There is often great restlessness during the fever, and in some a feeling of tightness or con- gestion about the throat, with bleeding in a few cases known to us. Ca- tarrhal symptoms are rarely present, although cough has occasionally existed. Bleeding from'the nose not unusual in children, and also increase in the menstrual molimen has been observed. Pain in the back and limbs markedly present, but no decided swelling of joints, no carbuncular en- largements or boils, as in the epidemic of dengue of forty years since, or in that of ' break -bone' which followed some years subsequently. Weak- ness and prostration have been very decided, but not nearly to such an extent as in previous epidemics. Some of the physicians consider that there has been a tendency to hepatic torpor or congestion — of no great severity, however. We have heard of no cases of decided jaundice. Nau- sea and vomiting seldom occur. " The disease does not affect all the members of a household, often- times only one or two being seized, though we have known six to be taken in one house; in this respect differing from the dengue, as described by Prof. Dickson, and from the epidemic seen by us some thirty years since. Then ten thousand were down; no one was well enough or strong enough to help his neighbor, and one had to learn to walk over again. " It is difficult to calculate the number who have suffered, as very many have not employed a physician; from two to three thousand, per- haps, approximates the number. " Very little active treatment has been used — as far as we can learn, as follows: a mild laxative, saline or mercurial, hot teas, nitre, pediluvia, sinapisms, etc., and quinine during and after the attack, upon theoretical grounds, with occasionally mild stimulants. Several persons have recov- ered with no treatment whatever. " It has prevailed among both races, perhaps equally, and not a single death is ascribed to this disease, as far as we can learn. The only disad- vantage which accrues to those who take it is the time lost, and the tem- porary pain and weakness from which they suffer. " Persons who were in the city and who visited the country had mild attacks. We know of four such; one of these had reached Asheville, 356 THE CONTINUED FEVERS. N. C, where we saw him. Cases of the fever have occurred in Summer- ville, thirty miles off, on the line of the South Carolina Railroad, among persons who had never visited the city; others sickened there who had paid flying visits, remaining a part of a day only." Diagnosis. Tlie diagnosis is not attended with difficulty. No other disease pre- senting analogous symptoms spreads with the same rapidity through a com- munity. No other disease whatever, except influenza — with which dengue can by no possibility be confounded — attacks entire communities, sparing neither the young nor the old, the poor nor the rich, and, as has more than once been recorded, not a single individual in a district. The natural history of dengue makes it unnecessary to point out the points of differential diagnosis between it and acute articular rheumatism, to which it presents, in the first febrile paroxysm, strong resemblances ; or between it and scarlet fever or measles, which the eruptions of the second paroxysm are said, in certain instances, to resemble. Its likeness to re- lapsing fever is confined to its course, which is in fact that of a relapsing fever. In future outbreaks careful microscopic examinations of the blood are urgently called for, in view of this resemblance, and the discovery by Obermeier of a minute organism in the blood of relapsing fever patients. Treatment. Efficient methods oi prophylaxis, as regards the individual in infected localities, are not known. As rega,rds communities, it has been recom- mended that a rigid quarantine of the districts in which dengue prevails, and the isolation of the patients, may prevent its spreading. These mea- sures, in view of the march of epidemics along the lines of human inter- course, the facility of its transportation in ships, and the enormous aggre- gate of human suffering which its unchecked progress occasions, will demand vigorous enforcement by the authorities of the city or region in "which dengue shall next make its appearance. There is no abortive treatment. It is a specific disease, for which we possess no specific remedy. Nevertheless, much can be done by a judicious medication to mitigate the symptoms and abridge the period of convalescence. The treatment is to be conducted in accordance with general therapeutic principles, and is for the most part symptomatic. Neither general nor local blood letting is of service. Either increases the tendency to debility and gives rise to vertigo during the convalescence, which is, at the same time, protracted. DENGUE. 357 Eliminative measures, in accordance with the practice of the tropics, have usually been employed in the beginning of the treatment. Emetics are highly spoken of. In several epidemics, pushed to the production of free bilious vomiting, they have greatly relieved the head and eased the pains. For this purpose tartarized antimony and ipecacu- anha were used. The latter is to be preferred. Purgation is called for by the constipation which exists during the first period of fever, and by the dark green color and highly offensive character of the evacuations which commonly take place at its critical termination. It is desirable to anticipate elimination by the bowels by recourse to mild, but efficient purgatives. The disappearance of the green color and the occurrence of more natural fecal discharges, has co- incided with a further amelioration of the symptoms. It is not neces- sary to push pui-gation to the bringing about of watery discharges. Rhubarb, aloes, magnesium sulphate, and the like, variously associated and combined, are proper remedies. The aggravation of the sufferings of the patient which attends the act of defecation cannot be rei^arded as a contraindication to their use, in view of the concurrent testimony of al- most all observers that they are of undoubted service. The bowels should be kept open throughout the sickness by the occasional adminis- tration of mild laxatives. With a view of acting upon the sMn, the sweet spirits of nitre, neu- tral mixture, or the effervescing draughts maybe regularly given at inter- vals of two or three hours. Warm baths have also been employed. Bartholow ' suggests that, as the first paroxysm usually terminates by crisis and commonly with sweating, the " behavior of nature " may be imitated, and this stage possibly shortened by the administration of pilo- carpine. If necessary, diuretics are to be administered along witli the foregoing remedies. Opiates, to relieve the pain, restlessness, and inability to sleep, form an important part of the treatment. The subcutaneous injection of mor- phia will in most instances best fulfil this indication. Dover's powder may be given at night. Belladonna in large doses has been highly extolled as favorably influen- cing the joint-pains. Its local application to the painful joints, in the form of a soft ointment, would probably constitute a valuable adjunct to the treatment. Salicylic acid and the salicylates, as yet untried in this dis- ease, would also probably prove useful against the rheumatoid phenomena. Alcoholic stiratdants should be given from the decline of the initial fever, in carefully regulated doses, regard being had to the habits and mode of life of the individual patient. ' Practice of Medicine, 1880. 358 THE CONTINUED FEVERS. Quinine, combinations of iron with strychnia, and particularly the tincture of the chloride of iron, or that preparation of it known as Bash- am's mixture, are to be given upon the subsidence of the fever of the second paroxysm. The impaired appetite and enfeebled digestion are best managed by minute doses of strychnia, 0.0015 — 0.001 gramme (gr. ■^-^ — gV ^- ^')} either alone or in combination with dilute phosphoric acid, and with or without iron. The itching which is so distressing a symptom in the second paroxysm, and during the desquamation which supervenes, may be in part relieved by the application of lotions of ammonium chloride and corrosive sub- limate in almond emulsion: '^. Ammonii chloridi 1 — 1.3 grm. gr. xv. — xx. Hydrargiri chloridi corr... 0.008 — 0.016 grm. gr. -^ — ^. Misturse amygdalse 32 c.c. fl. § j. M. or a solution of carbolic acid, one-half of one per cent, to one per cent. The lingering stiffness, pain, and soreness of the muscles and joints are best treated by systematic hot douches and massage, and by mild galvanic currents. INDEX. Abscess, hepatic, in typhoid fever, 185 of the spleen in relapsing fever, 333 Abscesses, in relapsing fever, 333 in typhoid fever, 189 multiple, in cerebro-spinal fever, 90 Adenopathie bronchique, in influenza, 34 Age, in etiology of cerebro-spinal fever, 59 in etiology of typhoid fever, 118 in etiology of typhus fever, 253 influencing the mortality in typhoid fever, 219 Albuminuria, transitory, in typhoid fever, 188 Alcohol, excess of, in etiology of typhus, 253 in typhoid fever, 226, 299 Alcoholism, diagnosticated from typhus fe- ver, 297 Anaemia, after relapsing fever, 333 Anaesthesia, • cutaneous and muscular, in typhoid fever, 167 in cerebro-spinal fever, 77 Arachnoid, condition of, in cerebro-spinal fever, 91, 93 Arteries, fatty degeneration of, in typhoid fever, 208 Bed-sores, in typhoid fever, 189, 240 in typhus fever, 286 Blood, changes in, in typhoid fever, 208 condition of, in cerebro spinal fever, 90 Boils, in typhoid fever, 189 in typhus fever, 285 Bowels, hemorrhage from, in typhoid fever, 174 Brain, changes in, in typhoid fever, 209 Brain, condition of, in cerebro-spinal fever, 93 condition of the dura mater of, iu cerebro-spinal fever, 91 condition of the substance of, 93 Bronchitis, capillary, as a complication of influenza, 33 in relapsing fever, 333 in typhus fever, 281, 284 Calvarium, condition of, in cerebro- spinal fever, 91 Cancrum oris, in typhus fever, 287 Catarrh, bronchial, in typhoid fever, 176, 181 the, of influenza, 30 Cellulitis, in typhus fever, 286 Cerebro-spinal fever (see Fever), 46 Chill, in cerebro-spinal fever, 73 Choroiditis, a sequel of relai^sing fever, 334 Circulation, in influenza, 29 in simple continued fever, 5 Circulatory system, symptoms referable to, in typhoid fever, 101 Climate, in etiology of cerebro-spinal fever, 57 in etiology of relapsing fever, 309 in etiology of typhoid fever, 116 in etiology of typhus fever, 251 Cold, antipyretic use of, in typhoid fever, 229 as an antipyi'etic in typhus fever, 298 Coma, in cerebro-spinal fever, 74 in relapsing fever, 334 Coma vigil, 366 Congestion, hypostatic, in typhoid fever, 239 160 INDEX. Constipation, in typhoid fever, 237 in typhus fever, 283 Contagium vivum, of t3'phoid fever, 121 Convulsions, in cerebrospinal fever, 75 in tyijhoid fever, 165 in typhus fever, 208 Cornea, perforation of, in typhus fever, 287 Cough, the, of influenza, 31 Countenance, in influenza, 30 , Cutaneous lesions, in cerebro-spinal fever, 77 Cystitis, in typhoid fever, 188 Deaf-mutism, after cerebro-spinal fever, 89 Deafness, after cerebro-spinal fever, 89 in typhoid fever, 191 in typhus fever, 287 Death, mode of, in cerebro-spinal fever, 98 Debility, in influenza, 32 in relapsing fever, 325 in typhus fever, 2G7 Deglutition, difBcult in typhoid fever, 184 difficult in typhus fever. 282 Delirium, in cerebro-spinal fever, 73 in relapsing fever, 324 in typhoid fever, 164, 23.*) in typhus fever, 265, 300 Dengue, 344 clinical history of, 350 diagnosis of, 356 etiology of. 348 exciting cause of, 349 historical sketch of, 345 treatment of, 356 Diarrhoea, a complication and sequel, of re- lapsing fever, 333 in typhoid fever, 173, 236 Diet, in typhoid fever, 225 Dietetics, of typhoid fever, 222 Digestive system, condition of, in simple continued fever, 5 derangement of the organs of, in cere- bro-spinal fever, 84 in influenza, 30 symptoms due to disturbance of, in relapsing fever, 331 symptoms referable to, in typhoid fever, 170 Diphtheritic processes, in typhoid fever, 184 Drmking-water, contamination of, in eti- ology of typhoid fever, 184 Duodenum, changes in, in typhoid fever, 203 Dura mater of the brain, condition of, in cerebro-spinal fever, 91 condition of, in typhoid fever, 209 Dysentery, a sequel of relapsing fever, 334 in typhus fever, 287 Dyspnoea, the, of influenza, 31 Ear, disorders of, in cerebro-spinal fever, 86 disorders of, in influenza, 35 disorders of, in typhoid fever, 106, 191 Ecchymoses, subpleural, in tj'phus fever, 294 Effusions of blood, in typhoid fever, 189 Emaciation, in dengue, 354 Endocarditis and pericarditis, in typhoid fever. 184 Endocarditis, vi'ith cerebro-spinal fever, 91 Enteric fever (see Fever), 107 distinguished from cerebro-spinal fe- ver, 95 Enteritis, diagnosticated from typhoid fe- ver, 212 Epididymitis, in typhoid fever, 188 Epistaxis, in typhoid fever, 166, 169 Eruption, of cerebro-spinal fever, 77 of typhoid fever, 167, 168 of typhus fever, 169, 277 Erysipelas, after relapsing fever, 333 facial, in typhoid fever, 189 in cerebro-spinal fever, 78 in typhus fever, 2S0, 285 Erythema, in cerebro-spinal fever, 78 Exanthem, in dengue, 353 Exanthems, diagnosticated from typhoid fever, 211 Excreta, decomposing, in etiology of ty- phoid fever, 124 Eye, condition of, in cerebro-spinal fever. 85 disorders of, in typhoid fever, 167, 191 disorders of, in typhus fever, 268 Febricttla, 1 Fever, ardent continued, 4 Fever, asthenic simple, 4 Fever, cerebro-spinal, 46 analysis of the symptoms of, 72 clinical history of, 64 complications and sequels of, 87 diagnosis of, 94 INDEX. 361 Fever, cerebro-spinal, disturbances of the organs of special sense in, 85 etiology of, 56 historical sketch of, 47 pathology and morbid anatomy of, 89 prognosis and mortality of, 97 symptoms referable to the organs of respiration in, 84 symptoms referable to the skin in, 77 treatment of, 98 varieties, 69, 71 Fever, enteric or typhoid (see Fever, ty- phoid), 107 Fever, herpetic, 6 Fever, infantile remittent, 195 Fever, pernicious intermittent, distin- guished from cerebro-spinal fever, 95 Fever, relapsing, 302 anatomical lesions of, 336 analysis of the principal symptoms of, 324 clinical history of, 320 complications and sequels of, 333 diagnosis of, 337 diagnosticated from typhoid, 211 etiology of, 309 exciting cause of, 312 following typhus, 319 historical sketch of, 303 prognosis and mortality of, 335 symptoms due to disturbance of the digestive organs in, 331 treatment of, 340 Fever, remittent, diagnosticated from re- lapsing fever, 339 diagnosticated from typhoid, 211 diagnosticated from typhus fever. 296 Fever, scarlet, distinguished from cerebro- spinal fever, 95 Fever, simple continued, 1 analysis of symptoms of, 5 diagnosticated from typhoid, 211 clinical history of, 3 duration and diagnosis of, 7 etiology of, 3 prognosis, mortality, and treatment of, 8 Fever, typhoid, 107 analysis of the chief symptoms of, 153 anatomical lesions of, 202 Fever, typhoid, clinical history of, 147 complications and sequels of, 178 diagnosis of, 210 differential diagnosis of, 95, 338 etiology of, 116 exciting cause of, 120 expectant treatment of, 234 geographical distribution, 115 historical sketch of, 108 management of the patient during convalescence from, 240 prognosis and mortality of, 213 relapses of, 196 special forms of treatment of, 227 symptoms referable to the circulatory system in, 161 symptoms referable to the digestive tract in, 170 symptoms referable to the nervous system in, 163 symptoms referable to the organs of respiration in, 176 skin, condition of, in, 1 67 treatment of special symptoms, com- plications, and sequels of, 235 treatment and prophylaxis of, 221 urine, condition of, in, 177 varieties of, 193 Fever, typho-malarial, 196 Fever, typhus. 241 analysis of the principal symptoms of, 264 anatomical lesions of, 293 clinical history of, 260 complications and sequels of, 284 diagnosis of, 295 diagnosticated from cerebro-spinal fever, 96 diagnosticated fron!i typhoid, 211 differential diagnosis of, 338 exciting cause of, 256 etiology of, 251 following relapsing fever, 319 fomites of, 258 historical sketch of, 242 phenomena of the fever in, 269 prognosis and mortality of, 290 symptoms manifested by the skin in, 277 symptoms referable to the respiratory and digestive systems in, 281 treatment of, 297 362 INDEX. Fever, typhus, varieties of, 288 Fomites, in typhoid fever, 130 in typhus fever, 258 Gangrene, in relapsing fever, 333 of the lung in typhoid fever, 182 of the lung in typhus fever, 285 Germ, of enteric fever, 121 reproduction of, 136 capable of repioducing itself outside of the human body, 143 elimination of, with the fecal dis- charges, 140 must undergo certain changes before it becomes capable of producing the disease, 141 propagated by the atmosphere, 145 remains in vyater and is conveyed by it, 144 retains its activity for a long time, U2 Glossitis, in typhus fever, 287 Gurgling, in right iliac fossa in typhoid fever, 174 Hair, falling of, in typhoid fever, 189 Hematuria, in typhoid fever, 188 Hasmoptysis, in typhus fever, 285 Hallucinations, in cerebro-spinal fever, 73 Headache, in cerebro-spinal fever, 72 in influenza, 32 in relapsing fever, 324 in typhoid fever, 163, 235 in typhus fever, 264, 300 Hearing, disturbances of, in cerebro-spinal fever, 86 Heart, condition of, in cerebro-spinal fever, 90 changes in, in relapsing fever, 337 changes in the muscle of, in typhoid fever, 208 enfeeblement of, in tjrphoid fever, 162 Hemorrhage, from the bowels, in typhoid fever, 174, 238 Hemorrhages, cutaneous, in typhoid fever, 189 in relapsing fever, 332 in typhus fever, 285 Herpes, in cerebro-spinal fever, 77 ia influenza, 35 in typhoid fever, 188 in typhus fever, 280 Hiccough, in typhoid fever, 165 Hydrocephalus, chronic, after cerebro- spinal fever, 88 Hypostasis, in typhoid fever, 176 Hyperaesthesia, cutaneous, in typhoid fe- ver, 107 in cerebro-spinal fever, 76 Hysteria, 97 Infantile remittent fever, 195 Infarctions, hemorrhagic, in typhoid fever, 182 Influenza, 10 analysis of the symptoms of, 29 clinical history of, 26 complications and sequela of, 33 diagnosticated from typhoid fever, 21 2 etiology of, 21 historical sketch of, 12 morbid anatomy and diagnosis of, 37 pathology of, 30 prognosis and mortality of, 38 symptoms referable to the nervous system in, 32 treatment of, 39 Insomnia, in relapsing fever, 325 Intelligence, feebleness of, after cerebro- spinal fever, 87 Intestines, changes in, in relapsing fever, 330 changes in, in typhoid fever, 203 perforation of, in typhoid fever, 185 Iritis, a sequel, of relapsing fever, 334 Jaundice, in cerebro-spinal fever, 84 in relapsing fever, 321, 332 in typhoid fever, 185 in typhus fever, 287 Joints, affection of. in dengue, 352 inflammation of, in cerebro-spinal fe- ver, 85 Kidneys, condition of, in cerebro-spinal fever, 91 changes in, in typhoid fever, 208 changes in, in typhus fever, 293 Laryngitis, acute, in influenza, 35 in typhoid fever, 179 in typhus fever, 284 in relapsing fever, 333 INDEX. 363 Liver, abscess of, in typhoid fever, 185 condition of, in cerebro-spinal fever, 91 changes in, in typhoid fever, 207 changes in, in typhus fever, 294 changes in, in relapsing fever, 387 enlargement of, in relapsing fever, 331 Locality, in etiology of cerebro-spinal fe- ver, 58 Lungs, changes in, in relapsing fever, 337 changes in, in cerebro-spinal fever, 90 gangrene of, in typhus fever, 285 hypostatic congestion of, in typhoid fever, 181 Lymphatics, in dengue, 353 Mania, in typhoid fever, 190 Measles, diagnosticated from typhus fever, 296 Meat, diseased, in etiology of typhoid fe- ver, 133 Membranes of the spinal cord, condition of, in cerebro-spinal fever, 92 Memory, weak, after cerebro-spinal fever, 87 Meningitis, diagnosticated from typhoid fever, 213 epidemic, 96, 97 in typhoid fever, 189 tuberculous basilar, distinguished from cerebro-spinal fever, 94 Menstruation, in typhoid fever, 188 Mesenteric glands, changes in, in typhoid fever, 306 Meteorism, in typhoid fever, 173 Mode of death, in cerebro-spinal fever, 98 Mucous membrane, gastro- intestinal chan- ges in, in typhus fever, 293 intestinal, in cerebro-spinal fever, 91 Muscles, changes in the voluntary, in ty- phoid fever, 208 condition of, in cerebro-spinal fever, 90 changes in, in typhus fever, 293 disorders of, in typhoid fever, 165 Nails, condition of, in typhoid fever, 189 Nausea, in relapsing fever, 331 in typhoid fever, 171 in typhus fever, 283 Neck, stiffness of, in cerebro-spinal fever, 74 Necrosis, in typhus fever, 387 Nervous system, condition of, in simple continued fever, G symptoms pertaining to, in cerebro- spinal fever, 72 symptoms referable to, in influenza, 33 symptoms referable to, in typhoid fever, 163 Neuralgia, a sequel of relapsing fever, 334 in influenza, 35 in typhoid fever, 191 Noma, in typhus fever, 287 Nutrition, state of, in cerebro-spinal fever, 83 CEdema, pulmonary, in typhoid fever, 181 , 210 Occupation, in etiology of typhoid fever, 119 in etiology of typhus, 253 Ophthalmia, post- febrile, 334 Opium, in cerebro-spinal fever, 103 Orchitis, in typhoid fever, 188 Otorrhcea, in typhoid fever, 191 Overcrowding, in the etiology of typhus, 353 Pachymeningitis, hemorrhagic, a sequel of relapsing fever, 334 Pain, in influenza, 33 in relapsing fever, 335 in typhoid fever, 163 abdominal, in typhoid fever, 171 in typhus fever, 264 Pancreas, changes in, in typhoid fever, 210 changes in, in typhus fever, 294 Paralysis, in cerebro-spinal fever, 76 after cerebro-spinal fever, 87 in typhoid fever, 190 in typhus fever, 2G7, 287 local, after relapsing fever, 334 Parotid gland, swelling of, in cerebro- spinal fever, 85 inflammation of, in influenza, 35 inflammation of, in typhus fever, 286 swelling of, after relapsing fever, 333 swelling of, in typhoid fever, 184 Perforation, intestinal, in typhoid fever, 185 Pericarditis and endocarditis in typhoid fe- ver, 184 364 INDEX. Pericardium, condition of, in cerebro- spinal fever, 91 Peritonitis, diagnosticated from typhoid fever, 212 in typhoid fever, 239 in typhus fever, 294 Petechia, in cerebrospinal fever, 78 in typhoid fever, 169 " in typhus fever, 2G1 Phlegmasia dolens, in typhus fever, 285 Phthisis, in typhus fever, 285 Physiognomy, of typhoid fever, 170 Pia mater, condition of, in cerebro-spinal fever, 91 in typhoid fever, 209 Plague, diagnosticated from typhus fever, 296 Pleura, condition of, in cerebro-spinal fe- ver, 91 Pleurisy, in cerebro-spinal fever, 87 in influenza, 35 in relapsing fever, 333 in typhoid fever, 183 in typhus fever, 285 Pleurosthotonos, in cerebro-spinal fever, 75 Pneumonia, catarrhal and croupous, as complications of influenza, 33 in cerebro-spinal fever, 87 in relapsing fever, 333 in typhoid fever, 182 in typhus fever, 284 Pregnancy, in influenza, 35 with relapsing fever, 323 with typhoid fever, 188 with typhus fever, 288 influencing the mortality in typhoid fever, 220 Prophylaxis, in cerebro-spinal fever, 98 in typhoid fever, 221 Protomycetes, of relapsing fever, 312 Pulse, in relapsing fever, 328 in typhoid fever, IGl in typhus fever, 272 Pupil, condition of, in cerebro-spinal fe- ver, 85 Pyemia, in typhus fever, 285 Rachialgia, in cerebro-spinal fever, 76 Relapses, in dengue, 355 in typhus fever, 290 Relapsing fever fsee Fever), 302 Remittent fever, diagnosticated from re- lapsing fever, 339 Respiration, symptoms referable to the organs of, in cerebro-spinal fever, 84 symptoms referable to the organs of, in typhoid fever, 176 Restlessness, in cerebro-spinal fever, 74 Retinitis, a sequel of relapsing fever, 334 Roseola, in cerebro-spinal fever, 78 Salivaky glands, changes in, in typhoid fever, 209 Scarlatina, diagnosticated from cerebro- spinal fever, 95 Season of the year, in etiology of cerebro- spinal fever, 37 in etiology of relapsing fever, 309 in etiology of typhoid fever, 116 in etiology of tj-phus fever, 251 Secretions, the, in influenza, 30 Sewage, in etiology of typhoid fever, 122 Sex, in etiology of typhoid fever, 119 in etiology of typhus fever, 252 influencing mortality in typhoid fever, 220 Simple continued fever (see Fever), 1 Skin, condition of, in cerebro-spinal fever, 90 condition of, in simple continued fe- ver, 5 hypersesthesia of, in cerebro-spinal fe^ ver, 76 in relapsing fever, 330 state of, in typhoid fever, 167 symptoms referable to, in cerebro- spinal fever, 77 Sleeplessness, in cerebro-spinal fever, 74 in typhoid fever, 235 treatment of. in typhus fever, 300 Small-pox, diagnosticated from typhoid fever, 211 Sordes, in typhoid fever, 236 in typhus fever, 282 Somnolence, in typhoid fever, 165, 235 Spinal cord, changes in, in cerebro-spinal fever, 93 condition of the membranes of, in cerebro-spinal fever, 92 Spine, contraction of the erector muscles of, in cerebro-spinal fever, 74 Spirilli, of Obermeier, 322 INDEX. 365 Spleen, abscess of, in relapsing fever, 333 condition of, in cerebrospinal fever, «4, 91 changes in, in relapsing fever, 337 condition of, in typhoid fever, 172, 207 changes in, in typhus fever, 293 enlargement of, in relapsing fever, 333 enlargement of, in typhus fever, 2S3 Splenization, in typhoid fever, 210 Stomach, changes in, in relapsing fever, 336 changes in, in typhoid fever, 203 Sudamina, in cerebio-spinal fever, 78 in typhoid fever, 109 Synocha, 1 Temperature, in cerebro-spinal fever, 78 in etiology of typhoid fever, 117 in influenza, 29 in simple continued fever, 5 in relapsing fever, 326 in typhoid fever, 153 in typhus fever, 269 Tenderness, abdominal, in typhoid fever, 171 Thirst, in cerebro-spinal fever, 84 in typhoid fever, 171 in typhus fever, 282 Thrombosis, venous, in typhoid fever, 183 Tinnitus aurium, in influenza, 16 Tongue, condition of, in cerebro-spinal fe- ver, 84 condition of, in relapsing fever, 331 in typhoid fever, 17(), 236 in typhus fever, 282 Tremor, in typhoid fever, 236 Trichiniasis, diagnosticated from typhoid fever, 213 Trismus, in cerebro-spinal fever, 75 Tuberculosis, acute, diagnosticated from typhoid fever, 212 acute miliary, after typhoid fever, 182 Tympany, in typhoid fever, 237 in typhus fever, 283 Typhoid fever, 107 Typho-malarial fever, 196 Typhus fever, 241 Urine, condition of, in cerebro-spinal fe- ver, 85 condition of, in relapsing fever, 321 condition of, in simple continued fe- ver, 5 condition of, in typhoid fever, 177 in dengue, 353 in relapsing fever, 330 in typhus fever, 274, 280 retention of, in typhoid fever, 165 Urticaria, in cerebro-spinal fever, 78 in dengue, 353 Ventricles, cardiac, dilatation of, in typhoid fever, 183 Vertigo, in cerebro-spinal fever, 73 in relapsing fever, 324 in typhoid fever, 163 in typhus fever, 264 Vibices, in typhus fever, 279 Vomiting, in cerebro-spinal fever, 73 in relapsing fever, 331 in typhoid fever, 171 in typhus fever, 282 Wakefulness, in typhoid fever, 165 Weather, state of, in etiology of typhoid fever, 117 UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped belo\». ^b^ DEC 3/971 MV 2 9 RECD Form L9-40m-5,'67(H2161s8)4939