HX00014001 ColuntWa 59nttJers(ttj) itttljfCitpofBmtork CoUege of ^ijpsiciang anb burgeons; Hibrarp ii CGHJ, ^/fr> ^ms ^'^'U £^ ^^m;^ ^O^y ^^^^^4i? 0^ . FEOM THIS ROOM Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/treatiseoncontinOOmurc THE CONTINUED FEVERS OF GREAT BRITAIN LOXDO' : PHIXTED BY SrOTTISWOODE ASD CO., SEW-STUEET AND PAELIAMEXT STUEET ?L''^-' A TEKATISE THE Ce^^NUED FEYERS OF GKE4T BRITAIN O CHAELES MUEGmsON, M.D,, LL.D., F.E.S. Kl~ '•■■-,<■ FELLOW OF THE R^AL COLLEGE OF PHYSICIANS ; PHYSICIAN AND LECTORER ON THE PRINOIPIJES AND PRACTICE OF MEDICINE, ST THOMAS'S HOSPITAL ; VICE-PRESIDENT, AND OOSStfLTING PHYSICIAN, LONDON FEVER HOSPITAL ; FORMERLY PHYSICIAN AND LECTURER ON;,,^EpiCINE, MIDDLESEX HOSPITAL ; PHYSICIAN TO THE LONDON FEVER HOSPITAL ; ON THE MEDICAL STAFF OP H.M. BENGAL ARMY ; PROFESSOR OF CHEMISTRY IN THE MEDICAL COLLEGE OP CALCUTTA ; PHYSICIAN TO THE BRITISH LEGATION AT TURIN ; AND PRESIDENT OF THE ROYAL MEDICAL SOCIETY OF EDINBURGH % / THIBD EDITION EDITED BY CAYLET, M.D., F.R.C.P. PHYSICIAil IjJ'O THE MIDDLESEX HOSPITA L AND THE LONDON FEVER H0SP1TM» LECTUEBK^'Cftf MEDICINE TO TflS-TSfiSraiESEX HoiS^'Xi^CHOOL OF MEDICINR. LONGMANS, GEEEN, AND CO. 1884 All rights reserved "Ke lot CD -J O Oi PEEFACE ■-■^ TO ^ THE THIED EDITION. IN preparing for the press a new edition of Dr. Murchison's Treatise on Continued Fevers the editor has believed that he would best meet the wishes of the Medical Profession, as well as of Dr. Murchison's representatives, by making as few altera- tions ill it as possible. He has not therefore considered himself justified in materially modifying any views expressed by the author, and wherever he has thought it necessary to add to or dissent from any statements of importance, he has indicated this by enclosing the passage in brackets or in some other manner. His task then has in the main consisted in embodying in the text the more important results of recent researches. But as it has not been considered advisable to increase the size of the volume this has necessitated some omissions. These con- sist chiefly in the curtailment of the arguments adduced in support of points which are now definitely settled, as the specific distinction of Typhus from Enteric and Eelapsing Fever. Fresh cases illustrating different points in pathology and treatment have been added or substituted, and new tables from the reports of the Eegistrar General inserted to show the prevalence of Fever in the United Kingdom since the date of the previous edition. The account of the supposed organisms of Enteric Fever, with the accompanying drawings, has been supplied by Dr. Heneage Gibbes, and the editor has to thank Dr. Heydenreich for permis- sion to use the plates of his work on the parasites of Eelapsing Fever. 27 WiMPOLE Street, London, W. May I, 1S84. PREFACE TO THE SECOND EDITION. IN the eleven years wliicli have elapsed since the appearance of the first edition of this work, many circumstances have con- tributed to increase public as well as professional interest in the subject of Continued Fevers. The long delay in the appear- ance of this edition, since the sale of the first, has resulted from my desire to embody in it as far as possible the results of ob- servations on the recent epidemics of Fever, made by other physicians as well as by myself. Although the original plan has been retained, the present edition is far from being a mere reprint of the first. Many parts of the work have been entirely rewritten. The statistical Tables in the first edition were based on 6,703 cases of Con- tinued Fever admitted mto the London Fever Hospital during ten years (1848-57), while those in the present edition are based on 28,863 cases admitted during twenty-three years (1848-70), comprising, m fact, the entire medical history of the Fever Hospital from the time that the different Continued Fevers were first distinguished in 1848, until, from the transfer of the pauper patients to the New Fever Asylums in 1871, the ex- perience of the Fever Hospital ceased to be any test of the prevalence of Fevers in the metropolis. After the publica- tion of the first edition, London was visited by great epidemics of Typhus and Eelapsing Fever ; the demands for admission into the Fever Hospital in consequence greatly increased, and to meet these demands the accommodation was more than doubled.' In the nine years 1862-70, the number ' This fact must be borne in mind in employing the statistics of the Fever Hospital as a test of the lorevalence of Fevers in the metropolis in different years. Vlll PREFACE TO THE SECOND EDITION. of patients admitted amounted to 28,707, the admissions in tlie previous sixty years of the hospital's history not exceeding 32,250. Of the 28,707 cases, fuhy one-half were under my care, and notes more or less complete of these cases were taken by the Eesident medical officers, Dr. Horace Jeaffreson, Dr. C. Squarey, and Dr. J. Barbour, and by myself. I have subjected all my note-books to a careful perusal, made a catalogue of all cases of unusual interest, and incorporated the results in the present edition. I have thus endeavoured, as far as possible, to give to the Profession the results of the experience which I enjoyed at the London Fever Hospital during the most eventful years of its history. Wie Gott giebt mir So geb' icli dir. Of the 44 illustrative cases contained in the first edition, 5 have been expunged, and 54 fresh cases added, making a total of 93. The 5 coloured plates of the cutaneous eruptions of Continued Fevers have been reproduced ; 8 new statistical diagrams have been substituted for the 10 in the first edition, the woodcuts have been increased from 13 to 22, while 11 new diagrams, showing the temperature-range in Typhus, Belapsing, and Enteric Fevers, have been added. Since the publication of the first edition, the literature of Continued Fevers has been enriched by the admirable lectures of Dr. Hudson of Dublin, and by numerous memoirs by observers in this country, as well as in Germany, France, India, and other parts of the world. It has been my endeavour to incor- porate with the results of my experience those of my fellow- workers, and it has been no small satisfaction to me to find that, whatever may have been the shortcomings of the first edition, its publication has induced other observers, more able than myself, to test the correctness of my statements and to place their experience on record. With regard to the references to works consulted, the plan adopted in the first edition has been retained. In a work From 1849 to 1864 the hospital accommoilatod 180 patients. In January, 1864, the number of beds was increased to 240 ; in 1 866 it \va,s r£i,ised to 300 ; and in December, 1S69, to 364. PREFACE TO THE SECOND EDITION. IX contaming more than 3,000 references much needless repetition has been thus avoided, while the Bibliography has been ex- tended to the present date. The rapidity with which the first edition (as well as a German translation by Dr. Zuelzer, of Berlin) was disposed of, induces me to think that I was not mistaken in the original plan of the work. In the preparation of this edition I have en- deavoured throughout to be as concise as possible, and to keep in mind the advice given by Boileau to authors in revising their compositions : ' Ajoutez quelquefois, et souvent effacez ; ' but with the immense amount of fresh naaterials at nay disposal, the work has somewhat increased in size. The numerous questions, however, addressed to me on subjects connected with Fever encourage me to believe that the work will not, on this account, be less acceptable to my professional brethren. Finally, I venture to hope that, although some of the views expressed in this work may be refuted by the fresh investi- gations which they may call forth, the facts now placed on record, to the collection of which I have devoted the best part of my life, may be of use to future students of Continued Fevers. 79 WiBiPOLE Street, London, W^ June 2, 1873. PBEFACE TO THE FIRST EDITION. NO apology is necessary for offering to the Profession a Treatise on tlie Continued Fevers of Great Britain; as no work of tlie kind lias been published by any English physician for nearly a quarter of a century, notwithstanding the great advance of late years in our knowledge of the diseases in question. Some account, however, may be expected of the author of a work on what is acknowledged to be one of the most difficult subjects in Medicine. During my connection with the London Fever Hospital, extending over upwards of six years, I have had unusually favom-able opportunities for studying the diseases of which I treat. I was also a clinical clerk in the Edinburgh Pioyal Infirmary, during the great epi- demic of Typhus and Eelapsing Fever in 1847-S. Afterwards, I studied Fever for several months in Dublin and Paris ; and, while serving with the army in Eidia and Burmah, I had the advantage of being able to compare the Fevers of tropical climates with those of this country. Lastly, havmg twice suffered from one of the diseases which I have here attempted to describe, I may adopt the plea, by which Thucydides justified himself in writing the history of the Plague of Athens : ravra SyXcoaco avTos T£ voai^cras^ koI avros IScov aWovs irda'^ovTas. It has been my humble endeavour, in this work, to follow the example of Louis, and, wherever it has been practicable, to reduce my observations to a numerical expression. Some writers object to the application of statistics to medical science, and prefer trusting to what they call experience. But ex- perience, to be of value to any one besides the immediate PREFACE TO THE FIRST EDITION. XI observer, must be something capable of definite expression. Moreover, the mind is apt to attach to accidental occurrences an importance, which is at once dispelled by an appeal to the * force brutale de chiffres.' A feature unusual in a practical work is the large share of attention here devoted to the Causes of Fevers. My conviction that Continued Fevers are diseases which may be prevented, and the circumstance that the questions discussed have occupied greatly the attention of scientific men of late years, induce me to think that my remarks on this subject will be of service, if it be only in stimulating other observers to further investi- gations, for the purpose of testing the correctness of the con- clusions at which I have arrived. The history of Continued Fevers, possessing, as it does, an importance which does not attach to the history of most other maladies, has also been considered at some length : it involves an account of some of the greatest calamities which have befallen our race, and it teaches important lessons, by means of which we may hope to prevent similar calamities in future. In discussing certain topics, I have not hesitated to express freely my own opinions, although they are occasionally at variance with those of some of my professional brethren, for whose judgment I entertain profound respect. But, where this has been the case, I have adduced the evidence on which I have based my dissent, and I trust that I have not been wanting in that deference to the opinions of others, which ought to charac- terise all scientific discussions. With regard to the specific distinctness of Typhus and Enteric Fever, it is right to state, that I was taught to regard them as mere varieties of one disease ; and that, with this impression, I commenced their study at the London Fever Hospital. If my subsequent obser- vations, aided by the convincing arguments of Drs. Stewart and Jenner, have led me to an opposite conclusion, it cannot be said that my present convictions are the result of preconceived opin- ions. Whatever be the decision arrived at on this subject and on other disputed points, many of the observations collected in this volume have an important bearing on the question at issue, Xll PREFACE TO THE FIRST EDITION. and ' I know that the truth is in the facts, and not in the mind which observes them.' In the treatment of each subject, I have given the results obtained by other observers, as well as by myself, and I have collected, in a Bibliography, the more important monographs and essays referred to in the text. The references throughout are restricted to the author's name, with the date and page of the work. The full title of the work will be found by referring to the Bibliography. By adopting this plan, much needless re- petition has been avoided, while, at the same time, an attempt has been made to bring together the more important works on Continued Fevers, and thus to supply a want which has been often complained of. In addition to the forty-four illustrative cases selected from many hundreds of which I have notes, I have given throughout the work the results of an analysis of numerous cases reported by myself on a uniform plan, the notes being taken daily on printed sheets with a heading for each system. Many of the statistical tables referring to the etiology and mortality of Con- tinued Fevers were contained in an essay which I read to the Eoyal Medical and Chirurgical Society of London in 1858. These tables were compiled with great labour and care from the Eegis- ters of the London Fever Hospital, extending over a period of ten years ; and most of them have now been brought down to the present date. It is believed that the statistics of an hospital, where the different Fevers have been distinguished for nearly fifteen years, cannot fail to be useful. The coloured plates of the cutaneous eruptions met with in Continued Fevers have been successfully drawn from nature by Dr. Westmacott, and copied on stone by Mr. William West under my superintendence, and they will help to make the descriptions given in the text more intelligible. 79 WiJiPOLE Street, Cavendish Squake ; October 15, 1862. CORNELL ^\'l^':t:E6i?Mt'i'''--:0L OF NURSIl^G LYDIA E. ANDERSON LIBRARY ONTENTS. CHAPTEE I. INTRODUCTION. PAGE A. Prevalence and Importance of Continued Fevers . . . . . i B. Nosological Eolations 2 C. Plurality and Classification 2 D. Causes 8 E. Theory of Pyrexia 13 Indications for Treatment . 22 CHAPTEE n. TYPHUS FEVEB, Section I. Definition . 23 ,, II. Nomenclature . , . . . . . . . 23 ,, III. Historical Account ....... 26 „ IV. Geographical Pi.ange . . . . . . . . 56 „ V. Etiology .......... 62 A. Predisposing Cause>s . . . . . . . 62 B. Exciting Cause ....... 80 1. Contagion . . 81 2. Independent Origin 99 „ VI. Symptoms 119 A. Clinical Description . . . . . .120 B. Illustrative Cases . . . . . . . 124 C. Analysis of Principal Symptoms . . . .129 ,, VII. Stages and Duration 179 ;, VIII. Complications and Sequelee . . . . . .190 „ IX. Varieties .......... 227 „ X. Diagnosis 228 XIV CONTENTS. PAGE Section? XI. Prognosis and Mortality 234 a. Rate of Mortality .234 h. Circixmstances influencing Mortality . . . . 236 c. Prognosis from Sjinptoms and Complications . 245 d. Mode of Fatal Termination 248 „ XII. Anatomical Lesions 248 „ XIII. Treatment 267 A. Prophylactic 267 1. Rules for preventing Origin . . . . . 267 2. „ „ Propagation . . . 270 B. Cm-ative 272 CHAPTEE m. RELAPSING OB FAMINE FEVEB. Sectiox I. Definition 311 ,, II. Nomenclatui-e . . . . . . . . . 311 „ III. Historical Account 312 „ IV. Geographical Range . 321 „ V. Etiology 324 A. Predisposing Causes 324 B. Exciting Causes 329 1. Contagion 329 2. Independent Origin ...... 335 Relation of Relapsing Fever to Tj-phus . . . 342 VI. Symptoms 344 A. Clinical Description . . .- . . . . 344 B. Illustrative Case ....... 347 C. Analysis of Principal Symptoms . . . . 348 „ VII. Stages and Diu-ation 371 „ VIII. Complications and Sequelse 378 „ IX. Varieties 388 „ X. Diagnosis , 390 „ XI. Prognosis and Mortality ....... 394 a. Rate of Mortality'' . 394 b. Circumstances influencing MortaUtj'^ . , , 395 c. Prognosis from SjTiiptoms and Complications . . 399 d. Mode of Fatal Termination ..... 400 „ XII. Pathological Anatomy — Presence of the Spii'ochffite . . 400 „ XIII. Treatment 407 A. Prophylactic . 407 B. Cm-ative 408 CONTENTS. XV CHAPTER IV. ENTEBIC OB PYTHOGENIC EEVEB. PAGE Sectioisi I. Definition 416 „ II. Nomenclat'ure 416 „ III. Historical Account . . . . , . ..419 „ IV. Geographical Range ....... 434 „ V. Etiology 437 A. Predisposing Causes ...... 437 B. Exciting Cause 458 1. Contagion ........ 458 2. Independent Origin . 471 Objections Considered ...... 483 „ VI. Symptoms 500 A. Clinical Descrij)tion 500 B. Illustrative Cases . . . . .- • • 503 C. Analysis of Principal Symptoms . . . .510 VII. Stages and Dm-ation 545 VIII. Complications and Sequelae 556 IX. Varieties 591 X. Diagnosis . 596 XI, Prognosis and Mortality . . . . . . . 604 a. Eate of Mortality 604 b. Circiimstances influencing Mortality . . . . 605 c. Prognosis from Symptoms and Complications . 610 d. Mode of Fatal Termination . . . . ..612 XII. Anatomical Lesions . . . . . , .612 Organisms of Enteric Fever , . . . . . 64 5 XIII. Treatment 648 A. Prophylactic 648 1. Eules for Preventing Origin 648 2. „ „ Propagation . . . . 650 B. Curative 650 CHAPTEE V. ON THE SPECIFIC DISTINCTIONS OF TYPHUS AND ENTEBIC FEVEB. A. Arguments derived from their Symptoms and Anatomical Lesions . 678 B. Arguments derived from their Etiology 678 XVI CONTENTS. CHAPTEE VI. SIMPLE CONTINUED FEVER OB FEBBICULA. PAGE Section I. Definition .......... 680 II. Nomenclatiire ......... 6S0 III. History and Etiology 681 IV. Symptoms and Varieties 683 V. Complications . . 685 VI. Diagnosis 686 VII. Prognosis 686 VIII. Anatomical Lesions ....... 686 IX. Treatment 686 CHAPTER VII. ON THE RELATIVE MERITS OF ISOLATING PATIENTS SUFFERING FROM INFECTIOUS FEVERS, AND OF DISTRIBUTING THEM IN THE WARDS OF A GENE- RAL HOSPITAL 688 BIBLIOGEAPHY 699 INDEX 719 Corrigenda. Page 107. For ' Fig. 4 ' read ' Fig. i." „ 4gg, note. For ' Dr. Daw ' read ' Dr. Dow,' T \ LIST OF ILLUSTEATIONS. COLOUBED PLATES AND LITHOGRAPHS. PAGE I. Eruption of Typhus at an early stage . . . .To face 1 30 IL „ „ advanced stage . . . . „ 132 III. Lenticular Eose-spots of Enteric Fever . ,, . „ 5^° IV. „ „ unusually numerous ... „ 514 V. „ „ and taches bleuatres, in a case of Enteric Fever . . . . . . . „ 516 VI. Spirochaste or Spirillum of Relapsing Fever — Bacilli of Enteric Fever ..,.....„ 646 DIAGBAMS. I. Annual number of admissions of each of the Continued Fevers into the London Fever Hospital, during twenty-foiir years . „ 52 IL Ages of 1 8, 1 38 cases of Typhus Fever, with the number of deaths at each age ...,...„ 64 III. Quarterly admissions of Typhus Fever into the London Fever Hospital, during twenty-four years . . . „ 68 IV. Temperature-range in Typhus Fever . . . . „ 136 V. Temperature-range in Typhus Fever from first day of attack. Treatment by cold baths and large doses of quinine „ 136 VI. Temperature-range in Typhus Fever . . . . „ 136 VII. Temperature-range m Typhus Fever showing rapid rise before death on 17th day. After Wunderlich . . „ 136 a XVlll LIST OF ILLUSTEATIONS. PAGE VIII. Variations, according to age, in the rate of mortality of 18,138 cases of Tji^lius Fever To face 2^6 VIII. A. Temperature-range in Typhus Fever treated by cold baths ,,284 IX. Temperatm-e -range in Eelapsing Fever from first day, of attack . . . „ 35^ X. Temperature-range in Eelapsing Fever from first day of attack , o ,...••• » 35^ XI. Temperature-range in Eelapsing Fever showing two relapses ,, 35^ XII. Ages of 5,911 cases of Enteric Fever, with the number of deaths at each age „ 43^ XIII. Quarterly admissions of Enteric Fever into the London Fever Hospital dm'ing twenty-four years . . . „ 446 XIV. Admissions of Enteric Fever into the London Fever Hospital during each season of twenty-four years . „ 446 XV. Temperature-range in a mild case of Enteric Fever from first day of attack. After WimderHch . . . . „ 518 XVI. Temperature-range in Enteric Fever. Sxidden fall on tenth day from intestinal haemorrhage, and rise on twenty-seventh day from Thrombosis of femoral vein „ 518 XVII. Temperature-range in an abortive case of Enteric Fever „ 550 XVIII. Temperatm-e-range in a severe case of Enteric Fever with Eelapses. After Wunderlich . . . . „ 55^ XIX. Variations, according to age, in the rate of mortality of 5,911 cases of Enteric Fever „ 606 WOOD ENGBAVINGS. 1. Ground-plan of the Old Bailey, illustrating the accomit of the ' Black Assize' m 1750 107 2. Ring-finger, showing markings on nail thhteen weeks after an attack of Typhus 136 Index-finger, showing markings on nail fom'teen weeks after an attack of TjTphus 136 4-8. Si)hygmogi-aphic tracings of pulse 140 4. The firm and long pulse of vigorous health 140 5. Normal soft pulse 140 LIST OF ILLUSTRATIONS. X15 6. Soft and frequent pulse of mild pyrexia, often present in early stage of Typhus 7. Irregular pulse of Irritative Fever ...... 8. Irregular undulatory pulse of advanced Typhus 9. Microscopic crystals of Chloride of Ammonium obtamed from the breath of a patient in the typhoid stage of Typhus . 10. Ground-plan of Boys' School at Colchester Union . 11. Plan of the Drauaage of Windsor 12. Perforation of the Ileum in a case of Enteric Fever, produced by sloughing of the Peritoneum. Drawn from nature by Dr. West macott ........... 13. Intestinal Lesions of a case of Enteric Fever, fatal at the end of 47 houjTS. Drawn fr-om nature by Dr. Westmacott 14. Intestinal Lesions of a case of Enteric Fever, fatal on loth day, Drawn from natm'e by Dr. Westmacott .... 15. Intestinal Lesions of a case of Enteric Fever, fatal on 17th day Drawn from nature by Dr. Westmacott . 16. Pin-hole Perforation of the Ileum, in a case of Enteric Fever Drawn fr-om natm-e by Dr. Westmacott .... 17. Perforation of the Ileum, produced by sloughing of the Peritoneum Same as Fig. 12 . 18. Perforation of the Ileum, produced by ruptiu:e of the denuded Peritoneum, in a case of Enteric Fever. Drawn by Dr. West- macott ............ 628 19. Microscopic appearances of the Abnormal Contents of the Intestinal Glands, in Enteric Fever , . 642 20. Frame for bathing patients ........... 660 PAGE 140 140 140 144 476 574 618 619 623 626 627 A TEEATISE ON CONTINUED FEVEES. CHAPTEE I. INTRODUCTION. A. Prevalence and Impoetance of Continued Fevers. T?EW medical subjects are of such interest and importance to X the general public as that of the Continued Fevers — a cir- cumstance at once accounted for by their extensive prevalence. During the last thirty years they have destroyed 530,000 of the population of England and Wales, and 71,335 of that of London alone. The actual number of persons attacked, represented by this mortality, has probably amounted to between five and six millions in England and Wales, and to about 750,000 in London. The voluminous literature on the subject of Fevers proves the interest attached to them by medical men in all ages, down to the present day. Like other epidemic diseases due to a specific poison. Continued Fevers possess a peculiar attraction for the medical philosopher, inasmuch as their study involves an in- vestigation, not merely of their symptoms, pathology, and treatment, but of the causes of their varying prevalence at different periods, and of the laws regulating their origin and propagation ; while, at the same time, a knowledge of fever in the abstract is indispensable for the study and treatment of all acute diseases. * In the whole range of human maladies,' said Graves, one of the greatest authorities on the subject, ' there is no disease of such surpassing interest and importance as fever.' But the advantages derived from a study of Continued Fevers are not limited to the medical profession. Depending as they B 2 INTRODUCTION. do on causes, which to a great extent are under human control, their study is of special import to the military commander, to whom a healthy army is one of the most essential conditions of victory ; to the medical jurist, who ought to know that limited outbreaks of fever have often been attributed to criminal poisoning; to the statesman engaged in framing laws for the health of the people ; to the sanitary reformer, and to the community at large, whose duty and interest it is to avert disease and death. B. Nosological Eelations of Continued Fevers. Continued Fevers have been classed by medical writers of all ages as distinct, on the one hand from the Eruptive, and on the other from the Intermittent and Eemittent Fevers. But, although this classification may be in some respects convenient, the distinction is on both sides arbitrary. Some of the con- tinued fevers agree with the eruptive in being eminently contagious, in rarely attacking an individual more than once, and in being characterised by the presence of a peculiar eruption on the skin ; while, on the other hand, one of them (simple fever) is not at all contagious ; another (enteric) is but slightly so ; in two (relapsing and simple fever), one attack confers no immunity from subsequent attacks ; in two (relapsing and simple fever), there is no specific eruption; one of them (enteric) usually assumes a remittent type, so as to resemble malarious remittent fever ; and all of them may be said to agree with the malarious fevers, but to differ from the eruptive, in arising from preventable causes, or in being capable of spontaneous or independent generation. Hence the diseases known as ' Continued Fevers ' constitute a somewhat hetero- geneous class, and may be said to occupy an intermediate position between the eruptive and malarious fevers. C. Plurality of Continued Fevers. Many of the early writers on medicine, such as Eiverius, Willis, Hoffmann, Strother, Huxham, Pringle, and Macbride, recognised and described different forms of Continued Fever ; but their investigations did not suffice to establish absolutely the specific non-identity of the diseases which they observed. During the last thirty years, no subject has occupied more the attention of the profession, or created greater discussion, than PLURALITY OF CONTINUED FEVERS. 3 ihat of the specific identity or non-identity of the different forms of continued fever. But now the question may be regarded as finally settled. The investigations of Henderson and other writers on the epidemic of 1843 established the specific distinct- ness of relapsing fever from typhus, while those of Gerhard, Stewart, Jenner, and others have proved the non-identity of the irue typhus and the ' typhoid fever,' so ably described by Louis. These three diseases, then, are all included under the generic term ' Continued Fevers,' as likewise a fourth, which may be ■styled Simple Fever. The three former owe their origin to poisons which are as distinct as those of Measles, Scarlet Fever, ■and Small-Pox ; Simple Fever arises from non-specific causes, such as exposure to heat, nervous exhaustion, etc. Another ■circumstance worthy of notice is, that of the three specific fevers, two (typhus and relapsing, but particularly the latter) prevaO, for the most part, as great epidemics ; whereas the third (enteric) is ;an endemic disease. According to our present knowledge, the continued fevers of Britain may be classified as follows : — A.— Non-specific. I. Simple Fever, caused by . i Exposure to sun, t^ ' ( latigue, surfeit, etc. /Poison contained in II. Endemic (Enteric, Typhoid, or] drinking -water, Pythogenic) . . . . ] emanations from y sewers, etc. B.— SpEcmc.-i /Contagion, or the ,m 1 J concentrated ex- Typhus caused J t^i^tions from III. & IV. Epidemic ^^ ' " [ ggt! ^'''"''' vEelapsing Fever . Contagion or Famine. The plurality of Continued Fevers is now generally admitted and is advocated in this work. It is true that there are still some distinguished members of the profession, who believe that the fevers above mentioned are mere varieties and all spring from one poison. But the opinions of great authorities must not be allowed to bias the mind and make it misinterpret the facts of nature. It must not be forgotten that among our forefathers were men characterised by genius and powers of observation equal to those possessed by any living physicians, who regarded variola, measles and scarlet fever, as all modifications of one disease — different effects of the same poison, although their own recorded descriptions prove that the diseases they saw were as different as they are now. It is, in my opinion, difficult to B 2 4 INTRODUCTION. conceive how any person, who gives the evidence now accumulated in reference to Continued Fevers a fair consideration, can arrive- at any other conclusion than that they are as distinct as small- pox, measles and scarlet fever ; or to account for their failure in so doing, otherwise than on the supposition, that, like some- modern physicians and sanitary reformers, they regard not only continued fevers, but small-pox, measles, scarlet fever, the plague, remittent and intermittent fevers, as all modifications of the- same affection, the poison of all being the same.^ But even granting that the different continued fevers were specifically alike, it would be hardly less important to be able to distinguish them as forms or varieties of disease. From a practical point of view the necessity of an accm-ate diagnosis is the same, whether we regard them as species or varieties. The evidence in favour of non-identity and the arguments urged in support of identity will engage our attention hereafter ; but, in the meantime, it may be well to mention some of the circumstances which for so long a period led to the different con- tinued fevers being confounded, and which have not ceased to= operate at the present time. They are mainly the following : — 1. Observers, who have had experience of only one form of Continued Fever, have natm-ally thought that all cases resembled those which came under their own notice, and have consequently arrived at the conclusion that there is but one species. It is thus that many distinguished physicians in France, whose ex- perience was limited for the most part to the so-called ' Fievre typho'ide,' found it difficult to believe in the existence of typhus,, as a distinct affection ; whUe, on the other hand, the compara- tively few cases of the French fever formerly observed in Edin- burgh were regarded as a complicated variety of the true typhus, which was there so prevalent. 2. Argument-s have been frequently based on the name assigned to a disease prevalent at a given time or place, instead of on its symptoms and lesions. It is a remarkable fact, that several writers argue as if previous observers had employed the terms Typhus, Typhoid, etc., with strict accuracy, when they fail themselves to recognise any specific distinction between the dis- eases in question. 3. Different fevers have fi'equently been epidemic at the same time, and the published descriptions have included both, as one disease, under one name. » See Smith, 1830, \). 75 ; Hbndebson, 1843, p. 202 ; Miss Nightingale's Notes on Nursing, ist ed. p. 19. PLURALITY OF CONTINUED FEVEES. 5 4. In the case of Eelapsing Fever, the relapse has often not l)een recognised, from the patient being seen in only one of the attacks. 5. Much confusion has arisen from the undefined meaning attached to the term petechice. In its ordinary acceptation, this word implies small circumscribed extravasations of blood in the substance of the true skin, such as may occur in the course of any specific fever, or even in the advanced stages of other dis- •eases. But by some writers, both ancient and modern, the term has been used to denote the characteristic eruption of Typhus, which has in consequence been frequently designated ' Petechial Pever.' Hence, from the occasional occurrence of ordinary petechias in enteric fever, it has been argued that this affection must be identical with typhus. This subject will be discussed more at length hereafter. 6. There can be little doubt that the eruptions of typhus and of enteric fever have been frequently confounded, and ihat upon mistakes of this nature erroneous arguments have been based. 7. In distinguishing the different forms of Continued Fever, too much reliance has been placed on their symptoms and pathology, while there has been a want of sufficient investigation of their causes. Continued Fevers have many symptoms in -common. There is little difference between the typhoid state induced by typhus and the similar condition induced by enteric fever. Indeed, if the eruption be absent or indistinct, it may be •difficult, from merely seeing the patient in this condition, and knowing nothing of the previous history, to say whether the case be one of typhus or enteric fever. But the same difficulty exists in distinguishing typhus from many other acute maladies, and ■even from uraemia dependent on disease of the kidneys. Morbid •affections universally acknowledged to be totally different, and in most cases easily distinguishable, may, under certain circum- stances, have many symptoms in common, so as to render their -diagnosis difficult. Patients are constantly admitted into the London Fever Hospital, with medical certificates to the effect that they are labouring under contagious fever, whose real disease is not idiopathic fever, but some affection of the kidneys, brain, •or lungs. Again, the same fever may exhibit different features, at different times and under different cu-cumstances ; but in this respect the continued fevers do not differ from other acute dis- eases acknowledged to be distinct. Typhus may be complicated with tympanitis, diarrhoea, or dysentery, and so assimilate itself P INTRODUCTION. to enteric fever, which, in its turn, may exhibit an unusual tendency to cerebral symptoms (the typhoid state) and even to> constipation, and thus resemble typhus. Moreover, our know- ledge of the fundamental pathology of continued fevers is still far from satisfactory. Many other diseases can be distinguished by physical phenomena during life, or by the lesions found after death ; but in continued fevers, with one exception, there are no- specific lesions. Still, we are not justified in arguing from such facts in favour of the identity of the different forms of continued fever, any more than we are in maintaining that, because opium produces narcotism, all other narcotics must contain morphia^ or that their active principles are identical. It is generally admitted that most continued fevers result from the operation upon the system of some poison ; and the main question to be answered is, whether there be, or be not, an identity of poisons^ To arrive at any certainty in the matter, it is necessary to study the causes of continued fever in connection with their symptoms^ Now, recent investigations have rendered it probable that the circumstances under which the several continued fevers are generated and spread, are widely different ; that typhus is due- to the protracted concentration of the exhalations from living, human bodies ; that relapsing fever makes its appearance in that peculiar condition of the constitution induced by starvation ; while the poison of enteric fever is a product of decomposition of certain forms of organic matter. The coexistence of two species of continued fever in one epidemic is no greater evidence of their identity than is the coexistence of epidemics of scarlatina and variola a proof that these two diseases are the same. The recognition of several species of Continued Fever explains, many of the discrepant statements of different writers. For example, much difference of opinion has existed as to the con- tagious properties of Continued Fever ; but, on inquiry, it is found, that while few who have had any experience of trufr typhus doubt the fact of its being contagious, many, whose observation has been limited to enteric fever, have been inclined to question the contagious property of any form of Contmued Fever. It is obvious that if the conclusions based on the observation of enteric fever be applied to typhus, the most direful consequences might ensue. Thus, while cases of enteric fever may be distributed with impunity among the patients in a general hospital, no doubt can exist as to the impropriety of such an arrangement in the case of typhus. Again, while observers of typhus have contended that an eruption upon the PLUEALITY OF CONTINUED FEVERS. 7 skin is rarely absent in Continued Fever, observers of enteric fever, in which the eruption is comparatively inconspicuous and often overlooked, and of relapsing fever, which has no character- istic eruption, have not unfrequently maintained that the occur- rence of an eruption in Continued Fever is quite exceptional. Thirdly, most erroneous conclusions as to treatment have been arrived at, from confounding the different forms of fever. The advocates of blood-letting at the commencement of the present century appealed to the diminution in the mortality from fever in support of the efficacy of their treatment ; but the reduced mortality was the result, not of the treatment, but of the sub- stitution of relapsing fever for the much more mortal typhus. Lastly, the statements which have been made in reference to fevers having undergone a change of type or nature are mainly to be attributed to a non-recognition of different species, together with changes in the prevailing fashion of treatment. A careful study of the history of epidemics shows, that each of the Con- tinued Fevers and of the other acute specific diseases has main- tained its identity in all ages and countries. Sydenham's description of measles and small-pox is applicable to the measles and small-pox of the present day. The descriptions of typhus by Fracastorius and Cardanus, of relapsing fever by Eutty, and of enteric fever by Baglivi, Huxham, and Manningham corre- spond exactly with the clinical histories of these diseases now. No new species of continued fever has appeared among us, and the type of each has changed little, if at all. Cases of typhus fever occurring during an epidemic of relapsing fever require stimulants as much as when typhus is itself epidemic ; while cases of relapsing fever occurring in an epidemic of typhus will recover, whether left to themselves, or in spite of blood-letting, as readily as during unmixed epidemics of relapsing fever. But while it is essential, in distinguishing the different species of Continued Fever, to have a due regard to their causes, it is no less necessary to remember the existence of different species of continued fevers, in studying their causes from a sanitary point of view. The neglect of this precaution has been pro- ductive of much error, and has greatly impeded the progress of sanitary science. It will hereafter be shown that, while, on the one hand, it has been contended that continued fevers result from putrid emanations and are independent of destitution, on the other it has been urged that putrid emanations are perfectly innocuous, and that the great source of fever is destitution, with or without overcrowding. The cause of this discrepancy, of 8 INTRODUCTION. opinion has been that the opposing parties have drawn their conclusions from different diseases. D. Causes of Continued Fevers. Among the greatest benefits that medicine has conferred on the human race is the discovery of the causes of disease, and of the measures by which they may be prevented. Eecent researches have thrown much light on the causes of Continued Fevers, and render it probable that, whether or not these diseases be necessarily in every instance traceable to contagion, their pre- valence is to a great extent under human control. The causes vary according to the species of fever, and are equally deserving of study whether they be regarded as predisposing or exciting. Two hundred years ago, agues and other malarious fevers were among the most common diseases of this country. James I. and Oliver Cromwell both died of ague in London, and the latter of these rulers, speaking of ague, makes use of the following oft- quoted words : — ' Matrem pietissimam, fratres, sorores, servos, ancillas, nutrices, conductitias, quotquot erant intra eosdem nobiscum parietes, ac fere omnes ejusdem ac vicinorum pagorum incolas, hoc veneno infectos et decumbentes vidi.' ^ The country surrounding London was in Cromwell's time as marshy as the fens of Lincolnshire now are. But at the present day, owing to the almost universal drainage and cultivation of the soil, agues have, save in a few isolated districts, almost vanished from this country. Again, it would not be difficult to show that the Oriental plague, formerly so prevalent in London, but since the great fire of 1666 unknown, is not less contagious now than it was in the days of James IL, and that its disappearance is due to an improved construction of our dwellings. It is not un- reasonable to hope, with confidence, for a like extermination of the whole class of Continued Fevers. In the first edition of this work it was contended that we have it in our power, not only to arrest the spread of continued fevers, but in many cases to prevent their origin. This view has recently been ably advocated by independent observers, such as Virchow,'^ Bence Jones, ^ Beale,® Barker,^ etc. ; while, on the contrary, it has excited vigorous opposition on the part of many who seem to argue that if a disease can once be proved •> BOTJDIN, 1845, pp. 126-7. • ViRCHOW, 1868. ^ JoNKS, 1865, • Beale, 1865 and 1871. ' Babker, 1863. CAUSES OF CONTINUED FEVBES. 9 to be contagious, it cannot possibly arise in any other way than by contagion, and who maintain that in every instance of the apparently independent origin of such diseases, the introduction >of the poison has merely eluded observation, and that the advo- cates of their independent origin are in the untenable position ■of attempting to prove a negative. The strongest analogies and figures of speech have been appealed to in denouncing the doctrine of what is called the spontaneous origin of specific diseases. It has been assumed, for example, that contagia are vegetable parasites, and one writer, Professor Hallier,^ of Jena, has gone so far as to describe, figure, and name the parasitic fungus of each of the acute specific diseases. Such premises being taken for granted, it has been argued that the origin de novo of a fever poison is as impossible as the spontaneous genera- tion of plants and animals. After mature consideration of the arguments advanced on both sides of this difficult question, the following reasons induce me to adhere to my original opinion. 1. Admitting the parasitic theory of contagious diseases does not exclude the possibility of their independent origin, and for two reasons : — a. Hallier himself states that the two maladies in which he has studied the matter most, viz. cholera and sheep- pox, may arise independently of pre-existing cases, through the agency of minute fungi growing upon the rice-plant and upon blighted darnel ; h. It is still an unsettled question whether cer- tain minute animal and vegetable organisms, such as Bacteria and Vibriones, may not appear de novo in organic fluids.^ 2. The parasitic theory rests solely on analogy and is unsup- ported by facts.^ As to Hallier's views, it is difficult to account for the readiness with which they were accepted in this country, considering how unsatisfactory was his method of investigation, and what slight foundation there was for his conclusions ; his •observations respecting cholera, which were the key-stone of his edifice, have been demolished by the researches undertaken by Dr. Lewis in India, at the instance of the English War Office. Contagia no doubt resemble minute organisms in being endowed with the power of rapid self-multiplication and in retaining their vitality out of the body, but the highest powers of the microscope have hitherto failed to show that the spread of any of the acute specific diseases is due to the presence of such organisms. It is E Bjudlier, 1868. •■ See researches by Prof. J. H. Bennett, Ed. Med. Journ., March 1868 ; and Bastian, 1872. ' This statement now requires modifying, vide p. 12. \ 10 INTEODUCTION. true that Bacteria and Vibriones — microzymes, as they have been called — have been found in the blood of enteric fever, malignant pustule, and allied diseases ; but it is equally true that they are absent from many fluids possessing virulent contagious properties, and common enough in fluids which are known to be harmless. Their presence is therefore probably the consequence, rather than the cause, of disease. 3. Although the mode of introduction of a contagium often eludes observation, yet if all contagious diseases can arise in no- other way than by contagia, their germs must be both omni- present and indestructible by time ; and it is difficult to con- ceive how so many persons escape them. Their not furnishing, a suitable soil does not suffice to account for their immunity. Moreover, on this supposition, the germs of certain diseases, such as enteric fever, would require to be much more potent than they have yet been shown to be, to account for the ckcumstances under which these diseases often appear. 4. The poisons of all diseases must have originated at one time or another independently of a pre-existing case. Conta- gion necessarily implies the presence of two individuals, the giver and the receiver of the morbid germ. It is self-evident, then, that in the first sufferer from any disease its origin must, have been de novo, and there is no reason why the unknown causes of the first case may not operate at the present day. The history of medicine, moreover, shows that new contagious diseases have from time to time appeared, while old ones have died out. 5. Erroneous conclusions have resulted from discussing the question at issue on too narrow a basis, and the possibility of the several zymotic diseases differing greatly has been too much lost sight of. Some of them, such as Variola, are not only extremely contagious, but at the present day can never he traced to any other cause than contagion. "Whole continents, such as America and Australia, have remained exempt from them until they were introduced by an infected person. It is true that now and then we cannot trace even these diseases to contagion, but on the other hand we have never yet succeeded in referring them to anything else, while their appearance in isolated localities can almost invariably be traced to importation from without. Their prevalence, moreover, is little if at all influenced by sanitary defects, season, etc. How the germs of these diseases originated we know not, but probably even they were derived in the first instance from human beings, or from some CAUSES OF CONTINUED FEVEES. II of the lower animals, living under abnormal conditions. But the laws of one contagious disease are not applicable to all. It has been too much the fashion to generalize in this matter from small-pox as a type, although it is easy to show that the various contagious diseases are governed by very different laws. Some are propagated by inoculation alone, while the poison of others can be transmitted through the atmosphere and take effect without any breach of surface. Some are characterised by peculiar eruptions on the skin, or by local lesions ; others are not. Some occur only once in a lifetime, while others (relaps- ing fever, diphtheria, and cholera) may occur repeatedly, one attack conferring little or no immunity from a subsequent one. Generalization from one zymotic disease to another is clearly out of the question. Now in certain diseases, such as enteric fever, dysentery, and perhaps cholera, it is in many, if not most, instances impossible to account for the first case of an outbreak on the theory of contagion. The same thing, no doubt, may be said of some outbreaks of small-pox ; but there is this im- portant difference that, whereas it is easy to prove that the poison of small-pox fresh from the body is very potent, it is difficult to do so in the case of the other diseases referred to, which also differ from small-pox in the fact that their poisons multiply out of the body, and that their prevalence is greatly influenced by sanitary derangements, and by season, tempera- ture, and other atmospherical conditions. On the supposition that these diseases may arise de novo from such causes, it is probable that more than one factor will be necessary for their production ; for example, that such a cause as decomposing sewage may exist long without any bad result, which at once ensues on the concurrence of another factor, in the shape of some unusual state of the atmosphere. 6. There are certain contagious diseases, such as erysipelas, pyaemia, and puerperal fever, whose origin de novo may be said to be a matter of almost daily observation, and which in fact we have almost the power of generating at will. The poison of pyaemia is constantly produced de novo in the closed cavity of the peritoneum when it inflames, or in an unopened abscess in the vicinity of intestine or diseased bone, to which atmospheric germs could not possibly have gained access. Yet once generated, this poison has under favourable conditions a power of propaga- tion scarcely inferior to that of small-pox. If this be so, there can.be nothing a priori improbable in the origin de novo of the continued fevers. 12 INTEODIJCTION. For these reasons, and for others to be advanced hereafter, it appears to me that there are good grounds for beheving that contagious fevers have occasionally an independent origin. The real difficulty consists in reconciling this view with the facts that their poisons can retain their power for a lengthened time, and under favourable circumstances become indefinitely multi- plied. These properties cannot be satisfactorily explained on any physical or chemical theory ; but they do not negative a generation de novo of the poison. The recent researches of Beale,J Chauveau,^ and Sanderson,^ have gone far to prove that the virulence of contagious liquids is due to the presence of minute solid particles of organic matter derived from the human organism, and these particles are probably the degraded offspring of some kind of normal living matter, incapable of returning to its previous healthy state, but capable of being developed de novo in persons or animals living under conditions adverse to health. There is no proof that these particles are endowed with the power of self-multiplication, but, like a tubercle or pus-corpuscle, they can excite by contact a fresh formation of similar particles in the human body.™ This view appears to offer the best ex- planation of all the facts of the case ; and, if it be correct, the various pests to which man is subject are of animal origin, and ought by human energy and intelligence to be extirpated. [Since this statement of Dr. Murcliison's \dews on the nature of contagion the discovery of the microbes of relapsing fever, anthrax, fowl cholera, hog typhoid, and probably those of malaria, tubercle, and other specific diseases, together with the results of inoculation and cultivation experiments, has afforded fresh support to the notion that contagious fevers are due to parasitic organisms, and this must now be regarded as, in all probabihty, the correct view of their nature. But this view by no means disproves the possibility of their arising de novo, apart from the theory of spontaneous degeneration which few would be inchned to accept. For the researches of Pasteur and others have shown that the properties of these organisms may be modified in an extraordinary degree by placing them under different conditions ; hence it is quite conceivable that the germs of a disease like typhoid or typhus fever might under ordinary circumstances be harmless, and only acquire virulent properties when under the uofluence of pent up stagnating sewage, or overcrowding and imperfect ventilation, in the same mamier as the bacillus of anthrax may be rendered more or less virulent by being cultivated with the access of more or less oxygen."] J Beale, 1865 and 1871. * Comptes rendus, 1S68, LXVIII. p. 289. ' Sanderson, 1870. "■ On this see Bastian, 1872. ° Pasteue, 1881, THEOEY OF FEVEE. E. Theoey of Fevee. 13 The term Fever or Pyrexia is employed in two very different senses : first, to express that group of general constitutional symptoms which accompany local inflammations ; and secondly, to denote a similar group of symptoms, which, though occasion- ally complicated with local inflammations, are independent of them, and result from the absorption of some poison into the system from without, or from the action on the nervous system of a non-specific cause. In the former case, we say that the fever is symptomatic ; in the latter, idiopathic or essential. It is true that it has been contended that there is no such thing as idio- pathic fever, but that fever is always symptomatic of some local lesion. Thus with regard to the Continued Fevers, with which we are more immediately concerned, it was maintained by Broussais that all Continued Fevers were symptomatic of inflam- mation of the gastro-intestinal canal, and by Clutterbuck that they were symptomatic of inflammation of the brain or its mem- branes. The writings, however, of Graves, Stokes, and Christison, and the labours of modern pathologists, have demonstrated the fallacy of such views. It would be more curious than instructive to discuss the numerous views, according to which medical writers have en- deavoured to explain the phenomena of fever — to show how the humoral pathologists, headed by Hippocrates and Galen, looked upon fever as the result of a contest on the part of nature to expel from the system a superabundance of one or other of the four humours, blood, phlegm, yellow, or black bile ; how the solidists, represented by Fernelius, Hoffmann and CuUen, im- puted it to changes in the living solids ; how, on the one hand, Tweedie insisted that the blood was primarily affected, while, on the other, Christison urged that the first link in the chain of events was derangement of the nervous system ; how Brown held that fever was an asthenic state of the system arising from an abstraction of the natural stimuli, or from exhaustion direct or indirect of the excitability ; how Ploucquet, Beddoes, Clutterbuck, Armstrong, Mills and Broussais maintained that fever was always the result of inflammation or congestion. It is, however, not a little remarkable that modern investi- gations tend to reproduce, in a scientific form, certain crude opinions concerning the nature of fever, which were entertained by the earliest writers on medicine. The abstract definition of 14 INTRODUCTION. Fever given by Hippocrates, Galen and Avicenna, was * Essentia vero febrium est praeter naturam caliditas,' whilst the definition given by one of the greatest of modern pathologists, Professor Virchow, is ' Fever consists essentially in elevation of temperature which must arise in an increased tissue-change, and have its immediate cause in alterations of the nervous system.' ° Traube's definition is very similar : * Fever consists essentially in an in- creased temperature of the blood.' p It is now universally admitted that in all forms of fever there is an actual increase of the animal heat. Increased heat, in fact, is the pathognomonic symptom of fever. Haller and De Haen long ago proved by the thermometer that the temperature is increased even in the ' cold stage ' of fever. In certain cases of acute rheumatism the temperature rises to nearly 112° Fahr. ; in enteric fever it may reach as high as 108°; and in all fevers it exceeds at some period the normal standard (98-5° in axilla, and 99' 5° in rectum). The natural heat of the body is due to vital and chemical processes resulting in oxidation or combustion of nitrogenous and carbonaceous substances furnished to the blood by the tissues, but mainly by the food. The products of this combustion are eliminated from the lungs in the form of carbonic acid, and from the kidneys as urea and uric acid. The oxidation of carbon resulting in the formation of carbonic acid is effected by the corpuscles of the blood, whereas recent researches make it pro- vable that the albumen is transformed into urea and uric acid in its passage through the gland-cells of the liver, spleen and other glands, and through the cells of the blood itself.*^ The albumen which is thus being constantly transformed or split up into urea is not the fixed albumen of the muscles, nerves, and other formed tissues, but the so-called store albumen which exists in the blood and is constantly passing thence to the cells throughout the body and returning to the blood again. From this also the organs take what they require, and the waste is made up partly by the effete albumen cast off' by the tissues, but mainly by the food. The preternatural heat of fever is the result of vital and chemical action exalted above the standard of health, assisted perhaps by a disturbance of the processes by which heat is oarried away. The proof of this is found in the augmentation ViKCHOW, 1854; Pabkes, 1855 and 1871 ; Jennee, 1856; Gee, 1871 p Thaube, 1853. 'See Pabkes, 1871. THEOEY OF FEVER. 1 5 •of the products of metamorphosis eliminated by the lungs and iidneys, and by the loss of bodily weight far exceeding what can be accounted for by the mere abstraction of food. Eecent observations have shown that there is an increased elimination of carbonic acid in pyrexia. The percentage of carbonic acid in the expired air may be less than in health ; but owing to the frequency of respiration the quantity of air expired is increased, and the total amount of carbonic acid eliminated is augmented by one-half or more,*" although its elimination is liable to be impeded by a congested state of the lungs. The increased for- mation of carbonic acid accounts in part for the consumption of the fat in fever. It is, however, the increased elimination of nitrogen by the kidneys in fever which has been chiefly investigated. Many years ago Prout pointed out that the amount of urea formed in the body is always increased in fever, notwithstanding the diminution of the food, and this statement has been amply confirmed by recent researches. In a case of typhus under my care the quantity of urea excreted in one day was 1,012 grains ; and A. Vogel found 1,065 grains in a case of enteric fever, and 1,235 grains in one of pyaemia,® the normal amount for an adult on a fever diet not exceeding 200 or 300 grains. These were no doubt extreme amounts ; but it is now an accepted fact that in fever the quantity of urea in the urine is increased above the healthy standard of the individual. The increase of uric acid is even relatively greater than that of the urea. Moreover, there is evidence that the increased excretion of urea precedes any rise of temperature, and although the amount of urea cannot be measured by the degree of heat, there is a direct ratio between the two. As a rule, the temperature is highest and the quantity of urea greatest in the early stages of a continued fever, and when there is an unusual elevation of temperature there is an unusual amount of urea. There are no doubt exceptions. The temper- ature is modified by the amount of evaporation going on from the surface of the skin, and the urea may be lessened by albumi- noid matter more or less changed being retained in the blood. In badly nourished persons also it has been found that compara- tively little urea is eliminated, notwithstanding the rise of tem- perature ; but the latter is also less than in the robust and well-fed, and is probably due to an increased formation of car- bonic acid. In one respect the temperature of fever differs in *■ Letden, 1870; Gee, 1871, p. 331. ' ZeitscJirift f. jprakt. Med. Bd. iv. Hft. 3. 1 6 INTEODUCTION. its origin from that of health. In health the elimination of nitrogen is entirely regulated by the amount entering the body with the food ; but the increased nitrogen of fever does not come from the food, for it is out of all proportion to it. The fixed albumen of the muscles, brain and nerves, breaks down into cir- culating albumen, to be in its turn transformed into urea and other nitrogenous excreta. Hence it is that in fever the muscles waste and the brain becomes atrophied. The large amount of cerebral fluid so common in protracted fevers is merely thrown out to fill the space vacated by brain. The disintegration of the' nitrogenous tissues in fever is confirmed by microscopic observa- tion ; the granular and waxy degenerations of the muscles found by Zenker in enteric fever occur in all fevers of a severe type, while Beveridge has found a quantity of amorphous granular matter in the cervical ganglia of typhus. The only parts of the body that do not waste in fevers are the glandular organs, and especially the liver, spleen, kidneys, and lymphatic glands, which become enlarged and congested from the increased functions thrown upon them, the enlargement being greatest in the young and robust who have most tissue to spare for conversion into urea.* The gland-cells of these organs become swollen with minute granules, and a similar appearance is often presented by the white corpuscles of the blood, which are usually increased in. number. It is important to note that while the nitrogenous solids of the mdne are thus increased m fever, the water and the chlorides are usually diminished, and the latter may wholly disappear. The large amount of nitrogenous detritus formed in fevers may be all eliminated by the kidneys or bowels, or a portion may be retained in the blood, either as urea or as some half- transformed albuminoid matter, and then the temperature may be elevated without a corresponding augmentation of urea in the urine. The urea, or other less oxidized products of metamor- phosis, circulating in the blood and permeating the tissues, gives rise to symptoms of ursemic poisoning (typhoid symptoms).** t Pabkes, 1871. ° The exact pathology of urfemia is still a subject of discussion. According to Frerichs, the simple accumulation of urea in the blood will not give rise to so-called urajmic symptoms, and the real toxic agent is carbonate of ammonia resulting from the deeomiDosition of the retained urea by some ferment in the blood (Die Briqld'sche Niercnhrankheif, 1851). Hammond and Eichardson, on the other hand have more recently supported the old view, according to which the urea itself' is capable of exciting urremic symptoms (Hammoxd, in Americ. Joiirn. of Med Sc, January, 1861, and Edin. Med. Joum., October 1861 ; Eichaedson's Asdeviad, 1862). Oppler, of Berlin, opposes the view that urremic symptoms are due to urea in the blood, because Bright, Christison, and Owen Eees have THEORY OF FEVER. 1/ Every practitioner must have been struck with the remarkable resemblance between a case of typhus in its advanced stage, and one of uraemia dependent on renal disease ; in fact, the two con- ditions are very often mistaken for one another. It is highly XJrobable that the symptoms in both cases are due to the circulation of the same morbid materials in the blood, the difference being that in fevers these materials are generated in excess, while in renal disease the kidneys are unable to eliminate the normal quantity. This is not a mere conjecture. It will be shown in a subsequent part of this work, that in the different continued fevers with cerebral symptoms, no lesions are to be found in the brain or its membranes, but that urea is present in the blood, while the occurrence of epileptiform convulsions and other severe head-symptoms is often accompanied by a great diminution in the amount of urine. It is difficult to say why the nitrogenous matter is excreted in some cases, and retained in others ; but its elimination appears to be often prevented by some morbid con- dition of the large glands, and especially of the kidneys, either of old standing, or consequent on the febrile attack. Disease of the kidneys, indeed, is an almost fatal complication of typhuB and of many other fevers. There is also reason to believe that the half-changed albuminoid matter circulating in the blood may be deposited in the different organs, and thus cause secondary in- flammations in the course of fever. Cases of idiopathic fever have been observed, where a sudden diminution in the amount of excreted urea was followed by an attack of pleurisy or other local disease, the quantity of urea again increasing as the local complication receded.'^ It is important to add that critical de- posits are chiefly observed in the urine in cases where it might be inferred from the symptoms that the nitrogenous products of shown that urea may exist in large quantities in the blood without any symptoms of uraemia, and because certain French observers have injected a large amount of urea into the blood without producing any other effect than diuresis. He also objects to Frerichs's theory, because he did not find that the injection of carbonate of ammonia produced the heaviness and drowsiness of uremia, and because, after extirpating the kidneys and tying the ureters of animals, he found much urea, but no carbonate of ammonia, in the blood. He observed, that when the functions of the kidneys were arrested, products of retrograde metamorphosis (Kreatine and Leucine) were formed and accumulated largely in the muscles, and that the ex- tractive matters of the blood were greatly increased. He concludes that a similar increased metamorphosis occurs in the central organs of the nervous system, and that this chemical change accounts for the symptoms of uremia. Oppler also adduces experiments to show that the kidneys have the power of transforming kreatine into urea. (Viechow's Archiv. Bd. xxi. Heft. 3.) But whatever theory be adopted, the clinical fact remains, that the symptoms of ' uraemia ' are produced by whatever interferes with the excreting function of the kidneys. ' See Pabkes, 1855. 15 INTRODUCTION. metamorphosis have been retained in the system. After conval- escence is fairly established, and the patient is regaining weight, the elimination of nitrogen and also the temperature are found to be diminished below the normal standard. As the metamorphosis of albumen which occm's dm^ing health is under the control of the nerves, so the augmented metamor- phosis of fever is probably, in great measure, due to some abnor- mal condition of the nervous system. According to the well- known experiment of Claude Bernard, an elevation of temperature to the extent of from 7° to 11° Fahrenheit is produced on one side of the face of an animal, when the trunk uniting the sympa- thetic ganglia of the neck on the corresponding side is divided, the sensibility of the part becoming greatly excited and the vessels dilated and hypersemic. This elevation of temperatm-e must be referred to the hypersemia and the increased metamor- phosis in the part, which had before been held in check by the sympathetic nerve. The converse of this experiment has been performed by Waller, who found that contraction of the dilated vessels, diminution of vascular injection, and reduction of tem- perature followed the irritation of the divided sympathetic by the transmission of an electric current. Experiments on the vagus nerves have been attended with equally important results. Weber ascertained that section of the vagus was followed by in- creased rapidity of the heart's action, the number of beats being again reduced on passing an electric current through the cut nerve. Volkmann and Fowelin observed that section of the vagus caused an increased lateral pressure of the blood in the arteries, whilst Ludwig and Hoffa found the lateral pressure diminished by irritation of the nerve. '^ These and other^ obser- vations make it probable that the increased metamorphosis, the elevated temperature, and the accelerated action of the heart in fever are due to paralysis of the sympathetic nerves and the vagus. Many facts indicate that the nervous system exercises a X^owerful influence on the early phenomena of fever, such, for examx)le, as the rigors, pain, languor, and prostration usually complained of from the fii'st, and the occasional occm'rence of sudden death at the onset. In Simple Continued Fever, which is independent of a specific poison, the nervous system seems to be affected primarily. The best illustration is to be found in " See B7-it. and For. Med.-Chir. Rev. Ap. 1S56, p. 39S; HANDFrELD Jones, 1858. (No. 3.) * See, for example, Gee, 1871, p. 390. THEORY OF FEVER. 19 the fever that occasionally results from sheer nervous exhaus- tion, consequent on mental or bodily fatigue. But, as regards the other continued fevers which are due to some poison, the poison is probably in the first place absorbed into the blood, and through this medium produces its effects on the nerves. The facts recorded by Sir Henry Marsh and others, to the effect that persons may be seized with sjnnptoms of fever immediately ■on exposure to the poison, do not prove that the poison acts directly on the nerves without being absorbed into the blood, for hydrocyanic acid may prove fatal in a few seconds after its application to the tongue, and be detected after death in the blood of the heart.^ The muscles being deprived in the manner described of their healthy nervous stimulus, the patient naturally suffers from a feeling of incapacity for exertion or motion ; at the same time, the muscular and other tissues begin to waste. The amount of metamorphosis, or the severity of the case, will de- pend, not so much on the primary poison, as on the vitality, or the power of resistance, of the recipient, and his richness in muscle and fat. The blood sooner or later becomes contami- nated by the debris of the disintegrated tissues in addition to the ■original fever-poison. These morbid materials may be elimi- nated by the natural channels, and so be productive of no injury ; but if there be any impediment to their excretion, they give rise to the symptoms already referred to. When stupor, delnium and coma present themselves in the course of fever, it is the custom to refer them to the action of the fever-poison on the brain ; but the cerebral functions are more probably deranged, not by the fever-poison, which was the first and necessary link of the pathological chain, but by the accumulation in the blood of the products of metamorphosis, and by the perverted and ■defective nutrition of the brain. Hence it is, that the symptoms in the advanced stages of many fevers (' the typhoid state ') are closely assimilated, although the primary poisons have been perfectly distinct.^ Since the appearance of the first edition of this work, another theory as to the pathology of fever has been proposed. According to the views of Liebermeister, Brand, and others, the phenomena of fever are largely due to the direct action of the high temperature, which is itself caused by the fever-poison ' Cheistison, On Poiscnis, 3rd ed. p. 697. * Mdrchison, Clinical Lecture on the Pathology of the Typhoid State, Brit. Med. Journ. January 4, 1868. c2 2Q INTEODUCTION. disturbing the heat-regulating functions of the nervous system,. by which probably both the production and dissipation of heat are influenced. To the high temperature are ascribed the granular infiltration of the heart, and other organs, the vitreous, degeneration of the muscles, the acceleration of the circulation and respiration, the febrile consumption of the body and especi- ally the disturbances of the central nervous system, the delirium and stupor of the typhoid state. In support of this view it is urged that these phenomena occur in many diseases which have nothing in common but the high temperature. And it is possible to produce many of them by artificially raising the temperature. Thus Dr. Wickam Legge showed that by raising the temperature of dogs to 112° Fahr. granular infiltration and softening of the liver and other organs is produced. Eaising the temperature, moreover, increases the meta- bolism of the tissues. Bartels found that by prolonged vapour- baths, by which the temperature of the body may be raised many degrees, as evaporation from the skin and consequently compensatory dispersion of heat is prevented, the pulse and respiration were accelerated, the amount of urea increased 16 per- cent., and the weight of the body diminished. Similar results were obtained by Naunyn in experimenting on dogs. This increase in the discharge of the urea by raising- the temperatm^e presents another resemblance to that caused by fever, inasmuch as it was greater during the twenty-four hours- after the bath, when the temperature was again normal, than during the time when it was raised. This is analogous to the epicritical discharge of m^ea which takes place in those fevers which terminate by crisis. In both cases it is probably due tO' its partial retention and accumulation during the febrile period,, in consequence of the unfavom'able conditions for its elimination during this time. The effects of treatment too may be adduced in favour of this view. If a patient with delmum or stupor, with a dry brown tongue, tremulous muscles, greatly accelerated pulse, and other symptoms which are liable to occur in severe fevers, have his temperature reduced by being placed in a cold bath below 100° Fahr., a remarkable improvement usually manifests itself; the stupor passes off, the delh-ium ceases, the tongue becomes moister, the pulse less frequent, the symptoms again recurring when the temperature rises to its former height. Many other facts would, however, indicate that this view is THEORY OF FEVER. 21 ■only in part correct. The increased metabolism, as shown in the increase in the discharge of urea, is in part at least due to iihe direct action of the fever-poison, and not solely to the high temperature. Thus, in the artificial septic fever of the lower animals produced by the injection of pyrogenetic substances, it is found that the increased discharge of urea precedes the rise of temperature. The same thing takes place in intermittent and relapsing fever. The granular infiltration and softening of the heart and other organs may also occur independently of high "temperature, as has been observed after severe burns, where death has occurred before any febrile reaction has taken place. The delirium and stupor of fever are also not necessarily de- pendent on the temperature, though they are unquestionably largely influenced by it. They may occur in cases of renal disease, where the temperature is not raised, and in relapsing fever the temperature often reaches io6° or 107° Fahr., without there being any delmum. Dr. Charlton Bastian attributes the delirium and stupor of the typhoid state to plugging of minute vessels in the grey matter of the brain with masses of white corpuscles ; * but these «oagula, if constant, are probably only one of the results of the morbid state of the blood and circulation above referred to. Nevertheless, although it seems evident that the high tem- perature is not the sole cause of the principal phenomena of fever, it cannot be doubted but that it exercises a most injurious influence, inasmuch as it increases the frequency of the pulse and respiration, augments the metabolism of the albumen, and consequently the febrile consumption of the body, adds an ad- ditional factor to the granular infiltration and softening of the heart, voluntary muscles, and glandular organs, and injuriously affects the nervous system by both indirectly favouring the accumulation of the disease in the blood of the products of the disintegration of the tissues, and directly when it reaches a certain degree of height and duration by causing delirium, stupor, and coma. According to the present extent of our information, the phenomena of idiopathic fevers may be summed up as follows : — 1. The fever-poison enters the blood. 2. The nervous system (particularly the sympathetic and vagus) is paralysed, and consequently its heat-regulating func- tions disturbed. * Bastian, 1869. 22 INTRODUCTION. 3. The retrograde metamorphosis of the nitrogenous elements, of the blood and tissues is increased, while at the same time little or no fresh material is assimilated to compensate for the loss. Increased temperature, great muscular prostration, and loss of weight are the results. 4. This retrograde metamorphosis is increased by the accele- rated action of the heart. 5. The non-elimination of the products of metamorphosis gives rise to cerebral symptoms and local inflammations. 6. On the elimination of the fever-poison and of the products of metamorphosis, the nerves resume their normal function, th& undue disintegration of tissue is checked, and the patient re- gains his strength and weight. It is impossible to say why this termination occurs at a definite time in certain fevers. If this be the correct pathology of fever, our objects in treat- ment ought to be : — 1. To neutralize the poison and improve the state of the blood. 2. To promote elimination, not merely of the fever-poison,, but of the products of metamorphosis. 3. To reduce the temperature and the frequency of the action of the heart. 4. To maintain, as far as possible, the nutrition of the body^ and stimulate, when necessary, the action of the heart by appro- priate food and stimulants, taking care, at the same time, not to excite congestion, or increase the work, of the already over- tasked glandular organs. 5. To relieve distressing symptoms. 6. To obviate and counteract local complications. 23 CHAPTEE 11. TYPHUS FEVER. Section I. — Definition. A DISEASE, generated by overcrowding of human beings with deficient ventilation, prevaihng in an epidemic form, in periods, or under circumstances, of famine and general des- titution, and communicable by contagion. Its symptoms are : more or less sudden invasion marked by rigors or chilliness ; frequent, compressible pulse ; tongue furred, and ultimately dry and brown ; bowels, in most cases, constipated ; skin warm and dry ; a rubeoloid rash appearing between the fourth and seventh days, the spots never appearing in successive crops, at first slightly elevated and disappearing on pressure, but after the second day persistent, and often becoming converted into true petechias ; great and early prostration ; heavy flushed counte- nance ; injected conjunctivae ; wakefulness and obtuseness of the mental faculties, followed, at the end of the first week, by deli- rium, which is sometimes acute and noisy, but oftener low and wandering; tendency to stupor and coma, tremors, subsultus, and involuntary evacuations, with contracted pupils. Duration of the fever from ten to twenty-one days, usually fourteen. In the dead body no specific lesion ; but hyperaemia of all the in- ternal organs, softening and disintegration of the heart and voluntary muscles, hypostatic congestion of the lungs, atrophy of the brain, and oedema of the pia mater are common. Section II. — Nomenclature. Typhus fever has been described under many different ap- pellations. The following are the most important : — I. — Typhus. Typhus [Sauvages, 1760 ; Cidlen, 1769) ; Enecia Typhus {Mason Good, 1817) ; Typhus and True Typhus {Modern English Writers). 24 TYPHUS FEVER. 2. — Derived from its Contagio^is Character. AoLfw's pro parte (Greek writers) ; Febris pestilens {Galen? Celsus? Fra- castorius,iS46; SaliusDiversus, 1584; Biverius, 1623; Willis, i6c,g; Sydenham, 1668) ; One of the ' Morbi contagiosi ' of Fracastorius (1546) ; Parish Infection [English Bills of Mortality, 1600-1700) ; Infectious Fever [Lind, 1763) ; Pestilential Fever {Grant, 1755, Stoker, 1826) ; Der ansteckende Typhus {J. V. Hildenbrand, iSio) ; Typhus contagieux {J. C. Gasc, 181 1) ; Contagious Fever {Bateman, 1818) ; Tifo contagioso {Bossi, 1819); Contagious Typhus {English Writers). 3. — Derived from its Brevalence in Epidemics. Febris epidemica {J. Bur serins, 1625) ; Epidemical epidemic Fever {Bogers, 1734) ; Febbre epidemica {Basori, 18 13) ; Epidemic Fever, pro parte {English Writers). 4. — Derived from the Cutaneous Eruption. Morbus pulicaris {Cardanus, 1545) ; Febris pestilens quam Cuticulas velPuncticulavocant(i^racastor, 1546; Forestus,i$gi); Tabardiglio et Puntos {De Torres, 1574) ; Febris purpurea epidemica {Therceus, 1578 ; Coyttarus, 1578) ; La Pourpre {Early French Writers, P. a Castro, 1584) ; Fleckfieber {Early German Writers, P. a Castro, 1584) ; Febris stigmatica {Early Writers, P. a Castro, 1584) ; Febris pete- chialis {N. Massa, 1556 ; Sennertus, 1641 ; Selle, 1770; Burserius, 1785); Febris maligna pulicaris seu puncticularis {Pet. a Castro, 1584) ; Pipercoorn {Early Dutch Writers, Forestus, 1591); Febris peticularis {Boboretus, 1592) ; Morbus puncticularis {Donkers, 1686) ; Febris petechialis vera {F. Hojfmann, 1 700) ; Spotted Fever {Strother, 1729; Short, 1749); Febbre petecchiale {Basori, 1809); Morbo petecchiale {Acerhi, 181 1 ; Palloni, 1819); Das Fleckenfieber {Beuss, 1814) ; Typhus exanthematicus und Das exanthematische Nerven- 6.eheT {German Writers) ; Typho-ruheoloid {Boupell, 1831); Petechial Fever {Peebles, 1835) ; Petechial Typhus {auct. var.). 5. — Derived from the Presence of Cerebral Symptoms. Febris maligna cum sopore {Biverius, 1623) ; Fever of the Spirits {Quincy, 1721); Typhus comatosus (/SawtJa^es, 1760); Brain Fever, pro parte {auct. var.). 6. — Derived from Tendency to Prostration. Febris asthenica {var.) ; Febris atacta, jpro ^a?-^e [Selle, 1770) ; Fievre ataxique, Fievre adynamique, pro parte {Pinel, 1798) ; Adynamic Fever {Stoker, 1826; Burne, 1828). 7. — Derived from a supposed Putrid or Malignant Character.^ Febris putrida et maligna, Synochus putris and S. cum putredine {Early Authors) ; Febris malignapestilens(i?tycrwts, 1623; SennertuSf * The terms putrid and malignant have often been applied to other fevers of a severe or typhoid type. NOMENCLATUEE. 2$ 1641 ; Willis, 1659) ; Febris cacoethes (Bellini, 1683) ; Malignant Fever [Langrish, 1735 ; Fordyce, 1791) ; Febris continua putrida {Boerhaave, 1738; Wintringham, 1752); Putrid malignant Fever [HuxJiam, 1739) ; Febris exanthematica, maligna, venenosa, et perniciosa (/. F. BiancJiini, 1750) ; Febris maligna [LeBoy, 1771) ; Putrid continual Fever [Macbride, 1772); Febris continens putrida (Selle, 1770) ; Febris lenta nervosa maligna [Burserius, 1785) ; Das Faulfieber [Hecker, 1809) ; Febbre putrida (Ital.) ; Fievres putrides et malignes, pro parte (French Authors) ; Typhoid Fever, with putro- adynamic character (Copland, 1836). 8. — Derived from its Prevalence in Camps and Armies. Pestis bellica and Typhus belHcus (var.) ; Morbus castrensis vel Morbus Hungaricus, pro parte (Sennertus and many early authors) ; Morbus qui ex castris in Bavarian! penetravit (Bhumelius, 1625) ; Febris castrensis (Willis, 1659 ; Haller, 1742) ; Febris militaris (Petri, 1665) ; Febris castrensis petechialis epidemica (Brandhorst, 1746; vide Haller, 1758); Typhus castrensis (Sauvages, 1760); Camp Fever (Grant, 1775); ^^^ Kriegspest (Huf eland and Beuss, 1814) ; Typhus des Camps et des Armees (Louis, 1829). 9. — Derived from its Prevalence in Prisons. Febris contagiosa in carceribus genita [Huxham, 1742); Jayl Fever (Pringle, 1750; Heysham, 1782; John Howard, 1784); Typhus carcerum (Sauvages, 1760); Febris carceraria (Burserius, 1785); Jail Distemper (/, G. Smyth, 1795); Maladie des Prisons (French Writers). 10. — Derived from its Prevalence in Hospitals. MaHgnant Fever of the Hospital (Pringle, 1752) ; Febris nosocomiahs (Burserius, 1785) ; Fievre des Hopitaux (French Writers). II. — Derived from its Prevalence in Ships. Febris pestilentialis nautica (Huxham, 1752); Ship Fever (Lind, 1763, Grant, 1775); Febris nautica (Burserius, 1785); Infectious Ship Fever (Blane, 1789). 12. — Derived from its supposed Mode of Origin. •Ochlotic Fever (oxAos, a crowd), (Lay cock, 1861). 13. — Other Synonyms. Irish Ague (Old Irish designation) ; Morbus mucosus (Boederer and Wagler, 1762) ; Catarrhal Typhus (Irish Writers) ; Febris inirritativa (Darwin, 1800). The appellation Typhus, originating with Sauvages, adopted by CuUen, and sanctioned by general use, is not very appropriate. The word Tvjios literally means smoke, but was employed by 26 TYPHUS FEVER. Hippocrates to define a confused state of the intellect with a tendency to stupor (' stupor attonitus '). In the latter sense it. expresses a prominent symptom of the disease. The expres- sion, however, irvpsTos Tv^oihr]Sy or Fehris typhodes, as employed by Galen, Prosper Alpinus (1611), Eecalchus (1638), Juncker (171 8), &c., did not apply to any specific fever, but had a much more general application. Here is Juncker's definition : ' Typhodes dicitur, quando inflammatio erysipelacea, vel hepatis,. vel ventriculi, vel uteri, febrem provocat, quae anxiis, frigidis et inutilibus sudoribus conjuncta est. Derivatur a tv(J)os, seu res inanis fumo similis.' ^ Previous to the time of Sauvages, Typhus was known as Pestilential or Putrid Fever, or by some name derived from the eruption, or expressive of the locality in which it appeared, as Camp-, Jail-, Hospital-, or Ship-fever. Section IH. — Historical Account of Typhus Fever.*' TYPHUS FEVER is a disease of great antiquity. It was possibly one of the diseases to which frequent allusion is made ia the Sacred Writings mider the term pestilence, which appeared under the same circumstances — overcrowding and famine — as are now known to give rise to typhus. Typhus does not correspond with any of the divisions of fever made by Hippocrates, but some of the cases recorded in his book on epi- demics closely resemble it.*^ During the first fifteen centuries of the Christian era, numerous epidemics of contagious fever occurred under circumstances of over- crowding and famine in different parts of Europe, but the descriptions of the Greek, Latiu, and Arabian writers are not sufficiently precise to ^warrant us in asserting that the fever was typhus.® In many * Conspechis Medicines, Hala, 1734, p. 500. « The following history has no pretension to be complete. A complete history of typhus would be the history of Europe for the last three and a half centuries. An imperfect attempt has been made to give some particulars respecting the most famous of the great fever-epidemics, to ascertain the exact nature of the fever in each instance, to point out the circumstances under which the epidemic ap- peared, and to allude to the principles of treatment adopted at different periods. For additional details respecting the history of typhus, the reader is referred to the works enumerated in the Bibliography, and more particularly to those of Webster, A.D. 1800 ; Vilalba, 1803 ; Palloni, 1804 and 1819 ; Hildenbkand, 1811 ; Waweuch, 1812 ; Kasori, 1813 ; Aceebi, 1822; Schnubber, 1823; Ochs, 1830; OZANAM, 1835; GaULTIERDE ClAUBEY, 1838; WeST, 184O; HeCKBK, 1844 ; ElTCHIE,. 1855; Stark, 1865; and Zuelzer, 1869. ■* See, for example, Case XV., in the Third Book of Epidemics, Syd. Soc Transl. vol. i. p. 419. ' For references to the Greek, Latin, and Arabian writers on fever, see Dr. Adams's Translation of Hippocrates {Syd. Soc. Ed. vol. i. p. 339), and of Paulus- .^gineta {Syd. Soc. Ed. vol. i. p. 187). HISTORY. 27 instances the disease was oriental plague, while in others it was pro- bably typhus. These two affections were long confounded, and the terms Aoi/ao?, Pestis, and Febris ijestilens were applied to both in common. The plague of Athens, which broke out during a siege, when the city was suffering from famine and overcrowding, was pro- bably typhus. It was contagious, and the attendants upon the sick especially suffered. Dr. Adams, the learned commentator of Hippo- crates, believed that the disease was bubonic plague,^ but no mention of buboes is made in the graphic history of Thucydides, which corre- sponds in most particulars with the typhus that appeared in later times during the siege of Saragossa. In the works of Livy, Tacitus, and other Eoman writers, frequent allusion is made to pestilences which devastated Eome ; no account of the symptoms is preserved, but the pestilence usually appeared in seasons of famine, and on one occasion Galen fled from Eome on account of its contagious character.^ In the year 1489 no fewer than 17,000 of the troops of Ferdinand, then besieging Granada, were destroyed by a fever, which the Spaniards, from its spotted character, styled 'El Tabarcliglio,' a designation which was afterwards certainly applied to typhus.** The sixteenth century, remarkable for the revival of religion and letters, was likewise noted for the number and severity of its epidemics ; and now, for the first time, there is unmistakable evidence that many of these epidemics were typhus, in the accurate descriptions handed down by two Italian physicians, Fracastorius * of Verona and Cardanus of Pavia. J Fracastorius (nat. a.d. 1483, ob. 1559) described very minutely the symptoms of an epidemic fever {Febris pestilens) that prevailed in Italy m the years 1505 and 1528, its appearance on both occasions being preceded by very inclement seasons and almost total destruction of the crops. It was contagious and very fatal, and was characterised by an eruption, vulgarly denominated ' Lenticulfe ' or ' Puncticula.' ' Circa quartum, vel septimum diem, in brachiis, dor so et pectore, macule rubentes, ssepe et punicese, erumpebant, puncturis pulicum similes, ssepe majores, imitatae lenticulas, unde et nomen inditum est.' The other symptoms were great prostration, feeble pulse, thirst, sordes on the tongue, injected conjunctivae, blunting of the mental faculties, and, after the fourth or seventh day, mental aberration and low muttering delirium ; in some, wakefulness ; in others, somnolence ; and in others, both of these conditions in succession. The disease lasted from seven to fourteen days, and occasionally longer. Eetention of urine and a deficient or livid eruption were regarded as bad symptoms. A support- ing treatment was considered the best, and the majority of those who were bled perished.'^ The disease was distinguished from the true plague, which was described under the title of 'Febris vere pestilens.'' ' Transl. of Hippoc. Syd. Soc. Ed. vol. i. p. 384. « Transl. of Patjlus J]]gineta, Syd. Soc. Ed. vol. i. p. 281. '' ViLAiiBA, 1803, vol. i. p. 69. ' Fkacastoeius, 1546. J Caedanus, 1545* * * Certe res cecidit, ut major pars phlebotomatorum perierit.' 28 TYPHUS FEVEE. That the disease observed by Fracastorius was the typhus of modern times is confirmed by the circumstance that the eruption so closely resembled that of measles, that medical men found it necessary to point out the distinctions between the two affections. Cardanus said that one of the greatest errors committed by practitioners of his day was : ' Quod pulicarem morbum morbillum credmit.' ^ Nicholas Massa of Venice devoted a chapter to the distmctions between the petechice of fever and the eruptions of measles and small-pox ; ™ and Montuus remarked : ' Sed falso morbilli putantur puncta qusdam pulicum morsibus non dissimilia, qass per febres pestilentes in cutis superficie aliquando visuntur.' ° In the years 1550-54, during a season of great scarcity and a con- sequent crowded state of the large towns, a petechial fever prevailed in Tuscany and destroyed upwards of 100,000 persons. "^ About the same time (1552) a similar fever devastated the army of the emperor Charles V. during the siege of Metz, and was described by Andreas Gratioli.P In 1557 typhus was extensively prevalent in France, and formed the subject of an extensive work, ' De Febribus purpuratis,' by Coyttarusi of Poitiers. Some years later, Ambrose Pare"^ described a 'pestilential fever ' as prevailuig in France along with true plague, in which the skin was marked by ' macule puhcum aut cimicum morsui similes.' In 1566 the notorious 'Morbus Hungaricus ' appeared m Hungary in the army of Maximilian II., and thence spread over the whole of Europe. It was eminently contagious, and among its symptoms were intense headache, followed by delirium, a dry black tongue, and oc- casionally abscesses of the parotids and gangrene of the extremities. There was likewise an eruption upon the skin in many cases, consisting of spots resembling flea-bites, but differmg, as Sennertus pointed out, in the absence of a central punctum. The duration of the disease was from fourteen to twenty-one days.^ In 1580 Verona was again the scene of an epidemic of typhus, which was admirably described by Petrus a Castro, under the designation, 'Febris maligna pimcticularis seu peticularis.' * It was contagious, and prevailed chiefly in the winter months ; and one of the causes to which it was referred was famine. Among the symptoms were frequent, small, weak, pulse ; dry black tongue ; vascular injection of the face and eyes ; wakefulness and delirium ; stupor passing into coma ; tremors and subsultus ; parotid abscesses, in some cases ; and an eruption appearing from the fourth to the seventh day of the disease. This eruption was said to resemble flea-bites, but the points of distinction were noted. The disease, Castro states, was designated 'La Poivrpre ' by the French ; ' Tabardiglio ' by the Spaniards ; ' Petecchie ' by the ' Caedanus, 1545, ed. 1663, torn. vii. sect, i, cap. 36, p. 216. " Massa, 1556, cap. iv. p. 67-70. •■ Montuus, 1558, lib. vii. cap 2. " Vide Palloni, 1804 and 1819; and Peebles, 1835. p Gratioli, 1576; and Ozanam, 1835, vol. iii. p. 127. 9 CoYTTABus, 1578. "■ Pare, 1568. » Sennertus, 1619 ; Ozanam, 1835, vol. iii.; andRiTCHiE, 1855. Fornumerous other references consult Ploucquet's BepcrtoHum. ' Castro, 1584. HISTORY, 29 Italians ; and 'FlecJcfieber'' by the Germans (p. 45). Bleeding, both general and local, was commended at the begimiing of the disease ; but at a later stage was thought to be dangerous. All the patients exliibited ' ardentissimum vini desiderium, ut continue vinum expostu- lantes lacessant.' This epidemic appears to have extended over Italy, and formed the subject of another excellent monograph by Salius Diversus of Faenza." In 159 1 Italy was agam visited by a severe famine and an extensive epidemic of contagious fever, which lasted for four years and was well described by Octavius Eoboretus of Trent, in his work, * De Peticulari Febre.'^ The symptoms corresponded precisely with those of the Febris peticularis of Petrus a Castro. On several occasions during the sixteenth century an epidemic of contagious fever prevailed in Spain, which received the name of ' Tahar- diglio ' or ' Puntos ' from the spotted character of the skin. Much discussion took place as to whether this fever was identical with true plague or was a distinct malady.'^ During this century, the first recorded instances occurred m Eng- land of the ' black assizes,' to which attention will subsequently be directed. Petrus Forestus of Alcmaer,^ in the latter part of the sixteenth century, observed a fever in HoUand, then suffering from famine and from the efforts made by the Dutch to throw off the Spanish yoke. This fever was said to agree in every respect with the ' Lenticulse ' of Fracastorius. Speaking of the eruption, Forestus observed, * Cum vero stigmata latiora essent et rubedinem haberent, melius evadebant. At nigrse et minutte, instar piperis nigri, lethales erant. Vulgus, a simi- litudine, appellabant Pipercoorn, nostro idiomate.' Another symptom of the fever was ' typhomania, vel genus delirii cum levi furore mixtum.' J. C. Ehumelius,y of Munich, published a very curious history of an epidemic of typhus, which appeared in 1621 among the confederate troops encamped at Wiedhausen, and spread over the whole of Bavaria and Grermany. The Bavarian army in Bohemia lost 20,000 men from what became known as the ' Bohemian Disease.' During the thirty years' war (161 9-1 648), the whole of central Europe was devastated by famme and contagious fever.'^ An excellent description of this fever, as it appeared in the south of France, is given by Lazarus Eiverius of Montpelier, mider the title of 'Febris maligna j^estilens .^ * In the city of Montpelier it broke out during a siege in 1623, and almost one-third of those who were seized died. The skin was marked by an eruption of red, livid, or black spots, resembling ilea-bites, which appeared from the fourth to the ninth day over all parts of the body, but most frequently on the loins, chest, and neck. As regards treatment, tonics and acids were commended, and wine was often found extremely beneficial : bleeding was never practised, " Salius DiVEEsus, 1584. ^ Roboeetus, 1591. " ViLALBA, 1803. ^ FoEESTUs, 1591, cd. 1653, tom. i. lib. vi. obs. 35, et seq. ' Ehumelius, 1625. ' West, 1840, p. 287. » Riveeius, 1648. 30 TYPHUS FEVER. except in very plethoric persons. In 164 1 the south of France and indeed the whole of Europe were still devastated by typhus, which was celebrated in song by Zylmgius.^ ' Per omnes Burgundos et quas stagnans Arar irrigat urbes Insolita exarsit febris, quae corpora rubris Inficiens maculis (triste et mirabile dictu !) Quarta luce frequens fate pendebat acerbo. Pulsus erat minimus tremulusque, soporque, Mens vaga, visque labens ; lotium crassumque rubensque, Interdum tenue instar aqute.' .... ' Ilia eadem Italic gentes, miserumque Sabaudum Qui Sequanam Ehodanumque bibunt, Belgas et Iberum Corripuit, necnon Europa sffiviit omni.' ' Accusant alii pluvias, multoque madentem Autumnum per flatum austro, qui uligine coelum Corrumpit, fluidgeque parit contagia pestis. NonnuUi vitiata putant alimenta malignum Suppeditasse homini succum, qui putris adepts Labe venenatum in venis produxit ichorem. Undfe venenati morbi, unde et maxima clades Obsessos inter cives et agentia castra. Sunt qui purpureum hunc morbum pesiemque sequeyitem Italici sobolem belli ..... et ortas In castris febres, .... censent.' In the spring of 1643, while the Earl of Essex was besieging the town of Eeading, a fever (' Fehris pestilens ') broke out in the army of the Parliamentary general, and also in the garrison commanded by Charles I. ; in both armies, the troops were said to have been greatly overcrowded. The fever was accompanied by an eruption of spots, partly red and partly livid. It was contagious ; it was communicated to the inliabitants of Oxford and of the surroimding country and proved very fatal. These particulars are obtained from the account published by Thomas Willis, the celebrated anatomist, then studying medicine at Oxford."^ Again, in 1658, a fever prevailed over England, which, according to Morton, converted the whole island into one vast hospital. It was contagious, and among its symptoms were a weak pulse, head- ache, watchfulness or stupor, occasionally subsultus, and an eruption of ' maculffi latse et rubicundae morbillis similes in toto corpore.' ^ In 1635, and again in 1669, the true plague appeared in Leyden and other parts of Holland, and on both occasions was preceded and followed by a contagious ' spotted fever.' ^ Diemerbroeck stated that in 1635 this petechial fever gradually increased in severity, ' donee tandem in apertissimam pestem transiret.' ^ The great plague of London of 1665 was likewise preceded and followed by an epidemic of malignant Contmued Fever {'Fehris pes- tilens '). One of the symptoms of this fever was a red efflorescence on »> Vide OzANAM, 1835, iii. 135. « Willis, 1659, ed. 1682, p. 113. * MoBTON, ed. 1696, tom. ii. exereit. 2. Appendix pp. 234-6. • Webster, 1800, i. 295. / Diemerbroeck, 1646. HISTORY. 3 1 the skin, which in a short time became dark and livid : no buboes were present. Sydenham's description of this fever is mixed up with that of the true plague, and indeed he observed : ' Eevera enim cum ipsis- sima peste specie convenit, nee ab ea nisi ob gradum remissiorem discriminatur.' The epidemic appeared at the commencement of 1665, during a season of extreme cold.s Sydenham describes another epi- demic of Continued Fever {'Febris nova '), which commenced in London in the spring of 1685, and extended over the whole of Britain, The two previous winters had been characterized by extreme cold ; in that of 1683-4, a fair had been held upon the frozen Thames. This fever presented all the symptoms of typhus : headache and pains in the limbs, dry brown tongue, delirium and subsultus, and an eruption resembling that of measles, but which was often accompanied by true petechia and was not followed by desquamation.^ In 1698 there was a great failure of the crops ; ^ and ' in October a fatal spotted fever began to prevail all over England.' J About the year 1700, F. Hoffmann, professor of medicine at Halle,'^ gave a very accurate description of typhus, under the title of 'Febris Petechialis Vera,' which he had observed among the German troops in 1683, and which he regarded as very malignant and contagious, and yet generated by impure air. Speaking of the eruption, he observed : * Quarto, quinto, vel etiam septimo die in conspectum prodeunt maculae, in dorso potissimum, et lumbis plus minus copiosffi, varii subinde coloris, plerumque tamen sine levamine, ideo symptomaticae magis quam criticEe.' Among the other symptoms were great prostration, severe head- symptoms and delirium, and occasionally gangrene of the ex- tremities. As to treatment, Hoffmann recommended nourishing food, the best wines ('vino nil datur excellentius'), and acid medicines. Under the term ' Febris Pestilens,' which preceding authors had applied to typhus, Hoffmann described the true glandular plague. At the commencement of last century, great attention began to be paid in Ireland to epidemic diseases, of which a careful chronological history, extending over a long series of years, is to be found in the writings of Kogers,i O'Connell,"^ and Eutty." Typhus, however, had been known in Ireland long before this, under the designation of * Irish Ague.' ° The first epidemic that Eogers observed was at Cork, in 1708. He could not say how long it had existed before, but it appeared to reach its climax in the winter of 1708-9 ; after that, ' it declined sensibly for a year or two, and then disappeared.' p No description is given of this fever, but it is stated that the symptoms were identical with those of the subsequent epidemics of 17 18-21 and 1729-31. Short, in his * History of the Air, Weather, and Seasons,' states that the spring and E Sydenham, 1685, ed. 1844, p. 95. ^ Sydenham, 1685, ed. 1844, p. 488. ' Short, 1749, i. 441. J Webstek, 1800, i. 344. ^ Hoffmann, 1699, ed. 1740, ii. cap. 11. p. 84. ' Eogers, 1734. " O'CoNNELL, 1746. » Rdttt, I770. " Bcvieio Bibliog. 1844, p. 38. ' ROQEBS, 1734, p. 4. 32 TYPHUS PEVEE. stmnmer of 1707 were the coldest, and the harvest the worst, that had' occurred for forty- seven years (that of 1698 excepted), while the wmter of 1708-9 was characterised by 'the greatest frost all over Europe withm the memory of man.' q In 1718, ' a fever, in all respects the same ' as that of 1708, became again epidemic in Ireland and continued until 1721, when 'it abated- of its severity, dwindlmg insensibly away, till at length it was rarely to be met with.' ^ It was always most prevalent during the cold months- of the year. From O'Connell's description there can be no doubt that this fever was typhus. The symptoms were headache and anxiety ; in some stupor, and in others wakefulness ; taciturn, or occasionally voci- ferous dehrium ; tremors and subsultus ; a dry black tongue, with sordes on the teeth, and an eruption of ' petechise rubrs, purpurese aut livid^ ; ' the duration of the fever was from fourteen to twenty-one days.® O'Connell practised venesection mider certam conditions ; but the contra-mdications, respecting which he says, ' a venesectione manum tempero,' were so numerous as to have precluded the practice from most cases. The rest of his treatment consisted in bUsters, salines, and cordials (sal-volatile). A similar fever commenced in York and other parts of England in 1718, reached its acme in July 1 7 19, and terminated ^about the close of the latter year.* Little is known as to the circumstances under which this epidemic appeared, except that the preceding summer and harvest time of 1 7 1 7 had been remarkably cold and wet." After 1 72 1, there was an interval of good health in Ireland, and there was scarcely any fever until 1728, when it returned after a succession of three bad harvests. Oatmeal, it is stated, rose to an extravagant price, and food of all sorts was so scarce that riots occurred all over the country, to suppress which the military were called out. This epidemic lasted four years, and reached its climax m 1731. Eogers attributed the orighi of the fever to the same causes as the 'jail-fever,' which had appeared at the Oxford and Tamiton Assizes. The symptoms, as recorded by Eogers, O'ComieU, and Eutty, show clearly that the fever was typhus. The tongue became dry and black ; the pulse was weak, and there was headache, dehrium, and stupor passmg mto coma. The eruption is well, though quamtly described by Eogers, as follows : 'An miiversal Petechial Efflorescence, not mihke the measles, paints the whole surface of the body, limbs, and sometimes the very face. This appearance is very general. In some few, and but few, have appeared Purple and Livid Spots, exactly circular, not milike those observed in the most mortal kind of Small-Pock, some as large as a vetch, others not bigger than a middling pin's head' (p. 7, 8). All the observers mentioned found that the fever ' did not bear bleeding,' and that a tonic and stimulant treatment was necessary. Eogers recommended 1 Short, 1749, i. 441 and 453. "• Kogeks, 1734, p. 4. ' O'Connell, 1746, p. 65,. » For notices of this epidemic, see Eogeks, 1734; O'Connell, 1746 Shokt,. 1749; Baekeb and Cheyne, 1821. " Short, 1749, ii. 21 ; Eogers, 1734, p. 5. HISTORY. 33 sack-whey, wine, salines, and blisters. This epidemic was not only- general over Ireland, but extended to England. In London, where it was described by Dr. Edward Strother, F.E.C.P., as a ' very remarkable spotted fever,' it proved fatal to many, and in one week raised the bill of mortality to nearly one thousand. The patients had both ' petechise and a rash.' In 1728 also, we find from Winteringham, that a fever was prevalent at York, characterised by ' red spots, not unHke flea- bites, on the breast, sometimes interspersed, so that the skin had a marbled appearance.' Huxham states that petechial fevers were pre- valent everywhere. Although Strother practised bleeding in ordinary fevers, he recommended in this spotted fever a stimulant treatment, consisting of * warm, moderately strong sack- whey, with tea, mutton- or chicken-broths, water-gruel and wine.' " In 1735 Dr. Browne Langrish, F.E.S., published an excellent account of the fevers prevalent m London m his time. Typhus was described under the term ' Malignant Fever,' and it was believed to originate from * the effluvia of human live bodies.' Its principal cause was thought to be overcrowding with deficient ventilation, as a result of which ' people were made to inhale their own steams.' At page 364, the cutaneous eruption is described as follows : — ' Petechial spots or red efflorescence in large areas sometimes appear upon the skin, and never rise above the surface. They seem to be constituted of broken particles of red blood oozing from the capillary sanguine arteries through the lymphatic arteries and cutaneous glandules, which, being not minute nor subtle enough to perspire through the pores of the epidermis, do remain between the epidermis and the cutis in the form of flat spots. They do not seem to be critical discharges from the blood, because the sick does not grow a whit the better for their appearance. The brighter red they are of, so much the better sign ; but when they appear of a purple brown, or dusky or black colour, they manifest a greater degree of putrefaction.' Under the head of treatment, Langrish recommended wine, sulphuric and other acids, and made the following remarks, which are worthy of attention at the present day : — ' All medicines which strengthen the action of the heart and arteries and raise the pulse, .... without colliquating and dissolving the globules of the blood and mcreasing the alkaline acrimony of the juices, are of excellent use.' ' But all the volatile salts and spirits, such as Sal. Volat. Succini, Sal. Corn. Cervi, Sp. Sal. Amnion., are destructive medicines, because they are known to break down and colliquate the blood-globules, and to render the animal juices more acrid and alkaline.' ^ The first edition of Huxham' s celebrated ' Essay on Fevers ' ^ ap- peared in 1739. Chapter viii. is entitled: — 'Of Putrid, Malignant, Petechial Fevers,' and contained one of the best descriptions of Typhus ■' The account of this epidemic has been extracted from Short, 1749, ii. 44 ; EoGEEs, 1734, p. 5; O'CoNNELL, 1746, p. 268 ; Huxham, 1752; Eutty, 1770, p. 24; Strother, 1729; Winteringham, quoted by Laycock, 1847, p. 790; Barker and Cheyne, 1821, i. p. 5. " Langrish, 1735, PP- 3^4 and 369. ^ Huxham, 1739; see also Huxham, 1752. 34 TYPHUS FEVER. that had yet appeared. He regarded the disease as contagious, and described both petechial spots and a measly efflorescence. ' The erup- tion of the 2^^techi(B is micertain ; sometimes they appear the fom'th or fifth day, sometimes not till the eleventh, or even later.' ' The more florid the spots are the less is to be feared.' ' We frequently meet with an efflorescence also, like the Measles, in malignant Fevers, but of a more dull and lurid hue, in which the skin, especially on the breast, appears as it were marbled or variegated.' Huxham recom- mended bleeding, provided the patient was very plethoric and seen at the commencement of the attack ; but in most cases he placed the greatest reliance on bark, mineral and vegetable acids, and generous red wine. ' Petechial Fever ' was unusually prevalent in Ireland in the sprmg of 1735 and in 1736 ; in connection with this, it may be observed that the years 1734 and 1735 were very rainy and the ' summers Avere like winters.' y After 1731, however, there was no great epidemic of fever initil 1740. The wmter of 1739-40 was one of intense severity both in Great Britain and in Ireland. Numbers of cattle and poultry perished of the cold, which also destroyed all vegetable products and especially the potatoes. The surplus produce of the preceding season having been all exported, a great scarcity followed, so that wheat was sold for 44s. the kilderkin, although the same quantity, two years later, fetched only 6s. 6d. There was great distress among the poor, and many died of starvation. O'Connell's words were : — ' Et, quod adhuc funestorum malorum cumulum multo gravius adauxit, radices istae tuberosae (bat- tata vulgo dictae), nutrimentmn fere constans et integrum plebeculfe et inferiorum hujus regni incolarum, a dirissimo hoc et diuturno gelu penitus putrescebant. Hinc funesta amion® charitas, et inter pauperes populumque inferiorem immaniter sseviens dira fames ; hinc putrida plebeculaB alimenta, ex pravis et corruptis istis radicibus, aliis pravi succi vegetabilibus, et morbidorum animalium cadaveribus conflata ' (page 325). In August, 1740, an epidemic of fever arose and raged over the whole of Ireland, but particularly in the pro\ince of Munster. The epidemic continued throughout the summer of 1741, but towards the close of the year began to abate ; m the winter of 1742, after an abundant harvest, it almost completely disappeared. The fever at- tacked the poor first, but from them it spread to the rich. O'Connell computed that in 1740-41, Ireland lost at least 80,000 inhabitants by famine and spotted fever, and that one-fifth of the population of Mun- ster, where the poor were worse provided for, perished. The fever was characterised by a ' measly rash,' and by the ordinary symptoms of typhus. It is important to notice, however, that there is evidence in Eutty's description of the co-existence of Kelapsing Fever with Typhus. This circumstance must be borne in mind, when we read that in some of the cases the pulse was full and hard, and that bleeding was of ser- vice — a statement which must be viewed in comiectiou mth the fact, ' EuTTY, 1770. Pref. p. 33. HISTORY. 35 * that many of the poor, abandoned through necessity to a low aces- cent diet, and some of them drinking nothing but water, recovered.' In the worst (Typhus) cases, it is stated that bleeding was of no service, and that the pulse was so depressed, as not even to be raised by ' gene- rous cordials and great plenty of sack.' Short says that in Gal way 'blisters and bleedmg had made doubly fine work of it.' O'Connell strongly condemned much bleeding ; and although he bled to ten ounces at the commencement of the complaint, he honestly acknow- ledged that the treatment was of no use. About the same period, although a little later, a very fatal epidemic fever made its appearance in England and Scotland, and there are records of its prevalence in London, Bristol, Worcester, Plymouth, etc. In Bristol and Worcester it was observed in 1740, but in London not until July 1741. In Lou don it is said to have broken out among the poor who had been half starved for two years, and obliged to eat uncommon and unwhole- some things. In all the accounts mention is made of the eruption ; in some cases it is described as like that of measles, in others as like so many small flea-bites, while in a few instances it is said to have been mixed up with petechiae and vibices. Parotid abscesses and buboes are mentioned by Huxham as frequent complications. In an anony- mous pamphlet, published at the time, the treatment recommended consisted in bleeding and purging ; but the experience of most ob- servers was opposed to bleeding. Dr. Wall treated his cases with bark and acids ; and, in reference to bleeding, he wrote, ' As to myself, I lay so little stress upon bleedmg, that I have always omitted it, unless some very urgent symptom seemed to require it.' Short tells us that the cases in London ' could not bear bleeding.' ^ In 1750, and again in 1752, Sir John Pringle, Physician- Greneral to His Majesty's Forces, and afterwards President of the Pioyal Society, described Typhus as ' the Hospital- or Jayl-Fever.' As to the eruption he wrote as follows : — ' There are certain spots which are the frequent, but not inseparable, attendants upon fever.' They are the true ]3etechice, being sometimes of a brighter or paler red, at other tunes of a lurid colour, and are never raised above the skin. They are small, and commonly distinct, but sometimes so confluent, that at a little distance the skin looks only somewhat ' redder than ordinary, but upon a nearer inspection the mterstices are seen.' ' They sometimes appear as early as the fourth or fifth day,' ' The nearer they approach to a purple, the more ominous they are.' From the account of the post-mortem appearances, however, it is obvious that Pringle included under Hospital-Fever, cases which were not Typhus, and which, in fact, were probably not fever at all. As to treatment, he ordered that the patient should first be removed out of the foul air. Speaking of depletion, he observed: — 'Large bleedings have generally proved fatal, by sinking the pulse and bringing on a delirium ; ' and again : ' Many have recovered * For an account of this Epidemic, see O'Connell, 1746; Shoet, 1749; Anonym. 1741 ; Eutty, 1770; Huxham, 1752; Baeker and Cheyne, 1821, i. ; Stakk, 1865. D 2 2,6 TYPHUS FEVEE. without bleeding, but few who have lost much blood.' He commended bark and serpentaria and thought there was nothing comparable to wine,. ' whereof the common men had an allowance to half a pint a day.' Concerning the cause of the fever, Prmgle observed : ' 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 the same sort arise in foul and crowded barracks ; and in transport ships, when 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.' ^ Towards the end of 1757 Typhus appeared in Vienna, and lasted till 1759. An account of this epidemic was written by Storck^ and Hasenohrl.° The disease principally prevailed m overcrowded loca- lities. The pulse was always soft, and the blood drawn in many cases, even at the commencement of the illness, did not coagulate. Although Hasenohrl recommended venesection in certain cases, he allowed that it was but an ' anceps auxilium.' He spoke, however, in the highest praise of nitric and sulphuric acids, and of the stupendous- virtues of Peruvian bark. Storck noted a fatal case, complicated with gangrene of the nose and abscesses of both parotids. About the same time (1757-8) the first epidemic of Typhus in Berlin, of which there are authentic records, was noted. It was very contagious, but its origin was traced to overcrowding and deficient ventilation with insufficient food. It was characterised by red or petechial spots and severe cerebral symptoms. In some cases there were buboes in the axillae and groins,, and occasionally death occurred as early as the third day.'i ^ . In 1763 Dr. James Lmd, physician to Haslar Hospital, pubHshed ' Two Papers on Fevers and Infections,' ^ in which he showed that Typhus fever was then a very common disease on board ship, especially during the long voyages from North America. He considered bleeding injudicious, and very often dangerous, treatment. In 1764 a dreadful epidemic of Typhus and dysentery raged at Naples, which was attributed to a great scarcity of provisions, and the consequent starvation and misery of the poorer classes, to whom the disease was for the most part confined. The people from the sur- rounding country flocked mto the city, where they had so few oppor- tunities for attending to the cleanliness of their persons, and were so overcrowded that their garments are described as saturated with a most offensive effluvium.^ After the epidemic of 1 740-41 , there was but little Typhus in Ireland until 1770. In that year we learn from Dr. James Sims, of Tyrone, a fever appeared in the east of Ireland which, in the summer of 1771, reached Tyrone, and, as autumn advanced, raged there with great violence, and lasted for about a year. It was contagious, and was characterised by constipation, soreness of the eyeballs, headache and • Peingle, 1750 and 1752, pi?. 291, 301, 317, 326. •> Stokck, 1761. ' Hasenohrl, 1760. '' Bajldinger, 1774, p. 426; Zuelzer, 1869, p. Iig^ ' LiND, 1763. ' Saecone, 1765, pp. 256, 314, 344. HISTOKY. 37 oppression ; about the fourth day, delirium and watchfulness ; and in the later stages, picking of the bed-clothes, pupils insensible to light, •black tongue, sordes on the teeth, and involuntary stools. There were also petechise of a yellowish colour, with a black speck in the centre. The disease lasted about a fortnight. Bleeding was injurious, and the author recommended acids, free exposure to cold air, bark in large doses, small beer, and claret. The fever prevailed principally among the poor, but was most fatal among the intemperate middle classes. Dr. Sims considered this fever as ' entirely different ' from the low nervous fever of Huxham, which had been prevalent for some years before.^ Webster tells us, that in 1770 there was a failure of the potato crop in Scotland, great inundations, and extensive mortality among the cattle in England, but he does not refer to Ireland.^ In the jears 1770-71, however, a general failure of the crops and famine in Germany was followed by a very fatal epidemic of typhus. Cinchona and acids were found to be beneficial, but bleeding was most injurious.^ In 1775 Dr. William Grant published ' An Essay on the Gaol, Hospital, Ship, and Camp Fever,' J to which I shall subsequently have ■occasion to allude. From the description it is obvious that typhus is referred to ; the origin of the disease was attributed either to the concentrated emanations from living bodies, or to contagion ; and as to treatment, it is stated that the antiphlogistic method did not succeed. In 1780 an outbreak of typhus occurred among the Spanish prisoners •confined at Winchester, of whom 268 died in 3^ months. Dr. J. Garmichael Smyth, Physician to H. M. George III., wrote an account of this outbreak and observed : ' That it arises from the putrefaction of the perspirable matter admits of every species of evidence applic- able to a matter of fact and observation.' He condemned the use of bleeding as ' highly mjudicious, hazardous and often fatal ; ' and he recommended wine and bark in every stage of the disease. On one occasion, he gave two bottles of port in twelve hours to a patient who recovered ; and in other cases, he ordered two bottles of Madeira daily for several days. ' Nothing surely,' he adds, ' can be more absurd, than to use any means to diminish the strength of the body, when we are certain that sooner or later the strength will fail and require bemg supported, and when, though the pulse may not be very sensibly sunk, there are the most evident signs of debility and dejection.' ^ In 1 781 an epidemic of typhus occurred at Carlisle, which will be referred to hereafter. Dr. Heysham,^ who described the disease, con- sidered it to be one of great debility, and treated all his patients with bark and plenty of port wine. Kasori™ has recorded an epidemic of typhus which occurred at Genoa in 1 799-1800, when the garrison was besieged by the French and half- famished. The fever was eminently contagious, and was characterised by great prostration, weak pulse, watchfulness and restlessness pass- 6 Sims, 1773. '' Webstee, 1800, i. 422. ' Zuelzer, 1S69, p. 123. J Grant, 1771 and 1775. ^ Smyth, 1795, p. 81. ' Heysham, 1782. "' Easori, 1812. 38 TYPHUS FEVER. ing into di'owsiiiess, diy tongue, sordes, very confined bo'tt'els, and an eruption ' not very imlike petechia,' wliicli indicated danger accord- ing to its abim dance. Easori followed his favourite practice of giving tartar emetic. At tlie end of the last, and the begimimg of the present, century,, another epidemic of typhus made its appearance m Ireland. It com- menced towards the close of 1797, reached its acme in 1800 and 1801^ and did not terminate until 1803. The period in question was, in Ireland, one of great calamity. The comitry, for some time before, had not only been threatened with foreign uivasion, but had been convulsed by internal rebellion. The upper and the lower classes espoused oppo- site pohtical opinions, and were arrayed against each other. The consequence was that the management of the large estates feU into the hands of agents who knew little about the tenantry, many of whom were deprived of emplo}Tnent, To complete the distressmg history, there was a succession of bad haiTests. An uncommon quantity of rain fell dui'ing the summer and autumn of 1797, which injured the crops. The three following years were equally unfavom-able, and a great deficiency of the usual supply of nourishment to the poor ensued. The price of bread, potatoes, and indeed of every necessary of life rose enormously. In Dublin, the seiwants of the upper classes were not allowed potatoes, and bread was portioned out to them sparingly ; few persons had 2nore than a quartern loaf in the week. The poor pawned then clothes, and even their bedding, for money to pur- chase food, and, as a natural consequence, it was common for several members of one family to sleep in the same bed. As a proof of the great prevalence of the epidemic, it may be stated, that durhig the two years 1800 and 1801, there were as many deaths from fever in the Dublin House of Industry, as dm'ing the next great epidemic of 181 7— 19. Throughout the epidemic, it was chiefiy the poor who suffered; but in proportion to the number attacked, the fever was most fatal among the middle and upper classes. In 180 1 there was an miusually abundant harvest, and the poor were again furnished with provisions of all kinds at a moderate price : the epidemic immediately began to decline, and by the end of the folio whig year it had well nigh dis- appeared. The epidemic spread to England, but was less prevalent there than in Ireland. The fever was mahily typhus, although in Ireland relapsing fever was also observed. It was described as highly contagious, and as characterised by the presence of petechiae and by great debility. Dr. Willan bemoaned the tendency of some physicians in London, to regard the fever as resultmg from inflammation of the brain ; and added, ' whoever is bled largely fi-om the arm is precipi- tated to certain death.' ° It was mauily m consequence of the fever prevalent at this time^ that numerous hospitals for the separate treatment of Fever cases were first estabHsbed throughout the comitry. The first was opened at » Consult Bakker and Chetne, 1821, vol. i. pp. 9 to 20; and Willan, 1801, p. 284, for an account of this epidemic. HISTORY. 39 Chester, and its origin was due to the able advocacy of Dr. Haygarth. Liverpool, Manchester, Norwich, Hull, Dublin, Cork, Waterford, and London soon followed this example, the London Fever Hospital being established in 1802.° During the first fifteen years of this century, typhus committed great ravages in the armies of Napoleon and among the populations 01 the countries which were the seat of war. It always arose mider cir- cumstances of misery and privation, and was particularly prevalent and fatal among the inhabitants of besieged cities. Witness, for example, the melancholy histories of the sieges of Saragossa p and Torgau,d it was calculated that 19,254, or one in eveiyninCo'f the jjopulation^i^uffered from it.^ Three^differer^ fevers were observed during this epidemic. In the first pla^e, there were a few cases of Enteric Fever. Most of these cases Qcefe'red at the commencement of the epidemic or before it, and were rfterely the remains of an extraordinary autumnal increase of this -^orm of fever. The summer and autumn of 1846 had been remarkable for their high temperature and protracted drought, and consequently, towards the end of 1846, enteric fever became miusually prevalent in E|9§feflid, even at many places where the epidemic of typhus fever never TY^deMs appearance} It is not surprising, then, that enteric fever should have been miusually prevalent in Edinburgh and Glasgow, and elsewhere. Moreover, most of the Eduiburgh cases occurred prior to outbreak of the epidemic fever, and came fi'om localities in the _ eighbouring country, and from the best houses of the New Town, and ^5tJrom the crowded courts of the Old Town to which the epidemic s afterwards restricted.J The epidemic consisted essentially of '' E. Patekson, 1848, p. 386. ' The evidence in support of this statement will be found under the head of Enteric Fever. i This appears from the residences of the patients given in Dr. Waters's thesis (unpublished). See Bib. 1847. HISTORY. 51 Typhus and Eelapsing Fever, with a preponderance of typhus in Britain, and of relapsing fever in many parts of Ireland. In the Glasgow Infirmary, where the different fevers were discriminated, the number of enteric cases admitted during the years 1847-8 was only 134, while that of typhus and relapsing fever was 6,225. ' I^i one instance only,' said Dr. H. Kennedy, of Dublin, ' did the fever so often seen in France come before me.' ^ The rate of mortality for the whole epidemic was high, but was always highest in proportion to the number of cases of true typhus. In Ireland it was only 8 per cent. ; but in Edinburgh, out of 19,254 cases, 2,503, or 13 per cent., died ; and in Glasgow, out of 11,245, ^^^ mortality was i4'4i per cent. The mortality, however, of the relaps- ing cases alone was in Glasgow only 6'38 per cent., and in Edinburgh, 4 per cent. ; while that of Typhus was 21 "2 per cent, in Glasgow, and 24*7 per cent, in Edinburgh. Stimulation was the treatment almost invariably resorted to in the typhus cases ; and, even in relapsing fever, depletion was seldom prac- tised. In some places, the relapsing cases were treated successfully by stimulants. Of 179 cases of relapsing fever among Irish reapers at Croydon, treated by Dr. Bottomley with abundance of stimulants and nourishment, only four died.^ The next epidemic of typhus which attracted much public atten- tion, was that which committed such awful havoc in the French and Eussian armies in the Crimea, after the capture of Sebastopol. Typhus had made its appearance during the preceding winter (1854-5) in both the English and French armies, but its prevalence was slight in com- parison with that of the following winter, when it was mainly confined to the French and Eussian armies. During the first six months of 1856, it was computed that out of a force of 120,000 French, 12,000 were attacked with typhus, of whom one-half died. The causes of this epidemic will be considered hereafter. Enteric fever was also met with in the Crimean armies, and among the English was perhaps more common than typhus ; but the symptoms, as well as the numerous post-mortem examinations made by Jacquot and others, prove that the great epidemic alluded to was genume typhus. In most of the cases, a stimulant treatment was found to be imperative."* The number of typhus cases admitted into the London Fever and other Hospitals since 1847 is given in Table I. (See also Diagram I.) ^ See H. Kennedy, i860, Ed. Joum. p. 217, and Irish Report, Bib. 1848, \iii. 56. ' The account of this epidemic has been obtained from most of the memoirs mentioned in the Bibliography for 1847, 1848, and 1849; from Geaves, 1848, i. 97 ; W. T. Gaiednek, 1859 and 1862 ; Christison, 1858; and from the reports of various hospitals. ™ For an account of the Fever in the Crimea, see ALFEEErEF, 1856; Batjdens, 1856 and 1858; Lyons and Aitken, 1856; Sceive, 1857; Review, Bib. 1857; Abmand, 1858; Jacquot, 1858; Cazalas, i860. £ 2 52 TYPHUS FEVER. TABLE I. Number of Cases of Typhus Fever admitted into different Hosintals of the United Kingdom since 1847. Loudon Edinburgh Glasgow Glasgow Dundee Aberdeen Cork Years Fever Eoyal Royal Fever Eoyal Royal Fever Hospital " Infirmary Infirmary Hospital P Infirmary Infirmary Hospital 1846 500 1847 2,399 ... 1848 786° 980 1849 154 342 .. ... 1850 130 382 ... 1851 68 919 1852 204 1.293 .. 1853 407 I 551 1854 337 760 .. ... 1855 342 385 ... 1856 1,062 385 1857 274 314 .. 1858 15 175 17 .. 1S59 48 175 128 .. ... i860 25 229 67 .. ... 1861 87 509 129 ii5 1862 1,827 X4 780 54 272 1863 1.309 74 1,286 236 379" 692 1864 2,493 212 2,150 264 811 1,021 1865 1-950 447 2,334 1,154 891 422 791 1866 1,760 847 1,055 384 706 167 247 1867 1.395 303 761 795 225 68 124 1868 1,964 280 620 1,02} 502 78 245 1869 1.259 259 1,430 2,023 402 170 136 1870 631 287 947 702 232 61 165 1871 411 lOI 418 511 257 3 397 It will be noticed that there was a great increase of typhus in London in 1856. This increase was confined to London, and was not of Irish origin, for of 910 patients admitted Lato the London Fever Hospital, in regard to whom the circumstance was noted, only 53 were natives of Ireland, and all but two of the 53 had resided in London more than three months. It ensued upon a temporary distress, or artificial scarcity, among the poor. . The disasters of the Crimean campaign had brought mournmg into many families of the higher class, and this, conjoined with increased taxation, suspense, and other causes, in- terrupted the ordinary gaieties of London life. Many of the working class, dependent upon the rich, were thrown^i out of employment, while at the same time all the necessaries of life rose greatly in price. The restoration of peace, an abundant harvest in 1856, and increased " See also Preface. ° The precise fever was not stated in 260 cases entered in the Register for the year 1848, \vhich was the first in which a record was kept of the diiierent Continued Fevers in the London Fever HospitaL These 260 cases were probably mostly typhus, and hence they are included in the above 7S6, but not in subse- quent calculations throughout this work, except when specially stated. p The numbers in this column represent the admissions in the twelve months ending April 30 of the year following that opposite which they are placed. « Four last months of year only. - c: 1 o o i> ■1 " m^r^ o ^^ s^^ -"■ "^ c- •* "* |"*^^^c^^ / ^^■^^^«^^ 00 \ ^^*^^*^fci ^^•^^^i__— . r— 1 v • [> \ V cs A CO ^^^,0^ ^ ^^^-^""^ 00 r H / OJ / CD / oo \ r-i \ ^ ■■ \ CD 1 2R \ \ o \ \ CO \ > 00 y T r—l / / CD / / "5 / i 00 f \ rH \ 00 \ in I }^ 00 f _,— -^^ r~\ t> -^^ "^ Ln _ ■^^ 4 CO -* \ _ — — - V CD \ ICl \ CO / — 1 _ ^ / LO - _ / r m — — • / J oo T . ^ \ <* 1 LO A ' CO jT 1 rH / \ CO / / \ U3 «c V 1 00 "^•^-^^^ N m r-i ^"^^^ \ ^r CV] "■^v,,^^ \ y ■O ^^"^gL \ ^r 00 ^V v^ > ^ ^ >^^ 00 <^ ^v 7 —1 ^-+- t^ ^ 1 ^ ^ o rV H f~ ^ +-> ^ o r^e Oi ■SN ,J t^ 0) -CN) ^ «H •3 ^ -^ . s 1l Q:; Q ,-ooL^ 1853 1354 1855 1856 1857 1858 185E 1860 1861 1862 1SS3 1864 1866 less 1867 18 G8 18G9 1870 1871 2600 2400. 1 1 \ 2400 \ X200 1 2/oaj 2000 2000 (900. \ 11 tSO(L 1 y \ _f800 nocL \ (600. \\ \ (500 \ \ 1 («)(L V I30Q_ ! _J300 IZOQ_ IIOCL. 1000 A 1 mo 30Q_ t eod. / 1 700. 1 1 eod. 1 _sop. f \ ( A ton. 1 ^ I \, -^ / \ 30Q_ /■ J 1 -V" V^ \ 200_ i \ / -N A y^ / J rod- — ■ ^ "f \ V \^ ' \ \ ~\ \y ^ — 7 V \ ^ V -^ > \ 1648 1849 1850 1851 1852 1853 1654 1S55 185G 1857 1858 1859 1860 1861 1862 1863 18S1 1865 1866 1867 1868 1869 1870 1871 Diagram I . skoxro Une, Aymacd iiamher of oLdntissions into the. LonAoro Fev&r Hospital oP Typhus ( red), Hdapsing Fever (bU;i^)& Enterlo Fever (hlax.lc) oUvring tmeyU-j-fovur years . HISTORY. 5 3 attention to sanitary arrangements among the poor, were speedily followed by a subsidence of fever, and for four years typhus was less prevalent both in London and throughout the United Kingdom than at any previous period during the present century. In 1858, only fifteen cases were admitted into the London Fever Hospital, and several of them were of doubtful character ; during the last six months of the year only one case was admitted. In the years 1858, 1859 and i860, typhus was so rare a disease in London, that the students at the various hospitals had no opportunity of seeing a single case, while serious thoughts were entertained of converting the Fever Hospital into a hospital for general diseases, its mission for the treatment of typhus having, as some thought, been fulfilled. A similar decrease took place in Scotland. Since the commencement of the present century, the number of admissions for fever into the Edinburgh and Glasgow Infirmaries, was at no time so small as during the years 1855-1862. In 1857, only 56 cases of typhus were admitted into the Edinburgh Eoyal Infirmary; in both January and May, 1858, I ascertained that the institution did not contain a single example of this fever. Writing in July, 1859,'" Dr. W. T. Gairdner remarked on the exemption from typhus during the previous five years, and observed that more that once a considerable portion of an academic session had passed over without his being able to show his students a single characteristic case of the disorder ; for several months, both in 1858 and in 1859, not one case was admitted into his wards. The admis- sions for fever into the Glasgow Eoyal Infirmary, in 1858 and 1859, were fewer than in any of the thirty-five preceding years, notwith- standing the enormous increase of the population during that period. But still, there was never such a complete absence of typhus in Glasgow as in London and Edinburgh. In Ireland, I am informed by Dr. Lyons, that for three or four years (185 8-1 861) typhus was certainly much less prevalent than formerly, although cases were by no means so rare as in Britain. Writing in 1863,^ Sir E. Christison ascribed this re- markable abatement of typhus to a change in the epidemic type of fever. But he lost sight of the fact that in 1856, and again while he wrote, the ' epidemic type ' and the prevalence of fever were different in London from what they were in Edinburgh. In 1 86 1 typhus again became epidemic in London. At the close of the severe winter of 1860-61, a larger number of cases were admitted into the London Fever Hospital than at any time since 1857. About the middle of December, the cases suddenly increased ; and after January, 1862, the number of admissions for typhus exceeded that at any period of the history of the hospital, while many patients were refused admittance for want of room. In the eight years from January 1862 to December 1869, nearly 14,000 cases of typhus were admitted into the Fever Hospital, while in the previous fourteen years the number of admissions had been less than 4,000 ; numerous cases were also under treatment in the other metropolitan hospitals. The deaths "■ W. T. Gaiedner, 1859, p. 241. " Christison, 1863. 54 TYPHUS FEVER. from ' typlius ' returned to the Eegistrar-General, were at first almost double the average of the years immediately preceding. The circum- stances preceding this sudden increase did not differ from those of former epidemics. There was no failure of the crops in England, but for some time before there had been great and increasmg distress among the poor of London consequent on the organised system of strikes, the effects of which had only temporarily been averted by the relief from the societies for promoting the short-hour movement. As hi 1826, 1836, and 1856, an artificial scarcity was the result. The unusual distress among the London poor was proved by the enormous increase in the number of applicants for parochial relief which continued throughout the epidemic. Li addition to this, the great distress in the provinces caused the poor population of London to be condensed by the arrival of labourers from the country m search of work, and this con- densation was further increased by the destruction of whole streets of houses consequent on the formation of railways through the heart of the metropolis. It was ascertained that almost all the first cases admitted into the Fever Hospital were male tramps, with no fixed residence, out of employment, and suffering for many weeks from want, and that many of them had only been a few weeks in London ; but there was no evidence that they had come from infected localities or that they imported the fever into London. Only a small proportion of them were Irish (page 58), and none had arrived recently from Ireland. Overcrowding, with destitution, appears to have occasioned the epidemic. After a duration of eight years, the epidemic in 1870 began to decline. In 1862, the cotton famine consequent on the American war led to the anticipation of an outbreak of typhus in the manufacturing districts of Lancashire.* In July the disease appeared at Preston, where for fifteen years it had been unknown, and in the ensuing autumn it became • epidemic in Liverpool and Manchester. The first cases m Preston were traced to overcrowding, consequent on destitution. The un- paralleled efforts made to relieve distress and to isolate the sick, alone prevented the epidemic assuming greater proportions than it did, but for upwards of four years typhus continued epidemic in Liverpool, reaching its height in 1865 and not materially subsiding till 1867." In Glasgow there was also an increase of typhus simultaneously with that observed in London. About 800 cases were admitted into the Koyal Infirmary between August i and December 31, 1861, or more than five times the number admitted during the entire two years 1858 and 1859. Here also there was no evidence that the disease was im- ported from Ireland. The epidemic which commenced in Glasgow in 1 86 1, as in London, subsided in 1870 and 187 1. Typhus became epidemic in Aberdeen and Dundee somewhat later, but it is remark- able that in Edinburgh, where typhus was formerly so prevalent, only four cases were admitted into the Infirmary between November i, 1 86 1, and July 29, 1862, and that for several years the number of admissions for typhus was small compared with that observed elsewhere. See first edition, pp. xv. and 54. " Dr. Trench's Eeports; also Buchanan, 1863. HISTORY. 55 (See Table I.) The non-manufacturing population of Edinburgh, which was not exempt from typhus during seasons of general famine, is less readily affected by the circumstances that generate artificial scarcity in London and some other large towns. Yet in 1826, when Edinburgh was suffering from the effects of failures m building specu- lations, typhus was far more prevalent there than in London. Although there was no e\ddence that this last epidemic originated in Ireland, typhus subsequently (1863-4-5) became very prevalent in Dublin, Cork, and other large towns of that comitry. The amiexed table gives the number of deaths from typhus regis- tered in the United Kingdom for the last ten years, from 1872 to 1881. TABLE II. Deaths from Tyiohus in the United Kingdom from 1872 to 1881. Tear England Scotland Ireland London Edin- burgh Dublin Liver- pool Glasgow Cork 1872 1864 795 702 174 107 97 IIO 180 38 1873 1638 628 691 277 75 66 79 79 28 1874 1762 726 756 312 100 106 123 114 60 1875 1499 615 694 128 27 74 219 96 65 1876 1 192 471 619 157 31 69 174 82 45 1877 II50 265 724 157 13 86 181 77 33 1878 964 263 749 151 24 97 104 50 34 1879 579 210 753 71 22 93 59 55 67 1880 573 934 77 II 162 52 43 91 1881 552 859 92 21 205 109 50 109 The foregoing historical sketch leads to the following conclusions : — 1. Typhus prevails for the most part in great and wide-spread epi- demics. 2. These epidemics appear during seasons of general scarcity or want, or amidst hardships and privations arising from local causes, such as warfare, commercial failures, and strikes among the labouring popu- lation. The statement that they always last for three years and then subside is erroneous. 3. Durmg the intervals of epidemics, sporadic cases of typhus occur, particularly in Ireland, and in the large manufacturing towns of Scotland and England. 4. Although some of the great epidemics of this country have commenced in Ireland and spread thence to Britain, appearing first in those towns on the west coast of Britain where there was the freest intercourse with Ireland, it is wrong to imagine that all epidemics have commenced in Ireland, or that typhus is a disease essentially Irish. The disease appears wherever circumstances favourable to its development are present. 5. In many epidemics. Typhus has been associated with Eelapsing Fever, and the relative proportion of the two fevers has varied greatly. 6. From the earliest times. Typhus has been regarded as a disease of debihty, forbidding depletion and demanding support and stimulation. 56 TYPHUS FEVER. 7. The chief exception to the last statement originated in the erroneous doctrines taught in the early part of this century, according to which the disease was looked upon as symptomatic of mflammation or congestion of internal organs. 8. The success believed at one time to follow the practice of vene- section was only apparent. It was due to the practice having for the most part been resorted to in cases of Eelapsing Fever and acute in- flammations, and to the results having been compared with those of the treatment by stimulation of the much more mortal typhus. 9. Although Typhus Fever varies in its severity and duration at different times and under different circumstances, there is no evidence of any change in its type or essential characters. The typhus of modern times is the same as that described by Fracastorius and Car- danus. The period during which epidemic fever was said to present an inflammatory type was that in which relapsing fever was most prevalent, and the times in which the type has been described as adynamic have been those in which relapsing fever has been scarce or absent. Section IV. — Geographical Eange of Typhus Fever. There is probably no part of Europe in which Typhus has not been observed. Some of the greatest epidemics on record have occurred in Italy and Spain.'' It has been described as prevailing in Germany, Belgium, Holland, and Denmark by many of the early writers,"^ and in the present century by Hildenbrand,'' Hufeland,^ Suchanek,^ Schutz,* Virchow,^ Dummler,'^ Messemann, Steensmann,*^ Zuelzer,^ Them-kauf,^ Eosenstein,^ etc. Huss has proved its common prevalence in Sweden ; ^ and numerous epidemics in various parts of Eussia have been recorded by Auer, Bidder, Lowenstein, Heimann,' etc. Although travellers have asserted that typhus is never seen among the Laplanders or Esquimaux,^ it is probable from the writings of Schleisner ^ that epidemics have often occurred in Iceland. Typhus was a common scourge of the armies under, and opposed to, the first Napoleon, in almost every country of Europe ; ^ and more recently the same disease deci- mated the French and Eussian armies in the Crimea and Turkey."* It is an error to suppose that true typhus never occurs in ^ See Historical Account, pp. 26, 27, 28, 35. ■" Ibid., pp. 28, 30. ^ HiLDENBEAND, 181I. y HUFELAND, 1814. ' SUCHANEK, 1849. * ScHDTZ, 1849. •" ViKCHOW, 1849. " DiJMMLER, 1849. '^ HlRSCH, I859, p. I53. ' Zuelzer, iSbg. ' Theukkadf, 1869. ^ Rosenstein, ib68. * Huss, 1855. ' HiESCH, 1859, p. 152. i Feegusson, 1846, pp. 162 and 176. " ScHLEisNEE, 1850. ' See p. 37. " See p. 49. GEOGRAPHICAL RANGE. 57 France. The works of Ambrose Pare, Fernelius, Eiverius and many other writers prove that in early days it was a common disease there." In the latter part of last century it seems to have been not uncommon in the hospitals of Paris, and the nurses and young surgeons were often attacked by it.° During the first fifteen years of the present century, epidemics of typhus were very common in different parts of France ; they are re- ferred to in the works of Gaultier de Claubry,P Jacquot,*! Barrallier,"" etc. Epidemics have also been observed at Beaulieu in 1827 ; ^ at Toulon in 1820, 1829, 1833, 1845, 185 1, 1855, and 1856 ; * at Eheims in 1839 ; "^ and at Strasbourg in 1854.'' In 1854 cases of typhus were not uncommon in Marseilles, Avignon, Paris, and other parts of France, among the soldiers returned from the Crimea."" It is possible also that sporadic cases of typhus occasionally occur in the large towns of France, but are mistaken for the more prevalent ^ Fievre tyijJio'ide.'' Both Andral "^ and Louis ^ state that in certain cases of Continued Fever they found the intestines after death perfectly healthy ; and similar observations have been recorded by Martin Solon ^ and Piedagnel,*^ and have been reported by different observers to the French Academy. Still, as French physicians are not likely to overlook the typhus-eruption, such cases must be very rare ; while, both in France and most other parts of the Con- tinent, epidemics of typhus have of late years been observed only occasionally in large armies, or in smaller bodies of men crowded together in hulks and prisons. It is in Britain, and still more in Ireland, that typhus has its peculiar habitat. Here, from time to time, epidemics have oc- curred, equalling if not surpassing in magnitude any that have been noted on the Continent. And not only so ; the disease, more especially in Ireland, is never absent in the intervals of great epidemics to the same extent as on the Continent, but as- sumes more or less of an endemic character. Although typhus is more prevalent in Ireland than in Britain, it is not imported from the former into the latter country, to the extent commonly believed.'' The following table - See pp. 28, 29. o Tenon, 1788. p De Claubky, 1838. 9 Jacquot, 1858. ' Barealliek, 1861, pp. 14 and 47. » Hiesch, 1859, p. 154. ' Keraudren, 1833; Fleuey, 1833 ; HiRscH, 1859, p. 154; Baeralliee, 1861, P- 47- " Landouzy, 1842. ' Forget, 1854. ^ Godeliee, 1856; Hiesch, 1859, p. 154. ^ Ande.al, 1833. ^ Louis, 1841. ^ Archiv. G4n. de MM. 2nd s^r. i. 400. " lb. 2, vii. 410. * Vide Cowan, 1838, and WCv-lj^qcu's, Statistical Account of the British Empire, 8vo. Lond. 1837. '' ^ TYPHUS FEVER. shows the birth-places of 12,686 typhus patients admitted into the London Fever Hospital during twenty years (i 848-1 867). TABLE III. Places of Birth 1848 to 1854 185s to 1867 1848 to 1867 Natives of London ,, rest of England ,, Scotland ,, Ireland ,, rest of world 902 394 16 244 13 57-48 2511 I -02 15-55 •83 8,344 2,000 74 546 153 75-05 17-99 066 4-91 1-37 9.246 2,394 90 790 166 72-88 18-87 •71 6-22 I-3I Total,wliose birth-place was noted 1,569 99-99 11,117 99-98 12,686 99-99 It appears then, that only 790, or 6*22 per cent., of the total 12,686 typhus patients were natives of Ireland, and that since 1854 the proportion of Irish has greatly decreased. Moreover, the majority of the Irish had been resident in London too long to have imported the disease. Of 350 Irish admitted during fourteen years (1848-61), only 38 had been resident less than three months, and all but 63 more than a year. That typhus has been imported largely by the Irish into Britain has been already shown. It was particularly noted to be so in the epi- demic of 1847-48 (see page 49) ; indeed most of the 38 patients but recently arrived from Ireland were admitted into the London Fever Hospital in 1848. But of 910 typhus cases admitted in 1856, whose birth-place was noted, only 53 were natives of Ireland, and 2 only of the 53 had been resident in London less than three months, and all but three more than a year. A similar observation was made in the epidemic of 1862. Of 992 cases admitted into the London Fever Hospital during the first six months of 1862, whose bhth-place was noted, only 44 were natives of Ireland, and all but 5 of the 44 had resided in London more than three months. But typhus in Britain has an Irish origin greater than might be inferred from the above figures, and independent of actual importation. From the census of 1861 it appears that, of the 2,803,989 inhabitants of London, 2,594,229 were born in London, England, or Wales ; 106,879 ,, Ireland; 35,733 „ Scotland; 67,148 „ other parts of the world. GEOGEAPHICAL RANGE. 59 Consequently, there were admitted into the London Fever Hospital with typhus in the twenty years, 1848-67, I in every 135 of the Irish inhabitants of London; I „ 223 „ English ' „ I „ 397 „ Scotch I ,, 404 ,, foreigners resident in London. Moreover, a large proportion of the patients marked ' natives of London ' were children of Irish parents or of Irish extraction. It is well-known that by the immigration of the lower classes of Irish, pauperism and habits of overcrowding and personal •uncleanliness — the main causes of the prevalence of typhus — have been greatly augmented in the large towns of Britain. In the United States and British North America typhus has prevailed extensively at different times, as shown by the excellent descriptions of Gerhard," Bartlett,*^ Austin Flint,® and Da Costa. ^ There is no evidence that typhus has been observed in Australia or New Zealand ^ except on rare occasions among the passengers landed from emigrant ships. ^ As yet, there are no authentic records of typhus, such as we see it in this country, having been met with in Africa or the tropical j^arts of America. Dr. E. Dundas described typhus as a common disease in Brazil ; but his descriptions, and the circumstance that he found a gradual transition between the so-called typhus cases and the ordinary malarious fevers of the country render it more than probable that the former were examples of Adynamic Pvemittent Fever.' Accounts have been published of typhus occurring in Mexico, Central America, and South America,J but none of the descriptions which have come under my notice make it conclusive that the disease was true typhus, and not the ordinary typhoid or adynamic remittent fever of these countries. The existence of typhus in India is a subject of much interest, and on which fm-ther information is required. According to Dr. Morehead, typhus is unknown on the continent of India ; and in the first edition of this work Dr. Morehead's statement was accepted as correct.^ Dr. Allan Webb many years ago described two cases of petechial fever observed at Simla ; but " Geehabd, 1837. * Bartlett, 1842, 1S56. ^ Flint, 1852. ^ Da Costa, 1866. e Hirsch, 1859, p. 158. ■■ Eleventh Rep. Board of Health, Victoria, 1867. ' Dundas, 1852. J Hirsch, 1859, p. 157 ; Dundas, 1852. ^ Clinic. Bes. on Dis. of India, ist ed. i. 307. 60 TYPHUS FEVER. the fever was not said to be contagious, and petechias occur now and then in the severe remittents of India, which have often been mistaken for typhus.^ More recently Dr. Ewart re- corded two cases of ' typhus ' in the jail of Ajmere ; but the characteristic eruption was absent, and there was no proof of contagion.™ Within the last ten years, however, a contagious continued fever in the jails of India has attracted much attention. There is still much difference of opinion as to its real nature. One thing is clear ; it is not, as has been contended,*^ enteric fever. In 1 86 1 Dr. W. Walker described an epidemic of this sort observed by him in the central prison of Agra,° and which had jpreviously prevailed throughout the North-Western Provinces of India. He believed the disease to be ' typhus,' and in 20 fatal cases, where the whole length of the bowel was examined, the ag- minated, solitary and mesenteric glands were perfectly healthy. The disease differed from true typhus in the absence of any eruption, and in the frequent occurrence of jaundice and re- lapses, but these discrepancies might be accounted for on the supposition of an admixture of cases of relapsing fever, which is now known to prevail along with typhus in the North-Western Provinces of India. In 1863 and 1864, a fever identical in its clinical characters with that described by Dr. Walker, prevailed in many of the prisons of the Punjab, and was described in official reports to Government by Drs. E. Gray, De Kenzy, and others. The fever at first was intermittent or remittent, but soon became con- tinued ; jaundice was common, but no eruption was noted on the skin ; the result of many autopsies was, that Peyer's patches were always found to be healthy. The origin of the disease was ascribed to 'underfeeding and overcrowding' of the prisoners, but it was unquestionably propagated by contagion. In 1869 a fever still more resembling typhus was observed in the prisons of the Punjab, and was described as seen in the jail of Eawulpindi by Dr. Fairweather. Although in some instances at first intermittent, it soon became continued. There was no jaun- dice, no abdominal symptoms, and no intestinal lesions, and there was a cutaneous eruption, whose characters were identical with those of typhus. With the description of the symptoms before us, it is impossible to dissent from Dr. De Eenzy's con- clusion, that typhus fever must henceforth be regarded as one • Paihologia India, Lond. 1848, p. 212. "• Ewaet, 1856. ° EOLLESTONE, 187I. " WaLKEE, 186I. GEOGRAPHICAL EANGE. 6 1 of the diseases of India.P Lastly, in 1864 Dr. Chuckerbutty recorded certain cases of continued fever observed by him in the Medical College Hospital of Calcutta, in which there was no disease of Peyer's patches, and the symptoms very closely resembled those of English typhus, the chief difference being that of the * mulberry eruption ' always disappearing on pres- sure, and returning on its removal.^ In connection with this subject, attention may be called to the occurrence in different parts of India of an ' Adynamic Eemittent Fever of suspected infectious character,' better known by the designations ' Pali Disease ' and ' Mahamurree.' For an excellent summary of what has been written on this malady, the reader may refer to the second edition of Dr. Morehead's * Clinical Eesearches on Disease in India.' *" It may be here stated, that the disease is believed to be contagious, that it is remittent in character, but with great tendency to become continued, and that adynamic phenomena are well-marked. In none of the cases have petechise, or a measly eruption, been observed ; but in the great majority, glandular swellings of the groin, axillae and neck have been present from the first. The mortality has been great : according to one observer, four-fifths of those attacked perished. This disease closely resembles, if it be not identical with, bubonic plague. Like both the plague and typhus fever, it ' has prevailed chiefly amongst the poor, in filthy, badly-ventilated houses and villages ; and has been preceded by seasons of famine.' And here I may anticipate an opinion sub sequently contended for, to the effect that there exists a strong analogy, if not identity, between typhus fever and true plague, the poisons being generated from similar causes, and differing only in intensity from the effects of climate and other collateral circumstances. Plague is perhaps the typhus of warm climates. There are few subjects more deserving of investigation than that of contagious fevers in the tropics. Dr. Morehead thinks it not improbable that remittent fever may assume adynamic or typhoid characters, and at the same time become infectious, in consequence of overcrowding and neglect; and this may have p Eep. on San. Adminis. of Punjab for 1869, p. 127, and app. 81, and Lancet, February 25, and May 27, 1871. Unfortunately in Dr. Fairweather's Eeport, which is only printed in abstract, two or three cases of enteric fever are included. (See EoLLESTONE, 1871.) There is no reason why cases of this fever should not occur in jails as well as in other localities of India, but it is to be noted that these cases differed from the general description of the epidemic in their duration and symptoms, and particularly in the absence of the characteristic eruption. In one of them it was noted during life that the symptoms were those of enteric, lather than of typhus, fever. 1 Chuckerbutty, 1864. ' 2nd ed. London, 8vo. i860, p. 155. 62 TYPHUS FEVER. been the real explanation of the epidemics described by Dr. Walker and others. It is not unreasonable to suppose that under such circumstances, the fever may be the result of malaria, with a poison resembling that of typhus superadded. The etiological relations of typhus and ' yellow fever ' are also well worthy of investigation.^ The natives of tropical countries are often attacked by typhus on visiting localities where it is prevalent. I have known several Ah'icans and East Indians admitted with typhus into the London Fever Hospital, the rash being distinct. Gerhard states that in the Philadelphia epidemic of 1836 the majority of persons attacked were negroes or mulattoes.* Section Y. — Etiology of Typhus Fever. The causes of Typhus are the Exciting and Predisposing. The primary exciting cause is a specific poison : the j)roperties of this poison, the question whether it be ever generated de novo, or always derived from an infected person, must engage our attention. Under predisposing causes, those circumstances will be referred to, which in themselves are insufficient to generate the disease, but which predispose the body to the in- fluence of the primary exciting cause, and without which the latter would often prove inert. A. — Predisposing Causes of Typhus. I . Sex. — Sex in itself does not predispose to Typhus. The fol- lowing table gives the sex of the typhus patients admitted into the London Fever Hospital, during twenty-three years : — TABLE IV. 1 "3 "3 S a ft "3 "3 1 5 H c3 >5 "3 ■3 1 1848 1849 1850 I85I 1852 1853 1854 1855 290 87 59 31 135 211 177 161 236 67 71 37 69 iq6 160 181 526 154 130 68 204 407 337 342 1856 1857 1858 1859 i860 1861 1S62 1863 450 135 7 20 14 52 982 579 612 139 8 28 II 35 845 730 1,062 274 15 48 25 87 1,827 i.3oy 1864 1865 1866 1867 1868 1869 1870 1,210 1,006 831 683 942 287 1,283 944 929 713 1,022 662 344 2,493 1,950 1,760 1,396 1,964 1,259 631 Total 8,946 9.322 18,268 • See Brit. Med. Journ. Dec. 1866. • Gekhabd, 1837, xix. 296. ETIOLOGY PREDISPOSING CAUSES. 63 Thus, out of 18,268 cases of typhus, the females exceeded the males by 376. Of 2,492 cases observed at Dundee, 1,142 were males, and 1,350 females;" while of 5,379 cases noted during five years in Glasgow, 2,554 were males, and 2,825 females/ The excess of females, however, is more than accounted for by the preponderance of that sex in the population. Taking the census of 1861 as a basis of calculation, i out of every 146 males of the entire population of London were admitted with typhus into the Fever Hospital during twenty-three years, but only I out of every 160 females. Moreover, in nine of the twenty-three years, the males absolutely exceeded the females, and at the commencement of the recent epidemic the patients were almost exclusively males. Of 21 cases admitted in December 1 86 1 , 19 were men out of work, and many of whom had but recently arrived in London without families ; up to July 1862, the proportion of males to females was 669 to 461, but subsequently the females exceeded the males. The pre- ponderance of male cases in the Scotch epidemic of 1847 was probably due to the previous influx of a large number of Irish labourers. In 1847, 1,419 males and 980 females suffering from typhus were admitted into the Glasgow Eoyal Infirmary,'^ while in the Edinburgh Infirmary there were 3,677 males to 2,226 females.'' The statement that sex in itself does not predispose to typhus holds good in regard to the other continued fevers, although opinions of an opposite nature, and yet often contradictory, have been expressed.^ The varying results at different times and places are no doubt owing to a preponderance of one sex in the population, or to local and accidental circumstances, which expose one sex more than the other to the exciting causes of fever, or which influence the admission into hospital of one sex in preference to the other. Taking all the forms of continued fever together, admitted into the London Fever Hospital during twenty-three years (1848-70), there has been a remarkable equality of the sexes, 14,255 having been males, and 14,348 females. 2. Age. — Typhus is for the most part a disease of adult age, " Maclagan, 1867. ■' EussELL, Ecp. Glasg. Fever Hosp. 1866-70. " Steele, 1848, p. 161. ^ Statist. Tables, 7th ser. p. 11. These figures included a considerable number of cases of Eelapsing Fever ; but the proportion for typhus only was similar, for of 1,069 typhus cases under Dr. R. Patekson {Bib. 1848) and Dr. W. Eobektson {Bib. 1848), there were 588 males to 481 females. y See 1st ed. p. 61. 64 TYPHUS FEVER. although no period of life is exempt from it. The records of the London Fever Hospital show that it may occur at every age from I month to 84 years. The mean age of 3,456 cases ad- mitted into the London Fever Hospital during ten years (1848- 57) I ascertained to be 29*33 years, which is about three years above the mean age of the total population.'' The following Table gives the number of cases of typhus admitted into the London Fever Hospital, in each quinquennial period of life during twenty-three years, 1848-70. (See Table V. and Dia- gram n.) TABLE v.* Typhus Fever. — Age and Sex. Number of Cases Percentage at each period of life Males FemRles Total Under 5 years . From 5 to 9 years ,, 10 to 14 ,, „ 15 to 19 „ ,, 20 to 24 ,, ,, 25 to 29 ,, „ 30 to 34 „ ,. 35 to 39 „ ,, 40 to 44 ,, „ 45 to 49 „ ,, 50 to 54 ,, „ 55 to 59 „ ,, 60 to 64 ,, ,, 65 to 69 „ „ 70 to 74 „ „ 75 to 79 „ Above 80 years . Age doubtful 112 579 1,058 1,546 1.304 866 728 627 673 481 363 196 198 90 34 14 2 75 122 617 1,131 1,386 1,096 861 790 831 834 558 427 245 202 98 50 18 I 55 234 1,196 2,189 2,032 2,400 1,727 1,518 1,458 1,507 1,039 790 441 400 188 84 32 5 130 1-29 6-59 i2-o6 i6-i6 13-23 952 8-36 803 830 572 4-35 2-42 2-20 i-o-^ •46 ■17 •01 Total, omitting doubtful cases . 8,871 9,267 18,138 9990 From this Table it appears that the two most common lustra for typhus have been between fifteen and twenty and twenty and twenty-five, and that one-half of the cases (9,248) occurred between ten and thirty. Moreover, more than two-fifths (41 '14 per cent.) of the cases were thirty or upwards, and more than one-tenth (i0'68 per cent.) were fifty or upwards; while less ' The mean age of the total population of England and Wales was, for 1861, 26-5 — males 26-1, females 27. {Reports of Census of 1861.) » In this Table, a patient who had completed his fifth year was reckoned as being between 5 and 10 ; and so on for all the other periods of life. 3000 3000 27S0 2500 2Z50 2000 1150 1500 1Z50 1000 _^ 750 _ _500_ 250 1 : — (=-. ^ lO o ^ O-i ^ CTi ^ CTi ^-V c^ CO ^ ^ i^ ^ -ft 4:d o R ■o ^o "O LO CI u-> c^ cv CO c<-5 -=* ''^l- -S -S o a -s f^ Didgrco-nvII, shows the. Ag&s of 18. 138 cases of Typhus Ftv^r, oAmttted iMo the Z ondx)n. Fever So spitaL, withy the nvumh&p of de/juths ■■ at e£Ldv cLg&. ETIOLOGY — PEEDISPOSING CAUSES. 6$ than one-fifth (19*95 P^i' cent.) were under fifteen. Two circum- stances also must be borne m mind, showing that the liabihty to typhus after 30 is even greater than it appears to be from the Table. First, the total number of the population above 30 years of age is very much less than of that below ; ^ and secondly, in many persons above 30 the liability to typhus is removed by the fact of their having already had the disease. A fact notable in the above Table is that at the period of life at which typhus was most common, viz., between 15 and 25, the number of males considerably exceeded that of the females, whereas between 25 and 30 the sexes were equally affected, and throughout the rest of life the females much exceeded the males. Thus, while out of a total of 18,138 cases 8,871 were males and 9,267 females, Of those between 15 and 25 years 2,850 were males and 2,482 females, below 15 years 1,749 ,, „ 1,870 above 30 „ 3,406 ,, ,, 4»o54 The excess of females in middle and advanced life also made itself apparent on calculating the mean age of all the cases. In every one of the ten years above referred to (1848-57), the mean age of the female typhus patients exceeded that of the males, and, taking the ten years collectively, the mean age of 1,742 female cases was 30*27, that of 1,714 males only 28*38. This fact is no doubt explained by the excess in the population of females above 30. In the epidemic of 1836 at Glasgow, how- ever, Dr. Cowan found typhus more prevalent among males than among females of an advanced age.° It is not so easy to account for the excess of males between the ages of 15 and 25, but the cause was probably local. From Dr. J. B. Eussell's statistics of the Glasgow Fever Hospital, it appears that in five years there were 778 female typhus patients between 15 and 25, and only 746 males. Another chcumstance to be noted is that the number of patients between 40 and 45 exceeded that of the previous lustrum, and that the excess was mainly in the male sex. Dr. Peacock'^ has shown that the ratio per cent, of typhus to the general admissions into the Edinburgh Infirmary, for the year ending September 30, 1842, was greatest under fifteen years of age and diminished progressively with the advance of life ; ^ According to the census of 1861, the total population of England and Wales amounted to 20,066,224 persons, of whom 12,481,323 were under 30 years of age, and 7,584,901 over 30. " Cowan, 1838. ^ Peacock, 1843, p. 7. P 66 TYPHUS FEVER. "but young children are rarely admitted into hospital for general diseases, while of those affected with typhus a disproportionate number are sent to hospital, owing to the contagious nature of the malady, and to the circumstance of whole families being often struck down by it at once. The fact that adult age is so prone to typhus involves im- portant social and moral consequences. The disease attacks and destroys the heads of families, at that period of life when they have children dependent upon their industry for support, and hence it is often a cause of widowhood and orphanage, and therefore of pauperism and demoralisation. 3. Months and Seasons of the Year. — Table VI. and Diagram III. show the number of cases of typhus admitted into the London Fever Hospital, during the months, quarters, and seasons of twenty-three successive years. Taking the twenty-three years collectively, January and March were the months in which there was the greatest number of admissions ; September, August and July those in which there was the smallest. The largest number was in winter and spring, the smallest in summer. But this distribution was far from constant in the different years. In three of the twenty- three years the smallest number of cases occm-red in January, and in six years there were more cases in September than in January ; in six of the twenty-three years there were more cases in sum- mer than in spring, and in nine years more in summer than in winter ; in three years the smallest number of cases was in winter, and in two the largest in summer. Epidemics of typhus thus appear to commence and progress irrespectively of season, so long as other known causes of the disease continue in operation. This conclusion is confirmed by a careful comparison of the most authentic records of different epidemics. Thus in Glasgow, in 1845, t^© largest number of cases occurred in January,® but the epidemic of 1847 was at its height in July.^ At the same time, both in London and else- where, it has usually been observed in a protracted epidemic that there has been a diminution of the disease in summer and autumn, to be followed by an increase on the approach, and especially after the persistence, of cold weather. In those periods also when typhus was not epidemic in London the few cases met with occurred mostly in spring, and in autumn the disease entirely disappeared. Thus from April 26, " Ore, 1846. ' Steele, 1848. ETIOLOGY — PREDISPOSING CAUSES. 67 i-T i-T i-T cT i-T i-T i-T i-T i-T 1 MS ri M 1-^ (noo 00 On rh O N 0\N 0\N row C^"*-^ m •^'O r^ i^ -^ ■* ■H vnoo i-n r<-) c\ O i-i iiM 11 Ti-wincsroN-rl-Ni-i t>. u^ N ii r O vD r^\0 1^ O r)- t^ M C) w 1-1 w f) I 00 M O 0\ 0\ N Tj- u-)^ o N •* Tj- 1^ i-H 00 u-) tJ-VO 1-1 N N 11 1-1 1-1 N N CO rJ^ ■* OnnO N w 00 I'l O OnO OnmOOMD NVO 1-1 N 1-1 w vD vO On • •'d- N rOi>NVO N • O ^^ O iri OnvO On r^OO O On M ■Oi-c :cr>Tt-t^iHON'^.HH wM-^O^i-iCNiM'-'ro N N >H M MM O i-n r^CO CO r^CO OiO^Nro •^0"^MO'-0 rO>^ u-) N VON NTf-f^ rJ-M n : i-.c/0i-ir|-i-ni-H^OrO 11 MNNNi-i"M Jr^ONiOi-HOOvDi-'lO"*>J^r<5 •mN'^i-'On "^co r^ i-o " vo cow w NwMMf^ : u-1 OnCO lOMD C ^00 N „ nwcviMwww rnt>.M>-iO'-''-iONr^Tj-nN -NMro On>0 i^ On u-i O "^ "*N i-iCOrO>-ii-iu^li1 . Tj-NCOONONO->i-C^rl- i-H wi-iMMNwi-iM 00 On O 1-1 N fO •* ir^vo t^oo On O w f^ ^O •* irivo 1-^00 On O •t^f- Ti-ir^iJ^u^u-)U^vriiou^io 1-OnO vo^OnOO^O^nOnoO t->. oocooooooooooooooooooooooooooooocooooocooooooo _g VO 3 ^ h _Q Oi c« ^ m (1) .^ r^ C4 3 S' r; cS ON ^ - IN (D M V, un ON "N t>.^ rt- 03 a n 3 ni 3 ■ * 1^ rt n^ S •-' ._, 0) ri a c3 ® a> Cl) S rn «+-( '-< rrl ^ m ^ .n S i8ee 1867 .UB8 1833 1810 1S11 MTIfet i 1861 1862 1853 1655 1856 j g^;_^. 1859 1860 1861 WG2 1863 iS6S iSee 1867 .1S68 1869 1810 1871 DIAGRAM III, sJtows iJie Quoj-terfy- cubrusszorbs of Typhvis Fevep, into the- London Fevei Eospztcd, diLvui^ twe-nt^-fou^r Years ( Covipare with DuLCfrounvUU-) W.Wc3t i. C h^\ ETIOLOGY PEEDISPOSING CAUSES. 69 .•shaw observed in Dublin, in 1865, that a warm moist state of the atmosphere seemed to favour an increase of typhus, whereas dryness with cold had a contrary influence. I have been unable to trace any such connection in my experience at the Fever Hospital in London, or in the records of e|)idemics elsewhere. It is not unusual for patients to attribute the disease to their having 'caught cold' or 'got wet.' Thus, of 1826 Typhus patients treated in the London Fever Hospital during seven years, 124, or 679 per cent., blamed one or both of these causes for their illness. Exposure to cold and wet, especially if long continued, independently of its exciting catarrh or local inflam- mation, has a depressing influence on the nervous system, and so favours the advent of typhus. Occasionally the poison of the fever seems to be stored up for some time in the system and does not take effect until after some such exposure, which then constitutes a ' Determining Exciting cause,' and is often mistaken for the exciting cause itself. 5. Occiqxition. — No occupations in themselves predispose to typhus, except those involving actual exposure to the poison. In the first edition of this work^ a Table was given showing the occupation of 5,095 fever patients admitted into the London Fever Hospital, but it has been thought unnecessary to repro- duce it, as many of the patients, although belonging to some trade, had been out of employment for weeks or months prior to their seizure. Butchers are said by Dr. Tweedie™ to be particu- larly exempt from typhus ; the statement is probably correct, and the fact is accounted for by the circumstance that butchers have usually a good supply of nourishing food. Most of the butchers admitted with typhus into the London Fever Hospital had been out of employment and destitute for some time before their illness. 6. Idiosyncrasy. — No peculiarity of constitution exempts from typhus, though some persons are more prone to it than others. According to Armand," many of the French soldiers in the Crimea appeared to enjoy perfect immunity from the disease, although placed in circumstances identical with those of others who contracted it ; it is difficult to say to what extent other pre- disposing causes may have operated. In the Fever Hospitals of London and Glasgow it has been found that all nurses not * Also in Med. CJiir. Trans, vol. xli. p. 242. ™ TwEEDiE, 1830, p. 79. Eeferences, however, to the occurrence of typhug :among butchers will be found in Smith, 1830, p. 431; Mateeb, 1836, p. 38; >Ckaigie, 1837 (2), 289-91 ; G. A. Kennedy, 1838, p. 37; Peacock, 1843. " Akmand, 1858, p. 409. JO TYPHUS fe^t:r. protected by a previous attack, contract typhus within three or four months of entering on their duties — some sooner than others. Those brought into less intimate contact with the sick may escape for a longer period. In 1862-3, one of the resident officers of the London Fever Hospital visited a large number of typhus patients, daily for upwards of twelve months before he took the disease ; and more recently the engineer, whose duties took him daily into the wards and included cleansing of the dirty bedding, died of typhus, contracted for the first time after fifteen years' service. On the other hand, some persons have a peculiar aptitude for typhus.. A few years ago a medical man contracted the disease from a single visit to the London Fever Hospital, and I myself have had two attacks. 7. Intemperance. — Habitual intemperance deranges digestion^ impairs nutrition, causes degeneration of the excreting organs^ retards the elimination of carbonic acid and urea, and lowers the tone of the nervous system. It is not surprising that under such circumstances the body becomes more susceptible of the poisoa of typhus. It was shown by Craigie ° and Davidson,P that more than one-half of the patients admitted with typhus into the Edinburgh and Glasgow Infirmaries had led intemperate lives. A single act of intoxication may also predispose to typhus. I have known several instances of persons exposed for months tO' the poison in its most concentrated form, who were not attacked until immediately after a debauch. There is no greater error than to imagine that a liberal allowance of alcoholic stimulants, fortifies the system against contagious diseases. 8. Bodily Fatigue. — Fatigue, want of sleep, or whatever lowers the vital energies and exhausts and debilitates the body^ predisposes to typhus. Instances are constantly occurring of medical students and hospital-clerks, who contract the disease under the influence of such predisposing causes. It is also pro- bable that the state of sleep favours the advent of typhus, owing to the nervous depression and languid circulation accompanying, this condition. The attendants upon typhus patients ought not to sleep in the same room. 9. Mental Fatigue and Depressing Emotions. — Mental fatigue and the depressing passions have an undoubted influence in rendering the body less able to resist the poison of typhus ; whilst cheerfulness and confidence have a contrary eflect. Of the predisposing causes included under this head, perhaps none ° Ckaigie, 1837 (2), p. 296. p Davidson, 1841, p. 64. ETIOLOGY PREDISPOSING CAUSES. 7 1 is more powerful than a dread of the disease. Many years ago, a remarkable illustration of this fact made a deep impression upon me. A medical student in Edinburgh had such a dread of typhus, that he could scarcely be induced to enter a ward in which there were any cases ; yet he was one of the first students who fell a victim to the disease in the epidemic of 1 847. De- pressing passions constitute one of the many predisposing causes of typhus in armies and prisons. 10. Previous Illnesses. — Previous ailments predispose to typhus. A person often escapes the contagion of typhus for a long time, but he contracts a febrile catarrh or an attack of simple fever, and then he falls a prey to the poison. In hospital practice, convalescents from other diseases are often attacked by typhus. Scurvy is generally admitted to be a powerful predis- posing cause of typhus : it was found to be so in the epidemic of 1847-8, and in the French army in the Crimea.'^ According to Hildenbrand,*" typhus rarely attacks persons labouring under phthisis. Out of several hundreds of cases of typhus which came under his notice, not one was phthisical. Of 100 typhus cases dissected by Davidson, traces of tubercle were found in the lungs of only 3.* I am inclined to doubt the correctness of Hildenbrand's opinion. Tubercle in the lungs is far from being a rare complication or sequela of typhus, and in many cases there is a history of phthisis prior to the attack of fever. Jenner * records the case of a phthisical child, who was attacked by typhus and died from a rapid deposition of fresh tubercles in the lungs ; and cases of the same nature have come under my notice. 11. Recent Residence in an infected Locality. — The following Table shows the length of residence in London of all the typhus patients admitted into the London Fever Hospital during fourteen years (1848-61), with regard to whom the point was noted : — *» Jacquot, 1858, p. 77. Baeealliee, 1861, p. 38. Lind believed scurvy to be a preservative against typhus, and a similar opinion has more recently been expressed by Boudin and Dalmas. ■■ HiLDENBBAND, iSlI, p. I44. ' DAVIDSON, 184I. » JeNNEE, 185O, XX. 457- 72 TYPHUS FEVEE. TABLE VIL Less than 3 months . 120 or 3-87 per cent. „ 6 „ . . 160 5-i6 I year . . 213 6-87 2 years . ; 271 557 8-74 » 10 » . 17-96 More than 10 years, but not for entire life 518 1671 For entire life , , 2 • 3 ,026 65*33 lOO'OO Total ,101 Thus of 3,101 cases, only one- fourteenth had resided in London less than a year, and only one twenty-sixth less than three months ; whUe 6$^ per cent, had resided in London all their lives, and 82 per cent, more than ten years. (See page 58.) It has long been known that the poison of Enteric Fever operates more readily on persons who have but recently been subjected to its influence, than on those who are habituated to it : it is doubtful if this character applies to typhus. The nurses and attendants on the sick of typhus acquire no immunity from mere exposure, unless they have already had the disease ; and there is no evidence that when typhus appears in a house, it selects the new comers by preference. On the other hand, prisoners living in the typhus atmosphere of jails, have been known to convey the disease to strangers, while they themselves have escaped. In some epidemics, a considerable proportion of the persons attacked have but recently arrived in the infected locality ; but then they have either brought the disease with them, or they are predisposed to it by their destitute condition ; or they pro- ]3agate, or perhaps help to generate, the poison by causing over- crowding. 12. Overcroicding. — Overcrowding of human beings, with deficient ventilation, is one of the most powerful predisposing causes of typhus. Admitting that typhus is propagated by emanations from the sick, it is obvious that its propagation must be favoured by the concentration of these emanations. All the historians of the great epidemics of typhus testify to the intimate connection between its prevalence and over- crowding. ETIOLOGY PEEDISPOSING CAUSES. 73 The following Table (VIII.), constructed from the register of the London Fever Hospital, shows the localities of the metro- polis from which 26,380 cases of fever were derived during twenty-two years (1848-69), as well as the area and population of each district." The returns of no hospital could be better suited for the purpose, as the patients have been brought from every district of the metropolis. It is true that, from various cu'cumstances, some districts have sent a larger proportion of their fever cases to the hospital than others, so that the returns do not correctly indicate the amount of fever in each district, yet they furnish a fair criterion of the form of fever prevalent in each. It will be noticed, that the typhus cases have come for the most part from the central and most crowded localities, and that on approaching more suburban districts their proportion gradually diminishes. Unfortunately, no district of the me- tropolis is entirely exempt from overcrowding, otherwise the contrast would be more striking. In Edinburgh, where there is a greater separation between the overcrowded dwellings of the poor and the houses of the better class than perhaps in any other city, typhus, even in the midst of the greatest epidemics, is almost restricted to the most crowded and wretched parts of the Old Town. Again, in the country districts of England typhus is a rare disease ; almost all the examples of ' typhus,' reported as occurring in small country towns and villages, are reaUy cases of enteric fever. 13. Destitution and Starvation. — Destitution and deficient alimentation are the most powerful predisposing causes of typhus. The influence of poverty on the prevalence of typhus is borne out by the experience of the London Fever Hospital. On in- vestigating the condition in life of 18,268 typhus patients ad- mitted during twenty-three years, it was ascertained that they belonged almost invariably to the lowest classes of the popula- tion, 95*76 per cent, being the inmates of workhouses or dependent on parochial relief, whereas comparatively few of the better class of patients, such as gentlemen's servants and persons able to pay for admission, were affected with typhus.'' And not only has this been so, but it has been constantly found "^ The districts are those into which London was divided under the ' Metropoli- tan Local Management Act.' In the year 1870 the area of many of the districts was altered, so that it was impossible to include this or subsequent years in the Table. '■ For the precise numbers, see section on Etiology of Enteric Fever. 74 TYPHUS FEVER. -a u-iOvOO 0>-<^iJ^ N w vo I^CO ro vo O vo On vo*^ ■* ro 1 O C^Lo^-^ vo M N O -* cq r-»cO OvCO o rooo ro Tj- « ^ 00 a h O\m0 r^ C^ cio vb fO On o. i^ « vb ro Tl- b oboo c» Kco b «5 \ M } 3 S B f^ NNOON OOVOt^rJ- ON Cvvo t^ O t^ Ov VO N N ■* Th o 00 d N trt rO^O M ON vo " N ■^ Tf •- ^J1^^Tl• Ul O vo OMi -^ On vo ro ro r) vO 00 vo 8 *>. t^ t^ 0^ -^oo o p 0^ 00 00 O -^r^ ON ON On f» « lO vo n "o >s i^NioTi- Ti-cyi"i^ vb b^ ^b ^ N vb bv voi--. CO oo do 1 1 (S " 00 Tj- w ro « N " ro vo N Ti- Tj- CO H M M (« M > ^OT^t^O^ NOOvOO^ 00 N Ov O vO m N •* N C^ rovo OvvO O ro vo c^ o> o o ■<*• N N ^ ro li^ i^vo lO vo N ►- ro •* t^ CI vo 1 (z; ro M rtvO w •. ' " CO b "I « ro fo N « CI ^ b N « ro ro « b i^ t^ -M o o C< 1-1 i 5* ph p. (§ oo : : w o o t^oo Ti- 00 1-1 o\ 1- fo vo I^ r~. l-- 1-1 On ro -ij- o M . ; HH 1-4 HH vo M rovo N - f^ r^ w M VO iz; ~ ■<<■ J2 g 1 a rj- Ttoo lO "* n- 1- o^ O CO w Tj- vooo Tj- ■I O C^ TfOO vo o S 00 pvO ON ^ rn rocp VO r^ -^ !>. vo -^ >- vo ON N « Ti- t^ oo vnbb>-i voN^i-w b a\ 'as\h "1 00 ^ ro i^ ro ^ i^ ro vo 5 1^ vo « -^t^ -"too t^vO t^ lO d vo •* ro VO vovO vO vO t>. 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'S *> BQ 1 ^j -u tC 0) c -s CO .9.S g 1 2" S| S s f^ =^ s s-i ri c o s m - ^ ■' > id t3 e3 • ;3 cS o 55 d d >■ > s d ^x S ETIOLOGY — PEEDISPOSING CAUSES. 75 \0 vO 11 00 00 Tj- o in O m t^ O 11 On 11 OnvD vO vo CO ON o c) o vp rn f<^ N c) i-i ^ M o ino r^ O ON n . . . OO " vp -o . m ■*VO o io i/^ i^ t-^ in b vb M r^ M N b " b ►H : : : CO CO t-^vb '• t^ b'i) '-^ CO " " " « M H " lO l>^ CN 1J% lO HH o ro N 00 n 00 N 11 vO : - • lO ONVO m • vo t^ m Ti- 00 irivo i->. 1-1 in N ON M 11 M in O •^ • : • •* rr : t^ ll w cq CO CO M '^ ff t^oo m 1-" «n 11 VO fO ro in M VO ro ro vovon .oovoovom t^ in t^oo Th VD Tl" w vp in o _^ N 00 vo vp ►-I OO in M vo r— ; c) vO mvo « :* mwco ^4- CT\cio rn rr> fr) Tt- io CTi b OO vb t^ b r^ ij^^ in " vb vb CO vb vb r^ iri'h CI b *^ 1 w M en invo 00 M w w Tj- n m ■* c» i-« ■* N m M 0\ N "* Tl- « c^ ro N O M \0 vo • CO On M invO S" O 'd- Tl- CO 0\ N rj- n •rj- M 'tl- M tnvo vo onoo ■* CO : CO w n O ON w T}- ON >H N M N w o% fO "1 n n P) CO in ro N t^vO OS Th m 00 " m t-% ro in •* . . . . "1 mi O .00 O . O lO O N w vo Oi ;* c^ ^ fO ON M w rj- Cl « . . . . M O lO ; CO CO • ^o vo « ^ N w N t^ ^ iocb w CO ^ « M ■ ^ w N * io Tl- ■ ;i- M V n O M N O t^ " >0 m Tj-OOOO lO-* CO 00 ■ • • • N coin • cj M : o vo CJ w in fo ro CI M t^ w M fl M N : : : : M « . t--. . HH n N N c»_ fo rooo m OS O o\ CO invo in 11 O co CO POOO O M N COVO vO o\ m M rl- vo rf p op w ^ ^ vp N M vp in t~. ON CO vo CO cs p ^^^ r' P^ T* vo OnOO 00 00 ro N vb t>.0<) OO ro Tj- CO t~»i^ t^vb bv bvcori-b b bv^vboo b CO CI M vb t>. r^vo t^ t^^O X^ 00 t^OO 00 vO vo ■* N CO « O ^00 J^vO CO »^ cooo lO vo roro roa\ O N O On O 00 On rN, r^ -^ vo CO n n 'O •*co O lO 00 moo in t^ w r~. IN n c< ■"i- ON 11 CO 11 OO vO M 00 M o m M N vo ■OOO On CO tN.00 t^ M__00 w rt M N vo vo CO M_ 11 C) M -^ •^ n CI vO_ N^ •^ " "i^ tC M N w o N r^ ro O ■rh UI r^ N •^ CO Tj-CTst^nvomO O CO o N t-^ Ov 3. t^ " 00 OO '^ o ON vo 1 O 00 •* CO *^ m O 00 O CO n N VO M VO 00 OS N_ q^ "^ q^ .inior^c) -^O.S . CO o t^ m j-^ 00 ro 11 C^00^\O_ 11^ n " o '^ "2 ^. °. 't'^ " : : I : "* "^^ ■ *"; *^ ON C\ ^cocc ds cf; ^ vo' cRoo" in cf cT O^ 's • • • • i-T tF r-^ • m CO : : '. ^ M O t^ ■<;J- O t-. fo f-i m moo vo i>. g t-^ C) M vo o 00__ VO O vo ro t^OO o O Onoo c) -5i- m M rovo M M VO n VO Tt- CJ ON T^vO O ■* "^ " ro mvO 00 OO M n " «^ t^ , VO ^00 r^ ON C( ■* CI VO t^ -^ N MO; C4 N n vo c< vO 0_ »~; CO M - m cooo *~; m M_ in q. i-T m" vo" ■i in OO • • • -na • • CO • • • ■ • en 1. n the Eas md Mile E Bow . c3 03 . . . . , . .^ . • M fl 02 ^ .2 3 '3 • ft m 03 St. Saviour St. Olave Bermondse; St. George, Newington Lambeth Clapham worth . Battersea Putney . Streatham Tooting Camberwel Eotherhith Greenwich Woolwich Lewisham •> ft 3 O 02 Beyond London D Residents in Hosp Not ascertained • '3 XX. XXI. XXII. XXIII. XXIV. XXV. XXVI. XXVII. XXVIII. XXIX. XXX. XXXI. XXXII. XXX. 'X XXX X "o H X 76 TYPHUS FEVEE. that a large proportion of the t^^phus patients have been on the verge of starvation for several weeks or months prior to ad- mission,"^ Indeed, in London, typhus is almost unknown among the middle and upper classes, save in a few isolated instances where there has been du'ect intercourse with the sick. I have been informed by Dr. Tweedie and Sh' W. Jenner that they have scarcely ever met with an instance of typhus among the better -classes, except in the case of medical practitioners and students, and my own experience confii'ms the statement. During the seventeen years in which I have been connected with the London Fever Hospital, I have attended only six private cases of typhus, of whom one was a medical man, one a clergyman, and one a lady who visited the poor. It is true that persons even in the highest ranks are constantly said to die of typhus, but the term ' typhus ' is so commonly employed to designate any form of fever, or indeed any disease with typhoid symptoms, that no weight can be attached to such statements. This indiscriminate application of the term ' typhus ' to all forms of continued fever accounts for the statement made by Sir K. Christison in his celebrated address to the Social Science Association in 1863, that in non- epidemic periods typhus is more prevalent in Edinbm-gh among the rich than among the poor ; ^ Dr. W. T. Gardner's investigations, hereafter referred to (p. 100), proved that at these times true typhus was restricted to the poorest of the popula- tion. y From the historical account of typhus it appears that all the great epidemics which have devastated Ii'eland, Great Britain, and other parts of the world, have occm-red during seasons of scarcity and want. In some instances the famine has been general, owing to failures of the crops, and the epidemics have been widespread ; while in others, the scarcity has been the result of artificial causes, such as strikes, commercial failures, sieges, etc., and the epidemics have been circumscribed. But, whatever may have been the cause of the scarcity, it has been a common observation in many epidemics, that the fever has raged among the poor in a degree proportionate to the privations they have endured.^ It was so in the epidemic of 1817-19,=* and in 1847 it was found in Dublin that those persons who had been reduced by insufficient food were first attacked, while in many See pages 49, 53. ^ Christison, 1S63. y W. T. G.uedxee, 1S59, p. 243. Alison, 1840, No. i, p. 22. * Baseer and Cheyxe, 1821. ETIOLOGY PREDISPOSING CAUSES. 7/ instances the fever first showed itself on recovery from the primary effects of famine.^ A similar observation was made in Philadelphia in 1836.'^ The influence of destitution in propagating epidemic fevers, (typhus and relapsing) was long since insisted on by Bateman, who observed : ' Deficiency of nutriment is the principal source of epidemic fever ; ' ^ while in later times it was almost proved to demonstration by Alison,*^ who even believed that the ' exist- ence of epidemic fever is a most important test to the legislator of the destitute condition of the poor,' The same views were supported, although carried too far, by Sir Dominic Corrigan *" of Dublin, in a pamphlet published in 1 846, entitled ' Famine and Fever, as Cause and Effect in Ireland.' Sir D. Corrigan' s memoir elicited, within a few months, an able essay from the pen of Dr. Henry Kennedy,^ which requires some notice. Dr. Kennedy en- deavoured to show that epidemic fever was independent of famine, and that there was even evidence that, under certain circum- stances, an excessive use of food might help to generate it. A reply to the more important of Dr. Kennedy's arguments will be found under one or other of the following heads : — I. Some of Dr. Kennedy's arguments were fallacious, from his having confounded typhus with enteric fever. Outbreaks of the latter fever, which is independent of destitution, and which is met with among rich and poor alike, cannot legitimately be adduced as evidence in disproof of the influence of destitution on the spread of typhus. It is well known that in 1846, prior to the great epidemic, a fever was prevalent, not only in Ireland,' Scotland,. and the large towns of England, where typhus afterwards raged so fiercely, but also in many country districts of England which entirely escaped the subsequent epidemic. Dr. Kennedy alluded to this fever as prevailing in the autumn of 1846 in Berkshire and London, to show that epidemics of fever might commence among the well-fed. This fever, however, was not typhus, but enteric fever. ^ The outbreak of enteric fever at this time in Edinburgh, described by Bennett* and 'Waters,J was of peculiar importance, as under ordmary circumstances the disease was. •^ Irish Report, Bib., 1848. ■= Geehaed, 1837, xix. p. 297. ^ Bateiian, 1818, pp. 4 and 11, ' Alison, 1840, Nos. i and 2. ^ CoEEiGAN, 1846. s H. Kennedy, 1847. '' On this point, see section on the Predisposing Causes of Enteric Fever. ' We assert with confidence,' says a writer in the British and Foreign Medical Bevieiu for April 1848 (p. 287), ' that tlie excess of fever in the autumn of 1846 did not constitute the foyer from which sjorang the fearful irruption of 1847.' ' Bennett, 1847. J Watees, 1847. 78 TYPHUS FEVEE. not common there. (See p. 50.) Although few Irish physicians distinguished the different forms of Continued Fever, the follow- ing extract from Dr. Popham's Eeport ^ of the epidemic at Cork is to the point : ' The state of health in this city was not below the average during the early part of 1846. Fever of a gastric type was rather prevalent in May, but no serious amount of illness existed before the failure of the potato crop.' The very hot summer of 1 846 preceded a failure of the crops, but seasons remarkable for a high temperature are characterised by an increased prevalence of enteric fever, whether the crops fail or not. 2. Dr. Kennedy stated that in certain epidemics, and particu- larly in those of 1740, 18 17, and 1836, there was an increase of sickness or fever, before the commencement of famine. But to admit this argument, it would be necessary to know more of the amount and nature of the sickness or fever alluded to, and of the precise condition of the population, than is perhaps now possible. If the argument be just, it is difficult to under- stand how the able observers who saw and wrote on these epidemics, attributed them to an unusual amount of privation among the poor. (See pp. 34, 40, 47.) 3. It was urged by Dr. Kennedy that epidemics of fever have been observed to continue after food has become plentiful. But to say nothing of the persistence of numerous foci of con- tagion, it is not surprising that persons whose constitutions have been enfeebled by long want should remain predisposed for some time after plenty is restored. Indeed, some observers have thought that, during an epidemic of typhus, a sudden change from a deficient and unwholesome diet to a fuU supply of nutritious food renders the body more susceptible.^ This is the only way in which a superabundance of food can con- tribute to the spread of epidemic fever. Still, it is a fact that most epidemics have declined soon after the restoration of plenty. 4. It was stated by Dr. Kennedy that the epidemic of 1826-7 actually subsided in Dublin, while the wants of the population were as great as when it commenced. The statement may be true ; but, before admitting it as a proof that the prevalence of typhus is not influenced by destitution and famine, it is neces- sary to consider certain peculiarities of the epidemic in ques- tion. It was not preceded by a general famine from extensive ^ Irish Report, Bib., 1848, viii. p. 278. ' Graves, 1848, i. 96. ETIOLOGY — PKEDISPOSING CAUSES. 79 failure of the crops, but it was due to local, or, to use the ex- pression of one of the historians of the epidemic, artificial scarcity. Twenty thousand artisans in Dublin were thrown out of em- ployment in the spring of 1826 and were actually starving. These 20,000 then, with their wives and families, included all who were unusually predisposed, and when they all had con- tracted fever, the material, so to speak, for the epidemic was exhausted. Now it was shown that, within twelve months, the number of persons attacked far exceeded 20,000. (Seep. 45.)'" 5. It was argued that epidemics of fever might occur without any famine ; and the argument is just, if, according to Dr. Kennedy, typhus and enteric fever be one disease. The epi- demic of 1 77 1, however, recorded by Sims ''and alluded to by Dr. Kennedy, was probably typhus ; but it does not appear to have been very extensive, and the accounts of it are certainly too meagre to warrant the statement that it was not preceded by unusual privation. Although Sims made no mention of famine, he stated that the fever prevailed principally among the poor, and among those of the middle ranks who led irregular and intemperate lives. (See also p. 37.) 6. Lastly, Dr. Kennedy appealed to the circumstance that, notwithstanding the failure of the crops, the year 1 846 in Ireland liad been ' unusually healthy and free from fever.' But he wrote on the eve of one of the greatest Irish epidemics of typhus on record. A careful study of the history of typhus epidemics demon- strates, in my opinion, the intimate connection between these epidemics and famine or distress. They have appeared during every variety of climate, season, and weather : famine and over- crowding have been the sole conditions common to them all. In fact, on more than one occasion, epidemics of typhus have been predicted from the occurrence of famine ; and the result has verified the prediction. (See pages 45 and 54.) Some persons imagine that famine from failure of the crops and epidemics of typhus both result from one common cause, such as an obscure ' atmospheric,' or ' epidemic influence.' But against such a view it may be argued, first, that in bodies of men living in the same locality, and exposed to the same atmospheric influences, the prevalence of typhus has been found to be in a direct ratio to the degree of privation. Con- trast, for example, the condition of the English and French "> Ebid, 1828. " Sims, 1773. 80 TYPHUS FEVEE. armies in the Crimea in 1855 and 1856. At the commence- ment of the siege, the English commissariat was inferior to the French, and the EngHsh suffered most from typhus. But in 1856, says Jacquot, 'Le temps s'ecoule ; les roles changent.' ' L'insuffisance, et surtout la mauvaise qualite, des vivres de I'armee fran9aise en Crimee sont un fait notoire et deja his- torique.' 'Aussi, les nouvelles epidemies et de scorbut et de typhus continuant a sevir en proportion de I'etat des armees, n'ont-elles aueune prise sur les Anglais, auxquels rien ne manque en fait de bien-etre, tandis qu'elles affaiblissent et deciment I'armee fran9aise.' ° Secondly, epidemics of typhus, appear during the state of privation consequent on strikes, commercial failures, and warfare ; or, in other words, artificially induced famine entails the same results, as the famine arising from failure of the crops. But it is not contended that famine can produce typhus, nor would it be right to say with Corrigan, ' If there be no famine, there will be no fever.' The circumstances which are believed to generate the typhus-poison, although they often co-exist with famine and destitution, are quite distinct. What is here main- tained is : that destitution is the chief predisposing cause of typhus, that it predisposes the constitution to the action of the specific poison at times when the latter would otherwise be inert, and that in this way famine causes a rapid diffusion of the fever, and converts a few isolated cases into a general epi- demic. Moreover, famine and destitution from want of work have the effect of concentrating the poor in large towns, and of thus producing overcrowding, from which the disease origi- nates. Famine only generates typhus, in so far as it causes over- crowding. B. — Exciting Cause of Typhus. The primary exciting cause of typhus is a specific poison emanating from the bodies of persons previously infected (con- tagion), or generated de novo. The contagious character of typhus has been attested by most observers since the time of Fracastorius. From this property, indeed, many of its appella- tions have been derived. (See Synonyms, p. 17.) Charles Mac- lean,P however, in an elaborate work on the plague, published in 1 8 17, strongly opposed the notion that any epidemic diseases could be communicated by contagion ; but his arguments are a " Jacquot, 1858, pp. 85, 92. p Maclean, 1817, i. 119. ETIOLOGY — EXCITING CAUSE. 61 melancholy example of facts misinterpreted in the light of 23reconceived opinions. Lassis,'! also, and other writers have denied that typhus is contagious. Even at the present day, a difference of opinion exists on the point. Some eminent physicians maintain that typhus always results from contagion, and that the specific poison is never generated de novo ; ^ others regard it as doubtfully contagious, although this conclusion is usually based on observation of enteric fever and not of true typhus ; while some sanitary reformers go so far as to assert that there is no such thing as contagion, and that the so-called * contagious diseases ' result, in every instance, from inattention to sanitary arrangements. It is essential that the profession and the public should have clear and decided views on this matter ; and it is therefore expedient to consider the more im- portant arguments and facts in favour of the contagious character of typhus, the laws by which its specific poison appears to be governed, and the question whether this poison always emanates from a person previously infected, or may not under certain conditions be generated independently. I. Contagion.^ The belief that typhus is contagious is based on such facts as the following : — A. When typhus commences in a house or district, it often spreads ivith great rapidity. It is not uncommon for an entire family, or all the residents in a large lodging-house, to be attacked in succession. Thus, on July 2, 1857, seven members of one family were admitted into the London Fever Hospital in differ- ent stages of well-marked typhus, and often ten, twenty, thirty, or even one hundred cases have followed one another in rapid succession, from the same house or court. Of 2,811 cases of typhus admitted into the London Fever Hospital during eight years, at least 729 or 28*13 pei' cent, referred the origin Of the disease to contagion. But the mere circumstance of many persons being successively attacked with typhus in the same house or district is not a conclusive proof that the disease spreads by contagion, because the fact may be explained on the supposition of some local cause. Other proofs, therefore, are required. ' Lassis, 1819. ' Watson, Lect. on Pract. of Physic, 5th ed. 1871, li. 895 ; W. BuDD,_i86r_. " Here and elsewhere in this work, the word ' contagion ' is used in its widest signification, and not to imply actual contact. G 82 TYPHUS FEVER. B. The 2)revalence of tyjjhiis in single houses or in circum- scribed districts, is in direct ijroportion to the degree of intercourse between the healthy and the sick. In a common lodging-house, it is the persons Hving in the same room with the first case who are first attacked. Again, in hospital practice, the nurses and attendants on the sick rarely escape. In 1814 typhus was introduced by some soldiers into the Salpetriere in Paris ; 1 20 persons attached to the hospital were attacked, and eight physi- cians died.* The following facts are recorded in reference to the great Irish epidemic of 18 17-19." In the Cork Fever Hos- pital, 198 cases of fever occurred within eighteen months among the attendants on the sick. ' No clinical clerk, apothecary, unseasoned nurse or servant escaped.' In the Dublin Fever Hospital, 13 of 47 attendants on the sick took fever in the course of eight months. In Steven's Hospital, * none of the nurses, none of the porters, barbers, or those occupied in the handling, washing, and tending on the sick, escaped.' " In the Edinburgh Infirmary, during the year 1827, 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.'^ Similar evidence was published in 1833 by Dr. Tweedie. 'Every physician,' he observed, ' with one exception (the late Dr. Bate- man), who has been connected with the London Fever Hospital has been attacked with fever during his attendance, and three out of eight physicians have died. The resident medical officers, matrons, porters, and nurses have, one and all, invariably been the subject of fever, and the laundresses whose duty it is to wash the patients' clothes, are so invariably and frequently attacked, that few women will undertake this duty. The resi- dent medical officer was attacked, and it became necessary to appoint some one to perform his duties. The first person who thus officiated took the precaution of sleeping at home, yet his duties were soon interrupted by an attack. He was succeeded by an individual in robust health, a disbeliever in the doctrine of contagion. He performed his duty only ten days, when symptoms of severe fever appeared.'^ In 1837 Dr. Cowan thus wrote concerning the typhus then prevailing in Glasgow : — ' All the ' B. Williams, 1836. " Barker and Cheyne, 1821 ; Harty, 1820, p. 151- ' In some of these cases, the disease communicated was no doubt relapsing fever, of which this epidemic was mainly comijosed. " Alison, 1827, p. 238. -^ Cyclop. I'ract. Med. Art. 'Contagion.' ETIOLOGY EXCITING CAUSE. H •gentlemen who have acted as clerks in the Fever Hospital for many years past have been attacked with fever, unless they had it previous to their election. During the last year, twenty- seven ■of the nurses of the establishment were seized, and five of them ) }> Eelapsing ,, 4 >} >f Febricula ,, 4 jj j> Scarlet „ 24 >> 5> Other diseases 16 Of the servants in the establishment not engaged in the wards, only 3 had typhus. Eemarkable illustrations of the contagious character of typhus were furnished by the Crimean campaign. It will suffice to quote the following : — An official return showed that y Cowan, 1838, p. 26. ^ West, 1838, p. 143. » RouPELL, 1839, p. 52. »> W. T. Gaiednkk, 1862, Ko. i. 359. Lind, 1763. <= Jacquot, 1858, pp. 99, 115. '^ Bateman, 1818. " The generation de novo of the typhus-poison — a question subsequently dis- cussed — is not contended for in this paragraph, as might be inferred from the reference to it in Aitken's Practice of Medicine (2nd ed. i. 455). Its object is to show that the poison, however generated, may, under certain conditions, be propagated by persons not suffering from it. Similar facts have been published, since the appearance of the first edition of this work, by Hudson (1867, p. 265) .and Davies (1867, p. 429), 90 TYPHUS FE\:ER. after visiting them/ One of the most remarkable examples of typhus communicated by the clothes was the ' Black Assize ' of the Old Bailey in 1750. Here the prisoners had not the disease which they communicated with such fatal effect to the court that tried them.^ Lind mentions several cases, where a single person, though not ill himself, imparted fever by his clothes to a whole ship's crew. Fodere records a remarkable instance, in which the soldiers of the French army, during their retreat from Italy in 1 799, communicated typhus to the inhabitants of fifteen towns and villages where they halted on their route. The soldiers suffered from privations of every kind : they were ill-fed, their clothes were in tatters, their bodies were covered with filth and exhaled a noxious smell, and their shirts, unchanged for several months, were glued to the skin. Yet this same army was not attacked by fever, until it arrived at its destination and was massed within walls and under roofs. Soldiers also travelling singly did not communicate the disease.^ Then, in our own day, there has been the notorious case of the Egyptian vessel, the * Scheali Gehaad ' at Liverpool, the crew of which disseminated the poison of tjrphus by their clothes and persons, although they had not the disease themselves.^ Both Lind J and Trotter ^ state that the nurses and porters at Haslar Hospital were well aware of the danger of contagion from piles of infected clothes, and from cleaning the bedding of the sick, and that they were in the habit of measuring the amount of danger by the badness of the smell. The following case is recorded by Barker and Cheyne : — ' A child, on being discharged from a fever hospital, w"as admitted into a charitable institution, and brought with her a small bundle of clothes which had not been disinfected. The bundle was opened by a woman resident in the institution, who perceived an exceedingly disagreeable odour to- issue from it. Li a few minutes the woman became ill, and her stomach sickened, which proved to be the beginning of a fever,, such as was prevalent. Hers was the first case of the epidemic in the institution.' ^ In January 1867 a patient in a surgical ward of the Middlesex Hospital was seized with typhus. She had been in the hospital four and a half months and in bed all the time. There were no other cases of typhus in the same '' Howard, 1784. *-■ Pringle, 1752 ; Heysham, 1782 ; Bancroft, 1811, p. 664. '■ FoDER^, Mdcl. Ltfgale, torn. v. ' Duncan, 1862. J LiNu, 1763. ^ Trotter, 1803, i. 177. ' Barker and Cheyne, 1S21, i. 472 and ii. 139. ETIOLOGY EXCITING CAUSE. 9 1 "v\'ard or on the same floor ; but a nurse in close attendance on a typhus patient downstairs, though in good health herself, had been in the habit of visiting this patient daily. Lastly, it has been a matter of common observation, that laundry-women, employed in washing the clothes and bedding of typhus patients, are liable to contract the disease, without having any dnect com- munication with the sick.™ Woollen substances, as being most prone to absorb and retain animal exhalations, are most fitted to transmit the typhus- poison. Haller of Vienna observes that ck?7t--coloured materials of clothing are more prone to absorb the contagion of typhus,, and to convey it to other individuals, than those w^hich are light- coloured. He found that among troops wearing dark- coloured, uniforms, it more frequently happened that new cases of typhus entered the hospital after a convalescent patient had rejoined his corps, than those wearing light or white uniforms. It may be mentioned, also, that Stork found that in dissecting rooms dark clothes acquired the cadaveric odour sooner, and were deprived of it less readily, than light ones ; and he ascertained by experiments that the absorption of odours is regulated by the laws which govern the absorption of light.'' Facts like the foregoing prove how highly reprehensible is the practice of employing street-cabs for the conveyance of typhus jDatients. Still it is satisfactory to know that the poison must be highly concentrated to be transmitted by fomites, and that it is rendered inert by cleanliness and free ventilation. There are no instances on record where a medical man has been the medium of trans- mission of typhus to his patient or to his family, as may happen in the case of scarlet fever and small-pox. ' I have visited,' WTote Dr. Gregory, ' more than a thousand patients in fever — many of them ten, twenty, or thirty times — yet I am certain I never brought the contagion into my own family.' ° I am assured by Dr. Tweedie that on no occasion during his connection of thirty-three years with the London Fever Hospital was he aware of having been the medium of communication of typhus ; and, after seventeen years' connection with the same hospital, I can confirm this statement as regards myself. 4. The i)eriod of incubation of the typhus-poison has been variously fixed as follows : — "" Vide ante, pp. 81, 82; Tweedie, 1833, p. 400; Henderson, 1843, p. 216. ° Hallek, 1853. ° See Clakk, 1802. 92 TYPHUS FEVER. Haygarth (i8oi( made the latent period 5 days to 2 months. Hildenbrand (1810) „ 3 to 7 days. Bancroft ( 1 8 1 1 ) , , i day to 5 or 6 months ! Sir W. Bm-nettP „ 7 to 18 days. Barker and Cheyne ( 1 8 2 1 ) , , a few minutes to 6 wks . Sir Henry Marsh (1827) ,, a fewhom-s to as many weeks or months. Dr. Gregory (1832) „ 10 days. Dr. Perry (1836) ,, never less than 8 days. Dr. Alison (1844) ,, very various. Dr. Copland „ 3 to 14 days. Huss (1855) M I to 10 days. Dr. Peacock (1856 and 1862) ,, 10 to 21 days. Jacquot (1858) „ 9 to 13 days. Barrallier (1861) ,, 12 to 15 days. Many of these statements are based upon one or two observa- tions, which are not detailed, or far from conclusive. According to my experience, founded upon 3 1 cases published in a recent memoir,i the period of incubation is usually about twelve days, frequently shorter, but rarely longer. Of the 3 1 cases, in i it was not less than 21 days; in i, exactly 15 days; in i, not less than 14 days ; in i, not less than 13 days ; in 4, exactly 12 days ; in 13, a period of 12 days was within the known limits ; in 2, it was not more than 10 days ; in i, not more than 6 days ; in i, exactly 5 days ; in i, between 5^ and 2 days ; in 2, not more than 4 days ; in i, not more than 2 days ; and in 2, there was no latent period, or only one of a few hours. It thus appears that in 17 out of the 31 cases, the period of incubation was either twelve days, or this duration was within the known limits. It may be added that Jacquot, who calculated the latent period from the date of embarkation of healthy French troops on board vessels infected with typhus, found that in a considerable number of cases it varied from 9 to 1 3 days, the average being somewhat less than 12 days.*" But occasionally the period of incubation exceeds twelve days. It did so with certainty in 4 only of my 3 1 cases, and in I only of the cases was there reason to think that it was as long as 21 days. Theurkauf records two cases, in one of which it was 1 8 days, and in the other between 14 and 19 days ; ^ and Peacock mentions one in which it was believed to be not less than 19 days.* I know no trustworthy facts, however, showing that p See Geegoky, 1832, p. 745. "J Murchison, 1871. ' Jacquot, 185S, p. 119. " THErr.KAri', 1S68, p. 40. * Peacock, 1862, p. 5. A patient, nineteen days alter admission into a surgical ward of St. Thomas's Hospital, was attacked with typhus, to which, it is ETIOLOGY EXCITING CAUSE, 93 it can exceed three weeks ; " and statements to the effect that it may extend over many months require confirmation. Few, at all events, will admit, on the evidence adduced by Bancroft,"* that an interval of five or six months may elapse between exposure to the poison and the commencement of the disease, an opinion to which he was forced by his determined opposition to the possibility of an independent origin of the fever. On the other hand, in many cases the period of incubation is less than twelve days. It was so in lo at least of my 31 cases. Davies states that in 1867 four Norwegian sailors, on the night of their ship's arrival in Bristol from Onega, visited some typhus fever-nests, and all four sickened with typhus eight days after ."^ Niemeyer mentions two cases in which the period of incubation was exactly eight days.'' In my own second attack the latent period was exactly five days.^ There are also authentic instances where there has been scarcely any latent period at all. The late Sir Henry Marsh collected 19 cases in which the disease manifested itself almost instantaneously after exposure to the poison.^ In most of the cases the persons complained of an offensive odour proceeding from the beds or bodies of the sick, and immediately suffered from headache, great prostration, nausea, or rigors, followed by the usual symptoms of typhus. Similar cases were mentioned by Haygarth ; * others were observed by Gerhard at Philadelphia in 1836 ; ^ and two of my 31 cases were of a similar nature. In some of these cases it might be difficult to exclude the possibility of previous exposure to the poison, but in others there were no grounds for such suspicion, and in all, the patients appeared to be conscious of the moment at which the poison entered the system. It would seem that the poison of typhus may be so concentrated, or the system so susceptible of its action, that its effect may be almost instantaneous. 5. Stage at ivhicJi typhus is most infectious. Haygarth men- tions the case of a man who was said to have communicated the disease to his family before the fifth day ; but he adds, that his information was less complete than he could have wished.'' argued, he could only have been exposed prior to admission. There were, how- ever, apparently cases of typhus in the medical wards at the same time. (Vide ante, p. 89.) " Baeker (1863, p. 138) mentions a case of six weeks, but It is doubtful if the fever was true typhus. " Bancroft, 1811. " Davies, 1867. ^ Text Book of Pract. Med. Amer. Trans. 1869, ii. 563. f MuRCHisoN, 1871, Case xx. ^ Marsh, 1827. » Haygarth, 1801, p. 65. ^ Gerhard, 1837, xix. 299. ' Haygarth, i 801, p. 62. 94 TYPHUS FEVER. Hildenbrand was of opinion that the contagious poison was chiefly developed at the time of the appearance of the eruption, and that, as the eruption became petechial, the disease almost ceased to be contagious.'^ The late Dr. Perry of Glasgow was the first to advance the opinion that the period of convalescence is the most infectious in typhus. His statements are as follows : * From numerous observations and experiments, I am satisfied that it (typhus) is not contagious before the ninth day, perhaps not till a later period of the disease. Among many circumstances which establish this opinion, I may mention one experiment which I made upon a pretty extensive scale. The fever w^ards of the Glasgow Royal Infirmary are each capable of containing twenty patients. The beds are arranged in two o]3posite rows, and are pretty near each other. While the patients are in the acute wards they are not allowed to put on their clothes, though they may be able to sit up ; they are, therefore, almost constantly confined to bed, except when rising to stool. Into the fever- house are admitted cases of measles, scarlet fever, and small- pox ; and patients are very frequently sent in labouring under bronchitis, pneumonia, erysipelas, and other local inflammatory affections. I found, by experience, that when the latter class of patients were sent to the convalescent ward, where they neces- sarily mixed with the others, almost all those who had not had a previous attack of typhus fever were either seized with it before leaving the house, or returned soon after their dismissal labouring under it ; the period intervening between the time of their being sent to the convalescent ward and the attack never being less than eight days. In consequence of these observations, I adopted the practice of not sending, as formerly, to the conva- lescent wards, those patients affected with inflammatory diseases, unless I ascertained that they were secured against typhus by having had a previous attack ; but kept them in the acute fever wards till they were so far recovered as to go to their own houses ; and the result was, after several months, that not one of those detained in the acute wards caught the disease while there, or returned with it afterwards.' ^ My observations at the London Fever Hospital confirm Dr. Perry's. I have often known typhus contracted by patients in the convalescent wards, but rarely in the acute wards. The circumstance, however, has Ijeen probably due, not to typhus being most contagious during Hildenbrand, i8ir, pp. 55 and 117. Perry, 1836, No. 2, })p. 386-7-8. ETIOLOGY — EXCITING CAUSE. 95 •convalescence, but to the patients in the convalescent wards wearing their own clothes, which, before admission, had been saturated with the typhus-poison, and to their being brought into closer contact with one another. My opinion is that the disease is really most contagious from the end of the first week up to convalescence, when the peculiar odour from the skin is strongest ; and that the body ceases to give off the poison as soon as the fever subsides and the appetite and digestion are restored. During the first week also of typhus there is little danger ; when the patient is removed within this time the dis- ease rarely spreads. *" Whether typhus can be communicated by the dead body is a question of some importance, but not very easy of solution. Morgagni believed that there was some hazard in dissecting the bodies of persons who had died from fever, and mentioned the case of a prosector who died of a petechial fever contracted by dissecting the body of a patient.^ Additional instances are recorded by Eochoux.^' But the difficulty in such cases is to exclude the chances of simultaneous infection from the living body. The following evidence from Dr. EouiDell's' work on typhus deserves to be mentioned. At St. Bartholomew's Hospital, in 1838-9, the bodies of 17 persons who had died of typhus were dissected. Eight students were engaged upon each body, and many others were lookers-on. Six of the Avhole students at the hospital took fever ; but four of them had not ■dissected at all, and the remaining two were also exposed to contagion in the wards of the hospital. I may state, however, that, at the time of my first attack in Edinburgh, I had never entered the medical wards of the infirmary, nor seen a case of typhus, but that I dissected for several hours a day in a close room, in which were many bodies of persons dead from typhus. 6. Inoculahility. The experiments of Dr. 0. Motschutkowski J would show that neither typhus nor enteric fever can be com- municated to man by inoculating the blood ; while relapsing fever can be readily communicated in this way. 7. Proportion of -persons liable to he attacked by typhus. If the poison be strong, the chances of escape are small, except in some rare cases of idiosyncrasy already alluded to (p. 69). Hay- garth found that of 168 persons exposed to contagion, only 5, or ^ Davies, 1867, p. 428. s Cook's Morgagni, ii. 592, '' EOCHOUX, 1840, p. 157. ' KOUPELL, 1S39, p. 56. ' MOTSCHUTKOWSKI, I876, g6 TYPHUS FEVEE. I in 33, remained uninfected.'^ Whole families of eight or ten, comprismg individuals of every age, are often attacked at one- time. During epidemics, it has often been noticed, that, although some may resist longer than others, all the nurses and hospital- attendants on the sick are attacked who have not had the disease- before.' Of 22 hospital-attendants in the service of M. Jacquot, every one took typhus.™ 8. Immunity from second attacks. It is generally believed, that typhus, like the exanthemata, attacks an individual only once in the course of his life. This opinion was expressed by Dr. Trotter, as the result of extensive experience of the disease amongst sailors.'' It was likewise insisted on by Hildenbrand.** In 1837, Dr. Perry stated that typhus is taken only once m Ht lifetime, that a second attack is as rare as a second attack of small-pox, and rarer than a second attack of measles or scarlet fever. This conclusion was drawn from the circumstance, that since 1831 he had never known a patient readmitted into the hospital with a second attack.^ A similar opinion was expressed in 1840 by Stewart ;i in 1843, by Henderson,'' Cormack,^ War- dell,* and others. In 1849, Sir W. Jenner stated that he had never known the same individual twice affected with typhus.'* Drs. W. T. Gairdner ^ and Lyons "^ both testify to the extreme rarity with which the same individual is attacked by typhus a. second time. The former observer informs me that he has never- met with a second attack of typhus with eruption in the same individual. Jacquot took the precaution of employing hospital- attendants in the Crimea who had already had typhus, and in no instance found any to have a second attack."" Indeed, the strongest argument in favour of acquired immunity is derived from the fact that nurses in fever-hospitals, constantly exposed for a series of years to the poison of typhus, are never known to take the disease twice. I have been unable to discover any instance of a nurse at the London Fever Hospital havino- had typhus with eruption twice, although some have been there for many years, whereas fresh nurses during an epidemic, who have not had the disease before, are almost certainly attacked. So also, out of many thousands of typhus patients, who have come k Haygarth, iSoi, p. 32. ' See page 81 ; also Tweedie, 1833, P- 400. ^ Jacquot, 1858, p. 104. ° Trotter, 1803, p. 213. " HiLDEXBEAND, 181I, p. I45. I' PeKRY, 1836, No. 2, p. 386. 1 Stewart, 1840, p. 300. ■■ Henderson, 1843. • CORMACK, 1843. ' WaRDELL, 1S46, XXxix. 273. " Jenner, 1849, No. i, p. 38. "' G.virdner, 1862, No. 2, p. 121. " Lyons, 1861, p. 213. ^ Jacquot, 1858, p. 225. JiTIOLOGY — EXCITING CAUSE. 97 under my observation at the London Fever Hospital, although "the same patient may have been repeatedly admitted for different diseases, I have never met with an unequivocal second attack of ■the disease, which, in my experience, is a much rarer occurrence than a second attack of Scarlatina or Variola. It is true that many writers have mentioned instances of persons having two attacks of fever,^ and cases are quoted — those of two distingTiished physicians in particular — where five or six attacks have occurred in the same individual. But after careful inquiry into the circumstances of many such cases, including the two specially referred to (Sir E. Christison and Dr. Tweedie), I have obtained no evidence that more than one attack was true typhus. Even Irish physicians, who particularly refer to repeated attacks of fever in the same person, but who, for the most part, deny the plurality of continued fevers, admit that fever with a petechial eruption rarely, if ever, attacks an individual twice.'' There are, however, rare examples of persons having more than one attack of undoubted typhus. In my own case (see p. 84), the characteristic eruption was well-marked, and the symptoms severe, on both occasions. Two instances are known to me of physicians who contracted a second attack of typhus after an interval of many years, which in one case was fatal. The case of an Irish physician is also recorded, who had typhus twice, with the characteristic eruption in both attacks. '•^ Jacquot admits that second attacks occurred in rare cases among the French soldiers in the Crimea, although he never met with an instance himself.^ Lastly, M. Barrallier tells us, that of 698 prisoners who had typhus in the hulks at Toulon in 1855, nine took the disease a second time during the epidemic of the follow- ing year. It is not stated that the eruption was present in both attacks ; but in seven, the first attack was slight, the second severe ; and in one both attacks were severe.^ In reference to Barrallier's results, I may state that I have observed at least six instances of persons, who, during an epidemic of typhus, and when exposed to the poison, have had what appeared to be abortive attacks — fever, malaise, dry tongue, and even slight delirium — lasting in three instances for exactly fourteen days, l)ut without any distinct eruption, and followed within a few ' See particularly Stokes and Cusack, 1848, iv. 138, v. 127; Douglas, 1845, 10; Steatton, 1847, p. 99 ; and Baetlett, 1856, p. 240. ' Baeker and Chbynb, 1821, i. 241 ; and Baetlett, 1856, p. 240. ' Irish Report, Bib., 1848, vii. 399. ^ Jacquot, 1858, p. 224. • Baeealliee, 1 861, p. 370. 98 TYPHUS FEVEE. weeks by an unequivocal attack of tj^Dlius with eruption. An abortive attack of typhus {'typhisation a petite dose,' Jacquot) j)robably protects the system no more than an abortive attack of Scarlatina. 9. Specific Gravity of the Typhus-Poison. According to Haller of Vienna, the contagious principle of typhus is lighter than atmospheric air. Ozone, when admitted into a fever ward, was ascertained to become first lost m the upper regions of the atmo- sphere. Moreover, when the under stories of a hospital were filled with typhus patients, those in the upper stories were always observed to become infected, when there was a communication between the ah' of the two stories. On the contrary, when only the upper stories contained cases of typhus, the patients in the under part of the house enjoyed perfect immunity.*^ In our own epi- demics it has been found much easier to isolate the disease on the upper story than on the ground floor of a crowded house.^ 10. Effect of heat on the Typhus-Poisoti. Henry proved by experiment the destructive influence of heat over the specific poisons of several of the exanthemata. The vaccine mus failed to take effect after exposure for some hours to a dry heat of 130° Fahr. In four different instances, flannel waistcoats taken from patients labouring under scarlet fever were exposed for some hours to a dry heat of 204° Fahr., and were then worn with impunity by children who never had the disease. Three flannel jackets were taken from a typhus patient and exposed for some hours to a temperature of 204° Fahr. One was kept under the nostrils of a person in health for an hour and three quarters ; a second was worn next the body of the same individual for two hours ; while the third was shut up in an air-tight canister for some days, and then kept for some hours within twelve inches of the face of the same person, a current of air being directed across the flannel to the face. No result followed, although the person had been fasting for eight hours and was much exhausted by disease, so as to predispose him to typhus.^ These observations, although per- haps insufficient for the purpose of scientific demonstration, afford strong presumptive evidence that dry heat is a powerful disinfectant agent in typhus. Owing, no doubt, to their doubtful propriety. Dr. Henry's experunents have not been repeated ; but where the principle advocated by him has been acted on, the results have been satisfactory.^ ^ Haller, 1853, p. 262. « Davies, 1867. ' Henry, 1S31. B See Report of a Committee of York Med. Sac. to investigate the disinfectant power of heat. Brit. Med. Joiirn. April 7, 1S60, p. 272. ETIOLOGY — -EXCITING CAUSE. 99 II. Typhus in lower animals. Many writers have described •contagious fevers among the lower animals prevailing under circumstances similar to those of human typhus. Cattle plague has been often designated the ' contagious typhus of horned beasts.' There is as yet, however, no evidence that a disease identical with human typhus occurs among beasts, or that human typhus is communicable to them. Hosier failed to com- municate it to dogs by injecting fresh typhus-blood into their veins, or by feeding them on fresh typhus-stools, although death with typhoid symptoms followed when the blood and stools had first been allowed to decompose.^ * 2. Independent Origin. Although in a large proportion of cases of typhus, especially during epidemics, the specific poison is derived from persons pre- viously infected (contagion), it is, I believe, equally true, that it may be generated independently. The conditions under which the poison is developed de novo are overcrowding of squalid human beings and deficient ventilation : in other words, the poison is generated by the concentration of the exhalations from living beings, whose bodies and clothing are in a state of great filth. The intimate connection between the prevalence of typhus and overcrowding has been already demonstrated, and is gene- Tally admitted. But the fact of typhus being confined during ■epidemics to overcrowded localities might be explained on the supposition that it always originates by contagion. It is obvious that during an epidemic all possible sources of contagion can rarely be excluded from houses situated in the centre of a large town. Still, it is worth observing, that typhus patients have often been admitted into the London Fever Hospital, who stated that there had been no previous cases of illness at their homes, who denied having been exposed to any contagion,^ and who could attribute their disease to no other cause than to having been one of eight, ten, or even twenty adults, who had slept for many weeks in one small room of a house situated in a narrow court. But more conclusive proofs of typhus being generated de novo are derived from a study of the mode of origin of sporadic cases Prag. Vierterljahrs., 1869. See also Irish Report, Bib., 1848, viii. 305. H 2 TOO TYPHUS FEVER. in the absence of any great epidemic and of outbreaks in public- institutions and in isolated bodies of men. a. Mode of origin of sporadic cases and of limited outbreahs of Tyijlms, Li 1 87 1 Dr. J. Heysham traced the origin of an outbreak of typhus at Carlisle to a house inhabited by half a dozen poor families. In order to reduce the window-tax, every mndow that even poverty could dispense with was built up ; and all sources of ventilation were thus removed. The smell in this house was overpowermg and offen- sive to an unbearable extent. There was no e^ddence that the fever was imported into this house ; but thence it Avas propagated to other parts of the town (see page 84), and fifty-two of the inhabitants died of it.J About the same time, Dr. John Hunter, physician to the army, recorded an mstance of typhus in a family in London. The family consisted of father, mother, and several children ; they were very destitute, and were lodged in a room not exceeding twelve by fourteen feet square. Typhus was not prevalent at the time, and m this instance it could not, after most careful inquiry, be traced to con- tagion.^ In 1836, an epidemic of typhus appeared at Philadelphia, where it had been unknown for years. The disease originated in a very crowded part of the town. ' Amongst the very first cases were seven negroes,, the entire population of a cellar.' 1 In 1843, an epidemic of typhus occurred at Broulhac, an elevated spot in the Canton de Puy in France. It differed from the ordhiary fever of the comitry in being very contagious. The sjonptoms were those of typhus, viz.: — Dull, heavy expression, constipation, dry bro^ni tongue, subsultus and delirium ; petechise and occasionally parotid buboes ; after death the intestines were found to be somid. Of the 118 inhabitants, 45 were attacked and 9 died. Starvation and over- crowding were the alleged causes. The first cases were traced to a house where there was overcrowding with no ventilation. One part of the village where the houses were of a better sort remained exempt.. There appeared to be no possibility of imported contagion, for the- report of the epidemics of France, from which this account is extracted, made no mention of the prevalence of typhus elsewhere, and the disease is at all times so rare throughout France that few French physicians have ever seen it.™ In 1859, typhus, after having disappeared from Edinburgh for some months (see page 53), again became prevalent, 30 cases being admitted into the Eoyal Infirmary from May to August. The localities whence they were derived were investigated by Dr. W. T. Gairdner ; tliey were in the worst and poorest parts of the town, and in regard to several it is stated that the disease appeared under circumstances of i Heysham, 1782. '' Huntee, 1785. • Gekhard, 1837, xix. pp. 294-7. '" Mhn. de VAcad. de Med. torn. xiv. p. 47. ETIOLOGY EXCITING CAUSE. lor extreme overcrowding and deficient ventilation," There was no evi- dence that the disease was imported into Edinbm'gh at this time. In 1862, typhus fever appeared at Preston in Lancashire. All the medical men who best knew typhus, through their experience of the epidemic of 1847, were certain that this disease had been absent for many years. For months the ' cotton-famine ' consequent on the American war had caused great distress among the poor. From in- ability to pay their rents, several families resided in houses which had previously been only occupied by one. It was impossible to trace any importation of the poison ; but the first cases occurred in a cottage where ' eight persons had crowded by night into a room, the utmost capacity of which was 800 cubic feet. They were dirty and underfed, and the boy who first fell ill had also been much exposed to the weather.' Almost at the same time other cases occurred under similar circumstances in a distant part of the town, having no communication with the first." (See page 54.) The following cases were carefully investigated by myself.? From April 20, 1858, to March 12, 1859, inclusive, only two cases of typhus with the characteristic eruption were admitted into the London Fever Hospital, although in 1856 the number had amounted to 1,062, In March 1859 seven well-marked cases were admitted from one house, 10 Meridian Place, Bermondsey. It appeared important to investigate the precise conditions under which this fever occurred, and the following account is drawn up, partly from inquiries made by myself on the spot, and partly from a communication for which I was -indebted to Dr. Challice, the Medical Officer of Health for the district. 1. The court in which the house was situated was paved and open at both ends, and was about eleven feet wide. The drainage in the court was satisfactory. In fact only a year before great improvements had been carried out. All the cesspools had been emptied and filled tip, the drains trapped and the water let on. The privy in No. 10 was furnished with a soil-pan and trapped, as was also the sink. These facts are important, inasmuch as the fever was not that which results from defective drainage, 2, The house. No, 10, consisted of two floors, connected by a very narrow staircase. There were two rooms on each floor ; and in each room a door, one window, and a fire-place. All the rooms were little better than closets, their dimensions being as follows : — 1 . Ground Floor — Front Koom . Back ,, 2. Upper Floor — Front Eoom . Back Length Width Height Ft. In. Ft. In. Ft. In. 8 9 8 6 8 ' 8 6 8 8 n 2 8 6 7 2 j 8 6 8 2 7 2 No. of Cubic Feet 595 544 680 497 The doors of the rooms on the ground floor opened into a passage not more than two feet wide. The windows in all the rooms could be " W. T. GaIRDNER, 1859, p. 243. BuCHiNAN, 1863. P MURCHISON, 1859 (2) 102 TYPHUS FEVER. opened ; but throughout the winter, and up to the outbreak of feveiv they had been always shut. 3. A mother with her six children occupied the two rooms on the ground floor. The mother was aged 34 ; and the respective ages of the children were 18, 17, 15, 10, 7, and 3. Three slept in one bed, in the front room, and four in the back room. After the fever broke out, the grandmother of the children came from Dover to nurse them, and she also slept in one of the rooms. The rooms upstairs were occupied by a man and his wife. 4. It will thus be seen that before the arrival of the grandmother seven human beings occupied 1,139 cubic feet of space, or each indi- vidual had only 163 cubic feet. After the arrival of the grandmother there were only 142 cubic feet to each.i 5. There were no means of ventilation. Dr. Challice described the- rooms as having the ' peculiar animal odour always noticed in cases. of overcrowding.' The habits of the family were filthy in the extreme. The parish-inspector found the rooms ' alive with vermin ; ' and the nurses in the Fever Hospital declared that they had scarcely ever known patients admitted in such a filthy condition. 6. The father of the family was a sailor, and had been at sea for- many months ; and although the family were not absolutely penniless,, the mother spent most of their little earnings in gin. 7. There were no other cases of fever in the court, nor in the- immediate neighbourhood. Indeed, true typhus was at the time ex- tremely rare throughout the metropolis. (Vide antea, p. 52.) None of" the members of either family, as far as could be ascertained, had been exposed to any contagious disease. Shortly afterwards, however,, several cases of typhus occurred in the next house, and two were admitted from it into the London Fever Hospital. 8. The mother and eldest child were first attacked about the end of February. Three of the other children were seized during the first week of March, and a fifth in the second week. The sixth child, the- youngest, escaped. The mother and five children were admitted into- the Fever Hospital on the 12th and 15th of March. All recovered.. The grandmother, who came from Dover early in March, took the fever, and died on the 15th, at 10 Meridian Place. The man who- resided upstairs was taken ill (contagion?) about the 9th of March,, was admitted on the 15th, and died on the 22nd ; his wife did not take- the fever. The next cases of typhus admitted into the London Fever Hospital came from No. 5 Henry Passage, St. Pancras. The circumstances were as follows : — 1. The fever first appeared in a family residing on the ground floor,. and consisting of a father aged 54, a mother aged 40, and six children of the respective ages of 16, 14, 12, 10, 8, and 5. 2. These eight persons resided and slept in two rooms, which "» In this and the following instances no allowance is made for the si)ace= occupied by the furniture. ETIOLOGY EXCITING CAUSE. IO3 together contained only 1,378 cubic feet of space, making an allowance of only i72"5 cubic feet to each individual. This I ascertained from personal examination. Each of the two rooms was furnished with a door, one window, and a fire-place. The mother informed me that during the winter, and previous to the outbreak of fever, the windows had seldom been opened. 3. The whole family had long been very destitute, the father having for many months been out of employment. 4. No source of contagion could be traced. These were the first cases of typhus in the court and in the neighbourhood. But, on the other hand, they formed a focus of contagion, whence other cases originated. Shortly after, cases appeared in the next house, one of which was admitted into the Fever Hospital. One of the mother's sisters came from an adjoining street to attend upon her. She caught the fever, as did also her husband and child, and all three died. A. third sister came to nurse this last one from another street in the neighbourhood. She was taken ill shortly after with fever, as were also her husband and child. The husband died. Here, indeed, was a melancholy instance of the results of neglect of sanitary precautions in. a single family. Again, after a complete absence of typhus for six months, several cases occurred m the spring and summer of 1860."^ I visited the localities whence all the first cases came. Several came from a court in Limehouse where the fever originated in an underground cellar, containing 912 cubic feet of space, with one window which was never opened. This cellar was inhabited by eight persons (114 cubic feet to each), who were in a state of great destitu- tion. There had been no fever before in the court or neighboiu-hood ; but from this cellar it spread by contagion to several other houses in the same court. Another group of cases came from Pump Court, White Horse Alley, Holborn. A family, consisting of father, mother, and four children of the respective ages of 18, 15, 11, and 9, inhabited a room on the ground floor, whose dimensions were 10 feet 5 inches broad, 12 feet 3 inches long and 8 feet 3 inches high, making 1,072 cubic feet. All six slept in this room, so that each person had only 178 cubic feet of space, which was still further diminished by a great accumulation of furniture, consisting of two large beds raised two and a half feet from the floor, a chest of drawers, several tables and chairs, and a number of boxes. In the night, when the beds were let down, the floor was literally covered with furniture. There was one door and one window ; the door was always shut at night and the window- shutters closed. The window looked into a court, a yard and a quarter wide, on the other ' It has already been stated that sporadic cases of typhus often become more common at the end of spring, or at that period of the year in which the dwelUngs of the poor have been longest subjected to overcrowding and deficient ventilation. When the poison is once generated, it may continue to spread through the summer by contagion, but, by the end of summer, the effects of ventilation have had time to come into play, so that in autumn the disease may entirely disappear. 104 TYPHUS FEVER. side of wliicli was a liigli wall, and beyond this a range of liigh liotises. The family had resided in this house for many months, and had latterly been in very reduced circumstances, OTiong to the father being out of work. Four of the six took typhus, which at the time was unkn own in the neighbourhood, and indeed was only known to exist in one or two distant localities throughout the metropolis. In a third case mvestigated the circumstances were very similar. Now, m the above cases it may be argued that we cannot be certain that the disease was not primarily introduced by contagion. But to this objection it may be rephed that at the periods in question there were no cases of t}^hus in the immediate neighbourhood ; that no member of the families first affected had been exposed to contagion ; and that typhus was scarcely to be met with, either in the metropolis or in any part of England. If the independent origin of typhus in these cases be objected to, it must be admitted that the specific poison is always and everywhere present, ready to take effect, whenever (and only when) the causes supposed to generate it are present. h. Jail-Fever. fSee Synonyms, page 25.) The disease, which was formerly so prevalent m our prisons and which was described as the ' Gaol-Fever ' and the ' Jayl-Distemper,' was Typhus. Many observations show that it originated in the prisons ; and it was the general behef that the cause was over- crowding, v,ith deficient ventilation. The prisons, indeed, constituted the prmcipal foci, whence the disease spread -^dth dire results among the population. Such was the story of the various ' black assizes,' of which history fm-nishes us with an accomit of six. A brief notice of these assizes may be of interest, although om- knowledge of some of them is too meagre to permit of their acceptance as positive proofs of the urdependent origm of typhus. The first occurred at Cambridge durmg the Lent Quarter Sessions in 1522, the thirteenth year of the reign of Hem-y YIII. The justices, gentlemen, bailiffs, and most of the persons present in comi; 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 smiilar to those of subsequent black assizes, in which the disease was undoubtedly t}^hus.® 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 Piowland Jencks, a bookbinder and a Eoman Catholic, for treason and profanity of the Protestant religion. Jencks was not the only prisoner brought before the court ; but the accomits state that, after judgment was pronomiced against him, ' an infectious damp or breath ' arose among those present. Many seem to have been taken ill on the • Waed, 1758, p. 703. ETIOLOGY — EXCITING CAUSE. 10$ spot, including Sir Kobert Bell, Chief Baron of the Exchequer, Sir JSIicholas Barham, Serjeant-at-Law, two sheriffs, one knight, five justices of the peace, and most of the jury, of whom several died within a few days. ' Above 600 sickened in one night ; and the day after, the infectious air being carried into the next village, sickened there an hundred more.' On the 15th, i6th, and 17th of July, 300 more fell sick; and between the 6th of July and the 12th of August, 510 persons perished. The following are mentioned as the symptoms: loss of appetite, 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 explanations offered being, that it resulted from the ' diabolical machinations of the papists,' or, accord- ing 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. Sometime before, 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 be- came 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 commmiicated by the prisoners, who had been removed from II Chester jail, to the judges and many others present in court. The Lord Chief Baron, the Serjeant-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 generated in * See Ward, 1758, p. 699 ; Bancroft, 181 i, p. 653 ; also Wood, Hist, atul Antiq. of the University of Oxford, 1796, ii. 188 ; Sir E. Baker's Chronicles of the Kings of England, Lond. 1665, fol. p. 353 ; and Stow's Chronicles, Lond. 1592, p. 6S1. Bancroft maintained that the disease in this instance was not typhus, and laid much stress on the statements in some of the accounts, that it was not con- tagious, and that none but those present in the court were attacked. But these statements, if true, would not be opposed to what is known of the effects of dilution upon the typhus-poison. (See page 88.) Bancroft also argued that the typhus-poison could not take effect so rapidly as in this instance, an argument which is now known to be without foundation. (See page 93.) " Bancroft, 181 i, p. 661. ■^ Gentleman'' s Magazine, May i7S0' I06 TYPHUS FEVER. the prisons,' was widely disseminated by means of the comity assize,. and occasioned great mortality. Among the symptoms were — great prostration and oppression, a florid rash with petechia, watchfulness, delirimn, tremors, subsiiltus, black dry tongue, and fetid breath. The pulse was weak from the commencement, even m the robust, and ' bleedhig killed the patient, and not the disease.' ^ The sixth and last ' black assize ' was that of the Old Bailey, in April 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 aflectedmth a very noisome smell.' Withm a week or ten days, many of those present were seized with a ' malignant fever,' among the symptoms of which were a weak pulse, dehrium and petechiee. Its duration was a fortnight. That this was the jail- distemper or typhus appears from a pamphlet pub- lished at the time by Sir Jolm Pringle. More than forty persons died of it, including the Lord Mayor, two of the judges, an alderman, an under-sherift', and several of the jm-y. In less than six weeks the disease disappeared. It is uncertam whether it was communicated by the sick to any who had not been present in the court. A remarkable circumstance is, that those who were situated highest m the court, as the Lord Mayor, Judges and Middlesex Jury, and those in the gallery on the left hand of the court, were chiefly infected -nith the fatal poison. This was attributed by Dr. Stephen Hales, F.E.S., to a wide sash-window on the left-hand side facing the judges being left open, through wliich an easterly wind entered, ' blowing down the most venomous vapour which was near the ceilmg,' agamst the persons chiefly attacked. It is also to be noted, that neither the prisoners under trial, nor any in the jail, were sufl'ermg at the time from typhus.* A plan of the Old Bailey, copied from Bancroft's work, is here annexed. Such events are not surprismg, when one studies the frightful pictures drawn by John Howard of the state of our prisons m former days.?' ' My reader,' said Howard, ' will judge of the maUgnity of the air of gaols, when I assure him that my clothes were, m my first journeys, so ofl'ensive, that in a post-chaise I could not bear the T^indows drawn up, and was therefore often obliged to travel on horseback. The leaves of my memorandum book were often so tamted, that I could not use it until after spreading it an hour or two before the fire.' Howard likewise recorded many mstances, where the fever appeared to be generated by overcrowding and a want of fresh air and cleanli- ness. For example, he related how seventeen women, bemg confined in a room in the Cambridge Bridewell, without any fire-place, the air soon became ' extremely offensive and occasioned a fever among them,' '' HuxHAM, 1752, vol. ii. p. 82. ^ See Foster, 1762, p. 74; Pp.ixole, 1750, 1752; HEYSHAii, 17S2; B.^-ceoft^ 181 1, pp. 140, 664. ' HowAED, 1784 and 1789. ETIOLOGY EXCITING CAUSE. 107 ■which proved fatal to three or four. The opponents ^ of the mdependent origm of typhus put much stress on the following statement of Howard : ' If it were asked what is the cause of the gaol fever, it would in general be said, the want of fresh air and cleanliness. But as I have seen, in some prisons abroad, cells and dungeons as offensive and dirty as any I have observed in this country, where, however, the distemper was imknown, I am obliged to look out for some additional cause for its production.' But Howard did not seem to doubt that the fever origi- Fig. 4- a. Passage from prison to conrt. 6. Bail-dock for prisoners before trial, c. Door under %vindow into court, d and e. Prisoners' Box, (Sic. /". Eencli for Lord Mayor, Judges and Aldermen. g. Table for counsel, h. Boxes for Sheriffs, j. Bencli for Counsel, k. Middlesex Jury. I. London Jury. m. Passages outside court, over which were galleries in court for strangers. n. Windows. The one facing the judges, on the right hand of the page, was open during the trial, o. Doors. nated hi the prisons, nor did he hint that the poison was imported. All that he said respecting the additional cause is expressed as follows : * I am of opinion that the sudden change of diet and lodging so affects the spirits of new convicts, that the general causes of putrid fevers exert an immediate effect upon them' (p. 231). Moreover, Howard did not say that the prisons, visited by him on the continent, toere at that time overcrowded, but merely ' offensive and dirty,' conditions which are not believed to generate typhus ; while so far from jail-fever bemg peculiar to Britain, the only mstances of its occurrence of late years, have been in continental prisons mider circumstances of unusual over- crowding. The public opinion resulting from Howard's investigations ■ Banceoft, 1811, p. 149 ; Watson, Lect. Pract. Physic, 5th ed. 1871, ii. I08 TYPHUS fe'\t:r. was tlius expressed in the x^reamble to an Act of Parliament, passed soon afterwards : ' Whereas tlie malignant, commonly called tlie Jail- Fever, is owing to a want of cleanliness and fresh air, be it enacted, &c.' ^ Thanks to the philanthropic labom's of Howard, the sanitary- condition of English prisons is now so perfect, that tj'phus can never be said to be generated m them. But so late as 1815, Harty showed that tj^phus was constantly generated in the prisons of Dublin. It always appeared after over- crowduig. The comdcts in the Dublin Newgate were allowed to accumulate for twelve or twenty months, and were then transported. Typhus always broke out among them shortly before each embarkation, and only then. It was not due to importation, for the convicts had little or no communication with the pubhc, and the disease did not appear at the periods in question in another class of prisoners in the same building, who had free commmiication mth the public, but who were not overcrowded.^ Again, during the present century, many epidemics of t}^hus have occurred in jails on the contment of Europe, under ch-cumstances the same as those in which the disease appeared in our own prisons, before the time of Howard. In the early part of the century, these outbreaks were very common. The epidemics m the prisons of Nantes and Auxerre were attributed to overcrowduig and deficient food, while that at Posen commenced m the prison and spread over the town.'^ The modern epidemics of typhus in the prisons of France have a special importance in reference to the question under discussion, masmuch as the circumstances mider which they have arisen have always been identical, and it is impossible to explam how the poison could have been imported from \\dthout, as, except in these isolated and overcrowded prisons, the disease has been almost unkno^Ti tln'oughout France. In 1839-40 an outbreak of fever occurred in the jail at Fiheims, which resembled typhus m most of the symptoms, and which differed from the orduiary fever of France m beuig eminently contagious. Of the attendants on the sick thirty-five were attacked. All the Sisters of Mercy who had typhus in 18 14 escaped, but several who had passed through enteric fever had now most severe attacks. There was no fever of a similar kmd at Eheims, nor probably indeed in France. According to Landouzy ; ' L'encombrement des prisons doit done etre regarde comme la cause determmante de I'epidemie de Eeims.' The number which one part of the jail was calculated to hold was eighty, or at most a hundred, and, although it had been the custom to admit as many as 120 or 140 prisoners, the number had been raised to 190 a month or two prcA-ious to the outbreak of the fever. The cells in which the prisoners were confined during ten out of the twenty-four hours were only large enough for three persons, but were made to contain sixteen. Moreover, the fever commenced in, and was confined Aldeeson, 1788, p. 7. '■ H.\RTY, 1820, pp. 161 and 282. Gaultiek de CLArBEY, 1838, ed. 1844, -p-p. 48, 61, and 81. ETIOLOGY EXCITING CAUSE. lOQ to, the overcrowded cells : only two cases occurred in the bnildrng- allotted to condemned prisoners, who were not overcrowded ; while the female department escaped entirely.*^ Lastly, in 1854 an outbreak of typhus occurred in the jail at Stras- bourg. From 1 8 14 to 1840, the prison had been remarkably healthy ; but from that date, owing to a change in the diet, scurvy began to prevail, but still there was no typhus. ' La maladie,' says Forget, ' s'est developpee sous I'influence de I'encombrement, le chiffre des detenus- ayant ete porte de 340 a 360 en moyenne a 780.' That the disease was true typhus was proved by the entire clinical history, and by the absence of any intestinal lesion after death. Before this, typhus may be said to have been unknown at Strasbourg since the wars of the first Napoleon. In 1841, when Forget ^YYote his work on the ordinary fever of France, he does not appear to have seen a case of typhus ; but in 1854 he at once recognised it as a new disease, and hastened to communicate to the French Academy proofs of the non-identity of typhus and typhoid fever.® From these and many other instances it follows that, whether in England or on the Contment, the circumstances under which the jail- fever appears are always the same, while every conceivable source of importation is often excluded. c. Shii^-Fever. (See Synonyms, page 25.) During last century typhus was a very common disease on board' ship, and was known as the ' Ship-Fever ' or the ' Lifectious Ship- Fever.' Dr. James Lind, Physician to the Fleet, although he believed that the disease was often traceable to contagion, added that it was for the most part confined to the small vessels of the fleet, and men- tioned several instances wherem he considered it to have origi- nated de novo from overcrowding on board ship. One was that of the ' Diana ' frigate, in which typhus appeared at sea, several weeks after leaving the coast of America. ' Thus,' he said, ' a seasoned crew became infected, as it would appear, from the closeness or damp below, occasioned by the hatchways bemg kept shut in consequence of a storm.' ^ Many shnilar observations were made by Dr Thomas Trotter,^ and by Sir Gilbert Blane, who served in the British Navy rmder Admiral Eodney, and who thus summed up the results of his experience : ' The infection of fever is not always imported from without, but may be originally and spontaneously generated on board. The causes of this are want of personal cleanliness, and also confine- ment and crowding in close apartments.' ^ Nor were these observations confined to British vessels. M. Fonssagrives, in his account of the * Landouzy, 1842. The symptoms and. post-mortem appearances of the fever at Eheims will be referred to subsequently. See Iiulex. " Forget, 1854. ' Lind, 1763, p. 25. « Trotter, 1803, i. 181 ; and iii. pp. 151, 153, &c. ^ Blane, 1789, 3rd ed. 1803, p. 228. no TYPHUS FEVEE. importation of typhus into the town of Brest in 1758, observes: ' Rien n'6tait d'ailleurs plus habituel, dans ces temps calamiteux, que de voir I'encombrement, la misere, les privations, le sacrifice de tous les interets de I'hygiene aux exigences irresistibles de la guerre, engendrer le typhus au sein des equipages. La plupart des epidemies de fievre grave, dont les annales de la na^dgation aient conserve le sinistre souvenir, n'ont ete autre chose que des irruptions du typhus, a bord des navires mal tenus, humides et encombres.'^ The following are a few more modern examples of the appearance of typhus on board ship, inde- pendently of any traceable importation. In the sprmg of 1810, typhus broke out among the French prisoners confined in the prison-ships m Plymouth harbour. Typhus was not prevalent in Plymouth ; and, even if it had been, the seclusion of the prisoners could not have been more complete. But on board, in addition to a spare diet and the mental depression consequent on their situation, the prisoners were packed together in a most shameful maimer. For thirteen hours out of the twenty-four, upwards of 400 of them were crowded into a space measuring 60 feet by 42 feet, and only 4^ feet high. The only ventilation was through the port-holes, which were almost closed by thick iron-gratings ; and the air was so dense, that a lighted candle appeared in it as through a thick mist. Such was the condition of the prisoners for some time before the com- mencement of the epidemic. Of 4,000 persons, 1,050 took typhus, and 150 died of it.J In the winter of 1829-30, an epidemic of typhus broke out on board the French convict-hulks at Toulon. The disease was unloiown in Toulon, there not being a single case, even among the workmen in the harbour. That it was really typhus, and not the ordinary Fievre typho'ide of France, was proved by the symptoms and post-rnortem appearances. ' Jamais on n'a rencontre I'exantheme intestinal qui appartient a la dothinenterie.' The origin of the epidemic was attri- buted to overcrowding and deficient food (I'encombrement d'hommes mal nourris').^ Five other epidemics of true typhus have been observed in these same hulks at Toulon — in 1820, 1833, 1845, ^^SS^ ^^^^ 1856. The disease has quite disappeared in the intervals, has never prevailed in the town of Toulon, and for the last forty years has been scarcely known throughout France. M. Barrallier, professor of Pathology in the Naval School of Toulon, thus writes respecting them : ' L'encom- brement a toujours ete considere comme la cause principale et deter- minante de la maladie.' Among the accessory causes were deficient food, over-fatigue, and want of personal cleanliness.^ Several instances are mentioned by Jacquot, where typhus seemed to originate from overcrowding on board the French ships employed in ' FONSSAGKIVES, 1 859, p. 243. ■i De Claubhy, 1838, eel. 1844, p. 37. i' Fleuky, 1833 ; Kekaudren, 1S33. ' BARKALLiEn, 1861, p. 1 89 ; Anoii. 1S33, p. 480. ETIOLOGY — EXCITING CAUSE. I 1 1 iransportiiig troops from the Crimea. With regard to some, the intro- duction of the poison by fomites is barely possible ; but, concerning one, M. Godelier averred to the French Academy : ' Ce typhus est ne 'Sur le " Monarque," et du " Monarque" meme.' ^ During the late war in Italy, typhus made its appearance in a French vessel, ' L'Entreprenante,' carrying troops from Algeria to the Adriatic. The men were all in perfect health on leaving Algeria, where typhus is probably unknown. ' Tous ont rapporte a I'encom- brement seul la cause de la maladie.' ^ Lastly, there is the remarkable case of the Egyptian frigate, the * Scheali Gehaad,' the crew of which imported typhus into Liverpool in 1 86 1. Three persons took typhus who went on board the vessel in the docks. The crew likewise communicated typhus to three of the attendants at the public baths, and to twenty-five persons in the Southern Hospital. This crew consisted of 476 persons, mostly Arabs. They came from Alexandria, where maculated typhus is not known to prevail." During the lengthened voyage of tliirty-two days from Malta, the weather was cold and stormy; and the men, unaccustomed to the rigour of a northern winter, and not provided with suitable ■' Maclagan (No. i), 1867. I 1 8 TYPHUS FEVER. 4. A cojisiderahle time is necessary for the production of the jjoison. There are many examples of a number of men being crowded in such a confined space that some have died within a few hours, and yet no contagious fever has appeared among the survivors. That most commonly referred to is the tragedy of the ' Black Hole of Calcutta,' which occurred in the night of June 20, 1736. ' Figure to yourself,' said Governor Holwell, the historian, and one of the survivors of the event, ' if possible, the situation of 146 wretches, exhausted by continual fatigue and action, thus crammed together in a cube of eighteen feet, in a close sultry night in Bengal, shut up to the eastward and southward (the only quarters from whence air could reach us) by dead walls, and by a wall and door to the north, open only to the westward by two windows, strongly barred with iron, from which we' could receive scarce any the least circulation of fresh air.' Of the 146 persons shut up by the orders of Surajut Dowla at eight in the evening, 123 were corpses at six next morning : 2^ only came out alive. The symptoms from which they all suffered were excessive perspiration, followed by violent thirst (which Holwell relieved by sucking the perspiration from his own shirt-sleeves), great dyspnoea, palpitations, delirium, and insensibility. All who survived were seized with a ' putrid fever,' which was characterized by an eruption of boils, but which was in no case fatal, and was not apparently typhus." In this, and in all like cases," death has resulted from asphyxia, and the non-production of the typhus-poison cannot justly be adduced as an argument against the possibility of its independent origin. There was not sufficient time for its de- velopment. 5. A certain temjjerature may he necessary to the development of the typhus-23oison. Below a certain temperature the contagium of Yellow Fever ceases to exist, and it is quite possible that the alleged exemption of the Laplanders and Esquimaux from typhus (if true), notwithstanding the bad ventilation of their dwellings, may be due to the extreme cold of the climate. On the other hand, when a tropical heat is conjoined with overcrowding, &c., other diseases than typhus may result {ride antea, p. 61). Although the nature of the poison of typhus has not yet " Holwell, 1758. ° For similar occurrences to that of the Black Hole of Calcutta see account of the Irish steamer ' Londonderry ' (Carpenter's Princip. of Hum. Plujs. 5th ed. \). 300); the tragedy of Ujnala [The Crisis in the Punjab, by F. Cooper, C. S. Lond. 1858, p. 162) ; Wells, On the Health of Seamen, 2nd ed. p. 17 ; and Baeealliek, 1861, p. 31. SYMPTOMS. 119 been demonstrated, it can hardly be doubted but that it consists of minute particles of living matter. This view, however, is not incompatible with its having an independent origin in over- crowding. The first effect of overcrowding with no ventilation is to cause the respiration of an atmosphere charged with car- bonic acid ; but it has been shown that even a small percentage of carbonic acid in the respired air is sufficient to cause a serious diminution in the amount of carbonic acid thrown off, and of oxygen absorbed, and thus seriously interfere with defsecation of the blood and tissues. ' It follows,' says Dr. Carpenter, ' that those oxidating processes which minister to the elimination of effete matter from the system must be imperfectly performed, and that an accumulation of substances tending to putrescence must take place in the blood. Hence there will probably be a considerable increase in the amount of such matters in the pul- monary and cutaneous exhalations ; ' p and the unrenewed air will become charged, not only with carbonic acid, but also with particles of degraded animal matter capable, like pus-corpuscles, of multiplying in a suitable soil. [Judging, however, from analogy with relapsing fever and other contagious diseases, it seems probable that typhus is due to a specific microbe which requires conditions of overcrowding and imperfect ven- tilation to develop its virulent and contagious properties.] Although the actual nature of the typhus-contagium can at present only be a subject of conjecture, the known facts respect- ing the etiology of the disease may be summed up thus : — 1. Typhus is due to a specific poison. 2. This poison is communicated from the sick to the healthy, through the atmosphere, or by fomites, but is rendered inert by free ventilation. 3. The poison is also generated de novo, in the exhalations of living human beings, by overcrowding and bad ventilation. 4. The great predisposing cause of typhus is defective nutri- tion. Section VI. — Symptoms of Typhus. It will be advantageous to give in the first place a connected clinical history of the disease with reports of a few cases in illus- tration, and then to proceed to a more detailed analysis of the individual symptoms. p Princ. of Hum. Phys. Sth ed. p. 301. 120 TYPHUS FEVEE. A. Clinical Description. The advent of typhus is, in most cases, somewhat sudden. Occasionally it is preceded by one or more days of slight indis- position, characterized by lassitude, vertigo, slight headache and loss of appetite, but not such as to incapacitate the patient from following his ordinary employment. With, or oftener without, these premonitory symptoms, the patient is seized with slight rigors or chilliness, followed by lassitude and disinclination for exertion, frontal headache, pain in the back, pains like those from bruises in the limbs, especially in the thighs, loss of appe- tite, and often, for a day or two, irregular chills and slight per- spirations. For two or three days, although the temperature may be five degrees or more above the normal standard, the patient complains of chilliness, and sits close to the fire. The tongue is large, pale, and coated, first with a white, and after- wards with a yellowish-brown fur ; the appetite is gone ; the taste is perverted, and there is more or less thirst ; the patient fancies different drinks, but he soon loathes all except cold water. Occasionally there is nausea, but rarely vomiting ; the abdomen is free from pain, but there may be tenderness in the hepatic region ; the bowels are constipated ; and the urine is scanty, high-coloured, and dense. The pulse is over loo; it is often full, but almost always compressible ; only in rare cases has it any firmness. Thei'espirations are somewhat accelerated, and sometimes there is slight cough. The face is flushed and dusky ; the edges of the eyelids are tumefied ; the conjunctivae are injected ; and the eyes water. The expression at first betokens languor and weariness, but soon becomes dull, heavy, and stupid. From the first there is vertigo, tinnitus aurium, restlessness, and often total loss of sleep ; but frequently the patient declares that he has not slept, and yet the attendants have watched him sleeping for hours. The sleep is disturbed by painful dreams and sudden starts, and after three or four nights there is talking in the sleep, with slight delirium between sleeping and waking. When awake the patient is still conscious, though perhaps some- what confused in memory and intellect. With all this there is early and rapidly increasing muscular prostration ; the gait is tottering, the hand shakes, and there may be tremors of the tongue ; soon there is an intolerable sensation of complete ex- haustion, so that about the third day the patient is compelled to keep his bed. SYMPTOMS. 121 Between the fourth and the seventh days, usually on the fourth or fifth, an eruption appears on the skin. It is composed of numerous spots of irregular form, varying in diameter from three or four lines to a mere speck, which are either isolated or grouped together in patches presenting a very irregular outline, and often closely resembling the eruption of measles. At first, these spots are of a dirty pink or florid colour, and very slightly elevated above the skin, and they disappear upon pressure ; but, after the first or second day, they usually become darker and more dingy, they resemble reddish-brown stains, are no longer elevated above the skin, and do not disappear, but only become a little paler, on pressure. They have no defined margin, but merge insensibly into the colour of the surrounding skin. These spots usually come out first on the anterior fold of the axillae and on the sides of the abdomen, and thence they spread to the chest, back, shoulders, thighs and arms ; m some cases they are first seen on the backs of the hands ; they are most common on the trunk and arms, and are very rarely observed on the neck or face. Along with these spots there are others which are paler and less distinct, and which, from their apparent situation beneath the cuticle, have been designated ' subcuticular.' When abundant, this subcuticular rash imparts to the skin a mottled or marbled aspect, which contrasts with the darker more defined spots before described, although sometimes the two appear to merge into one another. The eruption of typhus varies greatly in its appearance according to the relative abundance of the mottling and more distinct spots. Sometimes both are plenti- ful ; sometimes there are only a few of the more distinct spots ; and at other times there is nothing but a faint subcuticular mottling, which is apt to be overlooked. Its appearance also varies according to the degree of isolation or confluence of the distinct spots. - The spots and mottling together constitute an eruption which Jenner has described as the ' Mulberry rash ' of typhus, but which other writers have designated measly, mor- billiform, or rubeoloid. (See Plate I. and p. 131.) This is the history of typhus during the first six or seven days of the disease. About the end of the first week, the headache ceases and delirium supervenes. The delirium varies in character. Oc- casionally it is at first acute ; the patient shouts, talks in- coherently, and is more or less violent ; if not restrained, he will get up and walk about the room, or even throw himself from an open window. This violent state is usually followed by great 122 TYPHUS FEVEE. collapse, or the noisy condition passes into low, muttering delirium. More commonly the delirium is never acute, even at first. With either form there is usually sleeplessness ; and when spoken to, the patient becomes more excited. The countenance becomes more dusky, the conjunctivae more injected, and the expression more dull and stupid, while the prostration hourly increases. The symptoms of nervous excitement are usually most marked towards evening and in the night-time ; the pro- stration is greatest in the morning. At the same time, the tongue becomes dry, brown, and rough along the centre, and is tremulous ; sordes collect upon the teeth and lips ; constipation continues. The pulse varies from loo to 120 and may be full and soft, but is oftener small and weak ; the respiratory move- ments vary from twenty to thirty, and the breath is fetid. The skin is cooler than during the first week ; it is dry or slightly clammy, and gives off a peculiar odour. The eruption assumes a darker shade, and about the eighth or tenth day true petechise of a purple or bluish tint appear in the centre of many of the spots, these petechise at their edges gradually merging into the reddish-brown hue of the primary spots. (See Plate II.) After three or four days, the symptoms of nervous excitement are succeeded by more or less nervous depression and stupor. At first the stupor and delirium alternate, the latter being most marked in the night-time. The prostration is extreme : the patient lies on his back, moaning, muttering incoherently, or still and motionless, with a tendency to sink to the bottom of the bed. He is quite unable to raise himself, or even to turn on his side, is with difficulty roused, and is utterly indifferent to surrounding objects and persons. Tremors, subsultus, and picking of the bedrclothes may be observed. The expression is stupid and vacant ; the conjunctivae are injected, the eyelids for the most part closed, and the pupils often contracted. Deafness is not uncommon. If spoken to loudly, the patient opens his eyes and stares vacantly at those about him, and when told to put out his tongue he opens his mouth and leaves it open until desired to close it. These are all the signs of consciousness exhibited ; and even they may be absent. But all this time the mind is far from inactive ; the imagination conjures up the most frightful fancies, to which implicit belief is attached, and of which a distinct recollection may remain after recovery. The ideas often revolve on previous events of the patient's life. He believes himself persecuted and tormented by his attendants and dearest relatives ; be compresses years into hours, and in a few SYMPTOMS. 123 hours imagines that he has Hved a Hfe-time. They who have passed through these mental sufferings can alone imagine their intensity. The teeth and lips are now covered with sordes ; the tongue is hard and dry, dark brown or black, contracted into a ball, tremulous, and protruded with difficulty or not at all. The abdomen is flaccid, or sometimes tympanitic ; the bowels are still confined, or one or two slightly relaxed motions are passed daily in bed. The urine is more copious, but paler, and of low specific gravity, and is passed involuntarily, or retained so as to necessitate recourse to the catheter. The skin is cooler than before, and sometimes moist ; the number of spots presenting a petechial character increases. The parts subjected to pressure and particularly the skin over the sacrum become red and tender, and are liable to slough. The pulse is frequent (112 to 140), small, weak, and undulating, and not unfrequently inter- mittent, irregular, or scarcely perceptible ; the cardiac impulse and systolic sound of the heart are diminished in intensity, or absent. In this state the patient may continue for mauy hours or several days, with life trembling in the balance, until at last the stupor passes into profound and fatal coma; or sudden en- gorgement of the lungs with asphyxia supervenes ; or the pulse becomes imperceptible, the surface cold, livid, and bathed with copious sweat, and death ensues without any return to con- sciousness, the mode of fatal terjuination being apparently a combination of syncope and coma. But on or about the fourteenth day there is ofteji a more or less sudden amendment. The patient falls into ,a quiet sleep which lasts for several hours^ and from which he awakes another man. At first he is bewildered and confused, and wonders where he is ; but he recognizes his attendants and friends, and he is now conscious of his extreme debility. His extremities retain their sensibility ; but when he attempts to move them, they seem at first as if separated from the body. The pulse and temperature have fallen ; the tongue is clean and nioist at the edges ; there is a desire foy food, an 9 A.M. 1 9 P.M. > 9 A.M. 9 P.M. > 9 A.M. 9 P.M. P. T. P. T. P. T. P. T. P. T. P. T. p I P p ?, 108 105- 112 1 104-8 9 no 101-4 104 102-8 !■; 100 loo- 92 99- 4 108 103-6 108 104-6 10 112 101-8 110 102-6 16 92 99-2 84 100-4 S 100 103-4 112 105-2 II 108 101-4 120 I02- 17 84 98-8 92 97-2 6 114 104-8 120 1044 12 124 1036 120 104- 18 68 98-4 80 98-4 7 120 103-6 120 103-4 1.3 118 101-2 96 996 19 80 98-8 80 99- ii 108 I0I-8 108 102-8 14 88 994 92 IOI-6 20 80 99-1 72 97-8 SYMPTOMS. I2S ; CO J* , CMX) i^ b rodo CO tH b -^ r^ rooo ro b cJo M lOONi-i rorocoio t~~>0 00 \0 00 00 t^ CD ,_Q CD VO 00 J^OO rou-iM O NOOrorO'^'^Mii-i 00 '^ -^ r^ iriOO t^ >-i 00 O^00 -' O^00 roi-iOO'*^ ir^ir^j^uii-c ' '— 'O '■ '■ -*C<0 b^►-| bcJo b w-iiofoi^" rOM rob t^^ m N On '^ ' lO in ■ ■ ONOO a^ i-i '-O'^CjN-^O l^r^O row^o t^oo m rooo ^ N 00 m '-0 MO ^ O t^^ r^0^m■^■<:l-u^u-l■^^ororocommN ro ^1 -^ 'M A rn ^ vO O 00 inoo N M i-H vo O i-i t^ ^^ t^vO OvOinroO -^roi-i 0)mi-i •Nr<-)^Ni-MMNi-iNC-l"i-i"i-H(SMwi-Hi-iwi-c-.i-.i-)i-i :oooooooooooooooooooooooooo . H-i 00 CTn ChOO l-^NTj-ONCrv_ ■*■*'*•*_ . Nw rOOO N _ >n M CT» ■ ^b 00 b b M b^ OnK) ob^r ■^■^N m r^"*000>0^ forhro-^-rl-rO oooooooooooooooooooooooooo ►- C^OOOO O rofO^O 0\ur)mrocT>vO rom-^r^i-i o M rf•o^"^^-^o cooo oooo lOi-ioOvO roo MOO •+ T^ M ^ ro r<-)^ m m i^ m On " fo'^'^'^'+ij^ro'*rof^N""bt>OMN"bbNbbbbbbb OOOOOOOOOOOOOOOnOOOOCnOOOOOOO N mONONi-H m" roi-i i^i-i i-i 0\i-i ONOcnr^roi-H t^r^m f^fy-)i-i rot-~i~^roroi-i u-ir^ONfOONi-i mw mloro^^C^^r)t^CT^^^t^ O 00 O >0 Tt-00 N OVO O MOOOOOO NOOOOOO OOO '^OO -^^ ■<:f ; '*■ 00^-l-i-iOC?i I>.\0 >0 m^D VO \0 VO ^ ^ ^ 00 r^oo . 00 rtC/l (SON ■^^O 'OOOVOOOVOOOOOOOOO'OVO^ O^ ■^'O ■^VO O N OO'-'M'-iCS'-'i-'O ONOO 0^V0 \0 ■^vO ^ 00 t^Mj OMXi onOO on r^ Os gSBSSip JO Z'Bd 126 TYPHUS FEVER. Case II. Ty pints, shoiving Variations of Pulse, Temperature, Quantity of Urine, Urea, Chlorides, z>v%- ....«^>*. -^>-.^itiMiOTMif«.:w.„ 1«i r.Tjnti5 ^ SYMPTOMS. 131 petechial eruptions has been mentioned by all writers from the earliest times. (See pages 27, 29, 33.) Cases without any eruption are mostly mild. Much discussion has taken place respecting the title to rank among the exanthemata conferred upon typhus by the eruption." On its first appearance, the eruption is undoubtedly a true exanthem due to hyper gemia of the cutaneous capillaries. It is then of a pinkish or florid hue, disappears on pressure, and may be slightly elevated above the surface. The whole or part of the eruption may never pass beyond this state, and then, if death occur, no traces of spots are found on the dead body. But in most cases, sooner or later, an escape of blood-pigment into the cutis is substituted for the hypersemia ; the spots be- come darker, are no longer elevated, and do not disappear on pressure. The colour will vary according to the amount of pigment thrown out ; if this be small, the colour is reddish- brown ; if large, the spots are livid or petechial. The spots now persist after death, and on examining microscopically thin sections of the skin made through them, the colour is found to be due to an infiltration of dissolved haematine into the tissue of the cutis. In the reddish-brown spots, the tinging is limited to the surface of the true skin ; but in the darker forms it extends through the entire thickness of the cutis, and some- times even into the subcutaneous areolar tissue. The changes described may take place in a portion of the spots only, the others remaining pale or florid and non-persistent on pressure, or disappearing entirely. The subcuticular mottling also often disappears after a few days, while the spots continue to get darker. Hence, the eruption of typhus is often pale and confluent in its early stage, darker and more spotted in the advanced. Since the days of Nicholas Massa "^ and Sennertus,"" typhus has often been designated ' Petechial Fever ; ' but the term petechicB is used in very different significations, and hence has arisen great confusion. Eochoux restricted it to the eruption of typhus, although he regarded this as a true exanthem, and not due to local hsemorrhagc^ Lyons recognizes but one ■^ HiLDENBEAND (1811), RouPELL (1831), and PEEBLES (1835), all maintained the right of typhus to rank with the exanthemata. This view was opposed by West (1840) and others. " Nicholas Massa, 1556. " Sennertus, 1619. y ' On appelle generalement du nom de pet^chies deux affections sympto- matiques tres-distinctes, bien qu'elles aient le reseau muqueux de la peau pour siege •commun. L'une est une veritable exanthema ; I'autre, une hemorrhagie sous- z 2 132 TYPHUS FE^'ER. eruption in typhus wliich 'may be called indifferently either maculae or petechise,' and yet states that these petechise dis- appear upon pressure.^ But if we turn to systematic writers on diseases of the skin, we find that petechise are defined to be minute purplish spots or sub-cutaneous ecchymoses, which do not disappear upon pressure ; ^ and this is now the common acceptation of the term. Although petechige, as thus defined, are often developed in the centre of typhus-spots, they are not essential or peculiar to typhus. In many cases of typhus, the eruption never becomes petechial, and m few are true pete- chige seen except in the last stages ; while, on the other hand, petechife are observed in the course of many other diseases, both febrile and non-febrile. Febrile symptoms with petechiae do not constitute typhus, the peculiarity of which consists in an eruption which often becomes converted into petechige. Many of the early writers described the various stages of the typhus- eruption with wonderful accuracy, but the conversion of the spots into petechige was first noted by Staberoh,^ Stewart,^ and Jenner.*^ The eruption of typhus is very rarely absent. Of 18,268 cases admitted into the London Fever Hospital during twenty- three years, it was noted in 17,025, or in 93*2 per cent., and there can be no doubt that these figures exaggerate the pro- portion of cases in which it was absent. In certain cases where it was faint, it was noted as absent by resident medical officers who were not sufficiently vigilant or were new to then work, and thus the proportion varied in different years according to the care with which the register was kept. In the year 1864, when this was kept with unusual care, the eruption was noted in all but 55 out of 2,493 cases, or in 9777 per cent. epidermique. Je conserverai le nom de petechies k rexantli^me et j'appellerai riiemorrhagie pourpre, ou taches pourpr^es. Les p^t^chies peuvent etre eon- siderees comme le symptome le plus liabituel du typhus.' — Diet, de Med. 1841, Art. Petechies, p. 134. ^ Lyons, 1861, p. 121. " ' The term imrpura,^ says Bateman, ' is appropriated by "Willan to an efflor- escence consisting of small, distinct purple specks and patches, attended with general debility, but not always with fever. The specks and patches here men- tioned aYei^etechice andvibices, occasioned, not as in the preceding exanthemata, by an increased determination of blood into the cutaneous vessels, but by an extra- vasation from these vessels under the cuticle.'— Prac^. Synops. of Cut. Dis. 5th ed. Lond. 1819, p. 103 ; Atlas, 1817, PL 28. According to Erasmus Wilson, ' When the sanguineous spots (of purpura) are minute they are termed petechim, but when of large size, ecchymoses.' —Dis. of the Skin, 3rd ed. 1851, p. 337. Sir W. Jenner defines a petechia as ' a dusky crimson or purple spot, with defined edges, unaffected by pressure, and not elevated above the skin.' — Jenner, 1850, XX. 419. *• Stabekoh, 1838, p. <27, <= Stewart, 1840, p. 317. * Jennek, 1849. P1;^|--TT. pliiiili/MliilllllMliilliaiMiinmin Spots ieccmxaf converted i/ito y^eteiihi :ceciass from a; SYMPTOMS. 133 Moreover, of the few cases where it was not found, in some the patient had passed through the attack before admis- sion, so that probably the eruption had been present and had disappeared. Jacquot observed the eruption in 152 of 159 cases in the Crimea,'' and Eobert Paterson in no out of 114 cases in Edinburgh in 1847.^ Sex exercises no influence on the presence of the eruption, but in children it is oftener absent than in adults. Thus of 3,456 cases admitted into the London Fever Hospital in ten years (1848-18 5 7) whose age was noted, the mean age of the patients in whom the eruption was present was 29-74, and of those in whom it was absent only 26*28. Again, of 398 cases where there was no eruption 119, or 30 per cent., were below fifteen years of age ; while of 3,058 cases with the eruption only 444, or 14 per cent., were below fifteen years. In other words, of 563 cases below fifteen years the eruption was absent in 119, or in 21 per cent. ; whereas of 2,893 cases above fifteen it was observed in all but 279 cases, or 9 per cent. ; and of 17 cases below five years it was absent in 7. Jenner found the eruption in every one of ^6 cases above twenty-two years of age, but failed to find it in 13 of 55 cases of the age of fifteen and under. ^ In children the spots rarely become petechial ; but I have known the eruption perfectly characteristic at every age, from one month to eighty- four years. Flea-bites have often been mistaken for typhus spots, but with care are readily distinguishable by their more circular outline, the minute dark dot in their centre, and by their disappearing on pressure, excepting the central dot. Fracastorius fixed the first appearance of the eruption at between the fourth and the seventh day, a statement which has been endorsed by most subsequent observers. Dr. Stew^art analysed 52 cases with this object, and ascertained that 'in more than half of the entire number it appeared on the fifth or sixth days, and in exactly three-quarters it appeared from the fourth to the seventh day. Taking an average of the w^hole it appeared most commonly on the sixth day.' ^ Dr. Peacock ascertained the date of the first appearance of the eruption in 28 cases : in 2 it appeared on the second or third day; in 3, on the fourth ; in 5, on the fifth ; in 7, on the sixth ; in 6, on the seventh ; in 2, on the eighth ; in 2, on the ninth ; and in i on the ninth or tenth.^ Of course, those cases only * Jacquot, 1858, p. 172. ' R. Pateeson, 1848. s Jennee, 1849, XX. 457. •> Stewaet, 1840, p. 318. ' Peacock, 1856. * K 3 134 TYPHUS FEVER. are available for deciding the question, where the eruption first appears while the patient is under observation. According to my experience, the eruption seldom appears later than the fourth or fifth day, and most commonly it is visible on the fourth day. I have rarely met with a case in which I could be certain that the eruption made its appearance later than the sixth day. Of 64 cases, in which I especially noted the point in 1856, 37 were admitted into hospital after the sixth day, and the eruption was present in all at the time of admission ; in 1 2 admitted on the sixth day the eruption was likewise present on admission, and in 6 it was copious ; in 6 admitted on the fifth day it was present on admission, and in 2 copious ; of 3 admitted on the fourth day in 2 the eruption was present, and in i it appeared on the fifth day ; in 3 cases admitted on the third day it appeared on the day following, and in i case admitted on the second day it appeared on the third day. In many other cases observed since this calculation was made, the eruption has first appeared on the third, fourth, or fifth day, and in two or three instances I have known it present on the second day. Cases where it appeared as early as the third day are mentioned by Eoupell,-' Jenner,^' and W. T. Gairdner.^ The average duration of the eruption may be said to be from seven to ten days. In uncomplicated cases it continues, as a rule, until death or recovery ; but sometimes, especially when there is only faint mottling, it begins to fade after a few days, or even hours, and quite disappears several days prior to the cessation of the primary fever. On the other hand, when the eruption is dark or petechial, it may linger for a few days after the commencement of convalescence. In cases characterized by both mottling and distinct spots, the former may disappear after a day or two, while the spots continue growing darker until the termination of the case. At Edinburgh in 1859, according to Dr. W. T. Gairdner, the eruption was marked by earlier appear- ance and disappearance than formerly.*" The eruption of typhus never appears in successive crops. Fresh spots may come out for a day or two after their first appearance, but they are superadded to the first spots and do not take their place. This is the result of my observation in a large number of cases, where I have surrounded every spot with a circle of ink in order to satisfy myself of the point. Similar observations have been made by Stewart," Jenner,° Barrallier,? i BouPELL, 1839, p. 37. "^ Jennee, 1853, p. 285. ' Gmednek, 1859, p. 51. " Ibid. " Stewabt, 1840, p. 317. » Jennek, 1849. p B.VKE.\LLiEr>, 1861, p. 76. SYMPTOMS. 135 and, indeed, almost every recent writer on typhus, both EngHsh and continental. To quote from Barrallier (p. 'j6), ' Toutes apparaissent dans le premier, le deuxieme ou le troisieme jour de leur manifestation ; apres ce temps, il ne s'en montre plus de nouvelles.' 2. General Hyperemia of the Skin. The typhus -eruption is occasionally preceded or accompanied at first by a general pink flush, disappearing on pressure but immediately returning. This flush is apparently due to active hyperaemia. In the more advanced stages of severe cases, the surface often exhibits a leaden or livid hue, more especially on the dependent parts of the body. Here there is passive hypersemia, or stagnation of impure blood in the cutaneous capillaries, resulting from the enfeebled state of the circulation. Dr. W. T. Gairdner mentions a case in which a scarlet rash appeared on the twelfth day of the disease and persisted till the eighteenth.^ 3. Pu72JU7'a-S2Jots and Vihices are sometimes observed in severe cases of typhus, especially when complicated with scurv}^ They were particularly common in the Crimea, "■ where typhus and scurvy so often co-existed. These purpura-spots must not be confounded with the petechias already described. Although both are really subcutaneous ecchymoses,. the spots of purpura are not formed in the centre of typhus-spots, but are inde- pendent. 4. Taches hleudtres. In several instances, mostly of a mild nature, I have met with the ' taches bleuatres ' of French writers. They wiU be described under the head of ' Enteric Fever,' in which they are more common. 5. Sudamina are occasionally, though rarely, observed on the chest and abdomen in typhus about the end of the second week. Henderson found them in only 3 of 198 cases.^ According to Jenner, their appearance depends on the age of the patients; he failed to find them in any of 2.6 patients above forty, but found them in 5 of 17 cases below that age.* Several cases of typhus with sudamina, some of them in persons above forty-five, have come under my observation. They are usually, but not always, associated with perspiration. In several instances I have found the fluid contained in the vesicles to have an acid reaction ; and Barrallier has made a similar observation.** 6. Desquamation. During convalescence from typhus, the « Gaiedner, 1865, No. I. ' Jacquot, 1858, p. 178. ' Hendeeson, 1839. * Jennek, 1S49, No. 2. " BAEEAIiLIEB, 1.86 1, p. 2 1 8. 136 TYPHUS FEVER. skin is sometimes observed to be rough, and the cuticle separates in minute scales. This desquamation is most marked in cases where the skin has presented a general erythematous flush. I have never known the nails shed after typhus, but A. Vogel has described and figured a white band, and a furrow, which often Fig. 2. Eing-finger thirteen weeks after an attack Fig. 3. Index-finger, in profile, fourteen of typhus, a, hmula ; b, furrow gradually ad- weeks after typhus, n, lunula ; 6, vancing from lunula to extremity of nail ; c, furrow. After A. Yogel. white anasmio stripe. After A. Vogel. appear at the lunula four or six weeks after the commencement of the disease and gradually advance to the extremity.'' Most patients shed more or less of their hair during convalescence. 7. The Temjjerature (see Cases I. and II. and Diagrams IV. to VII.) rises rapidly from the onset of the disease, and usually, in cases of average severity, attains its maximum at from the fourth to the seventh day, or during the development of the eruption. I have never known it reach I04'9° F. as early as the first evening as stated by Griesinger. Occasionally the maximum is attained as early as the thii'd day, or it may, in severe cases, be postponed to the ninth or tenth day. The maximum is about 104° or 105° F. ; it scarcely ever reaches 106°, except in children, in whom it is rarely as high as 107°; and it may be below 103°. After attaining its maximum there may be little change for several days, but some time between the seventh and the tenth day, except in severe cases, there is usuaUy a slight remission, and then the temperature gradually falls until about the fourteenth day, when it rapidly subsides to the normal standard. In a single night it may fall from 4 to 6 degrees, but when there is pulmonary congestion, the fall is slower. Occasionally an elevation of two or more degrees pre- cedes the final fall, and then a brief fall of moderate amount may intervene between the final rise and the rapid descent. This sudden fall of temperature about the fourteenth day is peculiar ■^ A. Vogel, 1870, p. 341. <5i ^ S& 1 > < or o < Q 1 i ii ■ 1 I 1 '1 ^ - f_ ' — — — — — - 1 -1 [ — — •« ^ I V 1 O . L ^ U1 OJ 's > iS <: CM 1 V _ ■X » M r<- 1 ^ - 1 *r __^ » w "^ CM :s • \< o 00 4 ^- ^>. -J •< ■k tri ' ^ k "^ r CO T" ._ 1 ! 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I 1 1 1 __L_ 1 i ]^ 1 1 i 1 1 i M 1 / 1 i 1 CD ^ u _!_ .L i!- rf 1 1 ] j CO i \/ 1 V''' j 1 i < \ 1 1 r~ 1- i 1 1 V 1 -4 j 1 1 1 1 T "~- :>• 1 1 1 1 tP ■t" r -1 1 1 i I -^ : ! 1 ; 1 i in 1 1 4- >, •- - 1 : - 1 i k i'i [ 1 Ic- - " ; i 1 i 1 " i '-. > 1 1 1 i 1 i li r i ! i 1 1 iM 1 . 1 1 i 1 ' i ' '-III M ill! CO o 1 , t- 1 i 1 CO i i i i ' i i 1 i o 1 o _ a 1 O 1 ) ■ 1 — i 1 12 i : '* i 1 1 1 1 SYMPTOMS. 137 to typhus, and may be useful in diagnosis. Before attaining its maximum the daily variations of temperature are slight, but during the second week they may amount to two degrees, the maximum being usually, but not always, in the evening. A high range of temperature in the first week indicates severe cerebral symptoms in the second, but what is worse as regards prognosis is the absence of any remission about the seventh day ; while a decided rise of temperature in the second week is mostly due to the advent of some complication, which may postpone deferves- cence beyond the usual time, although even then some remission is usually observed about the fourteenth day. On the other hand, cases ma}^ be severe, and even fatal, mostly from asthenia or pul- monary obstruction, where the temperature has at no time ex- ceeded 103°; and a severe case is often characterized, not merely by a high temperature in the first week, but by an anomalous or irregular range in the second ; for example, by an absence of the morning fall, or by a sudden fall with a rise of pulse, or with no improvement in the general symptoms. In fatal cases there is usually a rise of two or more degrees just before death, or in the death agony (Diag. VII.). In the first week or ten days of convalescence the temperature is often below the normal stan- dard, but temporary rises, to the extent of two or three degrees, are apt to occur without any assignable cause. ^ 8. Moisture. The skin is usually dry from the second or third day until near the termination of the disease. Conva- lescence is sometimes ushered in by moderate perspiration, while death is often preceded by copious sweats, giving a sodden appearance to the skin. The secreted fluid has an acid reaction, but in two severe cases I have found it alkaline. In several cases, for the most part fatal, I have found that, on evaporation, it left a white efflorescence upon the eyelids and face consisting of rod- shaped and stellate crystals, composed of a free acid, fatty " AiTKEN (Pract. Med. 2nd ed. i. pp. 48, 432) and Buchanan (1866), adopting mainly the results arrived at by Wunderlich and Griesinger from ' not too nume- rous observations,' fix the temperature too high. According to Aitken the temperature ranges from 102° to 107°, the maximum is always above 104-7°, and frequently reaches 106°, and in a patient with fever the fact of the temperature falling to 103-3° during the second half of the first, or the first half of the second week, without any assignable cause, is a certain indication that the fever is not typhus. Every recent observer in this country has borne testimony to the incorrectness of these statements, and my observations made on a large number of cases three times in the day are in keeping with those of Pebky (1866), CoMPTON (1866), Waetee (1866), G. Smith (1866), Squaeey (1867), Gkimshaw (1867), MoEKs (1867), Miller (1868), Maclagan (1869), and Fox (1870). See also Lancet, 1865, ii. 647; 1866, i. 657; and Med. Times and Gaz. 1864, ii. 411"; 1867, i. 387. 138 TYPHUS FEM3R. matter, and a large proportion of chlorides. Barrallier makes a similar observation.^ 9. Odour from Skin {Tyj^hus-Odom-). A peculiar repulsive odour is given off from the body of most typhus patients, after the first week. This smell was noted three centuries ago by Salius Diversus,y and has been alluded to by almost every subse- quent writer. Lind compared it to the ' odour of rotten straw,' or to ' the disagreeable affecting scent from a person labom-ing under the confluent small-pox.' ^ Gerhard spoke of it as ' pungent, ammoniacal and offensive.' ^ Barrallier likened it to the odour of rotten straw, or to that given off by deer, or by certain reptiles, or by rubbing the leaves of rue between the fingers.^ By other observers it has been more aptly compared to the smell of mice, but perhaps it is more correct to speak of it as sui generis. It must not be confounded with the smell resulting from the urine being passed in bed, or with the putrid odour which sometimes precedes death from many diseases. The nurses in the London Fever Hospital are quite familiar with the tyx^hus-odour, and I have known them distinguish typhus by it alone. The odour is always strongest in damp weather, and when the ventilation is bad. As already stated (pp. 93, 119), there is reason for believ- ing that the typhus-poison is associated with this odoriferous substance. c. SymiJtoms referable to the Circulating System. I. The Pidse. As a rule the pulse from the first varies from 100 to 120, and rises with the severity of the general s;yTQptoms. It may rise to 150, or upwards ; but if it exceed 120 in an adult, the case is severe. Of thirteen cases observed by Henderson, where the pulse exceeded 134, five died, or 38 per cent. Some- times, on the other hand, the pulse, through the whole course of the disease, never reaches 100, or even 90, and in more than one case, I have known it not to exceed 40 for several days, while the rash persisted, the temperature was high and the tongue was dry and brown ; and then it gradually rose to the normal stan- dard, as the other sj^mptoms improved. Barrallier met with this slow pulse in several cases of typhus ; in one case, a man aged fifty-five, the pulse remained for three days at 28.<= Similar cases were recorded in 1853 by Dr. H. Kennedy,'^ and in 1869 by Maclagan.^ In these cases, the heart's action may be cor- ^ Baeealliee, 1 86 1, p. 247. ^ S.vlius Diveesus, 1584. ' Lind, 1763, p. 62. " Geehaed, 1837, xx. 298. " Baeeallieb, 1861, p. 223. "= Ibid. pp. 70, 87, 24S, 1 Ji. Kennedy, 1S53. ' Maclagan, 1869. SYMPTOMS. 139 respondingly slow, or the heart may beat twice for every stroke of the radial pulse, both conditions indicating that its action is greatly impaired. Of ninety cases of typhus in which I noted the pulse daily, it never reached 100 in nineteen, and it rose to between 100 and 120 in seventeen, to 120 in thirty-nine, and to above 1 20 in fifteen. Although a rapid pulse is, to some extent, a sign that a case is severe, a slow pulse does not necessarily indicate a mild attack. The cases where the pulse is remarka- bly slow are usually characterized by extreme prostration ; and I have repeatedly known cases terminate fatally where the pulse has never reached 100. The pulse may rise to 1 20 on the third or fourth day of the disease ; but in adults usually it does not exceed 100 during the first two or three days. Although throughout the evening rate is usually slightly in excess of the morning, the pulse varies little from day to day ; but it keeps at the rate which it has once attained, or it continues to increase until death or recovery. A favom-able change in the disease is often marked first by a gradual, and at last by a sudden and considerable, fall in the pulse. During convalescence, the pulse occasionally falls to below the normal standard, even when it has previously been very rapid. I have often found it to remain for several days below 50. A great rise in the pulse after falling denotes the advent of some complication. Although at first the pulse and temperature mostly rise together, it is important to note that there is no definite relationship between them, and indeed during the second week it often happens that the pulse is rising while the temperature is falling. At the commencement, the pulse is full, soft, and compressible, and day by day, as it becomes quicker, it also becomes smaller and weaker, until at last it may be quite imperceptible. In some cases, I have found the radial pulse to be imperceptible for several days prior to death. In young robust persons of sanguine temperament, the pulse during the first week may be firm and somewhat bounding ; but in true typhus, this is a rare phe- nomenon ; it occurred only four times in ninety cases in which I noted its characters, and in three of the four cases there was acute delirium. Most of the cases described in former days by Welsh, Armstrong, &c., as having a pulse of this character, were probably examples of relapsing fever or of acute inflammations. In most severe cases of typhus, during the second week the pulse is dicrotous or undulatory,^ and frequently it is irregular or ' See also G-eimshaw, 1867. 140 TYPHUS FEVER. intermitting. (See Figs. 4 to 8.) These characters always point to a very weak condition of the heart. Dr. Lyons has called at- tention to a very singular want of uniformity, in certain cases, of the force and volume of the arterial pulse in different parts of the system, the carotid, temporal or iliac arteries, or the abdominal aorta, acting with great violence, while the other arteries are not sensibly disturbed.^ As the pulse diminishes in frequency, it usually increases in volume and force. S'phycjmogra'phic tracings of Pulse, after Sanderson. Fiff. 5. Normal soft pulse. Pig. 6. Soft and frequent pulse of mild pyrexia, often present in early stage of typhus. Fig. 7. Irregular pulse of irritative fever. Fig. 8. Irregular undulatory pulse of advanced typhus. Another character of the pulse, observed both during the fever and in convalescence, is its acceleration and diminution in power on assuming the erect or semi-erect posture. As Dr. Graves^ pointed out, the greater the difference, the greater is the debility of the patient. 2. Action of the Heart. The state of the heart should be care- fully noted in every severe case of typhus, for this organ and the arterial pulse furnish the chief indications for treatment. It is to Dr. Stokes that the profession is indebted for pointing e Lyons, 1861, p. 155. ^ Duh. Hosp. Ecporls, 1S30, v. 469, SYMPTOMS. 141 out the cardiac phenomena of typhus, the chief of which are a diminution of the impulse, and an impairment, or loss, of the first sound.^ In mild cases, the impulse and sounds may remain unaltered, but in most severe cases, particularly in persons above thirty, the impulse diminishes progressively from the fifth or sixth day to the termination of the disease, and for several days prior to death or recovery it may be entirely absent. At the same time, the systolic sound of the heart, especially over the left ventricle, becomes daily more feeble and ultimately may be quite inaudible, leaving the second sound clear and distinct. Before the first sound is altogether lost, it may be so short that it is difficult to distinguish it from the second, and then, if the cardiac action be rapid, the sounds may closely resemble those of the fcetus in utero. Occasionally the first sound is accompanied by a temporary bellows-murmur. The arterial pulse is not an infallible guide to the condition of the heart, which, in all severe cases, should be investigated by the application of the hand and stethoscope. Although a small, weak, or imperceptible pulse is usually associated with a dimi- nution of the cardiac impulse and systolic sound, the arterial pulse may be distinct and not very weak, while the action of the heart is much enfeebled. On the other hand, the cardiac impulse may appear so strong as to distress the patient, and the sounds be dis- tinct, and yet the radial pulse may be imperceptible. Dr. Stokes gives the particulars of a case where this state of matters lasted for ten days prior to death ,J These abnormal phenomena result from a weakened condition of the central organ of circulation, often associated with disease of its muscular tissue. They constitute the best and safest guides to a liberal exhibition of stimulants. The state where the cardiac impulse is strong and jarring, but the radial pulse weak or absent, also demands stimulants ; the contractions of the heart, though violent, are incomplete, and do not suffice to propel the blood with any force into the nearest arteries, while at the same time there is usually great prostration of the nervous and muscular systems. ' For a full account of these phenomena, see Stokes, 1839; Graves, 1S4S, f. 249; Huss, 1855, p. 74; Bell, i860; Lyons, 1861, p. 152; also Stokes, On Diseases of the Heart, 1854, p. 366. J Diseases of the Heart, 1854, p. 384. 142 TYPHUS FEVEE, d. Morhid Phenomena of the Respiratory System. 1 . The Respiratory Movements in the first week do not usually exceed 24 in the minute ; but with the supervention of delirium, and the increased frequency of the pulse, they often rise to 30, or even higher. On the other hand, in cases characterized by great prostration and impairment of the heart's action, the respirations may sink to 8 in the minute.^ In grave cases the respiration is usually hurried, it may be sighing, irregular, spasmodic or jerking. Spasmodic or jerking re- spiration is observed in cases of great cerebral disturbance, and is apt to be followed by coma. Another variety of the respira- tion is very unfavourable, viz., the * nervous respiration ' of Sir D. Corrigan,^ where the breathing is blowing or hissing, while the mouth is kept closed, the cheeks puff out, and the nostrils dilate with each expiration. The breathing is then often irre- gular, a long pause being followed by a deep inspiration, and this by a number of other short and rapid inspirations. In some cases of nervous breathing, the action is entirely diaphragmatic, the thoracic muscles being apparently paralysed. All these abnormal characters of respiration may be due to cerebral dis- turbance and be independent of any pulmonary complication. 2. Hypostatic Congestion of the lungs, although included among the complications of typhus in the first edition of this work, is more properly a symptom. It is present in all severe cases and scarcely a case is fatal without it, and indeed it is this more than anything else that determines the fatal event. It usually commences about the middle, but sometimes at the beginning, of the second week. The rapidity with which it may extend is sometimes remarkable, and in several instances I have known death occur rather suddenly from this cause as early as the seventh or eighth day of the disease. This condition is often confounded with pneumonia, but is quite distinct. Owing to the paralysed state of the pneumogastric nerves "" interfering with the respi- ratory functions, and the diminished power of the heart, passive congestion takes place in the most dependent part of the lungs, while at the same time serum is effused into the pulmonary tissue, and there is increased secretion from the lining membrane ' See Dr. John Eeid's Anat. and Path. Res. p. 206. ' CoEKiGAN, 1853, p. 72. " Dr. John Keid showed that division of the pneumogastric nerves in animals produced appearances in the lungs similar to the pulmonary hypostasis so com- mon after death from typhus. {Anat. and Path. Res. pp. 199, 205.) SYMPTOMS. 143 of the bronchi. Puhnonary hypostasis, in fact, is always accom- jDanied by more or less bronchial catarrh. In its early stages this condition often escapes observation. There may be little or no cough or expectoration. Indeed, the absence of cough, betraying as it does the utter inability of the patient to rid the bronchi of the gradually increasing secretion, is an unfavourable indication. "\Yhen there is expectoration, it is tenacious and frothy, and often mixed with strealis or small masses of florid blood. The chief symptoms of this pulmonary congestion are increased frequency of respiration, with those of deficient aer- ation of the blood. The respirations are accelerated to 30, 40, or even to 60, and are laboured ; the pulse is correspondingly quickened, weak, and often irregular ; the temperature may rise slightly at first, but often falls considerably, while the pulse con- tinues to rise ; the face and extremities are livid, the surface is cold and often clammy, and the patient is in a state of stupor passing into coma. But the earliest indication of hypostatic congestion is to be obtained from physical examination of the chest, which ought never to be neglected when the breathing becomes at all quick- ened in typhus. At first a few coarse crepitating rales are to be heard over the bases and most dependent parts. These gradually extend upwards and forwards until they may be heard over the whole of both lungs. As the congestion increases, there is also dulness on percussion, with feeble, but not tubular, breathing, at first confined to the most dependent part of the lungs, which is a little higher than the base, but gradually extending in every direction. 3. The Exjnred Air. The breath of a typhus patient has always an offensive smell, which has been compared to yeast, but often closely resembles that exhaled by the skin, (See page 138.) In 1843 Dr. A. Malcolm, of Belfast, recorded the results of up- wards of fifty experiments on the air expired by patients labour- ing under typhus, with the object of ascertaining the amount of carbonic acid.*^ The experiments were performed with Dr. Front's apparatus, and seem to have been done with great care. The results were very uniform, and were compared with those obtained by Dr. Prout in healthy persons. According to Prout, the proportion of carbonic acid is 3-96 per cent, of the whole air exhaled in health. This is probably a low estimate. In Malcolm, 1843. 144 TYPHUS FE"V^E. some of the experiments of Messrs. Allen and Pepys, it was as much as 8 per cent. ; and about 4-35 per cent, may be taken as the average of the results obtained by different observers." But in typhus Malcolm found that the quantity was reduced ; in one case it did not exceed i'i8 per cent., while the average of forty-five examinations was only 2*492 per cent. He also ascertained that the quantity was smallest in the more severe Fig. 9. CrTStals of Chloride of A minonitim obtainfd from tlie breath of a patient suffering from Typhus. The octoliedral crystals to the right were probably chloride of sodium, derived from the acid. forms of the disease characterized by delu'ium, subsultus, and dry brown tongue. Vierordt has shown that, even in health, the proportion of carbonic acid in the expired air diminishes as the frequency of the respirations increases, and this is probably the real explanation of Malcolm's results in typhus. Thus Leyden of Konigsberg, while confirming Malcolm's statement that the percentage of carbonic acid in the expired air of typhus is diminished, has found the absolute quantity increased by one- half.? Caepenter's Princ. of Hum. Phys. 5th eel., p. 2S3. p Letden, 1870. SY3IPT0MS- 145 In 1854 Professors Viale and Latini of Eome'^ confirmed the statements of Marchand and Eeade,'' to the effect that small quantities of ammonia are constantly evolved with the expired air in health, and stated further that in some contagious diseases, more especially typhus, this quantity was much increased. In the same year, Eeuling found that the air expned in certain diseases, such as typhus, uraemia, and pyaemia, contained an excess of ammonia.^ These results were subsequently confirmed by the independent researches of Dr. Eichardson. In severe eases of typhus the breath has undoubtedly often an ammoniacal odour, and thick white fumes are produced on holding a glass rod previously dipped in hydrochloric acid close to the mouth of the patient. In 1862 I examined the breath in a large number of cases of typhus, and in grave cases with typhoid or putrid symptoms well developed I rarely failed to obtain dendritic crystals of chloride of ammonium, on making the patient breathe upon a glass slide moistened with hydrochloric acid. There are, however, reasons for suspecting that the ammonia obtained in these observations, both in health and disease, has been in part derived, not from the lungs, but from decomposing particles of food, epithelium, &c., in the mouth and gullet,* although my own observations lead me to think that both in uraemia and in typhus the expired air may contain ammonia independently of the con- dition of the mouth and pharynx. e. Sym'ptoms referable to the Digestive Orgcms. I. The Tongue is at first covered with a creamy white fur, which gradually increases in thickness and may assume a dirty- yellowish aspect. In mild cases, the tongue may remain moist and furred throughout (25-5 per cent, of my cases), but usually about the end of the first or beginning of the second week it becomes dry, rough, and more or less brownish along the centre (i5'5 per cent.). In severe cases, it contracts into a ball, and is covered with a dry, dark-brown or black, cracked crust (58*8 per cent.). The amount of dryness and darkness of the tongue is a fair criterion of the severity of the case. In almost every fatal case the tongue becomes dry and dark, but in exceptional cases, where death is due to pure asthenia, it may be moist to the end. 1 Viale and. Latini, 1854. ' ■• See p. 117. " Veber den Ammoniah-Gelmlt der Exspir. Lxift. Giessen, 1854. Pakkes, 1 87 1, p. 400. L 146 TYPHUS FEVER. With the first commencement of convalescence, the dry brown tongue becomes clean and moist at the edge, and then the brown crust is gradually removed. The colour of the tongue at the margin and tip is usually pale ; but in rare cases it is red and the papillge are enlarged. The crust which covers the hard brown tongue is often irregularly cracked, but the tongue itself is not fissured. The deep trans- verse fissures, so common in enteric fever, are rare in typhus. Still more rarely is the tongue in typhus red, smooth, glazed and fissured. In 90 cases, I found the tongue fissm-ed only twice ; and in 41 fatal cases, Jenner found it fissured only four times. In many cases the tongue is tremulous ; while in some, it is retracted and cannot be protruded. These phenomena usually co-exist with the dry brown tongue, but may be inde- pendent. 2. Brown Sordes usually begin to collect upon the teeth and lips, about the beginning of the second week in severe cases. These sordes, as well as the brown crust on the tongue, consist of an accumulation of epithelial debris, which becomes black from desiccation, or sometimes from admixture of blood. In rare cases, haemorrhage from the gums is observed.'* 3. Loss of Appetite is one of the earliest and most constant sjrmptoms of typhus, and lasts until the disease takes a favom-- able turn. Occasionally a demand for food is the first and only symptom of returning health ; and in most cases such a demand is to be regarded as a favourable indication, although no improve- ment may have taken place in the other symptoms. 4. Thirst is present to a greater or less degree in all cases. In about one-fourth of my cases, I have noted it as excessive. It is usually greatest during the first week, and later, in the stage of nervous prostration, it abates or ceases. 5. Dysphagia. {See Muscular Paralysis, 'p. 166, a:nd Pharyn- gitis under Comptlications.) 6. Nausea and Sickness are not common symptoms. Vomit- ing occurred in 9 out of 90 cases, in which I carefully noted the point in 1856. The vomited matters consisted, for the most part, of a green bilious fluid. In 4 of the cases slight vomiting was one of the primary symptoms, and did not recur after the second or third day. In 2 other cases, it was likewise a primary symptom and ceased on the second day, but recurred at inter- " Bajrealliee, 1 86 1, pp. 236, 360. SYMPTOMS. 147 vals from about the twelfth clay until convalescence. In the 3 remaining cases, it was only observed in convalescence. Since ihe above observations were made, I have met with several in- stances — mostly in persons naturally dyspeptic — where vomit- ing was a troublesome symptom throughout the complaint. I have also known it, when appearing at the end of the first week, to be the precursor of severe cerebral symptoms, such as con- vulsions. Of 198 cases of typhus observed by Henderson in the Edin- burgh Infirmary in 1838-9, nausea and vomiting occurred in ■only 12, chiefly at the beginning of the fever. 7. Meteorism is also not a frequent symptom in typhus. In 5 only out of 90 cases, in which I noted the point in 1856, was the abdomen abnormally tympanitic or distended, while in many it was flat or even concave. The late Dr. Todd ^ believed that meteorism was more common in typhus than in enteric fever, and a similar opinion is expressed by Dr. Austin Flint ; '^ but iheir view is contrary to the experience of most observers. In 3 only out of 41 fatal cases was the abdomen observed by Jenner io be unnaturally distended. Marked tympanitis was observed by West ^ in 1 1 out of 60 cases ; by Henderson,^ in 8 out of 198 ; by Stewart,^ in 1 5 out of 139; by Shattuck,'' in i of 9 ; and by Barrallier,^ in 4 of 1,312. Adding these results to those ob- tained by myself we have 1,849 cases, of which meteorism oc- ■curred in 47, or in i of 39*34. Excluding M. Barrallier's cases, which may be thought to have an undue preponderance, there remain 537 cases, of which meteorism was observed in 43, or iii I of 12*4. In the Crimean typhus, meteorism was observed by 'Garreau in i out of 8 cases, and by Mouchet, not at all : Jacquot noted it in about one-third of his cases." In the few cases where meteorism is met with, it occurs at an advanced stage ; it is associated not with abdominal pain or diarrhoea, but with great prostration and cerebral oppression ; and then, like the meteorism so common in paraplegia, it de- pends on want of nervous tone in the coats of the bowel, and is always a bad symptom. In rare cases it is excessive, so as even to interfere with respiration. 8. Gurgling, on pressure of the abdomen, is quite exceptional. In the few oases where there is diarrhoea it may be detected ; ■' Todd, i860, p. 168. " Flint, 1852. =" West, 1838. y Henderson, 1839. ' Stewakt, 1840, p. 310. * Baetlett, 1856, p. 199. " Barralliee, 1861, pp. 239, 361. •= Jacquot, 1858, p. 185. L 2 148 TYPHUS FEVEE. but then it Is not usually confined to any part of the abdomen.. Of 43 fatal cases, Jenner discovered gurgling in only one. 9. Ahdominal Pain is rarely complained of, but tenderness in the hepatic region is not uncommon. Eussell noted it in 40 out of 52 cases. '^ Occasionally, during the first week, there are colicky pains, which are transient and not attended by tender-- ness on pressure. Vomiting is sometimes associated with pain and tenderness at the epigastrium ; and a distended bladder, with pain and tenderness in the hypogastrium. But abdominal tenderness in typhus is never limited to, or most marked in, the cfecal region, nor is it accompanied . by diarrhoea or tym- panitis. 10. The Liver and Sjjleen are in some cases found to exceed, their normal boundaries on percussion. In 1,202 cases observed by Barrallier, the liver was slightly enlarged in 365, or 30*3 per~ cent. ; and the spleen, in 126, or 10-48 per cent.® In my ex- perience splenic enlargement about the fifth day is more common than these figures imply, but the organ does not offer the firm' resistance observed in relapsing, enteric, and malarious fevers.. It is rare that either organ is the seat of pain or tenderness. 1 1 . Constipation is the rule in typhus ; and diarrhoea the exception. Of 144 cases in which I noted this point in 1856, the bowels were constipated so as to requne the administration of laxatives in 78. They were opened once (33) or twice (18) a day in 51, but in many of these cases purgatives had been taken before admission into hospital ; in connection with which it should be observed, that in several cases of constipation, where laxatives were taken after admission, the bowels continued open afterwards. In only 15 cases was there any approach to diarrhoea ; and only in 6 was it necessary to have recourse to astringents. In 4 of the 15 cases diarrhoea was one of the earliest symptoms and was associated with sickness, but botb symptoms may have resulted from medicine ; in a fifth ease vomiting had been one of the primary symptoms, and the diarrhoea came on about the tenth day after a purgative ; in 9 cases there was diarrhoea for a day or two at the period of crisis about the end of the second week, the bowels having previously been constipated ; in the remaining case the bowels were con- fined throughout the primary fever, but diarrhcea and sickness supervened in convalescence during the separation of a large slough over the sacrum. Of 43 fatal cases observed by Jenner,. ^ KussELL, 1S64, p. 150. " Baeealliee, 1S61, pp. 240, 361. SYMPTOMS. 149 ;spontaneous diarrhoea occurred in only 4/ Of 1 54 cases, noted "by Henderson in Edinburgh, the bowels were costive in 50, easy in 99, and loose in 5.^ Of 139 cases observed by Stewart at Glasgow there was costiveness (notwithstanding purgatives) in 62, a relaxed condition after medicine in 53, while only in 24 were the bowels spontaneously relaxed.^ Of 1,302 cases ob- served at Toulon by Barrallier, there was constipation in 769, -diarrhoea in 136, and regularity of the bowels in 397.^ Adding these results to my own, it appears, that of 1,782 cases, diarrhoea occurred in only 184, or in io'32 per cent., while in 959 of 1,739 cases or 5 5' 14 per cent, there was obstinate constipation. Since the above data were collected, I have ascertained that during nine years (1862-70) 14,589 cases of typhus were admitted into the London Fever Hospital, of which diarrhoea was noted as a complication in 734, or in 5 per cent. ; of the 734 patients with diarrhoea 178 or 24-25 per cent, died, whereas the mortality among the patients without diarrhoea was only 18-14 per cent. It may be added, that the occurrence of diarrhoea in typhus in the French army in the Crimea was quite exceptional.^ Spontaneous diarrhoea may be present from the commence- :ment of typhus, or supervene at any stage of its course, but it is chiefly observed about the period of crisis. It may, in rare cases, be excessive, and cause such an increase of prostration as ,to endanger the life of the patient ; but it is not, as far as my experience goes, attended by abdominal pain or tenderness, whatever be the stage at which it occurs, and, if the patient die, the agminated and solitary glands of the ileum are healthy. In the advanced stage of typhus, the frequent passage of liquid stools may be due to paralysis of the intestines and sphincter and to the fluid character of the ingesta. (See ' Comjjlications.') 12. Characters of the Stools. "When there is no diarrhoea, and when the bowels are moved spontaneously without medicine, the stools are usually of normal consistence and colour, but sometimes they are darker than natural. When there is diarrhoea, ■either spontaneous or from medicine they are mostly of a dark- .greenish brown colour, but sometimes they are light and watery. The reaction of the stools is usually acid, as in health ; but the (spontaneous) relaxed stools, which are most common at an advanced stage, were found to be strongly alkaline, in two instances, by Dr. Parkes, probably owing to the presence of '^ Jennee, 1849. ' Henderson, 1839. ^ Stewart, 1840, p. 308. '' .BaBKALLIEK, 186I, pp. 240, 361. J JaCQUOT, 185S, pp. 185, 201. 150 TYPHUS FEVEE. ammonia. In many cases the relaxed stools contain numeroua. crystals of ammoniaco-magnesian phosphate.^ /. Morbid Phenomena referable to the Urinary System. I. The urine -undergoes important changes in typhus. The quantity varies with the amount of fluid ingesta, and according to the amount of fluid got rid of from the body by other channels ; but during the first week, it is diminished sometimes by one-fourth or one-half, notwithstanding the dry- ness of the skin and the large amount of fluids drunk. There appears to be an absolute retention of water in the system. In the advanced stage of severe cases, there is occasionally com- plete suppression of urine ; but more commonly, the quantity increases in the later stages. I have repeatedly found a large quantity of pale, limpid urine, of low specific gravity, passed during the typhoid stage. With the commencement of con- valescence, the quantity is sometimes greatly increased. The colour is usually dark in the early part of the disease,. and may continue so until the crisis. When the urine becomes scanty in severe cases, it may have a dirty brown colour, and. deposit a copious sediment containing altered blood and renal, epithelium. At the commencement of convalescence, often be- fore, but sometimes later, when the quantity increases, the urine may be pale and limpid. The specific gravity varies with the amount of water and with the stage of the disease. In the early stage, it is usually high (1024-30) ; but as the disease advances, it gradually falls. With convalescence there may be a sudden fall ; the density may then for several days be under loio; but this character is far from constant. The acidity is marked in the early stage ; but in the second week it becomes more feeble, while sometimes the urine is neutral or alkaline, and deposits phosphates. The total amount of urea voided daily in the urine has been investigated by Parkes ' (i case), myself (3 cases), Spanton™ (2 cases), Buchanan" (16 cases), Keith Anderson" (6 cases), SquareyP (17 cases), Eosenstein'i (16 cases), and Eussell and Coats ^ (4 cases). As might have been expected, the absolute. ^ Paekes, 1850, p. 396. ' Ibid. 1857, and On the Urine, i860, p. 258, "^ Spanton, 1864. "Buchanan, 1866. ° K. Andehson, 1866. p Squarey, 1867^ •» EosENSTEiN, 1868. ' BussELL and Coats, 1869. SYMPTOMS. 151 quantity is subject to great variations, dependent on the age and weight of the patients, the stage and symptoms of the disease, and the food and remedies employed. Making allowance for these sources of difference, the ascertained facts may be summed up as follows : i. The quantity is in the first instance always increased, notwithstanding the diminution of food. This in- crease is on the whole proportionate to the intensity of the fever, subject to variations according to the quality and quantity of the ingesta, &c. * Taking one case with another,' says Dr. Buchanan, * the daily quantity during the first week — the patient being fed on low diet, milk and beef-tea— may be stated as about double that of the fourth week, when he is sitting up and eating his fill of meat.' In one patient under my care whose urine was examined by Squarey, the quantity of urea on the 5th day was 851 and on the 12th day 1,011 grains. In three of Eussell's cases the highest quantity in one day was 910, 865, and 792 grains. 2. In the second week of typhus there are great differ- ences in the amount of urea. In some cases it remains large until the crisis, when it gradually, or it may be rapidly, falls. Under these circumstances, there may be much fever, but typhoid symptoms are rare. More commonly, in spite of the persistence of fever, the quantity of urea is less than in the first week, and it may even fall much below the normal standard. For example, in one of Eosenstein's cases, the urea, which on the 5th day amounted to 796 grains, fell on the 9th day to 105 grains.^ This diminution is no doubt due in part to the protracted low diet, and corresponds with the reduction of urea observed by Voit and others in fasting animals. Consequently, the diminu- tion will be greatest when the amount of nitrogenous matter in the food is least, and it may be prevented by feeding the patient on large quantities of strong beef-tea. For example, Dr. Buchanan found that in the same patient the quantity of urea was much greater when he was fed on strong beef-tea, than when the diet consisted solely of milk. The low diet, however, is not, as Kosenstein contends, the sole cause of the reduction of urea. In many cases, the urea which is formed is not all eliminated. Many observations point to this conclusion. Thus the quantity » This may account for Haller's statement that the urea in typhus is dimin- ished, but I have seen no account of his experiments (Haller, 1853). M. BarraUier concludes from observations on the urine of prisoners suffering from typhus in the hulks at Toulon, that there is a progressive diminution of urea from the earliest stage (Barrallier, 1861, pp. 141, 251, and 366). He does not, however, seem to have ascertained the absolute amount of urea, but only the proportion in 1,000. parts of urine. 152 TYPHUS FEVEE. may be suddenly increased by certain medicinal agents. In one case wliere the amount of m-ea was remarkably regular from day to day and averaged 530 grains, Parkes found that on one day, after giving 1 20 grains of extract of coffee, it suddenly rose to 723 grains. Secondly, when there has been a great fall in the amount of urea during the second week, the quantity often rises for a few days before and after the crisis, this rise, more- over, being often antecedent to any increase or change in the diet. In Eosenstein's case, already quoted, the urea, which had fallen to 105 grains on the 9th day, rose to 185 grains on the nth, and to 317 grains on the 12th day, before there had been any increase in the diet. In one of Squarey's cases the urea, which on the fifth day amounted to 851 grains, gradually feU, till on the nth day it was only 499 grains, but on the 12th day it rose to 1,011 grains. Thirdly, the retention of urea in the body is further shown by its presence in the blood and cerebral fluid of fatal cases. 3. For a variable period during the com- mencement of convalescence, notwithstanding the increase of food, the urea is much diminished in quantity, and it rises again to the normal amount as the patient regains his health and strength. As in other febrile conditions, the increased formation of urea, notwithstanding the diminished supply of food, is evidently the result of disintegration of the nitrogenous tissues. (See p. 15.) As long as the urea continues to be eliminated by the kidneys, no harm results ; but if the quantity exceed the capabilities for elimination of healthy kidneys, and still more, if, from any morbid condition of the kidneys, either antecedent to, or result- ing from, the febrile attack, its elimination be interfered with, it accumulates in the blood and gives rise to ursemic (tj^phoid) symptoms. If the urine be completely suppressed, as may happen, death speedily ensues under symptoms of coma, some- times with uraemic convulsions ; but if the elimination be less complete, it may still give rise to delirium, stupor, and coma. Indeed, it is very possible that these symptoms, so characteristic of typhus, are in a great measure due to the presence of urea, or some other derivative of albumen in the blood. (See page 19.) This supposition is confirmed by the ammoniacal odom- given off by the skin. But, what is more to the point, urea has been repeatedly found in the blood of persons dying of typhus with marked cerebral symptoms, even although there have been no disease of the kidneys and no diminution in the amount of urine. This was proved to be the case in 1844 by Mr. Michael SYMPTOMS. 153 'Taylor. A man, aged fifty-three, died on the twelfth day of an attack of typhus ; the eruption was well marked. Death had been preceded, for four days, by stupor and muttering delirium. Some hours after death three pints of urine were drawn off by catheter. After death the kidneys were found perfectly healthy — not even congested — and urea was discovered, in considerable quantity, in the blood removed from the heart and large veins.* In five fatal cases of typhus, in which there had been severe cerebral symptoms and in two convulsions, I examined the blood- serum and cerebral fluid for urea, and found it in all." Dr. J. B. Eussell also found urea in the blood of every one of four fatal cases of typhus.'' Christison records a case of typhus fatal on the tenth day from sudden coma and convulsions, where urea was found in large quantity in the serum of the blood, the kidneys, with the exception of congestion, being healthy."^ Hudson re- lates the case of a man who died of convulsions on the tenth day of typhus ; urea was found in the blood from the heart, and there was albumen in the urine."" Frerichs records cases of both tjTphus and enteric fever, in which death occurred from ursemia.^ Lastly, the observations made in relapsing and enteric fevers also support the opinion that the head-symptoms in typhus are due, not to inflammation of the brain or membranes, as was once believed, nor to the presence of the original fever-poison in the blood, but to the circulation through the brain of urea, carbonate of ammonia, or other products of retrograde meta- morphosis. The uric acid is also usually increased. Parkes, in one case, iound it 'in large amount,' but Buchanan, in another, found it not to exceed the normal quantity. Crystals of uric acid are often deposited spontaneously, and as a rule are thrown down in large quantity on the addition of nitric acid. Salts of uric acid, in the form of lateritious sediment, occur at any stage of the disease ; they are not necessarily critical, but I have observed them mostly within the first four or five days, or towards the termination of the disease, especially in cases with complications, or where the typhoid state has been well marked. The chlorides gradually diminish from the first, and by the eighth day they are reduced to a mere trace, and in severe cases they may be entirely absent. They reappear or increase before convalescence without any change in the diet. The diminution ' Tatloe, 1844. ° For details of four of these cases, see pages 174, 182, " KussELL, 1864, p. 355. * Christison, 0?i Gramtlar Degen. of Kidneys, -p. 167. ^ Hudson, 1857, p. 298. y Feeeichs, Die Brightsche NierenkrcmJc. p. 210. 154 TYPHUS FEVER. is not altogether due to the reduced quantity of salt in the food,, for Buchanan ascertained that, after administering as much as twelve drachms of salt by the mouth, about the eighth day of the fever, scarcely a trace of chlorides could be discovered in the urme for several days, but that when the salt was given just before convalescence it freely passed out by the urine. (See also Case II. p. 126.) Examination of the blood also showed that the chlorides did not accumulate in it. The patient on whom these results were obtained had no pulmonary complication and no diarrhoea. It would seem that either the power of absorbing chlorides is impaired, or that, as in the case of pneumonia, there is an absolute retention of them in the tissues. Whatever be the explanation, the absence of chlorides from the urine is not pathognomonic of pneumonia, as has been imagined.^ The excretion of jpliosplioric acid in the urine, according to Eosenstein, is not affected by typhus, except in so far as the quantity is diminished in the advanced stage of the disease, owing to the inanition. The quantity of sulphuric acid was found by Parkes in one case rather high. Albumen is not uncommon in the urine of typhus. Dr. G. W.. Edwards came to the conclusion that the urine almost always. becomes albuminous at an early period. Of 14 cases in which he tested the urine, between the sixth and eighteenth days, albumert was present in all ; of 2 cases examined on the sixth day, there was albumen in i ; and of 6 cases examined on the seventh day, it was present in all. One of the cases died, and in the remain- ing 13 the albumen disappeared between the fourteenth and eighteenth days. In 6 other cases, where the urine was tested after the twentieth day, no albumen was found. The quantity of the albumen was in some cases abundant, especially at its first appearance, and as long as it was present the specific gravity was usually low.'' Dr. Sidey found albumen ' in a very large proportion of cases of typhus ' in Edinburgh ; it occurred invari- ably towards the crisis of the fever, and in many cases on the sixteenth day of the disease.'' Albumen was present in 12 out of 1 8 cases examined by Squarey at the London Fever Hospital in 1866. Oppolzer noticed albumen in most cases of exanthe- matic typhus, and sometimes tube-casts also; the amount of albumen was often as great as in Bright's disease. *= Eosenstein ' See, for example, Bennett, Princip. and Pract. of Med. 2nd ed. p. 638. » Edwabds, 1853. »> Br. mid For. Med. Cliir. Rev. July 1853, p. 59. ■ Schmidt's Jahrbzich, 1857, No. n, p. 256. SYMPTOMS. 155 discovered albumen in 6 (2 fatal) out of 16 cases. Austin Flint found albumen in 7 out of 9 cases in America ; in 3 it was pre- sent on the first or second day : of the others, where it was not looked for until later, it was found on the sixth day in 2 ; on the tenth, in i ; and on the fourteenth, in i ."^ Da Costa, in Penn- sylvania, met with albumen in 8 of 2 1 cases ; excepting one, in which the quantity was very minute, the 8 cases were severe and 4 were fatal.® Moermg found the urine very often albuminous in the typhus of the Crimea ; ^ and Barrallier found small quantities of albumen in the advanced stages of typhus at Toulon.^ Cases of typhus with albumen in the urine as early as the eighth day are recorded by Drs. G. Johnson ^ and Gull.^ On the other hand, Buchanan found albumen in only 2 (both fatal) out of 1 5 cases ; Wunderlich in only 4 out of 49 cases of exan- thematic typhus .J During the spring of 1862 I tested the urine daily for albumen in 28 cases of typhus, from about the sixth to the twentieth day of the disease. The cases were not selected ; but the nurse was told to keep the urine of every patient admitted into hospital with a distinct typhus-rash. In 8 of the cases no trace of albu- men was ever present. All of these cases were mild ; none of them presented the typhoid stage well marked, and all recovered. In 20 of the cases, or 71 '4 per cent., albumen was present in greater or less quantity ; and of this number, 5, or 25 per cent., died. In 1 1 of the 20 cases the quantity of albumen was very slight, and in most cases it was transient, lasting only for a day or two about the termination of the disease ; one of these patients died on the ninth day of the attack, the rest recovered. In 9 cases the albumen was in considerable quantity, and lasted for several days ; in some of the cases it appeared as early as the seventh day, and lasted until death or recovery. All of these cases were severe ; in all the typhoid state was well marked, and 4 of the 9 cases, or 44*4 per cent., died. In most, if not all, the cases here analysed, the albuminuria was obviously induced by the febrile attack, and was not the result of any previous renal disease, for it was ascertained to commence during the attack, and in the cases that recovered it ceased with convalescence. It would therefore appear that in severe cases of typhus, the urine, as a rule, at some time contains albumen, and that when the albumen ^ Flint, 1852, p. 334. = Da Costa, 1866. ' Jacquot, 1858, p. 203. 8 Baeealliek, 1861, pp. 251, 367. '' Johnson, 1862. ' Gull, Med. T. and G. Ap. 5, 1862. J Parkes, On the Urine, i860, p. 260. 156 TYPHUS FEVEE. appears early in the disease, or the quantity is large, the danger to the patient is correspondingly great. Although albuminuria in typhus is occasionally the result of previous disease of the kidneys, it is oftener due to simple hypersemia and the altered condition of the blood, or to actual disease of the renal tissue induced by the febrile attack. I have often discovered epithelial casts, or sometimes even blood-casts, in the urine along with albumen. In many instances, also, where death has occurred during an attack of typhus, I have found the kidneys present all the characters of acute nephritis (see Case IX., p. 174), while in many others, where there has been no pre- vious history of renal disease, but where death has been due to complications during convalescence from typhus, I have found the kidneys much enlarged (in one case each kidney weighed 8 ounces), smooth and pale, with the capsule non-adherent, the €ortex hypertrophied, and the tubes gorged with granular epithe- lium. Dr. G. Johnson mentions two cases, where the kidneys became diseased during convalescence from typhus, one of which proved fatal.'' But, whether the albuminuria result from simple hyperaemia, or from more serious disease of the kidneys, antece- dent to, or consequent on, the attack of typhus, it usually shows that there is an obstruction to the channel by which the exces- sive amount of urea and other products of retrograde metamor- phosis are eliminated from the system ; and, accordingly, the danger increases with the extent and duration of the obstruction, as indicated by the quantity and date of appearance of albumen in the urine. The occurrence of blood in the urine is a still more dangerous sign. Possibly, in some cases, the albumen in the urine may be due to the blood containing an excess of that substance derived from the disintegration of the tissues, which the glandular structures have been unable to convert into urea. Epithelium and Tuhe-Casts. — In most cases the urine throws down a mucous cloud containing a quantity of vesical epithelium, sometimes mixed with renal epithelium and casts of the urini- ferous tubes. Leucine {G^^ Hjg NO4) and Tyrosine (Cig H,i NOg), two pro- ducts of the disintegration of albumen or fibrine, of a more complex character than urea, have been detected in the urine of typhus by Frerichs, and by myself. (See Jaundice, under Com- plications.) In most of the cases where they have been found,. '' Diseases of the Kidney, 1852, p. 74. SYMPTOMS. 157- there has been some morbid change of the liver, and the urine^ has Hkewise contained bile-pigment and the bile-acids.^ Sugar was found in the urine of 9 out of 14 cases of typhus by Dr. Buchanan ; but the quantity was small and its presence temporary and probably of no clinical significance. 2. Retention and Incontinence of Urine. (See SymjJtoms under Nervous System.) g. Morhid Phenomena referable to the Nervous and Muscidar Systems. 1 . Head-ache is one of the first and most constant symptoms of typhus. Of 92 cases, noted by myself in 1856, head-ache was complained of in all but 6. Henderson found it in 150 out of 1 59 cases at Edinburgh : in 92 out of 108 cases it was present on the first day ; its mean duration was ten days."^ Stewart noted head- ache after the fifth day in 98 out of 1 39 cases at Glasgow ; this number was exclusive of the cases in which the head-ache had ceased before the fifth day."^ The head-ache is always most severe during the first week ; it often lasts only a few days, and usually it ceases, or greatly abates, with the advent of delirium about the eighth day. In rare cases (i in 12-5, Stewart), mostly those in which there is no delirium, it is continued through the whole course of the disease. After the complete cessation of the head-ache, the patient may continue to complain of pains in other parts of the body. The seat of the pain is most often in the forehead or temples ; at other times it is general ; it is rarely confined to the vertex or occiput. The severity of the pain varies. In some patients, especially the young and plethoric, it is intense, and for a few days, it is the most prominent feature of the malady ; in most it is comparatively slight. The character of the pain is usually dull and heavy. The patient is often unable to define it. It is rarely described as darting, stabbing, throbbing, or bursting. 2. Vertigo. The head-ache is, in most cases,''accompanied by more or less giddiness, which is aggravated by sitting up, and increases with the progress of the disease. 3. Pains in the Back and Limbs are usually present from the first. As a rule, they cease about the end of the first week, but, • Fkeeichs, Diseases of the Liver, Syd. Soc. Transl. i. 168, 205 ; and Pabkes, On the Urine, i860, p. 191. =° Hendekson, 1839. ° Stewart, 1840, p. 306. 158 TYPHUS PEVEE. they are often complained of after the (5'essation of head-ache, and they may recur with some severity during convalescence. The pain in the back is of a dull, heavy character, and rarely approaches in severity to that which precedes the eruption of small-pox. The pains in the limbs resemble those resulting from bruises, or sometimes they are likened to cramps ; they are usually more severe than the pains in the back, or even than the head-ache ; occasionally they are articular and may be mistaken for rheumatism. 4. Impairment of the Mental Faculties. — Delirium. The mental faculties are almost invariably more or less affected in the course of typhus. It is only in exceptional cases of a mild nature that there is not some mental confusion, while in the majority there is actual delirium. Hence it is, that typhus is often denominated 'brain fever.' (See Synonyms, -p. 24.) The frequency and character of these symptoms, however, vary at different times and places, and are much influenced by the previous habits and condition of the patients. When typhus attacks persons in the upper classes of society, or the intem- perate, or the subjects of mental anxiety and fatigue, the de- lirium and impairment of the mental faculties are more con- stant, earlier in their development, and more marked. Of 90 cases noted by myself at the London Fever Hospital, the mental faculties were impaired in 78, or in 86*6 per cent., while in 52, or 57*7 per cent., there was delirium. Of 198 cases observed by Henderson at Edinburgh in 1838-9 there was delirium in 48, and in most of the others there was confusion or sluggishness of mind." The severity of an uncomplicated case may be measured by the degree of mental aberration and delirium. Of 1 1 fatal cases (included in the above 90) I noted great delirium in 10 ; in the remaining case, the primary fever was comparatively mild, and death resulted from complications during convalescence. Of 43 fatal cases recorded by Jenner, delirium (28 cases), or mental confusion only (14 cases), was present in all but one patient, who survived the primary fever and died of secondary phle- bitis.P In most cases it is towards the end of the first week that the mental faculties become blunted and confused ; the patient hesitates and looks stupid when spoken to ; he can give no account of his illness ; he forgets how long he has been in the ' Hendeeson, 1839. p Jenner, 1849, No. 2. SYMPTOMS. 159 hospital ; or he is even ignorant of where he is, while he is in- different to all that is passing around, and does not like to be disturbed. At the same time, there are often much moaning, restlessness, and talking in the sleep. In mild cases, this state of mental obfuscation may never be exceeded, but more commonly it is followed by delirium. Delirium does not usually come on until the end of the first, or the beginning of the second, week. Sometimes it does not commence so early : it may supervene at any time during the second week, or it may precede the crisis merely by a day or two. On the other hand, it may commence much earlier. I have had several patients under my care, who were seized with active delirium on the first night of the attack ; in more than one, the case was at first mistaken for mania. In my own first attack, delirium set in on the morning of the second day and lasted for twelve days. Jacquot^ and Barrallier "■ both mention cases where delirium came on during the first night. Of 1,005 patients •observed by Barrallier at Toulon, the delirium appeared during ihe first week in 371, during the second in 602, and during the ihird in 32. At first, the delirium shows itself at intervals during the night, or it lasts all night, and by the morning it may have -ceased entirely, again to return on the following evening and last ihrough the night. It is surprising how rational persons may seem during the day, who in the night are very delirious. By- a.nd-by, the delirium becomes more continued, but, as a rule, it is worse at night ; or, what is very commonly the case, the patients are wakeful and delirious at night, stujDid and drowsy in the day-time. After the delirium has commenced, it continues more or less until death or convalescence, provided it be not succeeded by great stupor or coma. With convalescence it ceases ; but in several cases I have known it persist for several days after the pulse and temperature had fallen to the normal standard and there was a general improvement in the other symptoms. Now and then maniacal, but temporary, delirium comes on suddenly after convalescence is completely established. There is no relation between the head-ache and delirium. In most cases, the former has ceased before the commencement of the latter — a feature of no small importance as regards diagnosis from cerebral inflammation. The character of the delirium varies greatly. Most com- ' Jacquot, 1858, p. 164. ' Babbailiee, 1861, pp. 231, 360. l6o TYPHUS FEVEE. monly it is of a low form — the ' typhomania' of Galen and' early writers/ The patient lies quietly, moaning or muttering incoherently, but he is at first easily roused so as to give coherent answers ; or he is restless, irritable, and sleepless, and answers in a rambling, incoherent manner ; ultimately, in either case, he becomes torpid and more or less unconscious. A second form of delkium is of a busy character, and more or less approaches the ' delirknn tremens ' of the drunkard. The patient is extremely prostrate, but at the same time restless and fidgety ; he sleeps badly, or not at all ; he moves about in bed, or he tries to get up, with apparently no definite object ; the pulse is quick and feeble ; the cardiac impulse is weak, the- skin is moist, and there are tremors of the limbs and tongue. Or, thirdly, the delirium is of an acute and noisy character — the 'delirium ferox' of some writers. The patient does not sleep ; but rolls his head from side to side, obstinately refuses drinks, shouts and screams incessantly, and makes constant attempts to leave his bed and roam about. His muscular- power is often surprising; he will lift heavy weights, and it may require several strong attendants to keep him in bed. At the same time, the pulse is rapid, full, and sometimes of good strength ; the cardiac action is violent ; the skin, hot and dry ,- the face, flushed ; the conjunctivae, injected ; the eyes, intolerant- of light, and the ears, of noise ; the physiognomy, bold and excited. In this state, patients often exhibit a suicidal ten- dency. Very often they attempt to throw themselves from a: window, and fatal consequences occasionally result from their succeeding.* One of my patients cut his throat with a piece of glass ; a second jumped out of a window ; a third, after bruis- ing her head severely with a hammer, endeavoured to strangle herself with a rope ; while a fourth, seizing a favourable oppor- tunity, rushed out of bed in his shirt and escaped into the street. Barrallier mentions the case of a patient, who inflicted a deep, gash in the hypogastric region in endeavouring to amputate the- penis." Bell alludes to a patient, who, fancying that a robber, was up the chimney, rose and attempted to climb up, but fell covered with soot and with his forehead cut against the fire-irons."" Among the French troops in the Crimea it was not uncommon, to see patients, in this state, running delirious over the fields ; '^ " The definition of typhomania, given by many of the early writers, is :_ ' affectus . ex phrenitide et lethargo mixtus.' Forestus defined it as ' genus delirii cum levi furore mixtum.' (Foeestus, 1591, ed. 1653, p. 239.) « See, for example, Eoupell, 1839, p. 176. » Baeralliek, 1861, p. 230. ■' Bell, i860, ix. 38. " Bakealliee, 1861, p. 83- SYMPTOMS. l6l and hence, we can understand the statement, m the account of the Oxford ' Black Assize,' that : * Some leavmg then- beds, occasioned by the rage of their disease and pain, would beat their keepers or nurses and drive them from their presence ; others, like madmen, would run about the streets, markets, lanes, and other places ; and some again would leap headlong into deep waters.' ^ This acute form of delirium is very apt to be followed by profound prostration, or fatal collapse; at other times, it gradually passes into the first form, or typhomania. On the other hand, typhomania, after lasting for several days, is, in rare cases, succeeded by ' delirium ferox.' Every possible gradation between these typical forms of deli- rium may be encountered. The acute, noisy delirium, however, is comparatively rare. In the Philadelphia epidemic of 1836, according to Gerhard, the delirium was only acute and noisy in one patient out of 20.^ Of 43 fatal cases observed by Jenner, Only 7 (or 16 per cent.) attempted to leave their beds and roam in the wards.'^ Of 90 cases noted by myself, delirium occurred in 52, but only in 8 was it acute. The frequency of acute deli- rium, however, depends in great measure on the pursuits, habits, and constitution of the patient. In the poor and badly-nourished, and likewise in the aged, whom typhus chiefly attacks, the deli- rium is almost always low and muttering from the first ; whereas, in the young and robust, and still more in persons in the upper class, it is often acute. The mental state of the delirious typhus-patient is peculiar, and well worthy the study of the metaphysician. As a rule, the memory is first and most affected ; judgment and power of con- nected reasoning often remain after the memory has entirely gone. The mind may labour under the strangest delusions, and often it appears to revolve obstinately around some fixed idea. The patients rave about objects which have greatly engrossed their attention, either immediately preceding the attack, or years before, and which are now jumbled with persons, scenes and events with which they have had no connection. At other times their ravings are centered on some article of furniture in the room, or upon their attendants, whose acts of kindness are occa- sionally construed into cruelty. In some cases, they are gay and jovial ; in others, they pass through intense mental distress, of which a lively recollection is entertained after recovery, although sometimes all that passes is buried in oblivion. During a few == Bancroft, 181 i, p. 655. y Gekhard, 1837, xx. 293. ^ Jenner, 1849, No. 2. M 1 62 TYPHUS FE^'EE. hours, some patients feel as if they had hved a lifetime ; and, as a rule, time appears to the patient greatly prolonged ; he almost invariably exaggerates the duration of his Ulness. In my first attack, my constant raving was about some rare plants which I had gathered a few months before on the Grampian Hills ; in my second, I conceived a gi-eat dislike to my nurse and to a valued friend, because on one occasion they had tied me down in bed. Somehow or other, these two individuals became mixed up with many events of my previous life ; they were constantly shutting mie up in dungeons from which I effected my esca]3e ; and my conviction was so firm that they intended to murder me, that on several occasions I shouted : ' Police ! police ! ' I travelled in my imagination to France, Italy, India, Burmah, and many other parts of the world, which I had reaUy visited, trying to escape from them ; but at every new place I arrived at, there these watchful demons were before me. Hildenbrand records his experience as follows : ' During an attack of typhus, my mind was constantly engaged in removing an awkward ornament from my stove, which stood dhectly opposite to me ; and being of course unable to move it, it tormented me in the most cruel manner. One of my pupils, having assisted a short time pre- viously at the opera called the " Mhror of Arcadia," performed dm'ing the whole of the nervous stage of typhus the character of viper-catcher ; and as he was obliged to swallow these disgusting reptiles, he experienced the most inexpressible anxiet5^ Another XDatient laboured under the painful and fantastic idea, that he was not only suffering for himself, but for all his comrades in the ward.' * Dr. Pickels, in his account of one of the great Irish epidemics at Cork, observes : * A cowherd, who had come from the country, fancying those patients who lay around him were the animals whom he had been accustomed to attend, endeavoured at intervals to rouse them into motion by a particular cry, which is usual for this purpose in the country. A thief raved of his thefts and accomplices. A faitbful steward refused, with many acknowledgments, to take his wine, as he had bis master's keys, and it might render him unfit to perform his business.' ^ Jacquot states that one of his patients chanted vespers for hours at a time, and also preached a sermon of an hom-'s lengtb, which the nurse could follow with tolerable ease ; another fought with the Piussians ; another gave commands to his troop ; another fancied that he was the King of Spain and tbe Bisbop of Lyons ; • HiLDEXBEAXD, I81I, p. 72. '' See B.URTLETT, 1S56, p. I90. SYMPTOMS. 163 :another burst into laughter when spoken to, and was constantly ■expressing his desire to go to sleep with the coffee-mill ; in two instances there was hydrophobia, although in other respects the patients were rational ; while two other patients, both medical men, fancied that they were each subdivided into two persons, one of whom was in good health, and commiserated the unfor- tunate lot of the other who was ill.° Pioupell mentions the case of a female, who, for ten days, believed that she was dead, and refused to speak, except to request that she should be buried.*^ Dr. Gueneau de Mussy has favoured me with the following interesting account of his sensations, during an attack of typhus caught on a visit to Dublin in 1 847 : — ' I first imagined that I had committed a murder in France, and that I had made my escape to England. Extradition, how- ever, had been granted against me, and having the power of flying, I soared through the air, uttering dreadful screams and trying to conceal my face with my arms and hands, in my endea- vour to escape from a party of soldiers who were pursuing me in a balloon and firing at me. I afterwards ascertained from the records kept by my medical attendants, that whenever I could escape from them I ran about the house, with screams and gestures indicative of profound terror. The explanation of all this was, that on the day before my confinement to bed I had heard of a murder committed by a gentleman on his wife, and that on the morning of the same day I had witnessed the ascent ■of a balloon carrying four soldiers. I substituted myself for the murderer, and the armed men in the balloon for the soldiers ordered to take him in charge. Then my delusion took another turn. I imagined that I was tied down in bed, and, though feeling no pain, I believed that I was gradually being consumed by spontaneous combustion, while some young women dressed as opera-dancers, were taking water from a pond near my bed and pouring it over me. With rhythmic movements, as my own destruction was going on, my sight grew confused, and my last thought at this time was that my brain was being consumed. This condition probably corresponded to another period of three days, during which I appeared to my attendants to be quite unconscious. These illusions were interrupted by others of a more transient nature. For instance, at the time I was being consumed by fire, I saw distinctly the facade of a friend's house at Paris in a state of phosphorescence, and one of his children Jacquot, 1858, p. 190. ^ EouPELL, 1839, p. 173. M 2 164 TYPHUS FE"\^K. suspencled hj the neck from a ^yindow. Another friend I saw killed in the street ; and so strong was this last impression, that during my convalescence, notwithstanding assertions to the con- trary, I often repeated that this friend was dead, and felt great concern about his loss. On my return to Paris, I made a point of seeing him immediately, in order to be convinced that he was alive. Sometimes I mistook my attendants for other persons who were absent ; and, after my recovery, I offered my thanks to a lady of Dublin, whom I believed to have been one of my nurses. But, during this delirium, I was not altogether uncon- scious of certain circumstances that occurred, and which are still fresh in my memory. Thus I remember, I may say I can hear, my poor friend, Dr. Oliver Curran (who died shortly after of typhus which he caught at my bedside), reading the Scriptures,, and I felt comforted by his brotherly love.' 5. Wakefulness, Somnolence, Coma-vigil. During the first- two or three days the patient is sometimes heavy and drowsy, but usually until about the tenth day there is more or less wake- fulness, at all events at night. The sleep is broken and disturbed,, or, for several nights, there may be none. This wakefulness may persist throughout the disease; and the first sign of" amendment may be the patient falling into a quiet natural sleep. I have noted wakefulness, to a greater or less extent, in 78 out of 92 cases. It is well to add, that a patient not unfrequently awakes from a sleep of several hours' duration, and insists that he has never closed his eyes, and may dispute the point with some vehemence, although in other respects perfectly rational. This condition is the coma-vigil of Chomel ® and of some other- writers. But in most cases (in 57 of 92), after a period of wakefulness and nervous excitement, or occasionally without any wakefulness preceding, the patient sooner or later, but usually about the middle of the second week, falls into a state of somnolence, more or less profound. He lies on his back quiet and motionless, and' with eyelids closed ; if spoken to, he opens his eyes and attempts to put out his tongue, and immediately relapses into his former lethargy. As a rule, from which there are few exceptions, this state of somnolence is preceded by more or less delirium. In grave cases, somnolence may pass into complete coma, which, usually, after a few hours, or sometimes days, terminates- in death. Patients, however, do often recover after having been " Chomel, 1S34. syjmptoms. 165 :for several clays in a state of profound somnolence approaching to coma, from which it is impossible to rouse them. Now and then, coma makes its appearance suddenly and unexpectedly, without any antecedent somnolence, and then it will usually be found that the urine is albuminous, scanty, or even sup- pressed. There is another condition to which the term coma-vigil is more appropriately applied, but which differs from the coma- vigil of Chomel in having the most ominous import. According to Sir W. Jenner's definition, this is that peculiar condition, in which the patient lies with his eyes wide open, gazing 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 cold and bathed in perspu-ation. He is evidently awake, but he is indifferent and absolutely insensible to all going on about him. This condition may, or may not, supervene upon somnolence ; it is invariably fatal. In 9, or in more than one-fifth of Jenner's 43 fatal cases, coma-vigil was observed from one to four days before death.^ 6. Prostration. Loss of muscular strength is one of the earliest and most characteristic features of typhus. In almost every case, there is more or less prostration from the first, the patient being at once struck down, so to speak, by the disease. This early and great prostration has been insisted on by all who have had much experience in true typhus. Pickels, in his report of an epidemic at Cork, observed : ' The debility was such that the patient was unable from the first to rise from the bed or to walk without assistance, and in some instances, even without the effort of rising, fainted in bed.' ^ On the second or third day of the disease the patient is compelled to take to bed, and before the end of the first week he is usually brought to hospital. Of 64 cases, I ascertained that the patients took to their beds on the first day in 22, on the second day in 28, on the thkd day in 10, on the fourth in 2, and on the sixth in 2. Agam, of 600 patients under my care in the Fever Hospital, 401 (66-83 per cent.) had not been ill more than seven days, and 115 (ig'i6 per cent.) not more than four days before admission ; not one had been ill longer than fourteen days. The mean duration of all the cases before admission was 6-99 days. Of 149 cases under Dr. Craigie at Edinburgh, 125 (or 84 per cent.) were admitted Jennek, 1849. *=' Baktlext, 1S56, p. 196. 1 66 TYPHUS FEVER. into the Infirmary on, or before, the eighth clay.^ Of 27 fatal. cases recorded by Jenner, all were confined to bed by the sixth day.^ As a rule, the prostration increases as the disease advances, until about the tenth or twelfth day, when it is extreme, the patient being perfectly helpless and unable to assist himself in any way. Out of 90 cases, I noted this extreme prostration in more than one-half. In 34 of Sir W. Jenner's 43 fatal cases, this extreme prostration was noticed, and in most it came on. between the ninth and the twelfth day of the disease. The prostration is always very great in those cases where there has been violent delirium, the strength being exhausted by the extraordinary efforts called into play during the stage of excite- ment. Sometimes there appears to be little loss of strength during the first six or eight days of the disease, and then extreme prostration sets in suddenly and may prove rapidly fatal. This form is chiefly observed in persons who have struggled against- the disease and followed their ordinary avocations for several days, and hence the importance of husbanding the strength from the first. In most cases, the patients are not only weak, but complain from the first of 2i feeling of great weakness and lassitude. 7. The Decubitus is in most cases dorsal. Except where^ there are restlessness and active delirium, the patient lies on his back, with his arms extended along the chest and the forearms> slightly flexed, the hands resting on the hypogastric region and sometimes interlaced. As the prostration increases, the head sinks from the pillow, and the whole body gravitates towards the bottom of the bed. 8. Muscular Paralysis. In addition to the general loss of power in the muscular system, there are certain muscles which often become entirely paralysed about the tenth or twelfth day. In most severe cases there is paralysis of the neck of the bladder and of the sphincter ani, causing involuntary discharge of urine and f£eces. The urine constantly dribbles away, soaking the bed-clothes and irritating the skin. At other times, owing to paralysis of the coats of the bladder, there is retention of urine, and recourse to the catheter is necessary. Neglect in such cases, may lead immediately to ursemia and convulsions, or more rem otely to catarrh and ulceration of the bladder. It must not. '' Ceaigie, 1837, No. 2. p. 32S. ' Jenner, 1S49, No. 2. SYMPTOMS. 167 be forgotten that retention and incontinence may co- exist, the urine dribbling away from an over-distended bladder. Con- sequently, in all cases of typhus, with great nervous prostration, the physician must not be satisfied by being told that the patient makes water, but must examine the hypogastric region daily by palpation and percussion. Out of 90 cases, I found that the stools and urine were passed involuntarily in 1 8, and the urine only in 29, while in 5 cases there was retention of urine. Of 50 cases in which there was involuntary discharge or retention of urine, 10 died ; while of 40, where these symptoms were absent, only I died. Of Jenner's 43 fatal cases, there was retention or involuntary discharge of urine in upwards of one-half, and involuntary discharge of faeces in 17 cases. The meteorism already alluded to, the occasional dysphagia, the inarticulate speech or complete aphonia, and the inability to protrude the tongue, all indicate paralysis of different parts of the muscular system. Of these symptoms, the worst is dys- phagia, which is usually the forerunner of death. Occasionally, the orbiculares muscles appear to be para- lysed ; the patient is unable to close his eyelids, and ulceration and sloughing of the cornese may result from the constant ex- posure. 9. Muscular Agitation. In few severe cases is some degree of tremulousness of the hands and tongue not observed during the second week. Occasionally, the entire body is in a constant state of tremulous agitation, which is increased when the patient is spoken to or in any way excited. Of 90 cases, I have noted great tremulousness in 12. The symptom is most developed in the aged and infirm, or in persons who, previously to their attack, have been much addicted to spirituous liquors, or been subjected to mental labour. It always indicates great pros- tration. In a few cases, I have observed rapid oscillatory move- ments of the eye-balls, or motions of the extremities resembling those of chorea. Subsultus tendinum and spasmodic twitchings of the face are observed in many severe cases. The tendons at the wrist are those most frequently affected. When the twitchings attack the face, one angle of the mouth is usually drawn up. Jenner alludes to two instances, in which the spasmodic action of the inferior recti muscles of the eyes and of the levatores palpe- brarum gave a peculiar aspect to the countenance ; in both cases, the movements were excited at any moment by suddenly raising either arm. In one of my cases, and in one of Barrallier's, 1 68 TYPHUS FEVER. there T^'ere well-marked choreic convulsions.J Another modi- fication of these spasmodic movements is picking or fumbling with the bed-clothes, or what is called Floccitatio or Carpliology. The hands are extended in every dh'ection, above the head and outside the clothes, while prehensile movements are exercised with the fingers, as if the patient desu-ed to draw towards him some imaginary object. Obstinate hiccup, often associated with great meteorism, is another symptom occasionally met with. All of these sjTiiptoms are of grave import, particularly sub- sultus, carphology, and obstinate hiccup. Many patients, how- ever, recover, notwithstanding the occui-rence for several days of subsultus, carphology, and general tremors. 10. Muscular Bigidity. Contraction and rigidity of certain muscles are observed more rarely, and only in severe cases. The fingers may be tightly clenched, or the fore-arms flexed, or in rare cases there is trismus or strabismus. In twelve cases, I have observed tonic spasms of many difterent muscles. Twice I have seen the legs and thighs so bent that the knees ahnost touched the chin ; both patients died. M. Godelier observed catalepsy in one case, a female at the hospital of Yal de Grace ; ^ and three similar cases, one male (fatal) and two females (who recovered), have come under my notice. In one fatal case I have observed weU-marked opisthotonos ; the head was di-awn back and the limbs were rigid. Perrj' mentions a similar case.^ 11. General Convulsions constitute one of the most formidable symptoms of typhus. They occur in about i out of every loo cases. They were noted in 132 out of 13,958 cases admitted into the London Fever Hospital in eight years (1862-9), and of the 132 cases all but 12 were fatal. They are most common in 23ersons who are plethoric, or of luxurious or intemperate habits. All writers since Hippocrates have regarded convulsions as an almost fatal symptom in fever,"" unless the patient has previously suffered from epilepsy." Dr. Henderson, however, mentions the case of a bo}^, aged 14, who recovered : after several days of .stupor this boy was seized with convulsions of the upper and lower limbs, insensibility and strabismus ; the fit lasted for about an hour, and did not recur. ° Another case of recover}' , after two severe fits of convulsions, is recorded by Dr. Hudson; in this J BaEKAILIEE, 1S61, p. S3. k GODELIEK, 1856, p. 893. ' PeRRY, IS66. " Hippoc. A2)h. iv. 66, 67 ; also Graves, 1848, i. 240. " Instances have been recorded where epileptic fits were suspended during -typhus, and two cases of this sort have occurred in my o^vn practice. (See G. A. IKE^-^•EDv, 1838, p. 22.) " Hexdeesox, 1839. SYMPTOMS. 169 «ase, the treatment consisted in abstracting ten ounces of blood by cupping from the neck, and purging with calomel.^ A third case is reported by Graves,*! and eight have come under my own notice. (See Case XI.) Kussell noted convulsions in 5 out of 300 cases of typhus ; 2 of the 5 recovered. Maclagan met with them in only 8 out of 1,750 cases at Dundee, and 4 of the 8 recovered. There are very rarely any cerebral lesions to account for the convulsions. Jenner records a case, in which a film of extra- vasated blood was- found after death in the cavity of the arachnoid, over the convex surface of the anterior lobe of the left hemisphere, but he was inclined to regard this as a result, rather than the cause, of the fits.*" The same lesion has been repeatedly observed after death from typhus where there have been no convulsions (see Anatomical Lesions), and its occurrence in cases of convulsions is exceptional. Eussell, however, records a case of typhus with convulsions in which the urine was free from albumen, and the kidneys healthy, but where a clot weigh- ing two ounces was effused on the surface of the brain, and in rare cases convulsions are excited by an abscess in the internal •ear. The convulsions cannot be attributed to the pressure of intra-cranial fluid, for in many of the cases the quantity of this fluid has been unusually small,' and there is often an abundance of fluid where there have been no convulsions. It is now well ascertained that, with rare exceptions, convul- sions occurring in the course of typhus have an ur£emic origin. In most cases there is albuminuria, betokening obstructed elim- ination by the kidneys, and these organs are found diseased after death, but occasionally convulsions result from simple retention of urine. I find in my note-books the records of 69 cases of typhus with convulsions, of which 61 were fatal. In one case, a female aged 21 who recovered, the convulsions were «clearly hysterical ; in a second, a man aged 27 who recovered, the fit was followed by a discharge of pus and blood from one ■ear ; in a third, a man aged 5 3 who recovered, the convulsions followed an attack of hemiplegia ; in a fourth, a female aged 56 who also recovered, the convulsions did not supervene until the •end of the fourth week, and were connected with the formation of a parotid bubo ; in a fifth, a female aged 48 who died, the convulsions did not occur until the twenty-first day, when the j)atient was suffering from erysipelas and pygemia; while in p Hudson, 1837, p. 353. q Graves, 1848, i. 239. " Jennek, 1850, xxi. 15. = See Cases YII. and VIII. and two cases mentioned by Peacock, 1843. 170 TYPHUS FEYEE. a sixth, an infant aged four months ^iio died, they supervened on extensive collapse of both lungs. In one only (Case XXH^.) was there positive proof of meningitis. Deducting these seven- patients, there remain 62, of whom all died but four, and in all of whom (from actual evidence or from analogy) the convulsions apiDeared to be m-semic. Of these 62 patients, 43 were males and only 19 females, although the total number of female patients exceeded that of the males (see page 62). Two were 5 years of age or under; 5 between 10 and 20; 11 (including all 4 who recovered) between 20 and 30; 14 between 30 and 40; 19 between 40 and 50; 8 between 50 and 60; and 3 over 60. In 23 cases the kidneys were examined after death, and in all found to be diseased ; and in 1 1 other patients (including the 4 who recovered) the urine was found to contain albumen. In many of the cases the urine was retained and very scanty, and in some quite suppressed, and it was often muddy and high coloured, and deposited a copious sediment containing blood and epithelium- casts. Christison states that in every case of typhus that has come under his notice, and been submitted to proper investigation, convulsions have been connected with an albuminous state of the urine and organic disorder of the kidneys.* In one case of Dr. Todd's, the urine was albuminous and contained blood-casts." In a case of Dr. G. •Johnson's,'' the urine was scanty and dark, like porter, and highly albuminous ; the patient was recovering from acute Bright' s disease at the time of his seizure with typhus. Maclagan found the urine albuminous in every one of his 8 cases, and Eussell in 3 out of 5 cases. In one case Christison discovered urea in large quantity in the serum of the blood, and tliis observation I have verified in two cases and Eussell in one (seepages 174, 175). Frerichs also has shown that convulsions occurring in the course of any of the eruptive diseases are connected with the presence of albumen and casts in the urine, and of urea or carbonate of ammonia in the blood.""' It may be added that the absence of albumen, and even an apparently healthy condition of the kidneys, are not opposed to the uremic theory of convulsions. Abundance of m-ea has been found in the Ijlood of relapsing fever complicated with convul- sions, where the urine was non- albuminous and the kidneys apparently healthy.'' Disease of the kidneys merely increases ' Granular Dcrjen. of Kidneys, 1839, p. 171. " Todd, 1S60, p, 143. '' JOHXSOX, 1862. " Die Brightsche NierenJcranklieit, 185 1. ^ See remarks on the Urine and on Con^iilsions in Eelapsing Fever. SYMPTOMS. 171 the chances of convulsions occurring, hy impeding the excretion of urea. Moreover, while albuminuria often exists in cases where convulsions never appear (see page 154), it is also probable that urea and other products of metamorphosis, which ought to be ehminated by the kidneys, often accumulate in the blood, independently of convulsions, and account for the stupor and other symptoms of the typhoid state. The appearances presented by the kidneys after death from convulsions in typhus vary. Sometimes (7 of my 23 cases) there is unmistakable evidence of disease of old standing, the organs being hypertrophied and fatty, oftener atrophied and granular ; but more commonly ( 1 6 of my cases) the morbid appearances are evidently recent and secondary to the fever. A'^ery often, as in Case IX., the kidneys present the characters of acute nephritis, and under these circumstances I have known them weigh to- gether as much as 19^, 2o|, or even 23^ oz. At other times, with the exception of moderate hypersemia, they appear healthy;, but on careful examination the cortex is found slightly hyper- trophied and friable, and the uriniferous tubes are gorged witk epithelium-cells containing a quantity of minute granules. Urasmic convulsions do not usually appear before the middle or end of the second week of typhus. Of 47 of my cases, m which the duration was known, they occurred on the sixth or seventh day in 5 ; on the ninth day in 4 ; on the tenth, eleventh, or twelfth day in 26 ; on the thirteenth or fourteenth day in 7 ; and during the third week in 5. Of 21 cases recorded by Chi'istison,y Hudson,^ Graves,'^ O. A. Kennedy,^ Aitken,° Jenner,*! Steven,^ TGdd,^ G. Johnson,^ and Eusseh,^ they appeared on the sixth or seventh day in 2 ; on the ninth day in 3 ; on the tenth day in 3 ; on the eleventh day in 3 ; on the twelfth day in 6 ; on the thirteenth in i ; on the fourteenth in 2 ; and on the fifteenth day in i. The fit is usually preceded for a day or two by an unusual amount of drowsiness or dehrium ; but in some cases the previous symptoms have been mild, or convalescence may seem to have commenced. In most cases where atten- tion has been directed to the circumstance, the urine has been found scanty or suppressed; in one of Christison's cases, the quantity for four successive days prior to the attack was only 16, 12, 8, and 3 ounces; and in a case recorded by Perry of fatal y Christison, oj). cit. p. 167. ' Hudson, 1837, pp. 344, 353; and 1842, p. 282. » Geaves, 1848, i. 239, " G. A. Kennedy, 1837. " Aitken, 1848. * Jennek, 1850, xxi. p. 15. •= Steven, 1855. ^ Todd, i860, p. 143, s Johnson, 1862. ^ Eussell, 1864, p. 160. 172 TYPHUS FEYER. convulsions on the ninth day of tyx)hus, only two ounces of urine had been secreted during the three previous days/ Death takes place either immediately after the first fit, or within four days, but in most cases (in 41 of 5 1 of my cases) in less than twenty- four hours. The convulsions are usually followed by coma which continues until death, and may or may not be interrupted by a recurrence of the paroxj^sms. An attack of convulsions some- times immediately precedes the fatal event. The following are examples of convulsions occurring in typhus : — Case VI. Typlius. Attach of Convulsions on i^th day , followed in 12,2 flours by death. Autopsy : — Brain and Membranes healthy. Hypostatic Congestion of Lungs. Old Disease of Kidneys. Elizabeth W , aged 49, admitted in L. F. Hosp. Jan. ijth, 1857 . Eight days before had been seized with head-ache, general pahis, and lassitude. Jan. i8th {loth day). — Pulse 120, weak. Tongue moist, with dirty, brownish fur. — Faint tj'phus-eruption on skin. No head- ache ; sleeps at intervals, but expression very stupid ; some delirium. Camphor mixture, "uine (4 omices), and beef-tea, were prescribed. Jan. igth (11th day). — Pulse 120; prostration Lacreased ; tongue dry and brown ; three stools, not in bed. Skin cool ; eruption more abundant, darker, and partly petechial. Slept badly, and has been very restless and delirious. Mental faculties Yery dull and confused, and great deafness. Pupils contracted. Brandy (4 ounces) was ordered, in addition to wine. Jan. 21st (13^/i day). — About 12.30 a.m. ]patient was suddenly seized with convulsions and foaming at mouth. Bowels were opened four or five times yesterday, but urine has been very scanty. The convulsions lasted for a few minutes and did not return, but were followed by profound coma, which ended m death at 3 p.m. The muscles of right arm were rigid ; left angle of mouth was drawn up ; pupils were dilated and insensible to light. The respirations were noisy and blowmg, and pulse was scarcely perceptible. Little or no urine was passed, and there was no dulness or tenderness over pubes. Autopsy, 20 hours after death. — Typhus-eruption visible on skui. Upper and lower extremities rigid. No oedema. No increased vascularity of membranes of brain. Sinuses moderately filled with fluid blood. No extravasation. Very scanty sub-arachnoid serosity on mider surface of middle lobe of brain. No fluid in lateral ventricles. Brain-substance normal. Pericardium contained i\ ounce of clear serum. Heart soft and flabby ; right cavities filled with dark fluid blood. Both lungs infiltrated with serous fluid and much condensed posteriorly, each weighing about 36 ounces, avoird. The condensed Glasg. Med. Joum. new ser. vol. ii. p. 157. SYMPTOMS. 173 portions were non-granular on section. Liver weighed 2^ lbs. ; its tissue was soft, flabby, and friable, and j)resented a pale nutmeg appearance ; secreting cells contained an unusual amount of oil. Kidneys small ; left, 3^ ounces; right, 3^ ounces ; surfaces marked by large granulations ; capsules firmly adherent ; cortical substance atrophied and dense, with several cysts. Intestines normal. Case VII. Typhus. Delirium ferox, folloiveclhy Convulsions, Coma, and Death. Urine Albuminous, with casts of uriniferozts tubes. Autoiny : — Moderate amount of sub-arachnoid serosity, but Brain and Membranes othenvise healthy. Becent disease of Kidneys. Eichard H , aged 40, admitted into the L. F. Hosp. on March ^th, 1862, at 3 p.m., having been ill about ten days. On adinission, patient was in a state of acute delirium, shouting loudly, and was with difficulty kept in bed. Face flushed, conjmictivae injected, and pupils contracted. Copious well-marked typhus-rash ; pulse 120, full and soft. Patient had not been half an hour in bed before he had several attacks in rapid succession of convulsions, with episthotonos and foaming at mouth. After the fits he continued restless for some time ; but in a few hours he passed into a state of coma, which lasted until death, at 6 a.m. the following morning. The treatment consisted in shaving head, blister to scalp, a drop of Croton oil by mouth, and a draught every three hours of nitric ether (5j), and acetate of potash OJ). Autopsy, 36 hours after death.- — No oedema of integuments. Mode- rate vascularity of membranes of brain. Small quantity of sub- arachnoid serosity ; six drachms of serum at base ; less than half a drachm m each lateral ventricle. No extravasation. Brain-substance normal. Heart flabby and somewhat soft, but muscular fibres, under microscope, apparently normal. Small, dark, friable coagulum in right ventricle ; but blood mostly fluid and dark. No staining of lining membrane of heart or vessels. Old adliesions and false membrane on surface of right Imig ; moderate hypostatic congestion of both lungs. Intestmes normal. Liver 54 ounces, pale-yellow, smooth, and friable ; hepatic cells contained an increased amount of oil. Spleen 8 ounces, diffluent. Both Iddneys much enlarged ; left, 8| ounces ; right, 8 ounces ; smooth and rather pale ; capsules separated readily ; cortical substances hypertrophied, and contained a few cysts, up to size of a pea ; all the urmiferous tubes were gorged with epithelium-cells, which appeared filled with mmute granules, and a few oil-globules. Bladder contained 4 fluid omices of urine, which had specific gravity of loio, and contained a considerable amount of albumen. A copious flaky deposit separated on standing, composed of renal and vesical epithelium and numerous hyaline and epithelial casts of uriniferous tubes. 1174 ■ TYPHUS FEVER. Case VIII. Typhus. Convulsions on iith day. Acute Nephritis. John G , aged 17, admitted into L. F. Hosp. lfa?-c/i 21st, 1866, -on fifth day of typhus. There was a copious eruption, but the symp- toms did not mdicate a severe case ; patient slept well and had no delirium. On March 26th {loth day) he seemed better; pulse had fallen from 120 (on admission) to 84; temperature also fallen; and ■some appetite. Eemained in this state till evening of March 2'jth, -when he was suddenly seized with violent convulsions, which recurred at short intervals till death after seven hours. No urine passed after occurrence of fits. Autopsy. — The kidneys were exhibited to Pathological Society {Trans, xvii. 172). Both enormously enlarged, together weighing 23^ ounces, avoird. ; surfaces smooth; capsules non-adherent ; colour deep chocolate, almost black ; much blood dripped from cut surfaces ; urmiferous tubes loaded with granular epithelium. Spleen large and soft. Case IX. Typhus. Convulsions and Death on gth day. Acute Nephritis. Blood fluid, containing Urea. Emma C , a robust female, aged 32, admitted into L. F. Hosp. April 25^/1, 1862, her illness having commenced six days before with shivering, pain in limbs, and head-ache. On admission pulse 84 and feeble; skin warm and dry; typhus-rash well out; tongue dry in centre ; bowels open ; stupid, confused, and rather drowsy ; pupils small. Beef-tea, milk, wine (6 ounces), and carbonate of ammonia were prescribed. Continued much m same state, and there was nothing to excite alarm, except that she was a little more drowsy ; still, she always answered when spoken to. But at 10 p.m. of April 2'jth, she was suddenly seized with violent convulsions and foaming at mouth, followed by death at lo^ p.m. Her bowels had been open in morning ; but nurse could not be certain if she had passed water. Autopsy, 17 hours after cZea^/i.— Slight rigidity; perceptible pitting of lower extremities on pressure ; typhus-spots still visible on chest and abdomen. Sinuses of brain filled with dark fluid blood ; moderate vascularity of pia mater. A small amount of sub-arachnoid serosity ; two drachms of serum at base, and one drachm in each lateral ventricle. Brain-substance normal. An ounce of clear serum m pericardimn. Eight cavities of heart and large veins filled with dark fluid blood ; muscular tissue and valves normal. A few ounces of serous fluid in both pleural cavities, and moderate hypostatic condensation of both hmgs. Peyer's patches and solitary glands normal. Liver hyperfemic. Spleen 7I omices, pulpy. Both kidneys much enlarged ; left, 6f ounces ; right 6\i ounces ; capsules separated readily, and surfaces smooth ; but both organs of an intensely dark chocolate colour, darker even than those figured by Bright {Reports, vol. i., PI. V.) ; the outer surface SYMPTOMS. 175 marked by a number of little rounded dots of a still darker hue ; con- sistence firm ; a quantity of blood dripped away on section ; tubes gorged with renal epithelium, and many of them contained blood. Not a drop of urine in bladder. Three ounces of blood from right side of heart were shaken for some time with six ounces of alcohol, and then filtered. The filtered fluid was slowly evaporated to dryness on a sand-bath. The residue was dissolved in two ounces of alcohol, warmed, and filtered. The filtered fluid was a second time evaporated to dryness, and residue treated with two ounces of distilled water. After filtration, this fluid was evaporated to consistence of syrup, and then treated with half its volume of nitric acid. Slight effervescence occurred, and a large number of crystalline scales, presenting the characteristic rhomboidal form of nitrate of urea, were formed. A decided urinous odour was given off during evaporation, and after addition of the acid. Nitrate of urea was also obtained, in smaller quantity, from blood in sinuses of •dura mater, by same process. Case X. Tyijhus complicated loith Dysentery, Parotid Bubo, Albuminuria and Convulsions. Urea in cerebral fluid. William D , aged 23, admitted into Middlesex Hospital Oct. 26th, 1866, on seventh day of typhus. Pulse 132; copious rash ; tempera- ture taken three times daily, but at no time exceeded 102 "4° ; restless- ness and much delirium ; tongue dry and brown ; great tympanitis and tenderness of abdomen ; 5 or 6 loose motions in day. On Nov. 1st {iTfth day), convalescence seemed to have commenced; pulse 104; temperature 98-8° ; but the diarrhoea and tympanitis continued. Nov. 6th, worse ; pulse 140; temperature 103*2° ; painful swelling over left parotid; for first time albumen in urine. Nov. ^th, frequent con- vulsions with coma, terminating in death after 24 hours on Nov. Sth {20th day). Autopsy. — Blood dark and liquid. Several ounces of cerebral fluid containing much urea, which was exhibited to Pathological Society [Trans, xviii, i). Kidneys large, smooth and congested ; tubes, loaded with granular epithelium. Spleen large and soft. Extensive dysenteric ulceration of descending colon, with flakes of lymph on peritoneal surface. Much congestion of lungs and sub-pleural ecchymoses. Case XI. Typhus. Convulsions commencing on iT,th day, and recur- ring repeatedly for nine days. Albuminous Urine. Becovery. Isaac T , aged 17, admitted into L. F. Hosp. April 12th, 1862. Father, mother, and brother had all had typhus, and one person with characteristic eruption had been brought to hospital from same house shortly before. He never had fits of any sort, except one in infancy during dentition. Left leg had been amputated some years before. 1/6 TYPHUS FEVEK. Twelve days before admission had been taken ill with shivering, head- ache, and loss of appetite ; after a few days, according to his mother,, he became spotted all over ; and for a week before admission he had. been violently delirious. The man who brought him to hospital stated, that he had ' a fit ' during the journey. On admission, he was ex- tremely restless and delirious, raving about his purse and looldng for imaginary objects under bed. Pulse 84, and feeble ; tongue moist and slightly furred ; bowels open. At 2 p.m. of A^Jril i^th, patient had several fits of convulsions, lasting nearly half an hour, followed for an hour by slight stupor, and then by a return of the delirium. Beef-tea, milk, and nitro-hydrochloric acid with nitrate of potash were prescribed. A]jril 14th [i^thday). Last night was violently delirious, but slept soundly for several hours after two doses of Vin. Ant. Pot. Tart. (nt XX.), and Liq. Morph. Acet. (nt x.), ordered by resident med. officer. This morning had two more fits, each lasting half an hour... At 2 p.m. was very restless and delirious, with contracted pupils and great rigidity of muscles of arms. Pulse 100 and feeble ; no rash ; 3' motions. Urine partly passed in bed; sp. gy. loio ; clear, and con- tained much albumen. Head to be shaved and blister to scalp. Wine 4 ounces. Ajnil i^tli. Two more fits. Urine still albuminous, with very copious deposit of colourless, rhomboidal crystals of uric acid ; sp. gy. 1013. April i6th. Pulse 80. Three fits since yesterday. Eyes staring and fixed ; pupils natural ; scarcely conscious, but takes notice when spoken to. Muscles of arm so rigid that entire body was raised in attempt to extend them. Urme still albuminous, and depositing lithic acid. No oedema. Blister to scalp repeated. On A23ril I'jth, albumen had disappeared from urine and patient was ordered an egg daily, and iodide of potassium (3 grains) three times a day, which was taken for eight days. Patient continued in same state, with two fits daily, up to the morning of Aijril 21 si. After this, the fits did not recur, and all the other symptoms improved ; on April 2^th, patient was allowed meat ; and on May 12th, he left hospital in his usual health. h. Morbid Phenomena presented by the Organs of Special Sense. I. Organs of Vision. The conjunctivae are in most cases.. much injected from an early stage of the disease. Jenner noted this appearance in 25 out of 43 fatal cases. The blood in the conjunctival vessels is of a dark hue ; the membrane rarely presents the bright red tinge observed in acute inflammations of the brain, or of the eye itself. Occasionally, extensive ecchy- moses of a brick red colour are observed beneath the conjunc- tivae ; in one case Barrallier found extravasations of blood between the layers of the cornea.J During the first week the eyes are usually moist, but afterwards they may be dry. J Bakk.UjLIEr, 1 86 1, p. 224. SYMPTOMS. 177 The pupils, in the advanced stages of severe cases, are mostly contracted and often insensible to light. Sometimes they are contracted to a mere point — the pin-hole pupil of Graves. This contracted pupil may accompany active delirium, or profound stupor. 1 have rarely, if ever, seen dilated insensible pupils associated with typhomania, or with delirium tremens, in genuine typhus. A similar observation has been made by Dr. W. T. Gairdner and Barrallier.^ Occasionally, when the stupor is very profound, or is passing into coma, the pupil, which before has been contracted or natural, becomes dilated, and sometimes slight strabismus is observed. [Inequality of the pupils is by no means an infrequent symp- tom. It may occur at any time during the course of the disease, even after the crisis, and does not seem to be of any prognostic importance. The same symptom may occur in enteric fever.] Photophobia is not uncommon : it was noted by Barrallier in one-third of 1,058 cases. 2. Organs of Hearing. Tinnitus aurium and noises in the ears of various sorts are occasionally complained of during the first four or five days of the disease, and again during conva- lescence. Deafness, often complete, of one or both ears, is a very common symptom after the fifth day, and may persist for several days after the commencement of convalescence. I am unable to state its precise frequency in figures ; but during the recent epidemic it occurred, in a greater or less degree, in fully one- half of the cases under my care. Since the time of Fracasto- rius ^ deafness has been regarded as a favourable symptom ; but it is doubtful if there are good grounds for this belief. It is true that many cases recover in which there has been complete deaf- ness ; but, on the other hand, deafness is present in a large pro- portion of the cases which prove fatal (in one-fifth of Jenner's). Deafness, however, is favourable when contrasted with the oppo- site state, or intolerance of sound, which is sometimes met with. It is difficult to give a satisfactory explanation of the deafness : it is far too common, and often too complete, to be due to accu- mulation of wax, or to swelling in the fauces ; and it certainly is quite independent of the administration of large doses of quinine, as suggested by Barrallier. Dr. Stokes thinks that the muscles of the ear, like those of the body generally, become ^ W. T. Gairdnee, 1862, No. 2, p. 148; Barrallier, 1861, p. 79. ' ' Surditas salutem portendit.' (Fracastorius, 1546.) ' Deafness is rather a favourable symptom in typhus.' (Alison, Edinb. University Led. 1849, not pub.) N 178 TYPHUS FEVER. softened, so that they no longer mamtain the conditions neces- sary for the proper communication of the atmospheric vibra- tions to the inner chambers ; but on this view it is difficult to understand the cessation of the deafness with convalescence. Occasionally, deafness is accompanied by otorrhoea, and it may then be due to inflammation of the lining membrane of the meatus. 3. Organ of Smell. A catarrhal state of the pituitary mem- brane is not uncommon at the commencement of the disease. Epistaxis rarely occurs at any stage of uncomplicated typhus. I have met with it about a dozen times in 7,000 cases, and then it was usually scanty and was sometimes due to picking the nose. Jenner noted epistaxis in only two cases ; but in one it was very slight, and in the other the patient had been liable to attacks during health. But under certain circumstances, as when typhus is complicated with scurvy, epistaxis appears to be more common. Among the French troops in the Crimea, where typhus was often complicated with scurvy, Jacquot found epis- taxis in about one-fourth of the cases ; it was most common in the early stage, but occasionally it seemed to be critical ; it was sometimes so profuse as to necessitate plugging the nose.^'* Barrallier observed epistaxis in 97 out of 1,302 cases among the prisoners at Toulon; but in all except 11, which were mostly complicated with scurvy, the bleeding was slight.'' Many instances of ' petechial fever ' with copious haemorrhage from the nostrils, which have been observed during some of the Irish epidemics," have probably been either examples of rela^Dsing or of enteric fever. 4. Organ of Taste. The taste is usually perverted from the first. All articles of diet, and more especially sweet things, are thought to have a bad taste. Acids are longest relished ; but after a time, cold water is preferred. In the advanced stages of severe cases, all sense of taste is usually abolished. 5. Cutaneous Sensibility. Complete anaesthesia of the entire surface is sometimes met with towards the termination of grave cases, even when the patient is sufficiently conscious to give rational answers. The opposite condition, or hyperassthesia, is occasionally observed. The patient starts, or calls out, on the slightest touch or movement of the bed-clothes. In the Phila- '" Jacquot, 185S, pp. 180, 198. " Bake.u.lier, 1S61, pp. 227, 359. " Profuse hemorrhages from the nose were very common in the epidemic of 1740. (See O'CoNNELL, 1746, and Eutty, 1770, p. 88.) Many of the cases, how- ever, were probably fever. STAGES AND DURATION. 179 clelphia epidemic of 1836 Gerhard states that the sensibility of the skin was always augmented when the stupor was not so great as to render the patient insensible, or nearly so, to all external impressions.? (For further description see under head of Enteric Fever.) Section VII. — Stages and Duration of Typhus. a. Stages. Authors have divided typhus into different stages. Hilden- "brand made eight ; Jacquot, three ; and Barrallier, five stages. Although all such divisions are arbitrary, the following appears to me to be in many respects convenient, and to apply to the majority of cases: — i, the stage of Incubation; 2, the stage of Invasion ; 3, the stage of Nervous Excitement ; 4, the Typhoid stage ; 5, the stage of Defervescence or Crisis ; 6, Convalescence. The duration of these stages varies in different cases ; some may be shortened, or altogether absent ; and occasionally it may be difficult to say when one stage ends and another begins. 1. The Period of Incubation has been already considered (page 92). 2. The Stage of Invasion extends from the commencement of indisposition to the appearance of the eruption. The access of typhus is usually rather sudden as compared with that of enteric fever, but less so than that of relapsing fever. It is rare for the patient, or his friends, to be unable to date the commencement of the attack. The patient is seized with cold shivers, lassitude, and disinclination for exertion, followed by pains in the limbs and back, head-ache, loss of appetite, white tongue, and thirst. Most commonly there are no marked rigors, but merely a feeling of chilliness, for the iirst two or three days, so that the patient is unwilling to leave the fire. In some cases the first symptoms are those of slight febrile catarrh. Occasionally, though rarely, the symptoms above mentioned are accompanied by nausea and sickness. Of 30 cases in which I noted particularly the symp- toms of the disease at its commencement, in 22 it began with cold shivers or chilliness and lassitude, followed by pains in the limbs and head-ache ; in several of the 22 cases there was also slight catarrh ; in 8 cases there were no rigors or chilliness at first, but the disease commenced with pains in the limbs and head-ache. The above symptoms were associated in 2 cases with p Gerhard, 1837. N 2 l8o TYPHUS FEVER. nausea and sickness, and in 4 cases witli great drowsiness ; in I there was delirium in the first night, and in i there was slight sore throat. In 6 of the 30 cases the chills or pains in the head- and limbs were preceded for some days by premonitory symptoms, such as lassitude and disinclination for exertion, vertigo, loss of appetite, or febrile catarrh, with much prostration; in the remainder the patient had previously been in perfect health. When j)remonitory symptoms occur, there may be some difficulty in fixing the precise date of the commencement of the disease, although this is usually marked by the sudden accession of head-ache, rigors, or chilliness. The premonitory symptoms can scarcely be regarded as part of the fever, first, because they are in most cases absent ; and secondly, because nurses and other attendants on the sick often complain of similar symptoms, without typhus succeeding. It is not impossible that, as Jacquot suggests, they are sometimes due to ' une typhisation a petite dose, au milieu de laquelle survient le vrai typhus.' ^ In other cases, a febrile catarrh may have been the predisposing cause of the typhus. In cases where the eruption has been said to appear later than the seventh day, premonitory symptoms have probably been included in reckoning the duration of the disease. 3. The Stage of Nervous Excitement usually extends from the appearance of the eruption until the commencement of somno- lence, and is characterised by restlessness, sleeplessness, and de- lirium. During this stage the head-ache ceases, and the tongue begins to grow dry and brown. 4. The Typhoid, Putrid, or Malignant Stage is characterised by extreme prostration, great impairment of the intellect, low muttering delirium, stupor, and more or less unconsciousness sometimes passing into coma ; not uncommonly involuntary evacuations, tremors, and subsultus ; sordid teeth ; dry, brown, crusted tongue ; and rapid, small, soft pulse. It is not every patient with typhus that presents this stage ; but the earlier and more marked the ' typhoid state ' is, the more severe is the case. Many other diseases besides typhus — other idiopathic fevers, blood-poisonings, and local inflammations — often pass into the ' typhoid state.' In other words, they come to resemble typhus, by presenting a group of symptoms of which it is considered the type. The early and some modern writers speak of cases assuming such characters, as putrid or malignant. Enteric fever. 1 Jacquot, 1858, p. 162. STAGES AND DURATION. l8l malarious remittent fever, yellow fever, cholera, m^semia from kidney-disease, pyaemia, acute phthisis, and pneumonia are familiar examples of diseases occasionally assuming a typhoid, malignant, or putrid character. Although in some cases, es- pecially when there is no local lesion, it may he difficult to distinguish the typhoid state induced by one disease from that induced by another, this difficulty affords no more ground for arguing that all Continued Fevers are identical in origin, than for maintaining that typhus exists in every disease that assumes the typhoid state. It is the fashion with some, indeed, to speak of typhus and the 'typhoid state' as synonymous, and thus we commonly hear of cases of ' gastric fever,' or of rheumatic fever, * passing into typhus.' But true typhus has a mode of origin and a clinical history of its own, which do not admit of its being confounded with every disorder that assumes a 'typhoid state.' It is very possible, however, that the typhoid state may have Sb common origin in all diseases, or may be due to the accumu- lation in the blood of the products of disintegrated tissue, as the result of the primary malady. (See p. 19.) The chief of these products is urea. When these products are retained in the system in consequence of organic disease of the kidneys, a condition is induced which it is often difficult to distinguish from the typhoid stage of typhus. In the typhoid stage of cholera, it is well known that there is a remarkable retention ■of the urinary solids in the blood. Again, in malignant (or typhoid) cases of yellow fever, Eoche found large quantities of urea in the blood ; '' Blair detected a large amount of carbonate of ammonia in the blood, and also in the expired air ; while Lahemant describes the sweat as of a penetrating urinous odour. ^ So also in typhus, urea has been found in the blood (p. 152-183), the skin has often an ammoniacal odour (p. 138), and the stools are occasionally ammoniacal and loaded with crystals of ammoniaco-magnesian phosphate. Whether the ursemic symptoms be due to urea or to carbonate of ammojiia, it is unnecessary here to discuss (see p. 17) ; but the connexion between the typhoid state and the presence of urea, or other nitrogenous detritus in the blood, is a subject that deserves further investigation. It has already been shown that convulsions occurring in "• Frerichs, Kliiiik der Lcherkrankheitan, Syd. Soc. Transl. i. 183. ' Report on Yellow Fever, B. and F. Med. Ghir. Bev. 1856, vol. xvii. I 82 TYPHUS FEYEK. typhus have an ursemie origin, and that albuminuria is not uncommon in the typhoid state, even when there are no con- vulsions. In many cases, also, where the typhoid state has been well developed for some days before death, urea has been found in the blood. The following are the notes of two of these cases : — Case XII. TypMis fatal on i6th day. Death ]}receded, for two- days, by Stupor and Coma. Blood fluid and containing Urea. George M , aged 69, admitted into the L. F. Hosp. July 21st,. 1862. His illness had commenced with rigors, head-ache, and general pains, seven days before admission. On admission, head-ache and restless nights ; little confused, but answered correctly ; tongue moist and furred ; bowels opened by medicine ; typhus-rash well out ; pulse 72. Ordered sulphuric ether, sulphuric acid, and quinine; also 4 ounces of wine, beef-tea, and milk. July 25^/2, (12^/1 day). — Head-ache almost gone, and sleeps better ; but is more prostrate, and tongue dry along centre. Brandy substituted for wine. July 2'jth {14th day). — Lies on back, and much more prostrate ; more stupid and confused, but understands when spoken to ; tongue dry and brown ; pulse 90, feeble. Brandy increased to 10 ounces. The same evening, became very drowsy, and on i^th day, was quite unconscious; pupils con- tracted. Pulse 90, feeble ; skin dry ; temperature in axilla not ex- ceeding 9975° Fahr. Patient was enveloped in a hot wet blanket, and then covered with dry blankets for three hours, while at the same time brandy was given freely. No improvement, however, took place ;, and on 16th day, patient much worse ; pulse scarcely perceptible ; surface livid and cold, and covered with perspiration ; complete un- consciousness ; contracted pupils, and floccitatio. Death occurred at 5.30 p.m. Autopsy, 22 hours after death. — With exception of moderate hypo- static congestion of lungs, and slight hyperffimia of liver and kidneys,, internal organs healthy ; no trace of disease in intestines. The blood contained in heart and great vessels was perfectly fluid and black... Three ounces of it, when treated in the manner described under Case IX. (p. 174), yielded crystalline scales of nitrate of urea. Case XIII. TypMis tvith severe cerebral symptoms. Albuminuria and ureajn cerebral fluid. John F , aged 27, admitted into Middlesex Hosp. Dec. T,rd, 1866,. on ninth day of typhus. Pulse 128; temp. io4'2° ; copious rash;, respirations 56 and embarrassed ; much congestion of lungs. On Dec. Tth {i^th day) violent delirium set in, followed next day by stupor, floccita tio, and involuntary evacuations, which continued till death, on Dec. 11th. The temperature, which on 12th day was as high as 104°,, STAGES AND DURATION. 1 83 fell on 14th and 15^/1 days to 98*2°, but then rose, till before death it again reached 104°. Autopsy. — Blood dark and fluid. About 12 drachms of cerebral fluid containing much urea. (See Path. Trans, xviii. 3.) Both kidneys A^ery large, together weighing 15-^- ounces; much congested, but no sign of old disease. Extreme hypostatic consolidation of both lungs, which together weighed 70 ounces. 5. Stage of Defervescence or Crisis. By crisis of a disease is Tinderstood a sudden change to recovery, usually accompanied by some increased secretion. There are few acute diseases in which at last a more rapid transition from unfavourable to favourable symptoms occurs, than in typhus, or in which the appetite returns so readily and may be gratified with so little impunity. This has been a matter of constant observation by those who have had an opportunity of closely watching the disease. Hildenbrand stated that the disease abated ' d'une maniere tres prompte.'* In 1840 Dr. Stewart wrote thus : ' All that I insist upon is the frequent, I may say the common, occur- rence of a perceptible crisis, or what is vulgarly termed, a turn in typhus. I think I may appeal to the experience of every Ijhysician, and more especially of every resident clerk in the Fever Hospital, whether they have not often been struck at seeing during their morning visits the glassy eye, the haggard features, the low muttering delirium, the stupor approaching to coma, the tremor, the subsultus, the carphology, the rapid, thready, tremulous and intermittent pulse of the previous even- ing, the formidable array of symptoms in short which seemed to indicate a speedy and fatal termination, exchanged for the clear eye, the intelligent countenance, the steady hand, the compara- tively slow and firm pulse, and the returning appetite of approach- ing convalescence. To such cases as these we might almost apply the Scripture phrase : " At such an hour the fever left him." In the great majority of cases we can point with precision to the day on which amendment took place.'" *La fievre,' says Jacquot, ' tombe souvent avec une rapidite etonnante.' ^ - Lastly, Barrallier observes : ' Cette periode (de remission) survient presque brusquement.' ^ These statements have been confirmed by careful thermometric observations. Although the acme of temperature may be attained in the first week, and after this there may be a gradual fall (see p. 136) ; and although, as Gairdner^ ' Hildenbrand, 181 i, p. 77. " Stewart, 1840, p. 305. '' Jacquot, 1858, p. 148. " Barrallier, i86i,p. 72, ^ Gaikdneb, 1865. 184 TYPHUS FEVER. lias shown, there may be also a gradual fall of the pulse in cases which recover extending over several days, the final defervescence, according to Wunderlich y (whose correctness on this point I have tested by numerous observations), is usually 'precipitous.' (See Diagrams IV. and V.) Improvement is often ushered in by sleep. The patient, who for days has been delirious and more or less unconscious, falls into a sound and quiet sleep and awakes refreshed, more rational, and another man. I have been unable to observe, however, any connection between the so-cahed critical dis- charges and the resolution of the febrile symptoms. There is no doubt that amendment is often attended by moderate per- spiration, and in other cases by diarrhoea, or by a copious deposit of lithates in the urine. On the other hand, the urme may deposit lithates at any stage of typhus, which are often wanting at the time of crisis, whUe both diarrhoea and sweating may occur either naturally, or as the result of treatment, with- out bringing about any favourable change. Moreover, according to Traube's researches,^ these evacuations, when they occur, are ' after-critical ' rather than critical, being always preceded by a considerable fall in the pulse and temperature ; if this be so, they seem to be the result, rather than the cause, of the cessation of the fever. Dr. Todd ^ was of opinion that death often resulted from the very effort of nature to relieve the system, or from an excess of the critical discharges, and cer- tainly profuse perspiration is rarely observed in typhus, except before a fatal event. Corrigan says that * a crisis by perspira- tion is of all forms that which is most to be dreaded in macu- lated fever.' 6. Convalescence. No sooner has amendment commenced, than convalescence advances rapidly. The tongue becomes clean and moist, the appetite is ravenous, and the bodily powers daUy improve. Unless the patient has been in a weak state prior to the attack, or convalescence is retarded by complications, three or four weeks usually suffice to restore perfect health and strength. By this time, indeed, it is not uncommon for the convalescent from typhus to boast of an unwonted amount of freshness and bodily vigour. It is rare for typhus to lay the foundation of any serious organic disease. ''Wunderlich iS7i,p. 330. » Teaube, 1853. * Todd, i860, p. 175. STAGES AND DURATION, 185 h. Duration. It is important, in reference to prognosis and treatment, to ■be able to fix the duration of typhus. The mean duration is thirteen or fourteen days ; it varies somewhat according to the -age of the individual attacked, being on the whole^ shorter in -the young than in those of adult or advanced life ; but in (uncompHcated cases it rarely, if ever, exceeds twenty days. Sometimes it appears to exceed this limit, owing to the presence of some local complication; but it is a mistake to confound the duration of the primary fever with the length of the illness. The duration of the fever, in 500 uncomplicated cases which recovered, and in 100 fatal cases, some of them complicated, I have ascertained to be as follows : — TABLE XI Days 6 7 8 9 10 27 5 II 31 5 12 13 14 15 16 17 18 19 20 Above 20 500 cases which ^ recovered . / 100 fatal cases . 2 I 2 4 8 7 65 13 123 14 119 II 77 9 29 4 II 2 4 5 3 5 I 13 Thus, in nearly one-half (242) of the total number, conva- lescence commenced on the thirteenth or fourteenth day, and in 384 cases, or in more than three- fourths, on the thirteenth io the sixteenth day inclusive. The mean duration of the 500 cases was I3"43 days. In these cases the termination of the ■disease was fixed by a fall in the pulse and a marked improve- ment in the general symptoms, but careful thermometric obser- vations have satisfied me that the usual duration of typhus in London of late years has been thirteen or fourteen days, and that too in cases treated without stimulants and left to their natural course. Similar observations have been made at King's College Hospital by Kelly,^ while "Wunderlich's investig-ations show that * defervescence most commonly occurs between the thirteenth and seventeenth days, less frequently between the twelfth and thirteenth, and still more seldom at an earlier date ' " The mean duration of the 100 fatal cases was i4"6 days, but, in all of the fatal cases protracted beyond 20 days, the fatal '' Lancet, 1866, i. 657. WUNDEBLICH, 1 87 1, p. 330. 1 86 TYPHUS FE^^E. result was due to some complication. Again, the mean stay in hospital of 500 cases which recovered was 23 days, and of 100 fatal cases, 7 da.js ; and the mean dm'ation of the illness before admission in 600 cases was 6-99 days. (See p. 165.) Little dependence can be placed on the statements made by many writers as to the duration of typhus, inasmuch as it has been shortened on the one hand by the admixture of cases of Eelapsing Fever and Febricula, and lengthened on the other by the admixture of cases of Enteric Fever and by including local complications with the primary fever. The following results are free from such objections. In the early part of this century Hildenbrand ascertained that the crisis ordinarily occurred on the fourteenth day.*^ Of 55 cases noted by Henderson at Edinburgh in 1838-39 in which there was marked tj'phus-erup- tion, the mean duration was 13! days.^ The average date at which death occm-red in 143 cases was calculated by Dr. John Eeid at between the twelfth and thnteenth day/ In the Edin- bm'gh epidemic of 1 847-48, I remember that it was a common observation among the physicians and nurses that the fever * took a turn ' on the fom-teenth day. In 1849 Jenner fixed the duration of typhus at between fourteen and twenty-one daj^s, and mamtained that uncomplicated cases were never prolonged beyond the latter date. Of 1 8 fatal cases in which he was able to ascertain the date of commencement of the attack, the average day of death was the 14* 27th, one patient dying on the tenth day, and another not until the twentieth. At Toulon, in 1855, BarraUier found that of 698 cases terminating favourably convalescence commenced between the tenth and twenty-second day in all but 74, in which complications were present ; and that of 436 fatal cases death occurred in the first week in i, at the commencement of the second week in 44, at the end of the second week in 270, during the third week in 84, and at a later date, as the result of complications, in ij.^ Lastly, the mean duration of 63 cases observed by Godelier, in the hospital of Val de Grace, was between fourteen and fifteen days ; ^ and that of 581 uncomplicated cases which recovered was found by Maclagan to be 13-39 days.^ But, although the dm-ation of typhus is usually about fom*- teen days and never exceeds three weeks, the disease may run a much shorter course. Many cases are on record where the ^ HlLDEXBEAXD, iSlI, p. 78. ' HeXDEESON", 1S39. t Eeid, 1840. ^ Bakealliee, 1861, pp. 257, 36S. >> GoDELizE, 1S56, p. 893. ' Maclagan, 1867. STAGES AND DURATION. 1 8/ disease has terminated fatally on the second or third day, or even after a few hours. Such were the cases of Tyinlius Siderans, or Blasting Tyijlms, which devastated the garrisons of Saragossa, Torgau, Wilna, and Mayence, during the wars of the first Napoleon.J Similar cases were observed in Ireland during the epidemic of 1847-84,^' and among the French troops in the Crimea, in 1856.^ From the testimony of several observers, both French and Eussian, it appears that the mean duration of typhus in the Crimea was only between twelve and thirteen days in 1855, and between ten and eleven days in 1856.°^ During the recent epidemic in London I have met with several instances where death occurred as early as the eighth, or even sixth day, mainly from pulmonary congestion. Barrallier " is of opinion that those epidemics are always most mortal, in which the disease has been characterized by the shortest dm-ation; but although the statement be true with regard to some epidemics, cases of short duration are in this country usually mild.° In my experience, mild cases of typhus (with eruption) have sometimes terminated on the tenth, or even as early as the eighth day. (Cases XIY. and XV.) It is pro- bable, moreover, that many cases of so-called Febricula, where the fever lasts only two or three days and is not attended by rash, occasionally result from a small dose of the typhus-poison ; at all events, cases answering to this description sometimes occur in the same family, and at the same time, as true typhus. Ac- cording to Gairdner,P both at Edinburgh and Glasgow of late years, typhus left to its natural course and treated without drugs or stimulants will in a large proportion of cases have its natural crisis before the twelfth day. Careful thermometric observation has satisfied me that this rule has not held good in London, while at Glasgow in 1 867 Eussell '^ found, from an analysis of 45 1 cases, the most critical days to be the 12th, 13th, and 14th, and the most fatal day to be the 15th. My observation does not support the applicability to typhus of Galen's doctrine of critical days which has been revived by Traube of Berlin.'' According to this doctrine the disease should terminate on one of the odd days, the seventh, ninth, eleventh, thirteenth, fifteenth, &c., and not on the in- j Gaultiee de Claubey, 1838; OzANAM, 1835, iii. 202. ^ See Irish Report, Bib., 1848, viii. 92 ; also Graves, 1848, i. 240. * Jacquot, 1858, p. 140 ; Baeealliee, 1861, p. loi. "^ Jacquot, 1858, p. 136. " Baeealliee, 1861, p. 102. " W. T. Gaielnee, 1862 and 1865. p Ibid. 1 EUBSELL, 1867. ' TeAUBE, I853. 155 TYPHUS FEVEE. termediate even days. Still Traube's investigations (although it is doubtful if they refer to cases of true typhus) are deserving of attention; and it is to be observed that by the term day Traube implies, not a period of twenty-four hours commencing at midnight, but, like Galen, a day of the disease commencing with its first symptoms. The two following cases are examples of typhus of short duration : — Case XIV. Typhus, icith Convalescence commencing on Sth day. Mary G , aged 47, admitted into L, F. Hosp. Jidy 2Sth, 1857. On 24th she had been quite well, but on 2^th she had been seized with shiveruig, head-ache, general pams, and nausea. July 2gth {^th day). — Pulse 84, and feeble ; much head-ache ; expression heavj% and is a httle confused, but answers correctly. Skin warm and dry, with a well-marked typhus-rash on the chest and abdomen. Tongue dry and brown. Some cough, with frothy expectoration, and sibilant and sonorous rales over chest. Continued much in same state mitil morning of Aug. 1st {Sth day), when she felt and looked much better ; pulse 72, eruption almost gone; tongue clean and moist, appetite good, and cough much relieved. From this date she improved daily. Case XV. Typhus, fatal on gth day. William W , aged 30, admitted into L. F. Hosp. April gth, 1862. Was well on the 4th, but on ^th was seized with shivering and head-ache, and took to bed at once. On admission, pulse 100, and feeble ; severe head-ache ; tongue dry along centre ; bowels confined ; no eruption. Ordered castor oil, nitre and nitro-hydrochloric acid, 6 omices of wine, beef-tea, and milk. On 6th day {April 10th) typhus- eruption began to appear ; and on Sth, it was noted as copious. On the jth and Sth days, patient had much delirium and became very weak. On the ^th was ordered four ounces of brandy, and on Sth 8 ounces. A2)ril 13^/1 (gth day). — Much worse. Pulse almost im- perceptible ; skin cold ; face livid ; eruption darker ; copious perspira- tion ; scarcely conscious ; pupils contracted ; much low delirium, and occasional subsultus ; motions and urine passed involuntarily ; re- spirations 40 ; moist rales over lungs. Head was shaved, and blister applied to vertex ; half an omice of brandy every hour. Death at io| p.m. c. Relapses. True relapses are extremely rare in typhus. I have never met with a case in which, after complete convalescence, a re- lapse of febrile symptoms has been marked by the return of an STAGES AND DURATION. 1 89 unequivocal eruption, or could not be traced to some local com- plication. ' I have never,' says Dr. Stewart, * among thousands of cases seen a single case of relapse, in the proper sense of the term, after the symptoms had begun to decline.' "^ A similar remark is made by Jenner and most other writers. According to Barrallier, relapses occurred within a few weeks of the first attack in 10 of 1,302 cases observed by him at Toulon; but no. mention is made as to the presence of eruption, or the absence of complications, in both attacks.* Out of 18,268 cases of typhus reported at the London Fever Hospital during twenty-three years, the following, observed by Dr. Buchanan, is the only in- stance" of a true relapse, although in several instances a genuine has been preceded by an abortive attack. (See p. 97.) A case similar to XVII. is recorded by Ebstein, where there was an interval of 25 days between the two attacks.'' Case XVI. Ty2)htis lasting two weeks; after a iveeh's interval, a Belapse ivith a Becurrence of Eruption lasting upivards of a fort- night. Ann B , aged 42, nurse in the hospital, was admitted as a patient Oct. 2Sth, 1855, having suffered five or six days from great head-ache and other symptoms of typhus. The night before admission she had been delirious. On admission, pulse 120; skin hot and dry ; distinct typhus-rash. Tongue furred ; bowels confined ; much vertigo. The chief symptoms after admission were sleeplessness and occasional delirium. On Nov. ;^rd patient was much better ; pulse only 70 ; but rash still distinct. On Nov. $th all cerebral symptoms had disappeared, and only faint remains of rash. After this she continued to improve and was walking about house, when, on Nov. 16th, after ailing for a few days, she became so ill as to take to bed again. The typhus-rash re-appeared very copiously on that day. Tongue brown and dry ; appetite gone ; occasional delirium ; pulse 120. Nov. igth. — Pulse 120; tongue still dry and brown ; great thirst ; frequent delirium ; urine passed in bed ; and prostration im- mensely greater than in former attack. No cough. Nov. 24th. Very restless and delirious at night; face flushed; pulse 120,- very weak. Eash still abundant. After this date no report was made until Dec. 10th, when patient was stated to be convalescent, but to be suffering from extensive ulcers of legs, which had followed application of mustard poultices for purpose of rousing her from a state of stupor. " Stewart, 1840, p. 300. * Baeeallier, 1861, pp. 262, 371. " In the case of Eelapse of Typhus reported as occurring in the London Fever Hospital in the Lancet for June 12, 1869, the first attack was Enteric Fever, ^ Ebstein, 1869. 190 TYPHUS FEVER. Section VIII. — Complications and Sequelje of Tzphus. Many cases of tj-plms present complications, which though constituting no essential part of the primary disease, yet modify its ordinary character and course, and are due, for the most part, to the weakened condition of the heart and the defibrinated im- pure state of the blood induced by the typhus-poison. In a large number of the cases which terminate fatally death is due to complications. Most complications commence before the cessa- tion of the primary fever, in calculating the dm-ation of which it must be borne in mind that the illness is often prolonged in this way to an indefinite length. Moreover, after convalescence is fairly established, it is occasionally interrupted by the occm-- Tence of sequela. Constitutional peculiarities also seem to predis- pose to certain complications, such as con\iilsions, gangi-ene, &c. ; different members of the same family sometimes presenting the same comi^lications, however unusual these may be."^ The frequency of different complications varies at different times and places. In some epidemics scurvy is a common complication, in others, dysentery ; whUe, as a rule, both are rarely observed. Parotid swellings, erysipelas, pyaemia, and local gangrene are sometimes common complications ; at other times they are rare. Of 43 cases examined after death in the Edinburgh Eoyal Infirmary between April 1838 and September 1839, true pneumonia was found in only one instance ; ^ whereas it existed in 11 out of 88 cases examiaed between September 1839 and September 1841 ; ^ and during the next year (1841-42), out of 27 cases there were two examples of pneumonia."^ a. Diseases of the Respiratory Organs. The advent of pulmonary compHcations in typhus is often most insidious, for the ordinary sj-mptoms, cough and expec- toration, may be slight or absent, and the patient is unable to complain of pain. It often happens that rapid breathing and lividity of the face are the first obvious indications of extensive disease of the lungs, and yet both of these sjTnptoms may exist independently of pulmonary disease. The quick breathing may be purely a cerebral sj^mptom, while the lividity of the surface may be caused by stagnation of impure blood in the cutaneous " Hrcsox, 1867, p. 26. ^ Eeid, 1S40. ^ Ibid. 1S42. ' Peacock, 1S43. COMPLICATIONS AND SEQUELS. I9I ■capillaries. Hence, in every case where there is the slightest doubt, the chest should be examined daily, or even oftener, by ^auscultation and percussion. For this purpose, the patient's strength will rarely enable him to sit up, but all the necessary information may be obtained by turning him on his side. 1. Bronchitis is a common complication of typhus, and in all severe cases it exists in conjunction with the hypo- static congestion of the lungs already referred to (see page 142). In some epidemics, it is often present to a greater or less extent even at an early stage of the disease. So much is this the case that in Ireland it has been the custom to speak of ' Catarrhal Typhus,' ^ whUe Eokitansky and other German pathologists, believing in the identity of typhus and enteric fever, but draw- ing their knowledge of the former chiefly from Irish sources, think that it merely differs from enteric fever, in the ' typhus- matter ' being localised in the lungs instead of in the in- testines.^ Bronchitis may usher in, or come on at any period of, typhus, ■and it may persist after the primary fever has ceased. All cases where it is present must be carefully watched. So long as the evidence of pulmonary disease is confined to occasional cough and a few sibilant rales over the chest, there is no immediate danger ; but, as the general prostration increases, the pulmonary disease is very apt to extend suddenly and insidiously, and to he associated with more or less hypostatic consolidation. More- over, owing to the patient's inability to cough, coupled with the impaired nutrition and paralysis of the muscular fibres of iihe bronchi, there is a tendency for the bronchial secretion to accumulate in the tubes and cause asphyxia. 2. Pneumonia. True pneumonia is rare in typhus. It is -chiefly met with after the crisis, and is either lobular with a tendency to terminate in abscess or gangrene, or lobar and very chronic, with a tendency to terminate in phthisis or fibroid condensation of the lungs. The majority of the cases of so- called pneumonia are examples of hypostatic eonsolidation-with bronchial catarrh, already described (p. 142). It is not always possible to distinguish these two conditions during life ; and, in fact, the two may exist together. If the dulness be limited to one lung, if the breathing be markedly tubular, and the sputa rusty, it is no doubt true pneumonia that we have to deal with. ' Lyons, 1861, p. 162. " Eokitansky, Path. Anat. Syd. Soc. ed. ii. 74 ; iv. 24. 192 TYPHUS FEVEK. According to Dr. Lyons, ° pneumonia in typhus first implicates' the upper and anterior parts of the lungs, which usually escape in ordinary pneumonia. My experience does not confirm this- observation. I have met with many cases of pneumonia, in- dependent of typhus, commencing at the apices and associated with symptoms of a low typhoid character ; but I have rarely chanced to meet true pneumonia in this locality, as a complica- tion of typhus. In several cases of typhus, however, I have known consolidation of the apices of the lungs produced by oedema. 3. Gangrene of the Lung. Now and then the pneumonia of typhus terminates in gangrene, which is recognized without difficulty by the peculiar and horrible odour emitted from the breath and sputa, the pinched ghastly expression of countenance, the local signs of pneumonia, and the serious aggravation of the general symptoms, and which is almost inevitably fatal. Two cases of this nature are recorded by Jenner,"^ and several have come under my own notice. Once I have observed this condi- tion to be associated with emphysema of the mediastinum and_ the walls of the chest, and the particulars of a similar case have been communicated to me by Dr. W. T. Gairdner. In one or- two instances I have noticed that the pulmonary gangrene was secondary to extensive bed-sores over the sacrum. Most of the- patients with this compHcation have been starving for many weeks prior to the attack of typhus. 4. Pleurisy is not a common complication of typhus. When it occurs, its advent may be latent. No sharp pain is complained of, and the affection may not be discovered until the effusion is so considerable as to embarrass the breathing. The effusion- is usually fluid and often purulent, and consequently friction is rarely to be heard. 5. Tubercle is occasionally deposited in the lungs as a complica- tion or sequela of typhus, although different opinions have been expressed on the point. Sir E. Christison states, as the result of his extensive experience in fever, that consumption is a very rare result of true typhus, and that its origin in typhus as a predisposing cause is very problematical in any instance.® Stokes ^ and Huss,s on the other hand, insist much on typhus predisposing to pulmonary tubercle, although it may be doubted if many of the cases from which their conclusions are drawn were not examples of enteric fever, which is more frequently- « Lyons, 1861, p. 171. " Jennek, 1849 (2) and 1850, xx. 456. ^ Chkistison, 1840. ' Stokes, 1854. s Huss, 1S55, p. 216. COMPLICATIONS AND SEQUELS. 1 93 followed by tubercle. Jenner, however, records an instance where a rapid fresh deposition of tubercle in the lungs occurred during typhus in a phthisical child ; ^ and Dr. Stewart informs me that he has met with not a few cases in which pulmonary phthisis has commenced during, or immediately after, an attack of typhus. I have observed several examples of the same nature ; there were all the signs during the fever of bronchitis or pul- monary congestion, which persisted after its cessation, when rapid emaciation, profuse sweating, and purulent expectoration took the place of convalescence. Still, according to my ex- perience, in most eases where tubercle occurs as a sequela of typhus, there has been a prior phthisical history. (See p. 71, p. 203, note i. and p. 212.) 6. Hcemoptysis I have known to occur under two circumstances in typhus. It may be due to pulmonary congestion supervening on previous tubercular deposit, or it may be one feature of the hsemorrhagic tendency met with in certain cases.^ (See p. 194.) 7. Laryngitis is an occasional and serious complication of typhus. Of 12,562 patients at the London Fever Hospital, it was present in 21, of whom 8 died. It occasionally assumes a croupal character, but the most common form is that of acute oedema of the glottis, which may follow erysipelas of the face, neck, or pharynx, a parotid or submaxillary bubo, a post-pharyn- geal abscess, or minute ulcers on the vocal cords. It may be very insidious at its commencement. There may be slight huskiness of the voice for a few hours or longer, and then there may suddenly supervene laryngeal breathing and rapid asphyxia. In fatal eases the swelling may have in a great measure dis- appeared from the glottis before the body is examined. Four patients with this complication I have known rescued from impending death by the timely performance of laryngotomy. The tube may usually be removed with safety after three or four days ; but now and then, when the cedema is below, instead of above, the rima glottidis, it may, as Dr. J. B. Eussell has shown, be followed by an organised and permanent stricture. J h. Diseases of the Blood and Organs of Circulation. I. Hcemorrliages — Scurvy. The blood in typhus may be so defibrinated and otherwise altered as to escape from the vessels ^ Jennek, 1850, XX. 457. ' See also Peasock, 1S62, p. 83. J KussELL, 187 1. 194 TYPHUS FEVER. with unusual facility. In severe cases of typhus the petechise may be large, or there may be extensive haemorrhages — purpura- spots, or vibices, beneath the skin. Epistaxis, hsemorrhage from the gums, haemoptysis, heematemesis, melasna, menorrhagia, or haemorrhage from the urinary passages may also occur; and after death we may find extravasations of blood beneath the serous and mucous membranes, in the arachnoid cavity, in the areolar tissue, and into the substance of the muscles. In one of my cases a fatal result was apparently determined by haemorrhage, to the extent of about thirty ounces, from a superficial excoria- tion of the scrotum. These occurrences are chiefly observed in persons who have been living very badly for a long time prior to the attack, and accordingly they are much more common in some epidemics than in others. As might have been expected, they have been particularly frequent when typhus has prevailed in conjunction with scurvy, as happened in the French army in the Crimea, and in the epidemic of 1847-48 at Edinbui'gh and elsewhere. 2. Pycsmia, with purulent deposits in the joints, is occasionally noticed in severe cases about the period of crisis, or more com- monly during convalescence. Fortunately, the complication is rare, as it is almost invariably fatal within two or three days. I can find only one typical case in my note-books (Case XVII.) ; but a second patient, a female aged 56, who had also parotid abscess, erysipelas and convulsions without albuminuria, had painful swelling of joints for several days, yet recovered. Stewart '^ and Anderson,^ however, met with it not unfrequently at Glasgow in the epidemic of 1836-38. It is ushered in by severe rigors, which are followed by great prostration and praecordial anxiety, extremely rapid and feeble pulse, swelling, redness, and tenderness of the joints, together with all the ordi- nary symptoms of pyaemia. There is almost always more or less jaundice, and often profuse perspirations. Sometimes scarcely a joint escapes, and many even of the smaller joints are filled with pus. After death, the synovial membranes are much injected and bathed with pus, but are free from ulceration ; purulent deposits are rarely found in the internal organs. Huss ™ and others have referred such cases as now described to suppurative phlebitis, originating in the absorption of pus into the veins from bed-sores. Stewart, however, states that in some of his cases there were no bed-sores ; and the complication pro- Stewabt, 1857. ' Andekson, 1861, p. 48. ■" Huss, 1855, p. 206. COMPLICATIONS AND SEQUELS. 1 95 l)ably originates in the blood itself, the typhus crasis,'' as Stokes has expressed it, becoming converted into pyaemia. Case XVII. Typhus foUoived by Pyamia and Pus in Joints. Fred. C , aged 28, admitted into L. F. Hosp. Feb. 11, 1868, on sixth day of typhus. He had a dry brown tongue, and a copious petechial rash. On the sixteenth day pulse and temperature fell and appetite returned, yet tongue continued dry. He seemed to be slowly recovering till March 2 {26th day), when he had a rigor with a return of fever, dry tongue, profuse perspirations, slight jaundice, delirium, great prostration, and painful swellings in the wrists, elbows, knees, and left calf. He had large doses of sulphite of soda without any good result, and died on March 19 (415^ day). Autopsy. — Thin flaky pus in affected joints. A patch of lobular pneumonia softening into pus in upper lobe of right lung. Liver and kidneys congested. 3. Venous Thrombosis — Phlegmasia dolens. During conval- escence, an affection of one of the lower extremities is occasion- ally developed, which resembles closely what is known as the phlegmasia dolens or white-leg of puerperal women. Stokes states that if, in convalescence from fever, the pulse continue very rapid without any local cause either in the chest or the abdomen, this complication may be anticipated. It always appears after the cessation of the primary fever, usually about the end of the third week, but sometimes much later. Accord- ing to Tweedie, it was formerly most common in cases of fever where bleeding had been practised to a large amount, while it is niost apt to occur in the parturient female when delivery has been followed by extensive uterine haemorrhage. The altered principles of treatment in fever may possibly account for the comparative rarity of the complication at the present time. During the last ten years it has been noted in only i out of about every 800 cases admitted into the London Fever Hospital. Maclagan noted it in 2 out of 1,756 cases in Dundee.^ Perry, however, in an analysis of 1,096 cases at Glasgow, says that it occurred in "a considerable number of cases.^ The term phlegmasia dolens is not strictly accurate, for the affection is not always painful. Sometimes there is so little pain, that the discovery of the local disease is entirely accidental ; but in most cases there is considerable pain and also tenderness in the iliac fossa and along the femoral vein ; and occasionally " See discussion at London Medical Society, Brit. Med. Joimi. October 26, 186 1. " Begbie, 1872, p Perry, 1866, o 2 196 TYPHUS FEYEE. shooting pains in the extremity are complained of for some days before any swelHng appears. Many of the patients are seized during the night with severe pains in the calf ; and in the morn- ing the whole, or part, of the corresponding lower extremity is tense and swollen. The swelling is usually of a firm brawny character, and sometimes it is enormous. The skin of the entire body, but particularly that of the affected limb, is pallid. The femoral vein can often be felt like a hard tender cord ; and, in some instances, a corded condition of the superficial veins is observed. There is seldom any great constitutional disturbance ; there is no nausea, vomiting, or jaundice,*! and most cases terminate favourably, the swelling gradually subsiding, but often leaving a hard cord in the situation of the femoral vein. But sometimes the swelling persists for several weeks ; and occasion- ally, as shown by Corrigan and Begbie, great swelling, with or without a varicose condition of the superficial veins, vasij last for many years, and be the source of considerable discomfort. Usually it is the left leg that suffers (probably from the compres- sion of the left iliac vein by the right iliac artery favouring venous coagulation in the left limb), and there is but one attack; but now and then the two limbs are attacked in succession. In 9 cases I found the left limb affected in 6, the right in 2, and both limbs in i. Three cases, independently of Case XIX., in which this complication terminated fatally, have come under my notice, and two are recorded by Gairdner *" and Eussell.^ The fatal result may be due to transportation of a portion of the thrombus to the right side of the heart and to the lungs, to su^jpuration uf the thrombus and subsequent pyaemia, or to other causes. Examples of this affection were observed in Edinburgh and Dublin during the epidemic of 1817-19,* but Dr. Tweedie was the first to direct particular attention to the subject in 1828."- Although the dependence of puerperal phlegmasia dolens on phlebitis had been rendered probable five years before by the researches of David Davies,"" Bouillaud,'' Yelpeau, and afterwards of Eobert Lee,"" Tweedie made no mention of the condition of the veins in the corresponding affection after fever, which he attributed to ' inflammation of the cellular tissues of the limbs.' Most modern pathologists, however, ascribe post-febrile, as well 1 In one ease I have noticed slight jaundice. (See Case XIX.) -• Gaikdnek, 1865, No. I. ' Glasgow Med. Jonrn. February 1869. ' Baiiker and Cheyne, 1821, i. pp. 467, 490; Christison, 1S40, p. 145. " Tweedie, 1828. '' Med. Chir. Trans. May 1S23, vol. xii. p. 419. " Arcliiv. Gdn. de Med. January, 1S23, s^r. i, torn. ii. p. 192. » Med. Chir. Trans. 182S. COMPLICATIONS AND SEQUELS. 197 as post-partum, white leg to plastic phlebitis, or more correctly to thrombosis of the iliac or femoral vein. This opinion is confirmed by the hard cord-like condition of the veins often felt during life, and by the fact that, in most of the few instances where there has been an opportmiity of examining their con- dition after death, these vessels have been found obstructed by a coagulum, dark in the centre but pale and adherent at the circumference. The cause of this coagulation is to be found in some morbid condition of the blood generated by the fever, and not in the absorption of pus or other material from abscesses or bed-sores/ nor in the passage of coagula formed in obstructed pulmonary capillaries into the systemic circulation, as some have contended. Although swelling of the leg may exist in con- junction with bed-sores, erysipelas, parotid bubo, or pulmonary congestion, I have frequently, as Dr. Stewart found at Glasgow in 1838,^ known it to occur independently. Venous Thrombosis, however, is not the sole cause of phleg- masia dolens. Two years after the appearance of Tweedie's memoir, Graves and Stokes^ published some observations on * Painful Swellings of the Lower Extremities,' in which they maintained the pathological identity of phlegmasia dolens oc- curring after delivery and the painful swelling which succeeded fever ; but they insisted that phlebitis ' could not in justice be considered as the cause of the disease,' as it was often absent. They agreed with Tweedie, that the disease consisted primarily in inflammation of the subcutaneous cellular tissue of the limb. Similar opmions were afterwards expressed by Graves in his * Clinical Lectures,' ^ where it is stated that phlebitis is not the j&rst link in the morbid chain, and that it is merely a con- sequence of some unknown cause, which determines the inflam- mation of the other tissues. More recently the same views have been urged by Dr. Mackenzie," according to whom phlebitis is not essential to phlegmasia dolens, but both are the result of some morbid condition of the blood. In one of my fatal cases the femoral and iliac veins of the affected limb were perfectly normal and free from coagulum. In some cases, as shown by Begbie,*^ the lesion consists in an obstructed state of the lymphatics, the swelling in this case being firm, brawny, rugose, and painless ; and in others it is due to inflammation of the areolar tissue. y J. B. Bennett, 1857. ^ Stewaet, 1857. "" Graves and Stokes, 1830. " 2nd ed. 1848, i. 264. -= Med. Chir. Trans. 1853, and Lettsom. Led. 1862. ■* Begbie, 1872. 198 TYPHUS FEVEE. Case XVIII. Ty2)hus Fever, followed by Phlegmasia Dolens, Jaundice and Death. Autopsy : — Fatty Heart. Acute Atroj^hy of Liver, No clot in femoral veins. Eosetta J , at. 42, adm. into L. F. Hosp. Feb. 24, 1857. Had been ill for eight or nine days ; in hospital her most prominent symptoms were: pulse 120, great prostration; great restlessness and much low muttering delirium ; mvoluntary stools and urine ; well- marked typhus-rash; dry, brown tongue, and constipated bowels. Treatment consisted in wine, carbonate of ammonia, and castor oil to keep bowels open. Five or six days after admission, an improvement took place; and, hj March 6, she had regained strength to a con- siderable degree ; appetite was good, and pulse 80. On March 9, or about 23r Trans. Soe. of Buss. Phys. April 1865. 204 TYPHUS FEVER. from simple intra-arachnoid heemorrhage, and ascribed to the intemperate habits of the patients.'^ Case XXII. Typhus complicated luith Meningitis. Jane G , aged 19, adm. into L. F. Hosp. March 22, 1864, ill one day. She had before enjoyed good health, but had been seized with fever on March 21, and followed in night by delirium. During night after admission had acute delirium, followed by coma, and I con- curred with Dr. H. Jeaffreson in regarding the case as meningitis, but on afternoon of March 24, a typhus-eruption appeared on chest and abdomen, which rapidly became petechial. Early on following morning patient died comatose. Autopsy. — Peteehiffi persistent. Intense injection of pia mater and brain substance ; white matter pink and grey, very dark. Patches of soft yellow lymph on surface of hemispheres superficial to arachnoid and following course of veins. No lymph at base and no tubercle any- where. No sub-arachnoid fluid. Walls of lateral ventricles diffluent ; each contained half a drachm of fluid. Spleen large and soft ; blood black and fluid. Case XXIII. TypMis complicated with Meningitis. Louis M , aged 7 months, adm. with mother into L. F. Hosp. June 7, 1863, ill three or four days. Both mother and child had fever, and a characteristic typhus-rash, and disease in mother ran usual course. Infant was very restless, moved its head constantly from side to side, and died on June 9, after severe fit of convulsions. Autopsy. — Pia mater intensely injected ; much yellow lymph plas- tered over base of brain ; no tubercle. 2. Mental Imbecility and Mania. As a rule, the intellectual faculties are completely restored after the first few days of convalescence ; but occasionally they remain blunted for some days or weeks after the patient has regained sufficient strength to walk about. The mind does not recover as quickly as the body ; the memory is, defective ; the patient takes a long time to answer questions, mistakes one person for another, fancies that he has seen friends who have not visited him, has delusions,^ and says and does comical things. Occasionally also, several days after convalescence has fairly set in, the patient suddenly bursts into a state of violent mania, which usually subsides in three or four days, but sometimes persists for many weeks, and which in two of my cases has necessitated temporary restraint in ^ These and other considerations led me to the conckision that in some epidemics of ' cerebro-spinal meningitis ' the primary fever was akin to typhus, if not identical with it (Muechison, 1S65); and this opinion was shared by my colleague at the Fever Hospital (Buchanan, 1866, p. 550). COMPLICATIONS AND SEQUELS. 205 a lunatic asylum. Cases of this sort were long ago recorded by Graves/ and similar attacks are known to occur during conval- escence from other acute diseases than typhus."* Eoupell mentions the case of a female who was maniacal for six months after an attack of typhus, and was confined in an asylum, but recovered after a miscarriage." One of my patients, a girl aged lo, was suddenly seized on the tenth day of convalescence from typhus with violent retching, head-ache, and screaming delirium ; these symptoms lasted four days, but ceased at once after the action of a castor-oil enema. There is no evidence that either the fatuity or the maniacal attacks depend on softening or inflamma- tion of the brain or membranes ; they are attended, not by fever or head-ache, but by anaemia and nervous depression, and are therefore benefited by sedatives and stimulants ; and they are generally observed in cases where the primary fever has been characterized by great and protracted delirium, and where there has no doubt been an unusual degree of cerebral atrophy. The immediate exciting cause of the maniacal attacks in some in- stances appears to be constipation, or some gastro-enteric or other irritation. As far as my experience and reading extend, the mental faculties are, with rare exceptions, restored at last. 3. General Convulsions. (See page i68.) 4. Paralysis is a remarkable, though not common, sequela of typhus. In Case XXI. there was complete, though temporary, paralysis of both upper and lower extremities. Barrallier met with two cases of temporary hemiplegia during convalescence from typhus, and similar cases are mentioned by Huss.° Trousseau mentions a case of permanent right hemiplegia supervening on typhuSjP and two similar cases have occurred in my practice. One was that of a man aged 65, who, on the twentieth day during con- valescence, had an apoplectic seizure followed by right hemiplegia and death on the 42nd day. The second patient had right hemi- plegia and aphasia, but recovered (Case XXIV.). In 1867, the late Dr. Scoresby Jackson recorded an interesting case of aphasia with right hemiplegia, supervening on the fifth day of convales- cence from typhus, in a gentleman aged 2 1 ; the hemiplegia passed away in five or six weeks, but ten months after the attack of typhus the aphasia was still present.'^ J. F. Weisse had previously observed three cases of aphasia after typhus at St. Petersburg; in one of the patients the power of speech 1 Clin. Led. 2nd ed. i. 256. '" See H. Weber, Med. Cliir. Tr. vol. xlviii. p. 135. " Eoupell, 1839, p. 176. " Baekalliee, 1861, p. 255; Huss, 1S55, p. 225. p Clin. Lect. Syd. Soc. ed. ii. 431. 1 Jackson, 1867. 206 " TYPHUS FEVER. returned at the end of three weeks, after a discharge of sero-pus from the ears/ In other cases the paralysis is more localised. In one of Gairdner's cases paralysis on one side of the face super- vened on the loth day/ and in one of my cases, a female aged 48, temporary facial paralysis showed itself on the 17th day. (See also Case XXXI.) Occasionally the muscles of one limb, or individual muscles, such as the deltoid, are paralysed ; these muscles after a time become shrivelled, and if some be more atrophied than others, club-foot and other distortions may result. These attacks of paralysis are often preceded by severe pain, or pricking sensations, and are accompanied by numbness, com- plete anaesthesia, or hypersesthesia, of the affected part. The pathology of these attacks of paralysis is obscure, but they are probably due to arterial thrombosis of the central organs of the nervous system or of individual nerves. Case XXIV. Typhus, folloived by right Hemiplegia and Aphasia. John M , aged 53, adm. into L. F. Hosp. Jan. 7, 1862, on 14th day of typhus. Eash still well out, but convalescence commenced. Appetite returned, and patient was apparently doing well till morning of Jan. 13, when he was found to have paralysis of right side, and to have lost power of speech, although he appeared quite conscious. Distinct paralysis of right side of face ; right pupil dilated, but tongue deviated to left. No albuminuria. On Jan. i8 had a slight convulsive seizure, followed by stupor, involuntary evacuations, cataleptic rigidity of left arm, and moderate albuminuria, Kemained in this state for a week, and then became much better, but complete paralysis of right side with loss of speech remained till patient's discharge from hospital on March 6. Patient seemed to understand everything said to him, and replied correctly by gestures, but only uttered a few inarticulate sounds. At time of discharge there was rigid flexion of right leg. 5. Muscular Pains. Aching pains in different parts of the body may occasion no small distress during convalescence. Their precise nature is obscure ; but they seem to have their seat in the muscles, and they usually cease after a few days. Occasionally the patient complains of severe pains in the feet and legs, which have almost a neuralgic character, and which ought always to excite attention, as they often precede phleg- masia dolens, gangrene of the feet, or paralysis. " Prag. Viertcljahrsschrift, 1S65, iii. 12. " Gairdnek, 1865, No. I. COMPLICATIONS AND SEQUEli^. 207 d. Diseases of the Organs of Special Sense. I . Deafness, which is so common a symptom during the fever (see page 177), now and then persists during convalescence. In most cases it ceases in a few days, but, according to Huss, it is sometimes permanent.* Sometimes it is associated with buzz- ing sounds in the ears, which may be so constant and distressing as to prevent sleep. These symptoms may be connected with otorrhoea, or with inflammation of the internal ear ; but often nothing abnormal can be discovered in the ears. In other cases I have known rigors, high fever, intense head-ache and delirium, and even convulsions, occur during convalescence, and cease at once on the appearance of discharge from the ear. Dr. G. A. Kennedy also relates instances where otorrhcea was preceded by profound coma, dilated insensible pupils, and involuntary stools ; " and similar observations are recorded by W. T. Gairdner.'^ In some cases, inflammation of the ear spreads to the membranes of the brain, as more often happens after scarlatina. 2. Amaurosis. "During convalescence from severe attacks there is occasionally slight dimness of vision, which ceases after a few days. 3. Sloughing of cornece. (Seep. 215.) e. Diseases of the Organs of Digestion. 1. Glossitis. In one of my patients, a male aged 17, acute glossitis supervened in the first week of convalescence from typhus, and required free incisions into the tongue ; the boy recovered. 2. Pharyngitis. Erysipelatous inflammation of the mucous lining of the pharynx is met with in some cases of typhus. It may precede, accompany, or succeed erysipelas of the face. It often gives rise to considerable difficulty in swallowing, and may lead to extensive suppuration around the pharynx. The dangers to be apprehended from it are interference with nutrition and oedema glottidis. 3. Hmmatemesisy which may be profuse and fatal, is occasion- ally observed in typhus. W. T. Gairdner has recorded the case of a girl aged 14, who without any antecedent history of gastric ' Huss, 1855, p. 223. " G. A. Kennedy, 1838, p. 28. '' Gairdnee, 1865, No. I. 208 TYPHUS FEVER. ulcer, during an attack of typhus vomited two quarts of blood, and for several days after passed much blood jJer (mum. She re- covered under the use of turpentine.'^ Perry mentions the case of a girl aged 14, who, on the tenth day of typhus was suddenly seized with profuse hsematemesis, and died within twelve houi'S ; there was no post-mortem.^ Eussell also has reported the case of a patient aged 32, who on the 13th day of typhus had profuse vomiting and purging of blood, and died on the following day ; the stomach and intestines were intensely congested, but there was no ulceration.^ Dr. Wojciechowski^ has recently reported a case where profuse haemorrhage took place from the bowels and stomach on the sixth day, and was repeated three times. The patient recovered. Fom' cases of hsematemesis have occurred in my practice. A man aged 41 had much pain at epigastrium, with vomiting and x^^'gi^g of blood, but recovered. The re- maining three jpatients died. One female, 54, had previously suffered from similar attacks of both haematemesis and melsena, and had evidently old disease of the liver. In a second female, 42, there was no ijost-mortem. The last case was a girl aged 15, who went on well till the tenth day, when she was seized with profuse hsematemesis and bleeding from the bowel, and died in fourteen hours; the stomach and intestines contained much blood ; their mucous membrane was intensely congested and ecchymosed, and that of the stomach was likewise studded with hsemorrhagic erosions, but the glands of the ileum were healthy. In all of these cases the cutaneous eruption was unusually abundant and dark. 4. Diarrhoea has been already referred to as an occasional complication of typhus. In some epidemics it is more common than in others. It was noted in 302 of 1,950 patients in the London Fever Hospital in 1865, or in 15*48 p. c. (compare with page 149), and Da Costa found it in 13 out of 31 cases in Pennsylvania.^ In fatal cases I have never found anything approaching to the lesions of enteric fever in the ileum, and similar results have been obtained by Peacock,^ Da Costa, and others. Case XXV. Typhus complicated with Diarrhoea. John S , aged 44, adm. into L. F. Hosp. A^ig. 31, 1864, on ninth day of fever. Typhus-rash well marked ; tongue dry and brown ; Gaiedneb, 1863. * Perky, 1866. ' Glasgoto Med. Journ. May 1869, p. 411. '■ ViECHow and Hiesch, Jahres-Ben'icht, 1879, ii. 34. » Da Costa, 1866. " Peacock, 1862, p. 137. COMPLICATIONS AND SEQUELS. 209 bowels relaxed. On Sept. 4 (isi^/i clay) pulse had fallen to 84, and rash fading, but diarrhoea obstinate ; motions liquid and dark brown. Diarrhoea resisted all treatment ; patient became gradually weaker, and died on Sept. 9, or iWi day of illness. Autopsy. — Intestines were exliibited to Pathological Society. {Trans. XVI. 124.) No congestion nor ulceration of any part of bowel; no enlargement of Peyer's patches nor of solitary glands of ileum. 5. Dysentery is not a common complication of typhus in Britain. In three cases I have observed typhus followed by fatal dysentery ; in one, death was due to copious haemorrhage from the bowels; in another the liver contained numerous pysemic abscesses ; the third case died with convulsions (Case X. p. 175). But in many instances of besieged cities, in some of the Irish epidemics, and in the French army in the Crimea, typhus and dysentery often prevailed together, and complicated one another. There is an additional interest in the connection between dysentery and typhus. Sir Gilbert Blane, Dr. Copland, and others have tried to show that these two diseases are sometimes vicarious, dysentery in the black taking the place of typhus in the white man.° The disease which carries off the wretched Africans in the crowded holds of slave ships is not typhus, but dysentery ; and yet the African is known not to be exempt from typhus. (See also p. iii.) That two poisons are developed under similar circumstances is far more probable than that the same poison should give rise to two diseases. 6. Intestinal hcemorrhage is an extremely rare, but very fatal, complication of typhus. When it occurs it is due to a liquefied state of the blood, and is often associated with hsematemesis and other haemorrhages, and in this respect it differs from the intes- tinal haemorrhage of enteric fever. Jenner states, that of nearly 2,000 cases of typhus, of which notes were taken at the London Fever Hospital during three years, the only instance in which bleeding from the bowels occurred was that of an old man who had haemorrhoids. I have met with it six times in about 7,000 cases : all six patients died. Four of the six have already been referred to under the heads of hsematemesis and dysentery ; in the remaining two there was no autopsy. Eussell"^ observed intestinal haemorrhage in three out of from 3,000 to 4,000 cases of typhus at Glasgow. AU three patients died, and one of them has been already quoted as an example of hsematemesis (p. 209). « Duncan, 1862, and Brit. Med. Journ. August 10, 1S61. ^ Glasg. Med. Journ. May 1869. P 210 TYPHUS FEVER. Tweedie mentions a case of well-marked typhus, where haemor- rhage from the bowels was the apparent cause of death ; Peyer's patches and the solitary glands were healthy, and there was no enlargement of the mesenteric glands ; but the mucous mem- brane of the ileum and of the commencement of the colon was red and tumid.® Frerichs records a case of 'typhus exanthe- maticus ' complicated with jaundice, in which extensive haemor- rhage from the bowel occurred, followed by great exhaustion; there were a few hsemorrhagic erosions found after death in the rectum, but the ileum and mesenteric glands were healthy.^ Barrallier observed extensive haemorrhage from the bowels in two of 1,058 cases of typhus.^ A fatal case of haemorrhage from the bowels is reported by Dr. Eeid in the ' Glasgow Medical Journal' for 1877 (p. 333) : death took place on the thirteenth day. On post-mortem examination there was found congestion and softening of the mucous membrane of the small intestine, especially of the duodenum, but no ulceration. The circumstance that in some epidemics tyxDhus is compli- cated with scurvy or dysentery, coupled with the non-recognition of the distinction between typhus and enteric fever, may account for the frequency with which intestinal haemorrhage has been observed by some Irish physicians. Dr. H, Kennedy ^ states that he has met with 30 cases of intestinal haemorrhage in typhus, and that no ulceration of the bowel was found in those which were fatal. 7. Jaundice is a common symptom of relapsing fever ; but in typhus it is extremely rare. Jenner never met with an instance. It is, however, occasionally observed, Henderson refers to such cases ; ^ 2 cases are recorded by Frerichs in his work on ' Dis- eases of the Liver ; ' J 4 cases are referred to by Perry ; ^' and 1 5 have come under my own notice : they are almost invariably fatal. Of my 1 5 cases, in 3 the jaundice did not appear until convalescence, and was due to congestion of the liver ; in a fourth, it was due to gastro-duodenal catarrh ; in the 1 1 remain- ing cases it coexisted with the typhus-rash, and 9 of the 1 1 cases were fatal. The yellowness was in all true jaundice, as shown by the presence of bile-pigment in the urine ; but no obstruction of the bile-ducts was found after death. As in pyaemia, yellow fever, snake-bite, and other blood-poisonings, the jaundice is due to some abnormal condition of the blood. For an account of « TwEEDiE, i860. *■ Dis. of Liver, Syd, Soc, Tr. i. 168, f B.utRALLiER, 1S61- "° H. Kennedy, i860. ' Hendeeson, 1S43, p. 220. j Syd. Soc, Transl. i. pp. 168, 170. ^ Pekry, 1866. COMPLICATIONS AND SEQUELJ3. 211 the pathology of these forms of jaundice, the reader is referred to the author's * Clinical Lectures on Diseases of the Liver.' In one of my cases (p. 198), the liver was in a state of Acute or Yellow Atrophy : it was not much reduced in size, but it was pale yellow and extremely soft ; it exhibited no trace of division into lobules, and it contained much oily and granular matter, while the secreting cells appeared to be undergoing disintegra- tion. Frerichs found leucine and tyrosine in the hepatic tissue of his cases; hitherto these substances (see page 156) have been chiefly found in the liver, kidneys, and urine, in cases of acute atrophy of the liver. Leucine and tyrosine were also pre- sent in the following case, in which they appeared to be substi- tuted for urea in the urine. Case XXVI. Typhus complicated loith Jaundice. Death hy Coma. Leucine and Tyrosine, hut scarcely any Urea, in Urine. Leucine and Tyrosine in Liver and Kidneys. Kobert E , aged 33, adm. into L. F. Hosp. Aug. 26, 1862. On admission, too confused to give any account of'liimself ; pulse 120, feeble ; tongue dry and brown along centre ; skin warm and dry, with distinct typhus-rash and a general yellowish tint. Ordered beef-tea, milk, brandy (6 ounces), sulphuric acid, sulphuric ether, and quinine. Patient became weaker and more unconscious. On 2d>th decided jaundice of entire skin and of conjunctivae ; brandy was increased to 8 ounces. Aug. 29. — Pulse 120 and feeble ; is drowsy and scarcely con- scious ; pupils contracted. Decided jaundice of skin and conjunctiva, and a well-marked petechial typhus-rash on chest and abdomen. In- voluntary evacuations ; tongue brown ; motions light-coloured, but contain bile ; no tenderness in hepatic region ; urine of a bilious colour, and yields the reaction of bile-pigment, but not of bile-acids ; clear ; acid ; throws down no deposit, and contains no albumen ; spec, gravity, 1017. Six ounces of the urine were evaporated, and the residuum was found to contain abundance of globular masses of leucine, and needle- shaped crystals of tyrosine, and also crystals of triple phosphate. When nitric acid was added to a drop of the urine, after concentration to one- twelfth of its volume, only a few small crystals of nitrate of urea could be discovered with microscope. A blister was applied to scalp ; but patient died comatose on Aug. 30. Autopsy, 20 hours after death. — Deep jaundiced tint of entire surface. Heart and lungs healthy ; blood fluid and dark ; spleen, 7 ounces, very soft. Liver, 62 ounces, rather pale and very friable, but lobules dis- tinct ; hepatic tissue contained numerous globular crystalline masses of leucine and tyrosine ; secreting cells loaded with oil and bile-pigment. Kidneys enlarged, each weighing upwards of 7 ounces ; surface smooth ; cortex hypertroplned and containing crystalline bodies similar to those found in liver ; uriniferous tubes gorged with epithelium ; intestines healthy. p2 212 TYPHUS FEVER. 8. Peritonitis is almost unknown as a complication of typhus. Jenner, however, has recorded the case of a girl aged i6, who died from acute idiopathic peritonitis, commencing suddenly on the fifth day of convalescence ; the ileum and mesenteric glands were perfectly healthy.^ A similar case is recorded by Dr. A. Collie.™ In 1862 a case of typhus proved fatal at the Fever Hospital from peritonitis, which resulted from the bursting of a softened embolic deposit in the spleen ; the mitral valve was covered with soft vegetations ; the ileum was healthy. In one case I have known death result from tubercular peritonitis, shortly after an attack of typhus. /. Diseases of the Urinary Organs^ 1. Disease of Kidneys. From what has already been stated (pages 155, 169), it is obvious that there can be no more serious complication of typhus than disease of the kidneys, whether this disease be of old date, or the result of the primary fever. 2. Catarrh of Bladder, sometimes inducing h(ematm'ia, may occur during convalescence, especially after neglected retention of urine. Hsematuria, with haemorrhages elsewhere, may also occur independently of cystitis. g. Complications referable to the Organs of Generation. 1. Menstruation. The Catamenia are not uncommon in the early stage of typhus, and in the advanced stage they are occa- sionally so profuse as to increase the prostration and protract convalescence. Once I have known death due to flooding. 2. Pregnancy. Pregnant females are not exempt from typhus, and women even in an advanced stage of pregnancy may pass through the disease without miscarrying. When miscarriage does occur, it is not necessarily fatal to either the mother or the infant. In the nine years 1862-70, 107 female patients with typhus in the Fever Hospital were known to be pregnant ; of these 49 aborted about the tenth to the fourteenth day of the disease ; 9 of those who aborted died ; the remaining 98 patients recovered. I have also notes of 7 patients in the ninth month of pregnancy who were confined during an attack of typhus ; 2 of the mothers died of puerperal fever; 5 recovered. All the 7 children were alive and did well ; in one, the cuticle at time of birth was desquamating in large flakes. Of 46 pregnant females 1 Jennee, 1850, xxii. 40S. ° Lancet, November 16, 1S72. COMPLICATIONS AND SEQUELS. 213 attacked with typhus observed by Eussell at Glasgow, 15 aborted, and only 2 (both aborted) died." Wardell says that at Edinburgh pregnant females, in typhus, had no disposition to miscarry." h. Diseases of the Supporting Tissues : Integuments, Bones, dc. I. Erysipelas is an occasional complication of typhus (in 92 of 14,676 cases, or i in 159). It may appear as early as the fifth day ; but, as a rule, it is not observed before the end of the second or the third week, and often it does not appear until con- valescence. It usually commences at one side of the nose, or in one ear (especially when there is otorrhoea), and spreads over the face and scalp, and it is sometimes accompanied by a similar condition of the pharynx or larynx. Other parts of the body are not exempt. It may be attended by delirium, coma, and other head symptoms, and it always adds greatly to the danger of the case (30 of 92 cases fatal). It often terminates by the formation of abscesses in the eyelids, beneath the scalp, or else- where. Some patients exhibit a remarkable liability to erysipelas, which, after disappearing, recurs repeatedly in the same place, or in other parts of the body, while in more than one instance I have known almost the whole body affected simultaneously. When many cases of erysipelas appear in rapid succession in a ward, they may often be traced to over-crowding or defective ven- tilation, or to some patient with foul and offensive bed-sores, or with erysipelas, in the same ward. 2. (Edema. Slight cedema of the feet and ankles, arising from debility, is sometimes observed when the patient begins to walk. It seldom lasts longer than a week. In rare cases, of which an example will be found at p. 202, there is general ana- sarca, which is sometimes connected with disease of the kidneys. 3. Gangren'^e from Pressure. Bed-sores are not uncommon in cases which are protracted by other complications ; but in uncomplicated typhus, according to my experience, they are rare. A similar observation is made by Barrallier.P They were noted at the Fever Hospital in 126 of 14,676 cases (i in 116); they were mostly due to neglect before admission, but sometimes they formed notwithstanding every precaution. Their most common situation is over the sacrum, but they also appear on any part of the body subjected to pressure, such as the trochanters, " Eussell, 1867 « Wardell, li p Baeralliee, 1 86 1, pp. 96, 220. 214 TYPHUS FEYEE. heels, occiput, ears, elbows, the lower angles of the scapulae, and the spmes of the last ceiwical and first dorsal Yertebrse. These bed-sores commence as an erythematous patch, which becomes hard and black in the centre. After a time a line of demarca- tion forms between this central dark part and the surrounding erythema; the central part becomes more and more detached and at last separates as a slough, leaYing a dhty excavated ulcer, which may extend by sloughing, ulceration, op burrowing, beneath the surrounding integuments and even down to the bones. Bed-sores protract the duration of the illness, and may endanger life by exhaustion, or by inducing other complications, such as gangrene of the lungs or pysemia. (See page 192.) 4. Spontaneous Gangrene. Parts free from pressm'e are not exempt from gangrene in typhus. Occasionally gangrene com- mences in the toes and spreads upwards, iuYolving all the tissues down to the very bones. At Ediubm'gh in 1848 I saw a patient who lost both feet fi'om this cause ; the gangrene extended to some inches above the ankles, where a line of demarcation formed, and both legs were amputated below the knee. Since then, I have seen several patients who have lost the toes, or the whole of one or of both feet, in a similar manner. The gangrene in all such cases, I believe, is due to thrombosis of the arterial trunks. (See antea, p. 192, and Case XIX.) Most of my patients have been in a state of starvation for weeks prior to the attack of fever. The gangrene is usually preceded by severe shooting pains, numbness, coldness, and lividity of the legs and feet. The nose,*! penis, scrotum, and pudenda I have likewise observed to slough. Dr. Lyons records a case, where the whole of the integuments over the anterior and superior part of the chest sloughed ; the patient, at the time of attack, was in the last stage of starvation.'^ I have seen a similar occurrence follow the application of a mustard poultice. Sloughing or ulceration of both corneae, with escape of the humours, I have met with in several instances, and similar cases are mentioned by Jenner * and Huss.* The affection appears to be partly due to the eyes being kept constantly open. 5. Noma or Cancrum Oris is a very fatal form of gangrene which attacks the mouth, tongue, and face. It is most common in children, and is met with in severe cases of measles, small-pox, and some other diseases, as weU as in tj^phus. It usually com- 1 M'Grigoe, 1S09. ■• Lyons, 1861, p. 191. ' Jennek, 1S50. ' Huss, 1855, p. 229. COMPLICATIONS AND SEQUELS. 21 5 mences about the end of the second week, in the form of gan- grenous ulceration of the mucous Kning of one cheek. The external integmnents become enormously swollen, red, tense, shining, and painful. By-and-by, a dark speck, like a spot of purpura, appears at about the centre of the external swelling, corresponding to the situation of the internal ulceration. This speck rapidly enlarges to the size of a penny, and becomes surrounded by a rim of ulceration, by means of which the central slough is gradually detached, disclosing the interior of the mouth. The corresponding side of the tongue is likewise more or less imj)licated. Three or four days are usually sufficient to put an end to life ; death, indeed, may occur before any attempt at separation of the slough. This complication was well described in 1 8 1 9 by Dr. Marshall Hall ; " and a good coloured representation of the disease has been published by Dr. G. A. Kennedy.^ In the Crimea it was a not uncommon complication of typhus, and was always fatal. Its occurrence has been attributed to the abuse of mercury ; but it occurs in cases where mercury has never been administered.^ I have met with it three times ; all three patients were girls, seven or nine years of age : two died, but one recovered after the free applica- tion of strong nitric acid to the inside of the cheek. 6. Hospital-Gangrene. Wounds and ulcerated surfaces are very liable, under the influence of the typhus-poison, to degene- rate into hospital-gangrene. South records an instance where an ulcer of the leg, which had existed for eighteen months, assumed all the characters of spreading gangrene on the patient being attacked with typhus. "" Jacquot states that, during the prevalence of typhus in the French hospitals in the East, wounds of every description were extremely prone to degenerate into hospital-gangrene, and that it was impossible to apply blisters without a similar risk.^ Similar observations were made by Larrey ; "^ others have been collected by Barrallier ; ^ and the fact must be familiar to every physician who has had much experience of typhus. It is not necessary that the patient with the wound or ulcer should contract typhus himself ; mere exposure to the typhus-poison, or to the conditions capable of " Hall, 1819. '' G. A. Kennedy, 1838. ^ Some writers restrict the term ' Cancrum Oris ' to gangrenous ulceration commencing in the gums and spreading to the lips and cheeks, but not producing sloughing of the entire thickness of the cheek ; while they apply ' Noma ' to the affection above described. (See Chelhis' Surgery, South's ed. i. 62.) ^ Chelius' Surgery, South's ed. i. 56. y Jacquot, 1858, p. 211. =^ Mem. de Chir. Milit. ii. 331. * Babkalliek, 1861, p. 96. 2l6 TYPHUS FEVER. generating it, is sufficient. Hospital-gangrene, indeed, always ar)pears under the same circumstances as typhus, viz., over- crowding and deficient ventilation ; and it is possibly due to a similar poison. From what has been stated, it is obvious that surgical cases ought never to remain in the same ward with cases of typhus. 7. Necrosis. Severe fevers are spoken of by surgeons as one cause of necrosis ; and in one of my patients an attack of typhus was followed by extensive necrosis of the fibula. Like spon- taneous gangrene, the necrosis is probably due to arterial thrombosis. 8. Accidental Eruptions. Herpes on the lips and other parts of the body are occasionally observed at the commencement, or towards the termination, of the disease. Jacquot found it in nearly one-fifth of his patients in the Crimea. In some cases I have seen hullce filled with light or dark fluid, or large pustules, appear on various parts of the body during the progress of the fever. Stokes has observed bullae of this description followed, after bursting, by deep ulcers with sharp margins, as if punched out with an instrument ; ^ while Henderson •= and Hudson ^ believe that their appearance is due to liquefaction of the blood consequent on uraemia. In several cases I have known urticaria appear before the crisis, or in early convalescence ; the patients were mostly young and recovered. Numerous hoih may also break out dm-ing convalescence and prove troublesome. 9. Diffuse Cellular Inflammation ending in purulent infiltra- tion is an occasional complication or sequela. Its chief seat is the lower extremities. Its main symptoms are frequent rigors and persph-ations, fever, great derangement of the stomach and bowels, prostration, sleeplessness, and pain in the aflected part. I have seen several examples of this complication, and others are recorded by G. A. Kennedy,"' Graves,^ &c. 10. Inflammatory Su-ellings, or Buboes, are not uncommon complications of typhus. Their most frequent sites are the parotid and submaxillary regions, and then they are usually attributed to inflammation of the glands ; but as was shown by Drs. Craigie s and Graves,^ the inflammation has its seat mainly in the subcutaneous areolar tissue, and not in the substance of the glands. The pus, however, often insinuates itself between ^ Stokes, 1854, xxix. 423. « Henderson, 1844. ■1 Hudson, 1867, p. 109. <= G. A. Kennedy, 1838, p. 35. *■ Graves, 1848, i. 261. ■? Cr.ugie, 1837, p. 301. '' Geayes, 184S, i. 194. COMPLICATIONS AND SEQUELS. 21/ the lobules of the gland, which, after death, may be unusually dense, and have the appearance as if dissected out, while on microscopic examination the glandular tissue is found to be loaded with oil. Large portions of the subcutaneous areolar tissue may slough, and very often circumscribed drops of pus, with a small central slough, are found in the soft parts, at the circumference of the abscess. Of 14,676 patients admitted into the London Fever Hospital in ten years (1861-70) parotid, to say nothing of other, swellings were present in 211, or in i in '69*5. In the two first years of the epidemic they existed as often as I in 50'3 (38 of 1,914 cases), whereas in the last three years they were only as i to 80*3 (48 of 3,854 cases). The swellings in the parotid and submaxillary regions usually appear at, or immediately after, the crisis of the primary fever ; but in several instances I have met with them in the first week, while in others they are not developed until convalescence. They occur at almost every age from 2 up to 70 ; but the majority of the patients have been above the average age of typhus cases, i.e. upwards of 29. (See page 64.) They are usually accom- panied by considerable redness, tension, pain, tenderness, and sometimes oedema, of the super-imposed skin ; by inability to open the mouth, or to protrude the tongue ; occasionally by cedema of the glottis, dysphagia, or deafness ; and, in most cases, by great prostration, congestion of the lungs, and aggra- vation of the general symptoms. They often form with great rapidity : at one visit the face may be natural ; at the next, a few hours after, one side of it may be enormously swollen. They also advance rapidly to suppuration, an extensive collection of matter forming in from two to four days ; at other times they recede without suppurating : or the swelling, after receding and almost disappearing, retm-ns and rapidly advances to suppura- tion ; occasionally, they coexist with erysipelas of the face or with a brawny swelling of the neck. When not opened artificially, they may burst externally by one or more points, or into the mouth, or into the meatus of the ear. In Case XXX. a parotid abscess was followed by complete facial paralysis. These inflammatory, or often carbuncular, swellings may occur on one or both sides of the face, and they are not restricted to this part of the body. I have met with them in the axilla, the groin, the mamma, the arms, thighs, legs, and substance of the muscles. In some cases they have seemed to originate in extravasations of blood. As a rule, they do not exceed one, iwo, or three in number ; but occasionally they are more 21 8 TYPHUS FEVEK. numerous, and they are not necessarily fatal. I had in 1862 under my care a case of typhus complicated with numerous (about 20) subcutaneous abscesses, varying in size from a hazel- nut to a man's fist, in every part of the body ; some of them burst and formed extensive gangrenous ulcers, and the patient sank from the profuse discharge. Dr. Stokes also records a case of typhus, in which * large and foul buboes formed in various parts and suppurated.' ^ In Case XXIX. a large abscess in the axilla led to profuse and fatal haemorrhage. Some writers have regarded these swellings as critical and auspicious ;J but, according to my observation, they are a formidable complication in every case where they advance to suppuration. It is true that they are occasionally met with in mUd cases about the period of crisis ; but now and then they are seen in the first week of the disease, and as a rule they add greatly to the severity of the case, if they be not the immediate cause of death. During the two years 1856-57, 21 cases of typhus in the London Fever Hospital were complicated with parotid swellings, of which 14, or 66*6 per cent., died; while the average mortality of all the remaining cases of typhus (1,315) during the same period was only 20 per cent. This comparison is, perhaps, scarcely fair, as most of the patients with parotid swellings were above the average age of the other cases, and the mortality from typhus increases with age. Still the average age of the 21 cases was 41 years, and during the ten years 1848-57, as weU as the two years 1856-57, the rate of mortality of all the cases of typhus (including the parotid cases), between 40 and 50 years of age, was only 35 per cent. Again, of the 211 cases of parotid bubo admitted during the ten years 1861-70, ^7, or 41 "23 per cent., were fatal, the mortality in the remaining 14,465 cases being only i8*ii per cent. Here the patients were not much above the average age, and a good many were children : their mean age was only 31-5. (See page 64.) Parotid buboes and other inflammatory swellings have been noticed in many epidemics of typhus, and have been usually spoken of as a serious complication. Many years ago, Eiverius, in his account of an epidemic of typhus at Montpellier, stated that a number of the patients had swellings of the parotid region appearing about the ninth or eleventh day, and that the majority of these cases j)roved fatal within two days.'' According to Lind^ many of the French prisoners at Winchester in 1762 laboured ' Stokes, 1S54; and Lyons, 1861, p. 193. i See Chkistison, 1840. ^ Eivebius, 1690. COMPLICATIONS AND SEQUELS. 2ig under a very malignant form of typhus, ' attended with huboes both in the groin and arm-pits, and other pestilential symptoms.' He adds, that at Haslar Hospital, although he had never seen ' fevers rise to such a malignant height as to produce buboes in the groin,' he had observed ' a swelling of the parotid glands,' and that * such as were in this manner seized commonly died.' ^ Swellings both in the groin and parotid region were noted by Dr. Monro in the typhus which prevailed in the British army in Germany in 1761.°* Parotid swellings were also observed in the typhus siderans of Saragossa, Torgau, and Mayence ; " and in his account of typhus at Dantzic, M. Tort says, * dans quelques cas aussi, manifestation de parotides ; toujours alors mort.' ° Parotid swellings were a common complication of typhus in the French army in the Crimea: *ces parotidites,' says Jacquot, 'uniques ou doubles, sont toujours tres-graves.' p Lastly, M, Barrallier met with inflammatory swellings in the parotid and submaxillary regions in 82 out of 1,068 cases of typhus, and adds : 'La sup- puration etendue des parotides, et du tissu cellulaire environnant, a souvent ete d'un facheux augure ; sur les 24 malades, qui ont presente cet accident (parotides suppurees), 15 ont succombe."^ Inflammatory swellings in typhus are interesting, as they constitute a connecting link between this disease and Oriental plague. The more the subject is studied, the more the convic- tion is forced on the mind, that there is a strong resemblance between these two diseases, in their causes, as well as in their symptoms, and that, in fact, typhus is probably the plague of modern times. In the first place, the two diseases resemble one another in their symptoms. The main differences are three, viz. : the more rapid i)i'Ogress of plague ; the presence in plague of buboes or inflammatory swellings in the inguinal, axillary, cer- vical, parotid, and submaxillary glands; and the presence in typhus of an eruption, the spots of which have a tendency to become converted into petechife. But first, it has been shown that typhus may be as speedily fatal as true plague. (See pages 186, 226.) Secondly, typhus is occasionally, like plague, complicated with buboes, which greatly aggravate the severity of the case. It is true, that these buboes appear later in typhus than in plague, and that they are met with in other febrile diseases, such as remittent and enteric fevers. But, although ' LiND, 1763, p. 90. «" MONEO, 1764. ° De Clauery, 1838, ed. 1844, PP- 33> 43. 45- " Ibid. p. 42. p Jacquot, 1858, p. 211. "J Baeealliek, 1861, p. 254. 220 TYPHUS FEVER. they are not pathognomonic either of plague or typhus, they are, as far as my knowledge extends, much more common in typhus than in any other febrile diseases, excepting plague, while in the typhus siderans of Torgau and Mayence they seem to have appeared as early as in plague. Thirdly, most writers agree in stating, that * dusky-red or pale purplish spots, which, as the disease advances, acquire a livid hue,' are very common in plague.'' Among the '^ Directions for the Searchers,^ drawn up by the Eoyal College of Physicians of London in 1665, is the follow- ing: 'Whether there be any tokens, which are spots arising upon the skin, chiefly about the breast and back, but sometimes also in other parts ; their colour is something various, some- times more reddish, sometimes inclining a little towards a faint blue, and sometime brownish mixed with blue.' ^ Many observers have been struck with the similarity in the symptoms of typhus and plague. The early writers often con- founded the two diseases {pestis &nd fehris pestilens) , while both Cullen and Sauvages regarded plague. as merely a severe form of typhus.* Sydenham, speaking of typhus (fehris pestilens), says : * Cum ipsissima peste specie convenit, nee ab ea, nisi ob gradum remissiorem, discriminatur.' " The historians of the outbreak of plague at Marseilles in 1720 observe : * La rapidite et quelques accidents sont les seules choses qui distinguent les fievres malignes ordinaires de la peste.' ^ Dr. Ferriar wrote as follows : ' Although the symptoms of eruptions and buboes be distinguished by individual characters in the plague, yet they do not depart, in their general type, very far from the symptoms of malignant fevers ; for the latter are very commonly attended by flat erup- tions, which physicians call petechise, and glandular abscesses are not unfrequent in them.' "^ According to Dr. Copland, the symptoms of plague * differ but little from those of true typhus fever, excepting in the appearance of carbuncles and buboes.' ^ Lastly, the celebrated Egyptian physician, Clot Bey, on visiting the London Fever Hospital some years since, was much struck with certain cases of typhus complicated with swellings in the parotid region, and declared that in Egypt they would be re- garded as examples of plague. Excepting the buboes, the x)ost- mortem appearances of typhus and true plague are identical.^ See article ' Plague ' in Lih. of Med. vol. i. 1840, p. 192. Heberden, 1801. Ty;phus Mgyptiacus (Sauvages) ; a variety of Typhus gravior (Cullen). Op, Om. Sycl. Sec. Ed. p. 96. ' Hancock, 1S21. " Feeel^, 1810, i. 268, Copland, 1858, iii. 196. ^ Ceaigie, 1834, p. 273. COMPLICATIONS AND SEQUELS. 221 But secondly, in the plague, as in typhus, there is reason to believe that the poison can be generated de novo, and that the disease does not of necessity arise from contagion nor from some epidemic influence. On this subject the reader is referred to the works of Heberden ^ and Hancock,^ and to the valuable report on the Plague and Quarantine, drawn up by a Commission of the French Eoyal Academy in 1 846, and published in the name of Dr. Prus.^ From the evidence collected in these works and elsewhere it seems probable, that the poison of plague is generated by the concentration of animal exhalations conse- quent on overcrowding with deficient ventilation. In Cairo, the modern head-quarters of the plague, the streets are extremely narrow, and the population is crowded into close chambers devoid of all ventilation. Throughout the rest of Egypt, the habitations are no better ; the house, or rather the hole, of the Egyptian is built of mud, and the door is so small and low that it can only be entered by cre.eping. A number of these huts, which resemble so many ant-hills, are constructed close to one another, and every means of ventilation is cut off, while whole families lie huddled together. Such are the localities in which plague appears, independently of any importation from with- out. Moreover, the great predisposing cause of plague, as of typhus, is starvation. Failures of the crops and other causes of famine convert sporadic cases of plague into great epidemics. Speaking of the events which preceded the great epidemic of plague in the fourteenth century, Hecker observes : ' Children died of hunger in their mothers' arms. Want, misery, and despair were general throughout Christendom.' "^ ' The outbreak of the plague,' says Dr. Milroy, in his review of the French Eeport, ' has not unfrequently followed upon wars, famines, and other wasting calamities ; and, on the other hand, its ravages have invariably been observed to become less frequent and less desolating, in proportion as the condition of the inhabitants of the affected countries, in point of civilisation and comfort, has improved.' •^ According to M. Prus, * Si nous recherchons, avec soin, les causes qui paraissent exercer I'influence la plus grande sur le developpement de la peste, nous pourrons les resumer ainsi : habitation sur des terrains d'alluvion ou sur des terrains marecageux; maisons basses, onal aerees, encombrees ; air chaud et humide ; action des matieres animales et vegetales en putre- faction ; alimentation malsaine et insvffisante ; grande miserc Hebeeden, 1 801. => Hancock, 1821, ^ Pp.us, 1846. « Hecker, 1844, p. 17. ^ Pkus, 1846. 222 TYPHUS FEVEK. physique et morale.'' ® The resemblance between the causes of plague and typhus requires no comment. It is possible that the warm, moist climate of Egypt may lead to the development of plague from causes which in this country would only suffice to generate typhus. But some centuries ago, when our dwellings resembled those of the Egyptians, plague was a common disease in London, and occasionally, like typhus, it appeared in great epidemics. It has been the fashion to refer the origin of all these epidemics to imported contagion ; but there is no satisfactory evidence that this was the case. If the poison of plague were always imported, it is strange that during the last two cen- turies, while an extended commerce has increased the means of importation a thousand-fold, plague (except in the form of typhus) has been unknown in Britain. No one will be bold enough to attribute this exemption to the operation of our Quarantine laws. The disappearance of the plague from London was coincident with an improved construction of the dwelling-houses, which followed the great fire of 1666. Heberden describes the state of the city prior to the fire as follows : ' The streets were narrow and crooked, and many of them unpaved ; the houses were built of wood and lofty ; they were dark, irregular, and ill-contrived, with each story hanging over the one below, so as almost to meet at the top, and thereby preclude, as much as possible, all access to a purer air ; they were besides furnished with enor- mous signs, which, by hanging into the middle of the street, contributed not a little to prevent all ventilation below.' ^ ' It is probable,' says Hancock, ' that if this country has been so long forsaken by the plague, as almost to have forgotten, or at least to be unwilling to own, its natural offspring, it has been because the parent has been disgusted with the circumstances under which that hateful birth was brought to light, has re- moved the filth from her doors in which it was matured, and has adopted a system of cleanliness fatal to its nourishment at home. But if ever this favoured country, now grown wise by experience should relapse into former errors and recur to her odious habits, as in past ages, it is not to be doubted that a mutual recognition will take place, and she will again be visited by her abandoned child, who has been wandering a fugitive among kindred associates, sometimes in the mud-cots of Egypt, sometimes in the crowded tents of Barbary, and sometimes in the filthy kaisarias of Aleppo.' ^ e Prxjs, 1846. ' Heberden, iSoi. s Hancock, 1S21. COMPLICATIONS AND SEQUELiE. 223 Moreover, many epidemics of plague in Europe have been preceded and accompanied by a great prevalence of typhus. Instances of this nature have already been referred to (pages 27, 29), and others will be found in the works of Heberden and Hancock. Many writers state that the one affection merged into the other, so that it was sometimes difficult to say whether a case was typhus, or genuine plague. 'Case XXVII. Tyi^hus complicated zvith Parotid Sioellings — Becovery. John F , aged 12, adm. into L. F. Hosp. Aug. 4th, 1856. Ill a week, and delirious for two nights before admission. Aug. ^th {Sth day). — Pulse 117, small and soft; skin, hot and dry; well-marked typhus-eruption. Tongue dry and brown along centre. Sordes on teeth ; bowels confined. Has a heavy, confused expression ; face dusky ; slept at intervals during night ; much delirium. Ordered car- bonate of ammonia, wine (6 ounces), milk and beef-tea, Atcg. 'jth (loth day). — Pulse 100. Slight swelling and tenderness, without any hard- ness, over both parotids. Poultices. Aug. Sth {nth day). — Swellings increased, especially that on right side, which is slightly red on surface and somewhat hard and tender. Swallows well. Aug. gth {12th day). — Pulse 100, and regular ; skin dry and cool, rash still out ; swellings larger, hard and painful ; much redness of skin below left ear ; tongue moist and furred, protruded with difficulty ; swallows well. One stool. Slept better and less delirium. Aug. i^th {16th day). — Pulse 120, and weak ; rash almost gone; purulent discharge from both ears, but swellings still hard, painful, and not pointing ; tongue moist, and some improvement in general symp- toms, but is very prostrate. Ordered quinine, milk, arrowroot, beef- tea, and one egg. Aug. i$th {iSth day). — Both ears discharging freely, and both swellings soft and pointing. Both opened by a free incision. A quantity of pus escaped, and on 2 1st a large slough came away from opening on right side. After evacuation of matter, patient convalesced rapidly, and on Atig. 2 yd openings had ceased to discharge. Case XXVIII. Typhus comiolicated ivith Bronchitis, Pneumonia, and Inflammatory Swelling in Left Parotid region. Death on 2'jth day. Fred. G , aged 34, adm. into L. F. Hosp. A2Jril yth, 1862. Taken ill on ^rd with rigors, head-ache, and general pains. On admis- sion, pulse 108 ; intense head-ache ; patient was confused, very restless, and slept badly ; skin was covered with a typhus-rash. Cold lotions, mineral acids, and beef-tea were prescribed. On gth day, head-ache had ceased, but patient was very delirious, getting out of bed ; rash was very abundant and darker. Wine {4 ounces) and the morphia and antimony draught were ordered, after which he slept. 224 TYPHUS FEVEE. On iith day, more prostrate and almost miconscious. Tongue dry and brown; pulse ii 6, feeble; urine and faeces in bed. Brandy was substituted for wine. On 14th day, pulse 102 ; very prostrate ; much quiet delirium ; takes notice when spoken to, and that is all ; eruption copious and petechial. Brandy was increased to 10 ounces. Ap. igth (i6th day). — Left parotid region became enormously swollen in a few hours and very painful. Prostration increased; pulse 120, and with difficulty felt ; tongue and hands tremulous ; swelling was painted with a strong solution of nitrate of silver, and covered with cotton wool. Liquor cinchonse, sulphuric ether, and ten ounces of brandy were pre- scribed, with the addition, after two days, of three eggs and two pints of porter. Ap. 2^tJi {22nd day). — Swelling has increased considerably, and a small opening has formed behind ear, from which a very little pus has escaped. Skin over entire swelling pits on pressure, but there is nO' distinct fluctuation. Has no cough, but breathing is hurried ; lips slightly livid, and sibilant rales audible all over front of chest ; rash has quite disappeared ; no albumen in urine. Sinapisms to chest, and a mixture containing ammonia, ether and senega, prescribed. On Ap. 2Sth, considerable discharge from opening, and swelling smaller and less tense; pulse 130, and feeble; respirations 68; face livid ; no cough nor expectoration, but moist rales audible over whole of right lung and on back and side of left lung ; both lungs dull on percussion posteriorly ; face livid ; swallows well, but is scarcely con- scious. Sinapisms to chest, 12 ounces of brandy, and a mixture con- taining 15 minims of sulphuric ether and turpentine every two hours. No improvement took place, and death occurred on April ;^oth. Autopsy, 24 hours after death. — On laying open swelling, whole of subcutaneous areolar tissue was found to be in a state of slough ; the lobules of parotid were unusually hard, and, as it were, dissected out and bathed in puriform fluid. In the muscles and other tissues, near circumference of swelling, were a number of circumscribed collections of pus, not larger than a pea, with a small central slough in each. The glandular tissue of parotid contained an immense amount of oily matter. Bronchial tubes filled with frothy mucus; great hypostatic consolidation of both lungs ; granular consolidation of lower sixth of right lung. Both sides of heart filled with dark coagulum and fluid blood. Intestines healthy ; liver somewhat friable ; spleen 6\ omices, rather soft. Eight kidney, 4f ounces ; left, 5|- ounces ; structure, normal. Case XXIX. Typhus complicated ivith Parotid hiho and fatal hemorrhage into abscess of Axilla. Thomas Y , aged 28, adm. into L. F. Hosp. Jan. ^th, 1864, on tenth day of a severe attack of typhus ; copious rash, dry tongue, muttering delirium, and swelling over left parotid at time of admission. On Jan. 8th, an incision made into swelling ; only blood escaped. On COMPLICATIONS AND SEQUELS. 22 5 Jan. 1 1 til, bloocTy serum discharged from left ear, and much swelling of left side of fauces impeding swallowing. On Jan. 12 th, two fresh incisions gave exit to two separate collections of pus. Swelling sub- sided, and patient seemed doing well, when on Jan. isth left arm was found swollen and oedematous, and there was a deep-seated abscess in upper arm ; an incision was made through fascia, and several ounces of yellow pus let out. After this, wound discharged bloody matter, very foetid ; injection of iodine and Condy's fluid did no good ; sinuses extended up to axilla, left side of neck became greatly swollen, and abscess formed in front of chest. On Jan. 22,rd much thin black blood began to escape from wound in arm, and this continued till death on Jan. 2^th. Autopsy. — A large cavity containing several ounces of foetid dark coagulum in left axilla. This burrowed between muscles of chest, back, and arm, and laid bare vessels and nerves ; but though vessels were injected with water, no opening discovered. A large sloughy cavity corresponding to left parotid, extending three inches down neck, and behind ramus of jaw, laying bare styloid process. Internal organs anaemic, but free from deposits of pus. Case XXX. Typhus comjjlicated luith Parotid Buho and Facial Paralysis. Hannah F , aged 52, adm. into L. F. Hosp. Nov. 2^th, 1S62, about ninth day of a severe attack of typhus; copious rash, dry tongue, and extreme prostration. On Nov. T,oth {14th day), after slight im- provement, had a rigor followed by swelling over right parotid. On Dec. 6th swelling pointed in front of ear ; superficial incision was made, and two or three drachms of pus let out. The opening continued to discharge freely, and swelling was subsiding. The wound, however, did not heal, and on Ja7i. 2nd, patient was observed to have complete paralysis of right seventh nerve. She became very prostrate and ema- ciated, and died on Jan. 16th. Wound continued to discharge to last, suggesting disease of bone ; but unfortunately there was wo post-mortem examination, and no note as to deafness. i. Other Specific Diseases. Hunter's doctrine ^ that no two of the so-called specific diseases can co-exist in the body has been disproved by modern observation. There is now abundant evidence that any two of these diseases may run their course together, both eruptions, in the case of the exanthemata, being present at one time. A resume of this evidence will be found in the * British and Foreign Med. Chir. Eeview ' for July 1859.' The co-existence of typhus with other specific diseases, however, still requires investigation. The following observations bear on the question : — '' Hunter's Works, Palmer's ed. i. 313 ; iii. 4. ' Muechison, 1859 (No. 4). 226 TYPHUS FEVER. 1. Variola. Barrallier, on the authority of several French navil surgeons, mentions a number of cases where typhus and variola ran their course together in the same per sons. J A similar case was observed at the London Fever Hospital in 1862. Case XXXI. Co-existence of Variola and Typhus. A girl, aged 15, was seized on Jime 1st, 1862, with severe pains in back, vomiting, and loss of appetite, followed by an eruption of vario- lous papules on June ^rd. On June 6th she was removed to Small-pox Hospital, where symptoms ran usual course of a mild attack of variola, modified by vaccination. There were good cow-pock marks on arm. The febrile symptoms, however, did not recede, and on Jiine 11th Sb tyj)hus-rash made its appearance on the trmik. On June 12th she was removed to the Fever Hospital ; and at this date there were a number of desiccatmg pustules on face, with a well-marked typhus- rash on chest and abdomen. This rash was still distinct on June i8th, but disappeared on following day, and patient made a good recovery. Several small-pox cases had occurred m next house to that where girl had been taken ill, and there was also much tj^Dhus in neighbom-hood. The girl had also been removed to the SmaU-pox Hospital in a carriage used to convey typhus patients. 2. Scarlatina. Although I have never seen the eruptions of tj'phus and scarlatma actually co-existing, as they appear to have done in a case referred to by Peacock,^ I have rejDeatedly known the one follow close on the other. I have notes of four eases where scarlet fever appeared within a fortnight of the commencement of convalescence from typhus, and in one the scarlet rash came out on the seventh day after the disappear- ance of the typhus rash. I have also notes of seven cases of typhus succeeding scarlet fever, m two of which the attack of typhus commenced on the third or fourth day of convalescence from scarlet fever, while the cuticle was desquamating. In one of the two cases extensive anasarca, lumbar pain, and scanty, albuminous, smoky urine were observed towards the termination of the attack of t}^3hns. 3. Diphtheria. In two or three instances I have known typhus complicated with diphtheria. The tongue and fauces were coated with thick adherent j)atches of false membrane. There was great prostration, but the patients recovered. In 1863 Gairdner, at Glasgow, saw 'several cases of diphtheria succeeding typhus, partly, but not all, fatal.' ^ i Bakkalliek, 1S61, p. 42. k Peacock, 1862, p. 13S. ' Private Letter. VARIETIES. 227 4. Enteric Fever. Evidence as to the occasional co-existence of these two fevers will be found in a subsequent part of this volume (Chai3. ¥.)• Sect. IX. Varieties of Typhus. Typhus Fever varies little in its general characters. Authors have described different varieties, depending on the severity of the disease, the j)rominence of certain symptoms, the presence of complications, and the circumstances under which the fever appears. The comparative frequency of some of these forms varies in different epidemics ; but this is probably due to differences in the constitution and habits of the patients, and to the circumstances under which the epidemic arises, rather than to any change in the constitution or type of the fever itself. The following varieties have been described : — 1. Inflammatory Typhus. This designation has been applied to those cases where there is great febrile reaction, much heat and flushing of skin, severe head-ache, and often acute delirium. This form is chiefly observed in the young and robust, and in persons of the upper class. It occurred in only 40 out of 1,302 cases observed by Barrallier. Most of the cases of Inflamma- tory Continued Fever, or Synocha, described by different writers, have probably been examples of Eelapsing Fever, or of acute inflammations. 2. Nervous or Ataxic Typhus is the form in which nervous symptoms, such as delirium, somnolence, tremors and subsultus, predominate. The eruption is usually dark and petechial. Such cases have also been designated Typhus Comatosus and Brain- Fever. This form occurred in 109 out of 1,302 cases observed by Barrallier. 3. Adynamic Typhus is characterised by the early superven- tion of marked asthenic symptoms — great prostration, involun- tary evacuations, impairment of the heart's action, and tendency to collapse. The skin may be cool and the pulse slow. I have known patients pass through an attack in a state of prostration approaching to collapse, with the mind little, if at all, affected. Barrallier noted the adynamic form in 92 out of 1,302 cases. Most commonly the adynamic and ataxic forms are combined, constituting — 4. Ataxo-adynamic Typhus or the Congestive Typhis of Arm- strong. This is by far the most common form of Typhus. It was observed by Barrallier in 810 out of 1,302 cases. Q 2 228 TYPHUS FETEE. 5. Typhus Siderans. This term has been applied to those cases ah'eacly alluded to (p. 187), where the disease has proved fatal Avithin a few days, or sometimes hours, of its commence- ment.™ 6. Mild Typhus. Cases are met ^yith, particularly at such times and places as the disease is not epidemic, in which the fever is of short duration, and runs a mild course without severe symptoms of any sort. The fever was of this mild character in 235 out of 1,302 cases observed by Barrallier. Were it not for the eruption, these cases would be regarded as examples of simple fever or febricula. Mention is made of this form by Hildenbrand, under the appellation of Typhus levissimusJ' Jac- quot described, under the head of TypMsatioyi a petite dose, certain symptoms such as malaise, slight fever, loss of appetite, gastric derangement, fatigue, head-ache, distm'bed sleep, and occasional confusion of the mental faculties, which occur in persons constantly exposed to contagion, without passing into actual typhus." I have observed at least six such cases. (See pp. 98, 187.) True typhus sometimes supervenes upon this condition ; but in some mstances this state lasts for several weeks, and ceases on removal from the typhus-atmosphere. 7. Catarrhal Typhus. This is a common designation of typhus in Ireland, owing to its frequent complication with bronchitis. (See p. 191.) 8. Scorbuiic Typhus. (See p. 193.) 9. Buhonic TypJtus. (See p. 216.) 10. Dysenteric Typhus. (See p. 208.) 11. Jail-Ferer. (Seep. 104.) 12. Ship-Fever. (Seep. 109.) 13. Military or Canqj-Fever. (Seep. 112.) 14. Hospital-Fever. (Seep. 114.) Sect. X. Dlignosis of Typhus. Before the appearance of the eruption, the diagnosis of t^^^hus must always be doubtful. The most characteristic symptoms are pains and aching in the limbs, head-ache, a feeling of pros- tration and lassitude, chiUiness, loss of appetite and furred tongue. (See p. 179.) If a person who has been exposed to the poison of typhus is attacked by these symptoms, the diagnosis " For an account of Typhus siderans, see De Claubrt, 1S3S (ed. 1S44), pp. 35, 43, 45, 119; Jacquot, 1858, p. 19. " HiLDEXBEAXD, iSlI, p. II3. " JaCQUOT, 185S, p. 212. DIAGNOSIS. 229 is tolerably certain. All doubt is removed on the appearance of the eruption. Many diseases may in their advanced stages assume a typhoid character, and differ mainly from typhus in the absence of the peculiar eruption. (See pp. 19, 181.) Fortunately, the erup- tion is rarely absent (see p. 132), for without it a certain diagnosis of typhus is impossible. The diseases with which typhus is most readily confounded are relapsing fever, enteric fever, some forms of remittent fever, purpura, measles, meningitis, delirium tremens, pneumonia, disease of the kidneys, pysemia, and other blood-poisonings. I and 2. The distinctions between typhus. and the Pielapsing and Enteric Fevers will be .best considered after the symptoms of these fevers have been described. 3. Remittent Fever. The remittent fevers of this climate can never be mistaken for typhus ; but certain forms of tropical remittent fever, known • as ' typhoid or malignant remittents,' and 'jungle fever,' occasionally present symptoms having a close resemblance to those of typhus, such as a small soft pulse ; dry, brown, retracted tongue ; dorsal decubitus and great pros- tration ; low, muttering delirium ; tremors and subsultus ; contracted pupils, and even petechige. Some years ago, I had an ojDportunity of seeing many such cases in Burmah. In dis- tinguishing the two diseases, the circumstances under which each is wont to appear should be borne in mind. Typhus re- sults from contagion or overcrowding ; remittent fever results from malaria and is non-contagious. Typhus is rare in those countries where remittent fevers, of the character described, prevail (see p. 59) ; and in countries where the two diseases have prevailed together, as in the Crimea, typhus is most common in the winter and spring, remittent fever towards the end of summer and in autumn. True remissions are not met with in typhus ; and careful observations of the temperature, and particularly the abrupt defervescence about the thirteenth or fourteenth day, ought alone to distinguish it from remittent fever. The great solid enlargement of the spleen, so often noticed in malarious fevers, is not characteristic of typhus ; while the peculiar eruption of typhus is never met with in remittent fever. Lastly, quinine, which is often a specific in malarious fevers, has no effect in shortening an attack of typhus. 4. Purpiira. Although Eiverius long since distinguished purpura {' petechicB sine febre') from the petechias of t^^jhus C/ehris iJetechialis '), the two affections have sometimes been 230 TYPHUS FEVER. confounded. The non-contagious character of purpura ; the absence of pyrexia ; the characters of the spots, which are larger than the petechia of typhus, and are not preceded by the cha- racteristic typhus-rash ; the occurrence of haemorrhage from the gums, nose, bowels, and other mucous surfaces ; the blanched countenance, and the absence of cerebral symptoms, are charac- ters which usually suffice to distinguish purpura from typhus. At the same time, it must be borne in mind that when typhus is complicated with scurvy, purpura-spots, vibices, and haemor- rhages from the mucous surfaces may be superadded to its ordinary symptoms. The purpura febrilis described by Dr. Copland p and other writers probably included haemorrhagic cases of typhus, variola, and other acute specific diseases. 5. Measles. Typhus in children may at first be readily mis- taken for measles from the similarity of the two eruptions, which in both cases appear about the fourth day. The eruption of measles, however, is of a brighter tint, and does not pass through the different stages observed in that of typhus ; it differs also from that of typhus in being preceded by sneezing and other catarrhal symptoms. The diagnosis may be assisted by ex- amining other members of the same family who may be affected at the same time. Measles is almost invariably confined to children ; whereas typhus rarely attacks children before the adult members of a family. 6. Meningitis ; Encephalitis. At the commencement of this century the symptoms of typhus were referred to cerebral in- flammation (see p. 42) ; and, at the present day, typhus is not uncommonly designated ' Brain-Fever.' The chief points of distinction between typhus and inflammation of the brain and membranes are the following. In inflammation, the head-ache is much more intense, and of a throbbing, darting, bursting, or constricting character ; in typhus, the patient rarely describes it by such terms. The delirium of inflammation is more violent and acute than that of typhus, and accompanies, or alternates with, the head-ache ; whereas the head-ache has almost always ceased in typhus before the delirium begins : the loud cries and screams observed in the delirium of meningitis do not occur in typhus. In inflammation, there is great intolerance of light and sound ; but in typhus the senses are obtuse, and deafness is more common. In both diseases the face is flushed and the conjunctivas are injected ; but in typhus the flush is more dusky. p Mccl. Did. iii. 553. DIAGNOSIS. 231 and the blood in the conjunctival vessels of a darker tint than in inflammation. In both diseases there may be general con- vulsions followed by coma, but typhus never commences in this way, as meningitis sometimes does. Inequality of the pupils, strabismus, ptosis, opisthotonos, and partial palsy are far more common in inflammation than in typhus. The physiognomy of meningitis is anxious and expressive of pain, or wild and defiant ; in typhus, it is oftener blank and stupid. In typhus, there is much more muscular prostration from the first than in in- flammation. The pulse in inflammation is usually firm ; in typhus, it is soft and compressible. Nausea and urgent vomiting are common in inflammation ; rare in typhus. Lastly, in tyj)hus there is the peculiar eruption appearing about the fourth or fifth clay. But the diagnosis is not always so easy as might be imagined,*! The delirium ferox of typhus (see p. 160) often closely simu- lates inflammation ; and in such a case, the presence of the eruption, or the exposure of the patient to the poison of typhus, can alone assist us in distinguishing this disease from meningitis. When the rash of typhus is present, there is probably, but not certainly, no cerebral inflammation, for post-mo7'tem examina- tions show that inflammation of the brain or of its membranes rarely occurs even as a complication in typhus. (See p. 203.) Stokes has well observed that the symptoms or inflammation of the brain, under ordinary circumstances, do not necessarily in- dicate inflammation when the case is one of typhus fever. Even such symptoms as inequality of the pupils, strabismus, muscular rigidity, and perhaps opisthotonos (pp. 168, 203), may be present in typhus without inflammation. When there is no rash, the diagnosis must sometimes be doubtful. 7. Delirium tremens. The delirium of typhus may often be justly designated delirium tremens (see p. 160). How then are we to distinguish the delirium tremens of the drunkard from that of typhus ? In the former, the tongue is moist and covered with a creamy fur, and not dry and brown as in the delirious stage of typhus ; the skin is moist, there is no eruption, and, above all, there is little or no elevation of temperature ; the mode of accession is also different, there are no rigors, head- ache, nor general pains, but the affection commences with loss of sleep and delirium. Lastly, the circumstances preceding and ■> See Hudson, 1867, p. 156. 232 TYPHL'S FESTER. giving rise to an attack of delirium tremens will seldom leave any doubt as to the nature of the case. 8. Pneumonia. Latent pneumonia is not unfrequently con- founded with typhus. In asthenic or typhoid pneumonia (where the apex is often the part of the lung first and chiefly implicated), the symptoms of the local disease may be entirely masked by those of a general typhoid condition. I have known many cases of this nature sent to the Fever Hospital as examples of typhus. "When a patient is seen for the first time in a typhoid condition, and when no eruption can be detected on the skin, the medical attendant should never fail to make a careful examination of the lungs. If signs of pneumonia be discovered, and especially if they be situated at the apices of the lungs, the typhoid symptoms may be ascribed to the local lesion, unless the patient has been exposed to some infectious poison, or the temperature reach or exceed 104° Fahr. after the fourth day of illness, and then the pneumonia is more probably secondary. 9. Diseases of the Kidney. From what has already been stated (see p. 17, 181), it is not surprising that m-semia from renal disease is apt to be mistaken for typhus. The dry, brown tongue, stupor, contracted pupil, low muttermg delirium, and all the characteristics of the typhoid state belong to both. It has often happened that cases of uraemia from kidney disease have been sent to the Fever Hospital as cases of typhus, where the absence of eruption has first raised any doubt on the point. The dia- gnosis is still further embarrassed b}'- the ch-cumstance that in typhus the urine may contain albumen and tube-casts, urea may be detected in the serum of the blood, and death may take place by convulsions and coma, although there has been no previous disease of the kidneys ; while, on the other hand, in those cases of renal disease (the contracted granular kidney) which most resemble typhus, there may be little or no albumen in the urine, and there may be no dropsy at the time of observation, nor any history of its previous occurrence. This form of kidney disease chiefly occurs in persons beyond middle age, and is often asso- ciated with gout, and hence in all doubtful cases inquiries should be made as to whether there be any gouty history. But the grand point of distinction is the temperature, which is increased in typhus, but, unless there be some concurrent local inflamma- tion, is at or below the normal standard in the uraemia of renal disease. In both conditions the symptoms are due to ihe accu- mulation in the system of the debris of the blood and tissues ; but diseases of the kidney simply prevent the elimination of the DIAGNOSIS. 233 normal metamorphosis, whereas in typhus there is an increased metamorphosis, and therefore an increased temperature. The fohowing case shows how closely renal disease may simulate typhus : — Case XXXII. Urcemia from Benal Disease simulating Typhus. A man, aged 60, adm. into King's College Hosp. under my care in August 1858, with all symptoms of typhoid state, — a dry, brown, re- tracted tongue, great muscular prostration, drowsiness, low muttering delirium, subsultus, contracted pupils. Pulse 96, feeble ; no eruption on skin, no indication of pulmonary disease, and not a trace of oedema. All history that could be obtained was that patient had been ill for only a week, and that his symptoms before admission had been ano- rexia and constipation, slight headache, loss of memory and mental confusion ; he had suffered from several attacks of gout, but never had dropsy at any period of life. He died at end of a fortnight from com- mencement of illness. For last three days of life he was m profound coma, but he had no convulsions. Unfortunately no urme could be obtained for examination, as the small quantity secreted was passed involuntarily. On post-mortem examination, kidneys were found to be very small, the two together weighing less than five ounces; surfaces granular, and capsules adherent ; cortical substance much atrophied and firm, and contained several cysts ; many of uriniferous tubes blocked by deposits of urate of soda. Many other cases of renal disease simulating typhus in every respect, save the absence of eruption and an apyretic tempera- ture, have come under m.y notice at the Middlesex and Fever Hospitals.'" 10. There are other Blood-poisonings, such as erysipelas, pyaemia, jaundice, glanders, &c., which may induce symptoms like those of typhus ; but these diseases have distinct characters, which can rarely leave any doubt as to the nature of the case. At the same time, erysipelas, pyaemia, and jaundice may exist as complications of typhus. Speaking generally, it may be said that the only certain means of distinguishing typhus from several other blood-poisonings is the presence of the characteristic eruption. When this is present, typhus is t?o be regarded as the primary disease, and the erysipelas, pyaemia, &c., as secondary complications. But in simple typhus the eruption may be absent or escape observation, and there is no reason why it should not also fail to be observed in complicated cases. Hence, in certain cases of uraemia, pyaemia, erysipelas, and "■ See also G. Johxson, Med. Times and Gas. Jan. i6th, 1858, p. 53. 234 T-n>HUS FEVER. typhoid jaundice, especially during an epidemic of tyj)lius, it may be difficult to decide whether they are the primary diseases, or complications of unspotted typhus. Sect. XL Peognosis and Mortality. In forming a prognosis in typhus, -we must take into con- sideration the rate of mortality, the cuxum stances which influ- ence that mortality, the presence and severity of certain symp- toms and complications in individual cases, and the mode of fatal termination. a. Rate of Mortality. In calculating the rate of mortality of typhus, all forms of continued fever have often been classified with it. It is obvious that, if cases of relapsing fever, which are seldom fatal, and cases of febricula, which always recover, be included with typhus, the gross mortality will be much less than that of typhus alone. The following results are free from such objections. Table XII. shows the mortality among the cases of typhus admitted into the London Fever Hospital dm'ing 23 years. TABLE XIL« Tears Admissions Deaths Mortalitj' per cent. Years > Admissions 1 Deaths Mortality per cent. 1848 1849 1850 1851 1852 1853 1854 1855 1856 1857 1858 1859 526 154 130 68 204 407 337 342 1,062 274 15 48 107 39 24 6 24 90 68 82 207 69 9 16 20-34 2516 1846 8-82 1 176 2211 2o-i8 24- 19-49 25-18 60- 3333 i860 1861 1862 1863 1S64 1S65 1S66 .1867 1868 1869 1870 25 87 1,827 1,309 2,493 1,950 1,760 1,396 1,964 1,259 631 10 15 369 207 439 395 342 273 298 255 "3 40- 17-24 20-19 15-81 17-61 20-25 19-43 19-55 15-17 20-25 17-90 Total 18,268 3,457 18-92 Deducting lo dead before reaching hospital 1 ' ._ „-„ -- i-r. i-r-^n and 30S who died within 24 hours . . / ''^^ | -"'-^^ '^ 49 Deducting 368 additional, who died within 48 1 t-7 rS-> o -7t I rr-^A hours j , ^'^ ~"^^ ^^^^ * In this and in other tables in this work, the deaths for each year have refer- ence only to the jjatients admitted in that year. A patient admitted iir December 1851, and dying in January 1852, has been entered as a death in 1851. PEOGNOSIS AND MOETALITY. 235 Thus, out of 18,268 cases of typhus, 3,457 died, making a mortaHty of iS-gz per cent, or i in 5'28. But 10 of ihe patients were dead before reaching the hospital, and a large proportion were moribund on admission. Deducting 686 cases fatal within forty-eight hours, the mortality falls to 1576 per cent., or i in 6'34. The mortality since 1862 has been less than it was before. In the first edition of this work, the mortality down to June 30th, 1862, was shown to be 20'89 per cent., or, deducting the cases fatal within forty-eight hours, I7"94 per cent. ; but the corresponding results since that date have been i8'22 per cent, and I4'98 per cent, respectively. With regard to these results, it is necessary to state that every patient admitted with typhus who has died in the hospital has been reckoned as a fatal case, although many have recovered from the typhus, and died of some sequela, such as tuberculosis, pneumonia, erysipelas, &c. TABLE XIII. Hospitals King's College Hosi^ital, 1840-5S, Dr. Todd's ) cases ' . . . . . . . / Edinburgh Infirmary, 1847-8, Dr. W. Ro-'\ bertson " . . . . . . .J St. Bartholomew's Hospital, 1860-7 ' . Edinburgh Infirmary, 1848-9 " . Do. do. 1847-8, Dr. Paterson^ Greenock, 1864 ^ ..... Belfast, 1847, Dr. Eeid^ Glasgow Royal Infirmary, 1843-53 " • Do. Barony Parish Fever Hospital, 1847-8 »> Guy's Hospital, 1862-5, and 1867-9 " • Glasgow Eoyal Infirmary, 1857-69 " . Aberdeen do. do. 1863-9" Glasgow City Fever Hospital, 1S65 70° Dundee Infirmary, 1858-70" Cork Fever Hospital, 1862-9"= Total Cases Deaths Mortality per cent. 108 27 25-00 538 133 2472 518 127 24-52 363 80 22-03 539 III 20-59 288 55 1909 1,366 258 18-88 9,485 1,700 1792 1,370 236 17-23 179 30 16-76 11,818 1,828 15-46 2,095 280 1336 5.379 668 12-42 3,853 428 ii-ii 3.504 335 956 41,403 6,296 15-26 The death-rate, however, of typhus in a community attacked by it is much less than might be gathered from the statistics of ' Brit, and For. Med. Chir. Rev. Oct. i860, p. 332. " Robertson, 1848, p. 370. "" Statist. Tables, 9th Ser. p. 14. y Eighth Rep. of Med. Off. of Privy Council, 1866. ^ Irish Report, Bib. 1848, VIII. 297. ^ J. Paterson, 1848, p. 337. Hosp. Rep. E. Paterson, 1848. M'Ghie, 1855, p. 161. Hosp. Reports. 236 TYPHUS FEVER. the London Fever Hospital. Many slight cases of the disease and many children attacked by it are never brought to hospital, and a large proportion of the patients in hospital have been the aged and infirm inmates of the metropolitan workhouses. Making allowance for these sources of fallacy, the actual death-rate of tj^phus is probably not more than 10 per cent. The varying death-rates of typhus in different hospitals given above depend in great measure on the regulations determining the class of patients a,dmitted into each. h. Circumstances influencing the rate of Mortality. I. Age exercises such a remarkable influence over the rate of mortality from typhus, that no just comparison between the rates of mortality at different times and places can be made, without taking into account the ages of the patients. In youth, it is far from being a fatal disease ; but in middle and advanced life, when degenerations have already taken place in the tissues similar to those produced by the fever (see p. 16), it is most mortal. These facts may be ascertained by comparing the mean age of the fatal cases with that of those which recover ; or still better, by determining the rate of mortality in each period of life. The former plan has been adopted with regard to the cases admitted into the London Fever Hospital during ten years (1848-57), and the latter with the cases admitted during twenty- three years (1848-70). The results are embodied in Tables XIY., XY. and XVI., and in Diagrams H. and VIII. TABLE XLV.. Cases 1 Number Mean Age Total cases in which age is known Cases which recovered Cases which died 3,456 2,753 703 2933 2615 4178 Thus, the mean age of the cases which recovered being 26, that of the fatal cases was nearly 42 years. Moreover, this difference of age not only applied to the cases admitted in the ten years collectively, but also held good for each individual year. From Table XV. it appears that the rate of mortality was somewhat greater during the first than during the second ten 100 ^ ^- "* S" ^ ose oo ^=0 >^ _ ^ ^ S ^ -S ^ hS O - - . - , - tD ^ ------ - ^ 5^ S S S ^ §- -S -S -2 -2 -S _2 -S <:o ^^ ^::i lo C5 'o Q5 >~o '-^ "^£> ts IT- r- Qq §^ f^ Bm^rccmMhtiDWstl^VariahxiTn^ accordmgtoA^e. in,fh& raM of MortoJjubf of 18 138 cases ofljphZisFtver, oA^tniited. mto the. Lovjiov^ Fpjvpjp Hospvt/xL [Ccm-ptxre -intk' Dutgr. PROGNOSIS AND MORTALITY. m years of life. Thus, the mortality during the first five years of life was 6-69 per cent. ; in the second lustrum, it fell to 3-59 ; between ten and fifteen it was only 2-28 per cent., and between fifteen and twenty, 4-46 per cent. After twenty, it went on pro- gressively increasing (see Diagram VIII.), until of those — Above 30 years of age 35*39 per cent. died. 40 M 43'48 >, 50 '. 53-87 60 ,, 67-04 ,, TABLE XV. -i Age Males Females Total ^-- ^^ *i 4:1 II 1 ■5 S rS.2 3 is .2 ■'^' "S a. OJ 1 ^ <•"■ fl %%. upwards ] 2 I loo'oo 3 3 100-00 Age doubtful 75 5 6-66 55 3 5-45 130 8 6-15 Total, including ) douttful cases J 8.946 1,760 19-67 9,322 1,697 i8-2o 18,268 3-457 18-92 The mortality from typhus in the London Fever Hospital has been contrasted unfavourably with that in other institutions, but w^hen a comparison is made between patients of the same age the discrepancy disappears. Compare it, for example, with that of the City of Glasgow Fever Hospital, in which, as already shown (p. 236), the total mortality has been remarkably low, and the smaller mortality is seen to have been in London. When typhus has been fatal in the London Fever Hospital under fifteen years of age, death has almost alwaj^s been due to some severe complication. Thus, of 46 cases fatal in this period <■ This Table includes the 10 patients dead before reaching the hospital, p. 234.) (See 238 TYPHUS FEVEE. of life, of which I have notes, in 21 there was some severe pulmonary complication ; in 9, convulsions ; in 7, parotitis ; in TABLE XVI. Ages London Fever Hospital, 1862-70^ Glasgow Fever Hospital, 1865-70 f Cases Deaths Mortality per cent. Oases Deaths Mortality per cent. Under lo years From 10 to 14 years ,, 15 to 19 ,, ,, 20 to 29 ,, „ 30 to 39 „ ,, 40 to 49 ,, Above 50 years 1,221 1,812 2,348 3^257 2,346 2,010 1,499 40 30 93 402 531 723 855 3-27 1-65 396 12-34 22-63 3597 57-03 1,033 1,075 916 1,029 641 464 221 32 18 61 130 143 169 115 309 1-67 6-66 12-63 22-31 3642 5203 5, cancrum oris; in 2, tuberculosis; in i, meningitis; and in i, an infant only three weeks old, marasmus. The increasing mortality of typhus as life advances has been a matter of universal observation. The following are a few illustra.ions. TABLE XVII. Years Under 20 ,1 30 Above 30 „ 50 Total Edinburgh Infirm- ary, 1841-26 X a o ^ S p. ^61 18 56s 4b 253 70 42 22 818 116 4-ga 8'i4 27-66 52-38 Edinburgh Infirm- ary, 1849'' 122 251 112 363 o ^ Q'OI I4'34 39 28 5°' Glasg ow Infirmary, 1847' Toulon, 1 855-6 J >-. . .c a ■s ° 0) t " Q R Is, 685 69 1007 _. _ 1,627 ^45 I5'05 381 go 23-62 772 26s 34'32 921 346 37-56 100 46 510 46- 156 92 436 59- 2,399 21 67 1.302 33-48 2. Sex. Most observations show that typhus is somewhat more fatal in males than in females. Table XV. gives the results at the London Fever Hospital for twenty-three years. From this it is seen that, while the total mortality among males <= 10 patients d3ad bef are reacMng the hosijital have been deducted. Of the patients above 50, a larger proportion in London were very old. Of 878 male patients between 10 and 14 only 10 (or 1-14 per cent. died). t Dr. Rnsscirs Annual licports. s Peacock, 184^. ■■ Statist. Tables, 9th Ser. p. 14. ' Steele, 1S4S, p. 161. J Baeralliek, 1S61, pp. 2S1, 375. The patients were prisoners, none under 18 years of age. PKOGNOSIS AND MORTALITY. 239 was 19*67 per cent., that among females was only 18-2 per cent. Moreover, notwithstanding the supposed prejudicial influences of pregnancy and suckling, the mortality was, at every period of life above fifteen, less in females than among males, so that the prognosis in a woman sixty years of age would be as good as in a man ten years younger. But in this respect the patients be- tween five and fifteen years of age presented a marked difference. At this period of life the mortality was twice as great among the females as in the males, while, deducting these cases, the rate of mortality in the remaining periods of life was 23*84 per cent, for males, and 21-7 for females. Barker and Cheyne,^ Cowan, ^ and Huss ^ showed that con- tinued fevers were more fatal to men than to women, and their statements have been confirmed with regard to typhus by subsequent observations, as will be seen from the figures which follow : — TABLE XVIII. Males Females p. Cases Died Mortality per cent. Cases Died Mortality per cent. Edinburgh Infirmary, 1841-2° 377 69 i8-3 371 45 12 12 1847° . 330 87 2636 208 46 22 II 1848P . 2S8 65 25-19 281 46 1637 Glasgow Infirmary, 18471 1,011 328 32-44 878 182 2072 1857-69'. 6,225 1,071 17-20 5,593 7S7 13-53 ,, City Fever Hosi^ital, 1 1865-70 ■• . . . / 2,544 327 1285 2,825 341 1207 Dundee Infirmary, 1858-66' . 1,142 150 13-13 1,350 127 9-40 Total . 11,887 2,097 17-64 11,506 1,544 1342 The excess of mortality among males has been attributed to the average age of the male typhus patients being greater than that of the females. This was ascertained to be the fact by Peacock at Edinburgh in 1 841-2. But in the London Fever Hospital the mean age of the females has exceeded that of the males, and 4374 of the female patients, but only 38-39 of the ^ Barker and Cheyne, 182 i, i. 90. " Peacock, 1843. p K. Paterson, 1848, p. 398. ' Hosp. Reports. Cowan, 1838. ■" Huss, 1855, p. 58, " Robertson, 1848, p. 370. 9 Steele, 1848, p. 161. » MaclacxAN, 1867, No. I. 240 TYPHUS FEVER. males, were above thirty (see p. 64) ; while Table XV. shows that at corresponding periods of life the mortality is greater in the male sex. Similar observations have been made elsewhere, so that a more probable explanation is that men have not only a larger amount of muscle for disintegration by the febrile pro- cess, but from intemperate habits and other causes they are more likely to have morbid states of the liver and kidneys, which impede elimination. (See p. 18.) In early life there are no such differences between the two sexes, and then the mortality is less in males than in females. The smaller fatality of typhus in young males is not peculiar to the London Fever Hospital, but is found to be the rule in Glasgow, Dundee, and Ireland.* Thus, the following result is obtained from an analysis of the Eeports of the City of Glasgow Fever Hospital for five years, 1865-70 : — Males j ' Females Cases Deaths Mortality per cent. j Cases Deaths Mortal' ty per cent. Bet-ween 5 and 15 years At other ages 956 1,588 8 31 •94 20-02 893 1,932 20 321 2-24 16-61 3. Months, Seasons, d-c. From the following table of the cases of tj^phus in the London Fever Hospital during twenty- TABLE XIX. Months and Seasr ns " Admissions Deaths Mortalilj- per cent. 20-29 20-78 20-04 20-64 20-85 20-83 2166 17-24 16-35 15-53 1553 1639 January February March April May June July August September October November December 1,976 1,621 1,906 1,642 1,525 1,296 1,251 1,183 1,162 1,429 1,667 1,610 401 382 339 318 270 271 204 190 222 259 264 Spring .... Summer .... Autumn .... Winter .... 5,073 3,730 4,258 5,207 1,039 745 671 1,002 20-48 19-97 1575 19-24 Total 18,268 3,457 18-92 Lyons, 1861, p. 215. " See p. 67, note *. PROGNOSIS AND MORTALITY. 241 three years (i 848-1 870), the mortaHty is seen to have been con- siderably less in the last five than in the first seven months of the year. But, as regards different years, the rate of mortality varied greatly, without any reference to months or seasons. The mortality has sometimes been observed to be smallest at those times when the disease has been least prevalent. Thus, in the year 185 1, when only 68 cases were admitted, the mortality was only 8*82 per cent. Again, at Edinburgh, the mortality during the great epidemic of 1 847 was i in 4 ; but about ten years ago when typhus was rarely met with, the mortality, according to Dr. W. T. Gairdner, did not exceed 3 in 45, or i in 15. "" This observation, however, does not always hold good, and certainly has not always applied to London. Thus, in 1856, of 1,062 cases of typhus admitted into the Fever Hospital, the mortality was under 20 per cent. ; whereas, during the three years 1858-60, when the cases were extremely few, the mortality was 42 per cent. (See Table XII.) At Dundee also Maclagan found the mortality much higher in the years when the disease was not epidemic.^ It has often been found that the mortality has been greatest at the commencement and height of great epidemics, and that it has declined as the number of cases has diminished. This is well shown in the annexed table, which gives the admissions and mortality of typhus cases during five successive quarters, com- mencing in October 1855 : — TABLE XX. Date Admissions Deaths Mortality per cent. October to December 1855 January to March 1856 . April to June ,, July to September ,, October to Dec. ,, 143 421 146 178 35 97 71 23 16 24-47 23-04 224 1575 8-98 A similar remark was made by Dr. Peacock ^ with regard to typhus in Edinburgh in 1839, '40, and '41, and the same thing occurred in Edinburgh in the great epidemic of 1847-8. This increased mortality may be accounted for in various ways — by ^ W. T. Gaibdneb, 1862, No. 2, p. 159. * Peacock, 1843. " MAciiAGAN, 1867, No. I. 242 TYPHUS FEVER. the circumstance that the disease first attacks the aged and in- firm and the sufferers from want of food, who are least able to resist it ; or, by the rapid development of the epidemic taxing the resources and deranging the economy of hospitals, and so leading to overcrowding and deficient nursing. Still, the mortality is sometimes equally great, when the disease is not very prevalent. 4. Station in Life. Dividing the cases admitted into the London Fever Hospital into three classes — viz.: (i) Paying patients ; (2) Free patients, unable to pay, but who have not been in the receipt of parish relief prior to their illness ; and (3) Paro- chial paupers — the rate of mortality in each class, during 14 years, 1848-61, was as follows : — TABLE XXI. No. of Cases Deaths ilortality per cent. First Class Second ,, ... Third „ ... 94 2,674 738 14 497 204 14-89 18-58 27-64 The increased mortality, however, in the third class, was mainly, if not entirely, due to the more advanced age of the patients. It has been a common saying, especially in Ireland, that ' fever ' is more fatal in the upper classes than in the lower,^ and the impression is probably correct, for persons of cultivated intellect, or who, though not intemperate, have lived too well, usually have the disease in a severe form. 5 . Recent Residence in an Infected Locality. Of 2,941 patients affected with typhus, who had been resident in London more than six months prior to their admission into the Fever Hospital, 532 or 18-09 per cent., died; whereas, of 160 patients who had resided in London less than six months, only 18, or ii'25 per cent., died. This difference, however, was mainly, if not entu-ely, due to the greater age of the former class. 6. Place of Birth and Race. Dividing the patients with typhus admitted into the London Fever Hospital during twenty years (1848-67) into English, Irish, Scotch, and foreigners, the rate of mortality was as foUows : - - r See Baekeb and Cheyne, 1821, i, 321, 329, 428, 467 ; Bartlett, 1856, p. 256, PROGNOSIS AND MORTALITY. 243 TABLE XXII. No. of Cases Deaths Mortality per cent. English .... Irish .... Scotch .... Foreigners .... 11,640 790 90 166 1,857 128 17 30 15-94 1620 18-88 18-07 No conclusion of importance can be drawn from these results. The difference is probably accounted for by differences of age. The mortality from continued fevers has always been noted as lower in Ireland than in Britain, but this result may, in most instances, be ascribed to the Irish statistics including a larger proportion of cases of relapsing fever and febricula. Taking maculated typhus alone, the mortality at Belfast was found to be 19 per cent., and according to Lyons in most Irish epidemics the mortality has been i in 3 or higher.^ At Cork, however, the mortality from typhus appears to be particularly low. (See p. 235.) In the Philadelphia epidemic of 1836, the mortality, according to Gerhard, was much greater among the blacks than among the white population.^ 7. In persons who are very fat or have large muscular develop- ment, the prognosis is unfavourable. 8. Intemperate habits, by inducing degeneration of tissue, greatly increase the fatality. 9. Previous diseases have a like effect. Hence, when typhus spreads in the wards of a general hospital, the mortality is often great. Diseases of the kidney and gout exercise a particularly unfavourable influence. I have rarely known a very gouty person recover from typhus. 10. Pregnancy adds little to the danger of typhus (see p. 212) ; but suckling induces anaemia and increases the chances of death by asthenia. 1 1 . Mental depression and a Cultivated Intellect have also an unfavourable effect. The former is, no doubt, one of the causes which renders typhus so fatal in prisons and besieged cities. Of 1,302 cases observed by Barrallier in the hulks of Toulon in 1855-56, 436, or more than one-third, perished.^ • Ltons, 1861, p. 215. » Gekhaed, 1837, xix. 301. " Baeballiee, 1861, pp. 281, 375. K 2 244 TYPHUS FEVER. 12. Fatigue and Privation before, and at the commencement of, the attack add greatly to the mortality. Persons who waste their muscular power by struggling against the disease during the first few days often become suddenly prostrate and die. During an epidemic, when it is difficult to find nurses for the sick, the immense amount of labour sometimes thrown on the devoted few who minister to their wants, not only predisposes them to be attacked, but renders the attack more fatal. The effects of fatigue, privation, and overcrowding in increasing the mortality are also manifest when typhus breaks out in armies in the field and in besieged cities. Of the French troops in the Crimea, one-half of those attacked died. According to Jacquot, of 12,000 cases of typhus among the French in the Crimea and at Constantinople during the first six months of 1856, 6,000 proved fatal. Among the Eussians even this rate of mortality was exceeded.*^ During the siege of Dantzig, it is stated that typhus carried off two-thirds of the garrison and one-fourth of the population, numbers which indicate a frightful rate of mortality, as it is not probable that every individual was at- tacked."^ Of 25,000 French troops who escaped the disasters of the campaign of 18 13, and who were afterwards besieged in Torgau, 13,448, or more than one-half, perished from typhus within the space of four months.® Of the 60,000 troops com- posing the garrison of Mayence in 181 3-14, there died of typhus 25,000.^ Other instances of an equally great mortality have been collected by Gaultier de Claubry and Barrallier.s 13. Neglect of Treatment increases the rate of mortality. In many patients, the good effects of removal from their crowded and badly-ventilated dwellings to the spacious wards of an hospital are manifest in a few hours. In the Philadelphia epi- demic of 1836, the mortality among the patients under treat- ment from the commencement was only i in 7 ; whereas it was I in 3 among those brought to hospital late in the disease.** Dr. Mateer, from observations made at the Belfast Fever Hospital during seventeen years, ascertained that the mortality from * fever ' ' progressively increased according to the duration of the illness before admission: of 1,625 cases admitted on the second or third day, only 54, or 3g- per cent., died; of 5,921 cases admitted during the first week, 267, or 4^ per cent., died ; « Jacquot, 1858, pp. 63, 150, 156. ^ De Claubry, 1838, ed. 1844, p. 41. « lb. p. 43- ' lb- P- 45- e Barballier, 1 861, p. 120. *> Gerhard, 1837, xx. 321. ' Mateer, 1836 ; Bartxett, 1856, p. 255. PEOGNOSIS AND MORTALITY. 245 and of ^i^^^j cases admitted during the second week, 397, or 10*8 per cent., died. These results are no doubt partly due to the bad effects of removal at an advanced stage of the disease. This was a point much insisted on by the late Dr. Alison ; J and I have repeatedly known patients die from exhaustion, caused by their conveyance for several miles in a shaky vehicle. It is important to add that, with proper precautions, the danger is not increased by the distance, within reasonable limits, of re- moval. The mortality in the London Fever Hospital has not been greater among patients brought from a remote part of the metropolis, than among those from its immediate vicinity. Thus, during five years (1862-7), of 145 patients between 40 and 50 years of age from Islington, in which the Fever Hospital is situated, and the two adjoining parishes of Clerkenwell and St. Luke, jy, or 32-41 per cent,, died; whereas of 82 patients of the same age from the distant parish of St. George's-in-the-East, there died 27, or 32*92 per cent. c. Presence of certain Symptoms and Complications. 1. A presentiment of death is a very unfavourable,^ but not necessarily a fatal, indication. It is most common in persons of the better class, and especially in medical men. 2. It is a bad sign if the pulse, in adults, exceed 120, and especially if it be at the same time extremely soft and compres- sible, or small, wavy, irregular, intermittent, or imperceptible. A fall in the frequency of the pulse is always favourable. On the other hand, typhus is occasionally fatal when the pulse has never exceeded 100 ; and an unnaturally slow pulse points to serious impairment of the heart's action. 3. Complete absence of the cardiac impulse and an inaudible systolic sound are indicative of great danger, and likewise a very excited, or thumping, action of the heart, associated with a feeble radial pulse (p. 141). 4. Hurried respirations, whether cerebral or the result of pulmonary disease (see pp. 142 and 190), are unfavourable. 5. Sleeplessness associated with delirium, protracted over several days, and not yielding to treatment, is a very bad sign, 6. Speaking generally, the danger in any case may be mea- sured by the severity of the cerebral symptoms, and is greater the earlier these symptoms appear. The greater the head-ache, J Alison, 1844, p. 451, and University Led. 1849 (not pub.). •^ Lyons, 1861, p. 194. 246 TYPHUS FEVER. the more complete the loss of consciousness, the greater and more constant the delirium, and the more profound the stupor, the greater is the danger. 7. The state of complete coma-vigU is invariably fatal (p. 165). 8. Extreme contraction of the pupil is a bad indication. Dr. Graves regarded ' a pin-hole piqnl ' as an almost fatal sign.^ 9. Deafness is not unfavourable, but neither is it a favour- able symptom as has been commonly believed (p. 177). 10. The danger is always great in proportion to the degree of prostration. Extreme prostration, at an early stage, is always a bad sign. It is a favourable sign when a patient, after lying for days on his back, helpless and motionless, turns round and sleeps on his side. 1 1 . Muscular tremors, and still more carphology, subsultus, and spasmodic twitchings of the muscles of the face, are of bad omen. Dr. Henderson found at the Edinburgh Infirmary in 1838 and 1839 that subsultus, to any considerable extent, was almost always followed by death.™ Still, in many of my cases, where these symptoms have existed for several days, the patient has recovered. 12. General convulsions are usually fatal (p. 168). 13. Urgent and protracted hiccup usually terminates in death. 14. Eigid contraction of the muscles of the limbs and stra- bismus are very bad signs (p- 168). 15. Eelaxation of the sphincters before the tenth day is a bad sign ; after this it is not uncommon in severe cases which recover. Eetention of urine is even more unfavourable than incontinence. 16. Extreme tympanitis, associated with symptoms of great nervous prostration, is always unfavourable (p. 147). 17. A dry, brown, hard, retracted, tremulous tongue is seen only in severe cases ; but many patients with these characters recover (p. 146). 18. The more abundant and the darker the eruption, ccsteris paribus, the greater the severity and the danger of the case. The presence of numerous purpura- spots, or vibices, is parti- cularly unfavourable (p. 131). Cases without rash are usually mild and rarely fatal, except from complications. 19. Great lividity of the face and extremities, and a dusky ' Graves, 183S. " Henderson, 1839. PROGNOSIS AND MORTALITY. 247 erythematous condition of the skin on the dependent parts of the body, are unfavourable. 20. It is a bad sign when the temperature continues very high (105° Fahr.), and still more if it rises rather than falls during the second week (p. 137). Coldness of the extremities with a high temperature in the rectum is very unfavourable. 21. Perspiration is not a favourable symptom unless accom- panied by other marks of amendment (pp. 137, 184). Profuse and continued sweating, coldness of the surface, cold breath, and a rapid, weak pulse are almost fatal signs. 22. The prognosis is favourable, according to the freedom of excretion of urea and uric acid. Although a large amount of these products in the urine indicates great febrile action, it is better that they should be eliminated than retained in the system. A sudden diminution in the amount of urea, while the temperature remains high, is unfavourable (p. 152). 23. Great diminution in the quantity of urine or the presence in it of albumen, blood, or renal casts are also unfavourable, as indicating a condition of the kidneys opposed to the free elimi- nation of urea (p. 156). Convulsions and coma are apt to super- vene in such cases. 24. The cessation, at the end of the second week, of several of the unfavourable symptoms indicates the approach of conva- lescence. The first signs of amendment are a diminution in the rapidity, with increased strength, of the pulse, and a slight return of appetite, while the tongue becomes clean and moist at the edges. By the experienced eye a change can also be re- cognised in the patient's manner and countenance. The dusky tint of the face diminishes ; the expression is less stupid, and the conjunctivse less injected; while the patient takes more notice and answers more rationally. 25. The presence of any complication is always unfavourable. Among the most dangerous complications are pulmonary hypo- stasis and bronchitis, pneumonia, gangrene of the lung, laryn- gitis, jaundice, pyaemia, erysipelas, parotid, and other inflam- matory swellings, bed-sores, gangrene of the extremities and of the mouth, renal disease and scurvy. 26. Even in the worst cases, the physician must not despair until the pa,tient is in articulo mortis. Patients occasionally recover, whose deaths have for days appeared inevitable. In no diseases is this observation more common than in continued fevers. 248 TYPHUS FEVER. d. Mode of Fatal Termination. It is important to study the mode of fatal termination in typhus, in reference to prognosis and treatment. Death from the primary fever may take place by asthenia or coma. In the one case, the heart's action is enfeebled from paralysis or dis- integration of its muscular tissue ; in the other, the blood be- comes poisoned by insufficient aeration consequent on pulmonary congestion, and by the admixture of urea and other products of decomposing albumen. Most commonly death is caused by a combination, in varying proportions, of asthenia and coma. As a rule, from which there are few exceptions, the patient is un- conscious for a considerable period prior to death. Lastly, in many cases death is due to one of the complications or sequelas already described. Sect. XII. Anatomical Lesions. The most extensive results of post-mortem examinations of typhus yet published are those of Messrs. Gerhard and Pen- nock" (50 cases), A. P. Stewart ° (22 cases), John Eeid^ (147 cases), Thomas Peacock "^ (31 cases), WilHam Jenner '^ (43 cases), Felix Jacquot ' (41 cases), and BarraUier * (166 cases). My own observations, amounting to several hundreds, entirely confirm the results arrived at by those authors. The chief abnormal appearances are here given. a. Generalities. 1. The Cadaveric Rigidity is of short duration. Of 34 cases examined by Jenner, at varying intervals up to fifty-two hours after death, it was absent in 26, or 79-4 per cent., and was well marked in only 8. 2. Emaciation. Death usually occurs before there has been time for the body to become much emaciated. [Nevertheless a considerable loss of weight takes place during an attack of typhus. Dr. Hermann, who investigated this point in the cases treated in the Obuchow Hospital during the epidemic at St. Petersburg in 1874-75 (' Petersburg. Med. Wochensch,' -^ Geehakd, 1837. " Stew.u^t, 1840. p PiEED, 1S40 and 1S42. Eight of Eeicl's cases were examples of enteric fever. 1 Peacock, 1S43. Three of Peacock's cases were enteric fever. ' Jenner, 1849, No. 2. ' Jacquot, 1S58. ' BARRAiiUER. 1861. ANATOMICAL LESIONS. 249 1876), found the average loss of weight was from |lb. to i^ lbs. daily ; in some cases it amounted to 2 lbs. to 3 lbs. ; the greatest total loss was 3 1 lbs.] 3. Putrefaction. In most cases there is a tendency to rapid putrefaction after death, more rapid than after death from other diseases at the same time of the year. &. Integuments and Muscles. 1. Discolorations. In all cases there is more or less livid discoloration, either general or in patches, of the integuments on the dependent parts of the body. Occasionally this lividity extends along the sides of the trunk, or even over the greater part of the body; the face is often livid. In some cases, there is a green or dirty-purple discoloration of the skin, corresponding to the course of the large sub-cutaneous veins of the neck and extremities. The walls of the abdomen and chest sometimes exhibit a green discoloration within forty-eight hours after death. This is due to the action of gas generated in the bowels, or in a gangrenous lung, for those parts of the skin protected from the action of the gas, such as the skin over the liver, a distended bladder, or a rib, remain longest un- changed. 2. The Eruption. When death occurs before the cessation of the primary fever, many of the darker spots of the eruption are found to persist in the dead body. The microscopic charac- ters have been already described. (See p. 131.) 3. The Muscles do not present their normal bright red colour ; they are often of a dirty greyish red hue ; in 6 out of 38 cases Jenner found them unusually dark. Laennec'^ and Stokes^ many years ago pointed out that the tissue of the voluntary muscles and heart was softer and more friable than natural, and in the first edition of this work (1862) it was shown that the softening of the heart was due to a granular degeneration of the muscular fibre. In 1864 Zenker "^ published a memoir on the changes of the voluntary muscles in enteric fever, which he described as either — (i) granular, consisting in the deposit of fine molecules in the contractile substance of the muscular bundles ; or (2) ivaxy, in which the contractile substance is con- verted into a homogeneous, colourless, waxy-looking material, forming cylinders which crack up into fragments and ultimately " TraiU de V AiiscziU.M^d. 2me ed. 1826, ii. 537. ^ Stokes, 18^9. ^ Zenkeb, 1864. 250 TYPHUS FEVER. crumble down into a granular detritus. Similar changes were subsequently found in the voluntary muscles of typhus ^ and are now known to be common in all protracted febrile diseases. ^ In typhus they are most common in cases fatal after the fourteenth day, and are most marked in the abdominal muscles and the adductors of the thigh. Occasionally I have found extensive extravasations of blood in the substance of the rectus abdominis and other muscles, independent of any external violence. These extravasations may soften and form pseudo-abscesses. Jenner ^ and Barrallier ^ mention similar cases. They are due to rupture of the muscular fibres, not from spasm as stated by Eokitansky, but from the destruction of the contractile tissue. Zenker has shown how, when recovery takes place, the muscles are re- generated by the enlargement of the existing, and the formation of new primitive bundles. c. Organs of Digestion. 1. Pharynx and (Esophagus. The lining membrane of the pharynx occasionally exhibits signs of recent inflammation. It is vividly injected, or of a dusky-red hue, and sometimes the mucous follicles are enlarged and contain a puriform fluid, or collections of puriform matter are found in the areolar tissue behind the pharynx. The mucous membrane may be covered with viscid mucous or with diptheritic flakes. The same appear- ances are occasionally found in the oesophagus. Eecent ulcera- tion is never found either in the pharynx or oesophagus after death from typhus. In 39 of 6y cases observed by Jacquot and Barrallier the pharynx was normal. 2. The Stomach in a large proportion of cases is healthy, and the only morbid changes occasionally exhibited by it are redness, mammillation, and softening of the mucous membrane. Of 78 cases examined by Jenner and Jacquot, the mucous membrane of the stomach was pale and healthy in 46, or in 59 per cent. Of the remaining cases there were patches of punctiform or ramified injection in 10, and minute ecchymoses in 5. Of 75 cases noted by the same observers the mucous membrane was softened in 17 or in 22 per cent. This ramollissement was either general (7 cases), or limited to the great cul de sac (10). In 4 of Jenner' s cases, there was such extreme softening of the ' MuRCHisoN, Path. Trans. 1865, xvi. 276 ; Buchanan, 1866, p. 549. y Gaz. Hibdom. 1866, p. 765. ' Jenneb, 1850, xxi. p. 15, » Babeallier, 1 86 1, p. 279. ANATOMICAL LESIONS. 25 1 great cul de sac, that it ruptured in the removal or washing of the organ. In a few instances, the consistence of the membrane is firmer than natural (7 of the 75 cases) ; but this condition is probably in most cases due to old disease. Mammillation of the mucous membrane was noted by Jenner in 7 out of 14 cases ; in I, it was general ; in 6, it was limited to the vicinity of the pylorus. Mammillation of the mucous membrane of the stomach towards its pyloric extremity was frequently seen by Gerhard and Pennock. Ulceration of the mucous membrane as a con- sequence of typhus is scarcely ever observed. I have never met with such an instance myself, and in none of Jacquot's and Barrallier's 207 cases is any mention made of such a lesion. In one only of Jenner's 43 cases was any ulceration detected. * Three inches from the pylorus, scattered over a space about an inch and a half in circumference and seated on the posterior wall of the stomach, were nine ulcers varying in size from a pin- point to a No. 4 shot ; their edges were well defined and not discoloured.' ^ 3. The Duodenum. Of 75 cases in which the duodenum was examined by Jenner and Jacquot, the mucous membrane was perfectly healthy in 60, or in 80 per cent. In the remainder it presented similar morbid appearances (various degrees of soften- ing and injection) to those found in the stomach, and in most cases the stomach was similarly affected. In no case have any traces of recent ulceration been discovered in the duodenum. 4. The Jejunum and Ileum exhibit no characteristic lesions ; in most cases the mucous membrane throughout is perfectly healthy. Invaginations of the small intestines were found by Barrallier in 3 cases ; but in none was there any adhesion, or sign of in- flammation, around the invaginated bowel. In 34 out of 39 cases examined by Jenner the colour of the mucous membrane was normal ; in 2 cases there were hsemor- rhagic spots beneath the mucous membrane, varying in size from a pin's head to a line and a half in diameter ; in i case the jejunum was injected, while the ileum was pale ; in another the fine injection was limited to the lower part of the ileum ; and in the last case both divisions of the bowel were of a deep grey tint. Marked capillary injection was observed by Jacquot in only 6 out of 41 cases. In my own cases the presence of injec- tion was exceptional ; it was observed as often in the upper part ' Jenneb, 1849 (2). 252 TYPHUS FEVER. of the intestines as in the lower, and it was never restricted to, or more intense in, the neighbourhood of Peyer's patches. Like Jenner and Barrallier,^ I have occasionally observed ecchymoses beneath the mucous membrane. Softening of the mucous membrane was observed in some cases by Keid, and occurred in 18 out of y^ cases (23 per cent.) collected by Jenner and Jacquot. In 13 of the 18 cases the softening was general; in 5, it was partial. The peculiar disease of Peyer's patches and of the solitary glands which constitutes the anatomical lesion of enteric fever is never found in exanthematic typhus. The evidence on this point is now overwhelming, although a few observers, who re- fuse to recognise any distinction between the symptoms of the two fevers during life, still publish cases of ' typhus ' with intestinal disease. Of 50 cases of typhus examined by Messrs. Gerhard and Pennock of Philadelphia in 1836, 'the glands of Peyer were found not merely free from the peculiar lesions occur- ring in dothinenteritis or typhoid fever, but these follicles and the rest of the intestine were more healthy in the petechial fever than in the majority of other diseases. We are the more certain of the state of these glands, because our attention was closely directed to this subject, and we had previously made most numerous examinations of the glands in typhoid fever and in other diseases ; we could, therefore, pronounce with certainty as to their actual condition. . . . There was but in one case, and that doubtful in its diagnosis, the slightest deviation from the natural appearance of the glands of Peyer. In the case alluded to, in which there had been some diarrhoea, the agglomerated glands of the small intestine were reddened and a little thickened ; but there was no ulceration, and no thicken- ing nor deposit in the submucous tissue. The disease of the glands resembled that sometimes met with in small-pox, scarlet fever, or measles, rather than the specific lesion of dothinenteritis. In all other cases the glands of Peyer were remarkably healthy in this disease, as was the surrounding mucous membrane, which was much more free from vascular injection than it is in cases of various diseases not originally affecting the small intestine.' '^ In 1840 similar results were published by Dr. A. P. Stewart. Out of a large number of cases of typhus examined by him at Glasgow in 1836, in not one did he discover any ulceration or "= Bakkalliek, 1861, pp. 109, 271. ■^ Gekhaed and Pennock, 1837, xix. 302, and xx. 289. ANATOMICAL LESIONS. 253 evidence of the specific lesions of typhoid fever. In a few ex- ceptional cases (2 out of 21) he found the patches distinctly elevated above the surface ; but he pointed out that the appear- ance in question was not that which characterizes typhoid fever.® Of 43 autopsies of typhus made by Jenner in London, Peyer's patches were perfectly healthy in all but 3, i.e. they were neither elevated, reddened, softened, nor ulcerated. Of the three exceptional cases, one was a case of tubercular ulceration ; a second was an example of dysentery, in which the inflamma- tion extended somewhat higher up the ileum than is usual, and involved the mucous membrane covering the elliptic patches in common with that around them ; in the third case there was merely slight injection of one patch, but no ulceration.^ Dr. Peacock, who, as pathologist to the Edinburgh Eoyal Infirmary and Physician to the Eoyal Free and St. Thomas' Hospitals in London, has had unusual opportunities of ex- amining the bodies of persons who have died of typhus, says that ' Peyer's patches are usually less distinct than in persons who die of other acute affections of similar duration.' s Dr. Wilks' experience at Guy's Hospital has been the same. In no fatal case of typhus has he found any disease of the small intestine.^ Jacquot, in his work on the Crimean typhus, has collected upwards of 400 cases, in not one of which were the lesions found after death which characterize the Jievre typlio'ide or dothinenterite of French writers. He observes : * L'absence des lesions dothinenteriques dans le typhus de I'armee d'Orient est aujourd'hui une verite acquise ; il ne reste, a notre connais- sance, qu'un medecin qui soutienne le contraire, c'est M. Cazalas ; mais comme il confesse qu'il ne pent distinguer un typhus d'une fievre typhoide, son assertion n'a des lors plus rien d'etrange.' Jacquot himself found ulceration of the mucous membrane in 5 out of 41 cases ; but, in all, the lesions were quite distinct from those of dothinenterite. In 2, the ulcerations appeared to have resulted from sloughing of the membrane over a patch of submucous ecchymosis ; and in 3, they were merely abrasions of the softened membrane ; in none was there any deposit in, or elevation of, Peyer's patches, or of the solitary glands, or any enlargement of the mesenteric glands.^ Equally conclusive evidence is' borne by M. Barrallier from his observations in the hulks of Toulon. He observes : ' Je • Stewaet, 1840, p. 332. ' Jenneb, 1849 (2). s Peacock, 1856. •^ Wiles, 1855 and 1856. * Jacquot, 1858, pp. 234, 256. 254 TYPHUS FEVER. n'ai jamais observe, sur les i66 sujets necropsies pendant les deux epidemies du bagne, aucune des alterations des plaques de Peyer et des follicules de Brunner que Ton rencontre dans la fievre typhoide.' To show the care with which he investigated the matter, he adds : ' Les intestins ont ete toujours detaches du cadavre, incises longitudinalement, etales sur des planches disposees a cet effet, et etudies soit a I'oeil nu, soit a la loupe, et quelquefois sous I'eau ; enfin rien n'a ete oublie, pour pouvoir reconnaitre et constater la moindre lesion.' All the dissections were made in public, by his colleague, M. Beau.^ In 1856 M. Godelier dissected 8 cases of typhus which ter- minated fatally in the hospital of Val de Grace, and wrote as follows : * Quant a 1' alteration caracteristique de la fievre ty- phoide, des plaques de Peyer saillantes, molles ou dures, erodees ou ulcerees, et I'engorgement des ganglions mesenteriques, nous ne I'avons jamais rencontree.' ^ Lastly, of more than 1 20 cases carefully examined by myself, in not one has there been any deposit in, or ulceration of, Peyer' s patches, at all resembling the appearances found after death from typhoid ' fever.' In a few only of the cases, the glands have been slightly more prominent than usual, but not more so than is seen after death from many diseases ; occa- sionally they have presented the appearance compared by "French pathologists to a newly-shaven beard. This appearance was present in 4 of Jenner's 43 cases, in 8 of Jacquot's 41 cases, and in about one-third of Barrallier's 166 cases. It consists in patches of minute black dots, without any thickening or pro- minence of the mucous membrane. These patches are found in any part of the small intestine, and are often most numerous in the upper portion. They do not constitute part of the specific lesion of enteric fever, as has been imagined, for they are found after death from many other diseases, such as cholera, phthisis, &c. The absence of any specific intestinal lesion in typhus will be again referred to, in discussing the points of distinction between it and enteric fever ; but it may be here stated that all the observers, whose experience has been referred to, have had ample opportunities for studying the intestinal lesions of the latter disease. 5. The Large Intestines are usually quite healthy. In 28 of 37 fatal cases examined by Jenner, and in 23 of Jacquot's 41 J Babbalubh, 1861, pp. no, 265. * GoDiLiKB, 1856, p. 894. ANATOMICAL LESIONS. 255 fatal cases, they exhibited no signs of recent disease. At other times the mucous membrane of this portion of the bowel is more or less injected ; and now and then there are indications of actual inflammation. Dysentery, in fact, in some epidemics, is a common complication of typhus. In 8 of Jacquot's 41 cases, in 4 of 37 cases noted by Jenner, in 5 of 132 cases examined by Keid, and in several cases examined by myself, signs of colitis were discovered, the membrane being bright red, soft, and tumid, and covered with patches of lymph. In Eeid's cases the inflammation extended to the lower part of the small intestine, but there was no enlargement nor ulceration of Peyer's patches. In 3 of Jacquot's cases, the inflammation of the colon had proceeded to ulceration, and in 2 of my cases the ulceration was extensive. It follows that serious lesions of the bowels are occasionally found in typhus ; but they are totally different from those which characterize enteric fever. 6. The Mesenteric Glands are almost invariably healthy. In several of my cases they were slightly enlarged and of a dark livid hue, owing to extravasation beneath the enveloping peritoneum. Similar observations were made by Barrallier. In Gerhard's cases they were always normal, or but very slightly injected. Of Jenner's 43 cases they were healthy in 41, and contained tubercle in 2. Of 38 cases noted by Jacquot they were slightly enlarged in 5 only, and in none did they contain deposit of morbid material. 7. The Spleen, in a considerable number of cases, is healthy (in 7 of 22 cases, Peacock; in 18 of 41 cases, Barrallier ; and in two-thirds of 166 cases, Barrallier). The chief abnormal appearances presented by it are hypertrophy and softening. It was hypertrophied in two-thirds of the cases examined by myself ; in one-half of Jacquot's cases ; in one-third of Ger- hard's cases ; and in scarcely one-sixth of those noted by Barrallier. The normal weight being between 4 and 5 ounces, the average weight in 34 cases of typhus was ascertained by Jenner to be 7 oz. 5 dr., and in 2 of the cases it weighed as much as 14 ounces. The consistence was diminished in 15 of 22 cases examined by Peacock, in 13 of 31 cases dissected by Jenner, and in two-thirds of my cases. Not unfrequently the organ is reduced to a reddish-brown pulp, which runs out when the capsule is divided. Softening is more common after, than before, 50 years of age, and before, than after, the four- 256 TYPHUS FEVEE. teenth day of the disease. Jacquot mentions a case where instant death resulted from rupture of the spleen.^ In several instances I have met with extensive recent fibrinous deposits in the spleen exactly like those ordinarily attributed to embolism, and in one instance a mass of this sort as large as a crown piece, and extending from the surface one- third of an inch into the interior, had become gangrenous. (See also p. 212.) 8. The Liver and G all-Bladder. The liver is occasionally healthy (in 16 of 41 cases, Jacquot; in 31 of 166 cases, Barral- lier) ; but more commonly it is hypersemic, or its consistence is reduced. It was hyperaemic in 17 of 41 cases observed by Jacquot, in 7 of 36 cases observed by Jenner, and in 62 of 166 cases noted by Barrallier ; its consistence was reduced in 22 of Jenner's 36 cases, and in 40 of Barrallier's 166 cases. Ac- cording to my experience, the liver is more commonly hy- pergemic, if death occurs on, or before, the fourteenth day ; but after this, it is often pale, flabby, and very friable. In every case where I have subjected this softened hepatic tissue to microscopic examination, I have found an increased amount of oil in the secreting cells. Frerichs has found leucine, tyrosine, and hypoxanthine, in large quantity, in the liver of typhus and of other blood-diseases, Messrs. Barudel and Jacquot met with a singular alteration of the liver in four cases of typhus, which the latter observer designated ' imlmonisation du foie.' ' Le parenchyme etait d'un brun verdatre livide, crible de vacuoles, aerolaire, spongieux, mou, friable, evidemment crepitant, contenant un peu de liquide spumeux, mele de bulles de gaz.'"" These were evi- dently examples of that rare lesion described by Frerichs as 'Emphysema of the Liver,' and believed by him to be due to a process of local disintegration." In one of my cases, where the liver was examined within twenty-four hours of death, this appearance was present; portions of the liver floated in water. There is never any ulceration of the lining membrane of the gall-bladder. The bile is usually dark green, or greenish- yellow, and of ordinary consistence. 9. The Pancreas, like the liver, is frequently found to be hypersemic when death occurs at an early stage; at a later > Jacquot, 1858, p. 235. ■" lb. p. 250. " Diseases of Liver, Syd. Soc. Transl. ii. 370. ANATOMICAL LESIONS. 257 stage, its consistence is often reduced. In the epidemic at Toulon, Barrallier found the pancreas in most cases hypersemic and sHghtly hypertrophied. 10. Peritoneum. With the rare exceptions akeady men- tioned, signs of recent peritonitis are not found after death from typhus. A small quantity of post-mortem serous effusion is occasionally seen, and now and then there are small ecchymosea in the sub-peritoneal tissue. (See p. 212.) d. Organs of Circulation and Blood. 1. The Pericardium often contains an increased amount of serosity, which occasionally presents a deep-red tint, owing to ■ the transudation of the haematine of the blood. The surface of the heart may present patches of dusky-red staining, or ecchy- moses. In one of Jacquot's, and two of my cases, there were signs of recent pericarditis." (See also p. 200.) 2. The Heart. In a large number of cases, the muscular tissue of the heart is flabby, soft, and easily torn. These cha- racters were noted by Peacock in 7 of 1 9 cases ; by Jenner, in 15 of 29 cases ; by Jacquot, in 7 of 39 cases ; and in more than one-third of my cases. The softening is independent of the duration of the disease, the age of the patient, the external temperature, or the interval since death. In many cases, it is confined to the left side of the heart. (See p. 141.) Laennec was the first to describe softening of the heart, as a consequence of idiopathic fever. According to him, it was always most marked when putrid (typhoid) symptoms had been most prominent, and it was merely part of a general softening of the muscular system.? Some years later, Louis described softening of the heart as a common lesion in ' typhoid fever ;' *i and in 1839, Dr. Stokes recorded a number of cases of both typhus and ' typhoid fever,' to show the importance of this con- dition, as accounting for certain cardiac phenomena during life already referred to.*" Eokitansky^ and other pathologists have stated that this softening is 'a simple diminution of con- sistence, not depending upon any disturbance of texture.' But of several cases, where I have subjected the heart in this state ° Jacquot, 1858, p. 230. P TraiU de VAuscult. M4d. 2me ed. 1826, ii. 537. " Louis, 1829 (ed. 1841, i. 298). ' Stokes, 1839 ; also work on Diseases of the Heart, p. 371. ' Path. Anat. Syd. Soc. TransL iv. 171. S 258 TYPHUS FEVEE. to microscopic examination, in every one there has been granu- lar or fatty, or sometimes waxy, degeneration of the muscular tissue ; the transverse stri£e have been at many places indis- tinct or absent ; and the fibrils have contained numerous granules or minute oil-globules. Similar appearances were found by Dr. Joseph Bell in five cases of continued fever, several of the patients being of an age at which fatty degeneration could scarcely have been expected as an independent lesion.* Dr. Bell believed that the appearances found by him were due to inflammation, and referred to Virchow's statement that myo- carditis may give rise to fatty degeneration." 3. Endocardium. The lining membrane of the heart and of the great vessels is often observed to be stained of a dusky-red (in 12 of 24 cases, Jenner ; in 6 of 41 cases, Jacquot). Both sides of the heart may be thus affected, but the right more commonly than the left. Although this staining is of a j)ost- mortem nature, it indicates a great alteration of the blood. Signs of recent endocarditis are extremely rare. One case is mentioned by Jacquot, and another has come under my notice (p. 200). 4. The Blood undergoes remarkable changes in typhus. In the first place, it is darker and more fluid than natural. Some- times the blood in the heart and great vessels is perfectly liquid, without any trace of clot ; at other times there are a few soft, black clots, mixed with dark fluid blood. These cha- racters were found by Keid, in 28 of 61 cases; by Peacock, in 14 of 2T cases; by Jenner, in 17 of 37 cases; and hj Jacquot, in 18 of 41 cases. When pale coagula are found, they are usually soft and friable, and mixed with dark blood. Firm, pale, fibrinous clots are very rare (in 2 of 61 cases, Eeid ; in 4 of 37 cases, Jenner), and are chiefly observed in cases where death has resulted from some complication, after the cessation of the primary fever. The blood, taken from the body during life, often coagulates imperfectly, the crassamentum being soft and diffluent and rarely exhibiting the buffy coat. Typhus blood is more apt to become putrid than healthy blood, or than the blood of most other diseases. On closer examination, there is found to be a marked diminution of fibrine ; the red corpuscles are also diminished, although increased relatively to the amount of fibrine. "" These changes are most obvious in the ' Bell, iS6o. " Cellular Patliologii, Dr. Chance's Transl. p. 352. " Caepentek's Frinc. of Hum. Phijs. (5th ed.) p. 175. ANATOMICAL LESIONS. 259 later stages of the disease, and in those cases where typhoid or putrid symptoms have been most marked. Eesearches are stin wanting on the changes in the sahne constituents of the blood in typhus, more particularly in reference to the non- appearance of chlorides in the urine. According to the obser- vations of Lehmann,^ the salts are increased, rather than diminished, as was formerly thought. When the blood is very fluid, the red corpuscles are found to be crenate and mis- shapen, as if undergoing solution, and they are loosely aggre- gated in amorphous heaps in place of adhering in rolls. The white corpuscles are often increased in number and size, and present an unusually granular appearance ; there is often much free granular matter, but the highest microscopic powers fail to reveal the presence of any fungoid forms in perfectly fresh blood drawn from the body before death. In many cases the blood contains urea or other products of disintegrated albumen (see p. 181). It has been suggested that it contains free am- monia,'' and there can be no doubt that blood artificially mixed with ammonia presents the same appearances, to the naked eye and under the microscope, as in typhus ; but the evidence that the blood of typhus contains free ammonia is not as yet absolutely conclusive (see p. 145). e. Organs of Respiration. 1. The Pituitary Membrane not unfrequently exhibits a bright- red, or livid hue. 2. Larynx and Trachea. Eecent disease of the larynx is occasionally met with (in 6 of 26 cases, by Jenner ; in 16 of 39 cases by Jacquot). The lining membrane is of a bright-, or dusky-red hue, tumid and coated with viscid mucus, diphtheritic flakes, or a puriform fluid ; its texture is softened, and some- times the mucous follicles are enlarged. Jacquot observed* diphtheritic exudation in 2 out of 39 cases. In some instances, oedema glottidis is found, and cases have been already referred to where it was the cause of death. Dr. Buck has published coloured plates of oedema glottidis, occurring in the typhus of Irish immigrants to America.^ It is only in exceptional cases that the larynx is ulcerated (i in 26, Jenner ; 4 in 39, Jacquot; and I in 1 66, Barrallier) ; and then the ulcers are always ' Lehmann's Phys. Chemistry, Day's Transl. ii. 262, 266. EicHAEDsoN, 1858. y Buck, 1848. s 2 260 TYPHUS FEVER. minute and superficial. These morbid appearances in the larynx are almost always accompanied by inflammation in the pharynx. 3. Bronchi. Catarrhal inflammation of the air-passages is one of the most common post-mortem appearances in typhus. The lining membrane is of a bright-, or dusky-red tint, and more or less filled with tenacious frothy secretion. These ap- pearances were present in 18 of 20 cases observed by Peacock, in 20 of 22 cases dissected by Jenner, and in 19 of 41 cases noted by Jacquot. 4. The Lungs are rarely healthy. Of 146 cases examined by John Keid, Peacock, Jenner, and Jacquot, they exhibited some deviation from health in all but 6. The most common morbid appearance is hypostatic conges- tion. In a slight form, this condition is rarely absent ; and it is certainly far more common than after death from other diseases in which the lungs are not primarily affected, while in not a few cases (in 21 of 131, Eeid ; in 1 1 of 35, Jenner) the congestion amounts to complete consolidation, so that the pul- monary tissue sinks in water and does not crepitate. This consolidation is sometimes mistaken for pneumonia, but is dis- tinguished by the followmg characters. It is limited to, or greatest at, the most dependent parts of the lungs (which are not at the bases, but in the hollows of the fourth, fifth, and sixth ribs) ; from the posterior surface the consolidation extends from one to three inches into the substance of the lung, and is not bounded by any defined margin, but passes imperceptibly into the surrounding crepitant tissue ; its cut surface is smooth and non-granular, and of a dark purple or chocolate colour, and exudes a quantity of non-aerated claret-coloured serum. Both lungs are usually affected in about an equal degree ; but some- times one lung is more implicated than the other, or the affection ■is limited to one organ (p. 142). (Edema of the lungs is sometimes the chief lesion, and may be greatest in the upper lobes, from which a large quantity of colourless serosity can be squeezed, as from a sponge. (Edema is often associated with pulmonary hypostasis. Trne pneumonia is not a common lesion in typhus. It was present in 12 of 131 cases (Reid), in 9 of 35 cases (Jenner), in 2 of 27 cases (Peacock), in 12 of 41 cases (Jacquot), and in 8 of 54 cases (Anderson) . It may be lobular or lobar, but more commonly it is lobular, and then it occasionally terminates in abscess or gangrene. Cases of this nature have been observed ANATOMICAL LESIONS. 26 1 by Peacock, Jenner, and Barrallier, and several have come under my own notice. 5. The PleurcB. Signs of recent pleurisy are rare after death from typhus (2 of 131 cases, Eeid; 2 of 36 cases, Jenner; 5 of 41 cases, Jacquot). The effusion is usually fluid, and is apt to become purulent; it rarely takes the form of plastic lymph. Simple serous effusion is occasionally met with (in 8 of 41 cases, Jacquot) ; and in some cases patches of sub-pleural ecchymosis are observed. /. Nervous System. I . The Cerebral Membranes often exhibit increased vascular- ity, but rarely any deposit of lymph or pus indicative of recent inflammation. Of 24 cases examined by Peacock, there was increased vascularity of the pia mater in only 8. In 10 out of 36 cases examined by Jenner the dura mater was congested ; in 22 of the 36 cases there was increased vascularity of the pia mater, the injection being trifling in 7, and intense in 7 ; in 13 cases there was no mcreased vascularity. Of Jacquot's 41 cases,, the venous sinuses were found gorged with blood m 29 ; in 1 2 there was no engorgement ; in 17 cases there was marked injec- tion of the large veins of the meninges, and in 9 there was intense fine injection; but in 13 cases the injection was insignificant, or there was none at all. The choroid plexuses are occasionally very vascular. The increased vascularity of the cerebral membranes in typhus must not be regarded as a sign of infiammation, and does not account for the cerebral symptoms observed during life. The vascularity is not greater, or more common, than when death results from disease of the lungs ; and in most cases where it is increased, some impediment will be found in the pulmonary circulation, or there has been evidence of greatly impaired cardiac action. The congestion, in fact, is mechanical or passive, never active. Moreover, I am satisfied from many observations that there is no relation between the vascularity of the mem- branes and the symptoms. I have repeatedly known the most severe cerebral symptoms during life, without abnormal vascu- larity of the cerebral membranes after death. Although it has been stated that infiammation of the cerebral membranes occurs in typhus, I have only met with two instances where the appear- ances justified such a conclusion ; and this result accords with the experience of Pieid, Peacock, Jenner, Jacquot, Barrallier, and 262 TYPHUS FE-^TR, most observers. M. Moering, of the Paissian army, examined the cerebral membranes and sub-arachnoid serosity microscopi- caHy in upwards of 200 cases, but in no instance could he detect a single pus-, or exudation-corpuscle.^ Notwithstanding the frequency and severity of cerebral symptoms, it is clear that meningitis cannot be reckoned among its ordinary lesions ; its occurrence as a complication has been already referred to (p. 203). Hemorrhage into the cavity of the arachnoid is a lesion in typhus to which attention was drawn by Peacock (i in 24 cases) in 1843, and which was found by Jenner in 5 out of 39 cases. In every case the coagulum was in the form of a delicate film, varying in thickness and consequently in hue in different cases, and in different parts of the same clot. It is usually situated on the convex surface of the brain, and may extend over an entire hemisphere, or even to the base. In none of the cases has the source of haemorrhage been discovered ; the brain has appeared healthy, and there has been no intense injection of the membranes. In one of Jenner's cases, blood was also extra- vasated into the substance of the rectus abdominis muscle, I have only met with this lesion in two or three cases, which have not been remarkable for the severity of the cerebral symptoms. John Pieid does not appear to have met with it once in 125 cases, Barrallier found it in only i of 166 cases. M. Moering found it in several cases in the Crimea.'* (See also pp. 169, 203.) It is usually found that the membranes can be torn from the brain with unusual facility, without removing any of the cerebral substance. Jenner noted this condition in 9 out of 1 1 cases. It occurs after death from many diseases, but it is cer- tainly unusually common in typhus. The Pacchionian bodies were noted b}' several observers in the Crimea as increased in number and size (in 17 of 41 cases, Jacquot) ; but, so far as we know, such appearances have no pathological signification. 2. The Svh-arach-noid Serosity and Ventricular Fluid. In- creased effusion of serum within the cranium is one of the most frequent morbid appearances in typhus. The most common seats of this effusion are beneath the arachnoid and in the lateral ventricles, and sometimes in the cavity of the arachnoid. The serum is transparent and usually colourless ; sometimes it is Jacquot, 1S58, p. 253. » Ibid. p. 2^4. ANATOMICAL LESIONS. 263 straw-coloured; and occasionally it appears opalescent, owing to slight opacity of the superposed membrane. It does not contain any flakes of lymph or exudation- corpuscles. The quantity beneath the arachnoid may be enough to separate the convolutions, but is rarely sufficient to elevate the arachnoid ; the amount in each lateral ventricle rarely exceeds two drachms, and that at the base of the cranium is seldom more than one fluid ounce. Of 125 cases in which the brain was examined by Dr. John Eeid, the sulci were more or less wide and full of serum in 60; and in 25 the quantity was sufiicient to elevate the arach- noid above the surface of the convolutions. Of 82 cases in which the fluid in the lateral ventricles was carefully measured, in 37 it was less than half a drachm ; in 37 it exceeded one drachm ; in 23 it exceeded two drachms ; and in 4 it varied from five drachms to an ounce and a half.^ Of 23 cases examined by Peacock, the sub-arachnoid serosity was scanty or absent in 1 5 ; of moderate quantity, in 6 ; and so copious as to elevate the mem- brane above the surface of the convolutions, in 2. The fluid in the lateral ventricles was more than half a drachm in 1 7 cases, half an ounce or upwards in 4 cases, and two ounces in i case." Of Jenner's 36 cases, more or less sub-arachnoid serosity was found in 23 ; in 25 serum was found in the cavity of the arach- noid varying in quantity from two drachms to two fluid ounces ; the average amount of fluid in the lateral ventricles was two or three drachms.'^ Of Jacquot's 41 cases the sub-arachnoid serosity was trifling in amount in 20; in 16 it was abnormally abundant ; and in 5 there was none at all. In 24 cases there was no serosity in the cavity of the arachnoid ; in 9 the quantity was considerable or abundant ; and in 8 cases there was an increased amomit of fluid in the lateral ventricles.® Barrallier met with an increased quantity of fluid in the ventricles in 30 of 138 cases, and occasionally with effusion of limpid fluid beneath the arachnoid.^ The increased amount of serosity within the cranium is no sign of inflammatory action, and does not account by pressure or otherwise for the cerebral symptoms during life. There is no relation between the severity of the cerebral symptoms and the amount of fluid. Thh'ty years ago it was shown by Dr. John Eeid, as the result of an examination of the brain in 125 cases of typhus, that the cerebral derangement was as strongly marked in those cases where no increased effusion within the cranium Eeid, 1840 and 1S42. <= Peacock, 1843. ^ Jennek, 1849 (2). Jacquot, 1858, p. 226. f Baekalliee, 1 86 1, p. 267. 264 TYPHUS FEVER. was found after death, as in those where the amount was exces- sive, and that occasionally there was very little cerebral derange- ment where the quantity was great. About the same time. Dr. Peacock arrived at similar results, and the fact is now ad- mitted by most modern pathologists. If the reader has any doubt on the point, it will be at once removed by referring to Eeid's masterly exposition of the subject.^ The quantity of fluid present within the cranium in typhus is not greater than is usually found in persons of an advanced age, or who have died from chronic emaciating diseases. Under such circumstances, as well as in typhus, the brain shrinks from want of proper nutrition, and the fluid is effused to fill up space (see p. 16). It does not exercise more than the normal pressure on the brain, and, as above stated, it does not account for the comatose symptoms of typhus.'^ 3. The Cerebrum and Cerebellum are often healthy; and their chief abnormal appearances are increased vascularity indicated by an unusual number of bloody pomts on section of the white matter, a darker tint of the grey substance, and diminished consistence. Eeid found the vascularity of the brain-substance increased in 34 of 82 cases ; Jenner in 15 of 36 cases ; Peacock in 6 of 24 cases; and Jacquot in 16 of 41 cases; altogether in 71 of 183 cases, or in 38-8 per cent. This increased vascularity, like that of the membranes, is no sign of inflammation and has no relation to the cerebral symptoms. In fact, according to my experience, it is less common in t3'phus than after death from some other diseases, such as affections of the lungs, where there has been no suspicion of cerebral disease ; while in some cases of typhus where cerebral symptoms have been most strongly developed, I have found no increase of vascularity, and even decided ansemia of the brain-substance. The increased vascularity of the brain, when present, is, like that of the membranes, either mechanical or ]Dassive, never active. Of 12 cases where the brain or mem- branes were found by Peacock to be abnormally vascular, the lungs were diseased in all. Softening of the brain has been observed occasionally by Eeid, Jenner, Jacquot, Barrallier, &c. Jenner found the brain of normal consistence in 29, and more or less softened in 7, of 36 cases. Of Jacquot's 41 cases, the consistence was normal in 27; there was softening in 12; and induration of both hemi- B Eeii>, 1S40 and 1842. ^ See Todd, i860, p. 159. ANATOMICAL LESIONS. 265 spheres in 2 cases. Barrallier met with softening in only 5 of 138 cases. The softening is either general or partial; and in the latter case it may affect the upper surface of the hemi- spheres, the inner surfaces of the optic thalami, the fornix, or corpus callosum. It may be cadaveric, or it may be produced by infiltration of serum from the neighbouring cavities ; some- times, as in the case of the muscles, it is probably connected with that process of disintegration and atrophy which the brain is known to undergo in typhus. I know of no instance, however, where true softening, distinguished by the presence of compound granular corpuscles, oil-globules, and disintegrated nerve-tissue, has been found as a result of typhus. According to Eokitansky, ' slight condensation of the brain is the rule in typhus ; while decided softening, which in fact is nothing more than oedema of the brain, is certainly common late in the disease.' ^ BarrallierJ has called attention to the remarkable indistinct- ness of the arbor vitce of the cerebellum in some cases. Of 28 autopsies, made by him during the epidemic at Toulon in 1856, this phenomenon was observed in 7 ; and in 2 of the cases the ai'hor vitce was almost completely effaced. 4. The Spinal Cord. Increased vascularity of the spinal membranes is less common than of the cerebral membranes. In most cases the spinal fluid is somewhat increased. Softening, like that of the cerebral substance, has been occasionally noticed by Landouzy, Godelier,'" and Jacquot.^ 5. The Sympathetic System has not yet been examined with requisite care. Mr. Marmy found many of the ganglia softened, especially those of the neck.™ Of 10 cases in which the cervical sympathetic was examined by Beveridge, in all, the ganglia were found to be increased in size and density from the deposit of an amorphous granular matter." g. Urinary Organs. I. The Kidneys. When it is considered that chronic renal disease is found in fully one-fourth of the patients dying in a general hospital, it will not be surprising that it is not uncommon after death from typhus. But in many cases of typhus the kidneys exhibit unmistakable evidence of recent disease, which varies in its character according to the date of death. If death ' Path. Aimt. Syd. Soc. Transl. iii. 425. J Bakralliee, 1861, p. 372. ^ BAKR.UiLIEE, I86I, p. 106. ' JaCQUOT, 1 858, p. 228. •" Ibid. ° Beveeidge, i860. 266 TYPHUS FEVEE. occur before the fourteenth clay, the organs are usually hj^peraemic and hypertrophied, while the tubes are gorged with granular epi- thelium and sometimes contain blood. Occasionally they pre- sent the appearance of acute nephritis, as intensely developed as in any case of scarlatina (see Cases VIII. and IX.). If death occur at a later stage, the kidneys are usually large and pale ; the outer surface is smooth ; the cortical substance hypertrophied and soft ; and the tubes loaded with epithelium-cells swollen out with minute granules. 2. The Bladdei\ The mucous membrane is sometimes in- jected, or marked by haemorrhagic spots. Occasionally it presents all the signs of inflammation and even ulceration ; ° but in my experience these appearances have been chiefly met with when the bladder has not been used with sufficient promptitude to relieve retention. h. Genital Organs. The genital organs of neither sex present any abnormal ap- pearance peculiar to typhus. The 2^ost-mortem appearances of typhus may be summed up as follows : — 1. There is no lesion constant in, or peculiar to, typhus. 2. The intestines never exhibit the peculiar lesions invariably present in enteric fever, and the mesenteric glands are not en- larged. 3. No evidence of recent inflammation is found in the brain nor its membranes, to account for the cerebral symptoms. 4. The chief morbid appearances are : a fluid condition of the blood ; atrophy of the brain, with increase of intra-cranial fluid; granular degeneration of the sympathetic nerves ; atrophy, with granular or waxy degeneration of the muscles and heart ; enlargement and congestion of the liver, spleen, pancreas, and kidneys, with a swollen granular state of the gland-cells ; bron- chial catarrh and pulmonary hypostasis. The relative frequency of these lesions varies at different times and places ; none are of constant occurrence, nor peculiar to typhus. " Perey, 1 866. TEEATMENT. 26/ Sect. XIII. Treatment. The treatment of typhus is divisihle into prophylactic and curative ; the former consisting in the removal of those causes which are known to favour its origin and propagation ; and the latter, in the application to individual cases of the resources of pharmacy and hygiene. A. Peophylactic Teeatment. It is easier to prevent typhus than to cure it. Indeed, the means for preventing its origin are, in a great measure, within our power. The remarks already made on etiology have antici- pated much that might be written on prophylaxis. To know the cause of a disease is to know how to remove it. The subject of prophylaxis resolves itself into two divisions — how to prevent the generation of the typhus-poison ; and how to arrest its propagation. I . Rules for Preventing the Generation of Typhus-Poison. What appears essential to the development of typhus is over- crowding of human beings with deficient ventilation, aided by whatever tends to debilitate the constitution. Eemove the es- sential cause, and typhus will cease to exist, A century ago there were no greater hotbeds of typhus than the jails of England ; but, thanks to the philanthropy of Howard, the nation is now freed from such an imputation. Similar reforms in the dwellings of our poor, and in the accommodation of our soldiers in time of war would, no doubt, be equally successful. It is difficult to fix the precise number of cubic feet required for each individual in a room. It has been calculated that an adult man expires about i6o cubic feet of air in twelve hours, containing about 4 per cent, of carbonic acid ; but as air con- taining more than i per cent, of carbonic acid cannot be breathed without injury, it follows that a man, confined in an air-tight chamber for twelve hours, would require 640 (160 x 4) cubic feet of space, and double that space for twenty-four hours. This on the supposition that there is no ventilation ; but the amount of space must always be in proportion to the amount of ventila- tion ; and, in fact, cubic space" is of far less importance than ventilation. A man shut up in an air-tight room will as cer- tainly be poisoned if the room be large, as if it be small : the only difference will be in the time required. The ventilation of 268 TYPHUS FEVEE. a room, then, must be the basis of a true judgment. The amount of ventilation requisite to prevent a room from contain- ing more than i per cent, of carbonic acid, is about i^ cubic feet of air per mmute for each per son, p But this percentage of carbonic acid is too great, and some authorities, such as Drs. Neil Arnott and Eeid, have recommended as much as lo or 20 cubic feet of ventilation per minute. The means for ventilation are either constant or occasional. The constant (the chimney and other unclosed openings) are more important than the occasional (doors and windows), and should be proportioned to the number of inmates. Indeed,, the excessive use of occasional means of ventilation is the best proof that those in constant use are insufficient. If the air in a room contain more than i per cent, of carbonic acid, or be in the slightest degree fusty, it may be held that the ventilation is defective, or that the number of inmates is too great. Although our present ignorance obliges us to take the amount of carbonic acid as the safest index of all the injurious substances which render ventilation necessary, this is not the only substance contained in air contaminated by over- crowding. Pure carbonic has no unpleasant smell or taste ; whereas the disagreeable fusty odour, produced by concentrated animal exhalations, is familiar to all. From what has been stated, it may be inferred that 500 cubic feet of space, with 2 cubic feet of ventilation per minute,, constitute the smallest amount that can be safely allotted to each person. The present regulations on this matter in London are as follows : — In workhouses the amount of space enforced by the Poor Law Board is 300 cubic feet for a sick ward, or for a dormitory occupied by night only, and 500 cubic feet in a ward occupied both day and night. In some districts of London the vestry considers a house to be overcrowded if the cubic space available for each individual fall short of 400 cubic feet. The common lodging-houses of London are under the supervision of the police, who have the power to enforce an allowance of 250 cubic feet for each person. But, notwithstanding these regulations, which err in fixing too low a minimum, and, what is far more important, in not providing for proper ventilation, I have repeatedly known whole families hving and sleeping in rooms, with not more than 120 or 150 cubic feet of space for each person, and with little or no ventilation. Such occurrences p On this subject, see Report, presented to Poor Law Board in 1856, by Dr. Bence Jones ; Dr. E. Smith's Report on Workhouse lulii-maries, and De Chau- mont, Lancet, Sept. i, 1S66. TKEATMENT. 269 are particularly common in seasons of scarcity, or when large bodies of men are thrown out of employment. In either case, the poor flock from the country to the large towns, where the channels of charity are most numerous ; and there swell the population of the already crowded lodging-houses and workhouses. (See pp. 49 and 54.) It is at such seasons, therefore, that the authorities should be most on their guard against the known effects of overcrowding. The prevention of scarcity of food, loss of employment, and other causes of destitution, is not always within human power ; but, under such circumstances, every means, both public and private, calculated to alleviate the distresses of the poor, should be adopted. Moreover, no time is to be lost in affording relief; it is difficult to stay the plague when once it has begun. Care also must be taken that the funds collected for such purposes do not produce the very evils they are intended to avert. The poor naturally flock in greater numbers to those localities where most relief is to obtained, and the result has often been increased crowding. The expediency of supplying relief to the poor, in then' crowded dwellings, may therefore be questioned. A prefer- able plan would be to establish, during seasons of scarcity, and when typhus is prevalent, temporary buildings of wood or iron, or tents, in the neighbourhood of large towns. Here, over- crowding could be prevented, the poor could be supplied with abundance of fresh air and food, while the number of persons resorting thither for relief would prevent overcrowding in the towns. The expense of such a plan would certainly not exceed what the spread of an epidemic always entails. Especial care must be taken to prevent overcrowding and bad ventilation during winter ; for although fires and the external cold increase the rapidity of the circulation of air, so that the openings for constcmt ventilation may be smaller, yet the poor are in the habit of closing every crevice to keep out the cold, and rarely resort to any means for occasional ventilation. The dwellings of the poor ought to be so constructed' as to ensure good ventilation. Closed courts surrounded by high houses are always objectionable. Every window-frame ouo-ht to be movable, and every room should be provided with means for constant ventilation. Human beings ought to be prohibited from living in underground cellars, where proper ventilation is impossible. Common lodging-houses, and indeed every house in populous localities, should be thoroughly cleaned, and the walls 270 TYPHUS FEVER. lime-washed, twice every year, and oftener when there is reason to apprehend an epidemic of typhus. Inasmuch as squalor aggravates the evils of overcrowding, personal cleanliness should be encouraged among the poor, by the erection of free public baths and wash-houses for their clothes. Most of these remarks apply equally to workhouses, jails, transport- and emigrant -ships, barracks, and camps. Typhus fever, ivJiich, during ivarfare, often commits greater havoc than the sivord of the enemy, may be prevented by plenty of fresh air and personal cleanliness. The regulations to be adopted must vary ac- cording to circumstances, but the general principles will always be the same : no overcrowding, good ventilation, personal cleanli- ness, and a nutritious diet. 2. Rules for Preventing the Propagation of the Typhus-Poison. An abundant supply of fresh air is not only the best means for preventing the generation of typhus, but is the surest safe- guard against its propagation to the attendants on the sick and to other persons. The truth of this statement has been already so fully established that it is needless to enlarge upon it. But, as this desideratum is not always attainable in the houses of the poor, the infected persons ought to be isolated, and, if pos- sible, removed at once to an hospital. At the same time, the house should undergo a thorough cleansing and ventilation, the inhabitants should be reduced in number, their clothes washed, and every means taken to ensure personal cleanliness. When typhus is prevalent, no person, whether ill or not, ought to be admitted among the other inmates of a workhouse, without having a warm bath and other clothing, while his own clothes are being purified. There cannot be a more reprehensible custom than that of bringing patients labouring under contagious fevers to hospitals in common street-cabs. Apart from the danger of the disease being thus propagated, the fatigue and shaking often inflict injuries on the patient from which he never recovers, and which may be immediately fatal. Fever patients ought always to be conveyed in covered litters, or in spring invalid-carriages, constructed for the purpose and maintained by the parochial authorities. When a typhus patient is brought to an hospital, care should be taken to disinfect his clothes, before they are restored to I TEEATMENT. 2/1 him or to his friends. The under- clothing ought to be imme- diately immersed in a solution of carbolic acid, Condy's fluid, or chloride of lime, and, after twenty- four hours, washed, boiled, and hung out to dry in the open air. The outer clothing ought to be exposed, for some hours, to a dry heat of 212° Falir., then subjected to the fumes of sulphurous acid or chlorine, and after- wards hung out in the open air, or in thoroughly ventilated wooden sheds, until the patient's recovery. Of all these measures, free exposure to the air is the most important. The linen and bed- clothes used by typhus patients ought to be treated in the same way as the under-clothing worn when he first fell sick. In general hospitals they ought to be kept separate from those used by other patients. Every typhus patient, on admission into hospital, ought to have a bath ; or, if he be too weak, the body should be fre- quently sponged with water, or with a weak solution of Condy's fluid. In hospitals, where typhus patients are admitted, there ought to be an ahowance of at least 1,500 cubic feet to each bed; the beds ought to be six feet distant from one another, and the freest ventilation should be maintained. Doors, windows, and other occasional means of ventilation must not be trusted to ; the greater the amount of constant ventilation, the better. During an epidemic, and particularly when ery- sipelas, pyaemia, local gangrene or parotid swellings are common complications, the wahs ought to be frequently lime- washed. Injecting showers of diluted Condy's fluid through the ward I have found to have a marked effect in purifying the atmosphere, and Dr. J. B. Eussell has suggested an excellent plan for the constant diffusion of carbolic acid with the vapour of boiling water ; *i but no method of fumigation must be allowed to inter- fere with the abundant admission of fresh au-. The bedding used by a typhus patient ought to be taken to pieces, thoroughly washed, and baked, and then exposed to the air. Where this cannot be done, it had better be destroyed. The bedstead should be washed with a solution of carbolic acid, Condy's fluid, or chloride of lime. In general hospitals, the same beds and bedding ought always to be reserved for typhus cases. Before his discharge from the hospital, each patient should have a warm bath, and afterwards put on his purified clothes. Friends, who visit the sick, should be prevented sitting on « Glasgow Med. Journ. Feb. 1S69, p. 210. 2/2 TYPHUS FEVER. their beds, or approaching so close as to inhale their breath or the emanations from beneath the bed-clothes. All unnecessary visits are to be prohibited. In a private house, after the patient's recovery, the walls and ceiling of the room ought to be scraped and whitewashed or re-papered, the floor and furniture washed first with some dis- infectant and afterwards with soap and water, and the doors and windows kept open night and day for a week. At the end of this time the room may be re-inhabited with safety. Not only must every measure be taken to destroy the typhus- poison, but all those agencies which are known to predispose the system to its influence must be avoided. Of these, the most powerful is debility from deficient food or from other causes. The Guardians of the Poor and the Commissariat departments of armies ought to be impressed with the fact, that a nutritious diet is one of the best preventives of typhus. Nurses and other attendants on the sick should have a liberal diet, and ought never to visit the wards with an empty stomach, while the opposite error of freely indulging in ardent spirits, in the mis- taken notion of warding off the fever, is equally to be depre- cated. The attendants on the sick should also have ample time for sleep ; they ought never to sleep in the sick room, and should be made to take exercise daily in the open air. Fatigue of mind or of body is to be scrupulously shunned by persons who are necessarily exposed to the poison of tj^phus. In the case of hospital nurses, occasional recreation is no less necessary for keeping up their spirits than for encouraging them in their dangerous duties. Personal cleanliness, frequent bathing, and frequent changes of under- clothing ought to be enjoined on every person who is exposed to typhus. Abundant evidence might be collected, to demonstrate the efficacy of the measures here recommended for preventing the propagation of typhus. B. Curative Treatment. In the treatment of typhus, medicines can do much to relieve symptoms, and may promote the chances of a favourable termi- nation ; but, so far as we yet know, they are powerless in arresting its progress or shortening its duration. Although many practitioners have at different times proposed to cut short an attack of typhus by such heroic remedies as blood-letting, the cold affusion, emetics, and quinine, we possess as yet no TKEATMENT. 2/3 such specific. In an admirable essay, published in 1802, Dr. W. Brown, of Edinburgh, showed that the power of medi- cine in arresting or shortening typhus was extremely doubt- ful/ Hildenbrand, in his day, observed : ' No method yet known, whether rational or empirical, can cm^e the contagious typhus, either in a direct or in an indirect manner, nor even abridge its ordinary and natural course, which is about fourteen days.' ^ In our own times. Dr. Stokes speaks equally strongly : ' The treatment of fever,' he says, ' is reduced to a formula. We cannot cure fever. No man ever cured fever. It will cure itself. If you keep the patient till the fourteenth, the eighteenth, or the twenty-first day, he will recover.' * My experience has led me to a similar opinion. A patient with typhus is like a ship in a storm ; neither the physician nor the pilot can quell the storm; but by tact, knowledge, and able assistance, they may save the ship. One of the first things to be done is to secure the services of an experienced and judicious nurse, strong enough to lift the patient when necessary. Much of the success of any treatment will depend on good nursing. The friends or relatives of the patient ought not to take the place of a practised nurse ; for, as Graves has observed, affection and sorrow are apt to cloud the judgment, w^hile the mistaken tenderness of relatives, and their want of due firmness, presence of mind, and experience, fre- quently mar the best efforts of the physician. The moving or raising the patient in bed, and changing his linen, are duties performed very differently by a nurse and an inexjDerienced 2:)erson ; and even the delirious patient appreciates the tender- ness and skill of those who minister to his wants. The nurse ought to note in writing the hours at which food or medicine has been administered, or at which any remarkable change in the symptoms has occurred. In directing the treatment of typhus the objects to be kept in view are those already mentioned in the introductory chapter of this work (p. 22) ; but care must be taken that the means resorted to for attaining these objects in no way thvv'art the natural process of recovery. I. Neutralize the Poison, and improve the state of the Blood. Different remedies have been recommended for this object, according to the view^s held with regard to the nature of the Brown, i8i8. ■ Hildenbrand, i8ii,p. 149. ' Stokes, 1S54. T 274 TYPHUS FEVEK. typhus-poison and its effects on the blood, although it cannot be said that we as yet possess any remedies which can neutralize or destroy the typhus-poison. I. The Mineral Acids are largely employed on the idea that they exercise some such power. Whatever be the nature of the primary typhus-poison, there are reasons for believing that in the fever which it lights up, the blood becomes loaded with nitrogenous products more or less ammoniacal, and that an acid treatment is calculated to do good. Although I am far from ascribing to the mineral acids the wonderful influence over typhus which some writers have claimed for them, my experience of them in many thousands of cases has satisfied me of their beneficial effects, whether they act as alteratives of the blood, or promoters of digestion. I have often observed the tongue become moist, and a marked improvement follow the commencement of the acid treatment at whatever stage of the disease it was tried. It is curious also to observe that acids have been recom- mended for typhus in all countries since the disease was first described. Long ago they were extolled by Forestus, Syden- ham, Van Swieten and Boerhaave ; and in our own day they have been commended by Huss of Stockholm,'' Haller of Yienna,'' and by F. W. Mackenzie,"^ Chambers,'' Eichardson, &c., in our own country. The Elixir Acidi Halleri,^ so commonly employed in Germany in the treatment of typhus and allied diseases, has sulphuric acid as its chief ingredient. The acid usually given in this country is hydrochloric. Half a drachm of the dilute acid with a like quantity of the tincture and syrup of orange may be given in solution every three hours. In severe cases with a marked typhoid condition, the dilute sulphuric acid in combination with ether and small doses of quinine has appeared to me preferable to the hydrochloric acid. Huss gives preference to phosphoric acid, in doses of 25 to 40 drops (Ac. Phosph. dil. B.P.) every second hour, on the gi'ound that it not only acts beneficially like other acids, but that the phosphorus exerts a special influence on the central organs of the nervous system. In the advanced stage of the malady, and particularly if numerous petechiae and ecchymoses, or profuse sweating, be present, he recommends the substitution of sulphuric acid, in doses of 15 « Huss, 1855, pp. 141, 168. " Haller, 1853. " Path, and Treatment of Phlegmasia dolens, 1S62, p. 123. " Chambers, 1858, p. 109, also in Brit, and For. Med. Chir. Rev. Oct. 1S63, and my criticisms in Brit. Med. Journ. 1863, i. 548. y This consists of one i^ait of concentrated sulphuric acid to three of rectified spirits. • It is given in doses of 5 to 20 drops in solution. TREATMENT. 2/5 to 20 drops (Ac. Sulpli. dil. B.P.) every hour or every second hour. 2. A?itise2Jtics. Creasote, carbohc acid,^ the chlorate and permanganate of potash, the peroxide of hydrogen, chlorine, sulphurous acid and its salts, have been recommended as anti- septics or correctives of the blood in typhus, or with the view of destroying the fungoid germs, on the presence of which, it is contended, the disease depends. I have tried all of these remedies, but without any marked result, except perhaps from free chlorine, which in the typhoid state has seemed to act beneficially like the mineral acids. With regard to the hypo- sulphites, I have never seen the slightest improvement follow then" employment. In Glasgow and in Dundee they have also been fairly tried, and with a like result.^ 3. Inhalation of Oxygen. With the view of improving the carbonized blood in pulmonary congestion, I have made several patients inhale oxygen gas, diluted in different proportions with atmospheric air, from Mr. Earth's apparatus, but no marked benefit nor change has ensued. 4. Iron. Dr. A. P. Stewart informs me that he has given the Tinctura Ferri Perchloridi with great advantage in typhus, in doses of half a drachm every three hours. II. Promote Elimination not merely of the Fever-ijoison, hut of the i^rocliicts of metamorphosis. I . Fresh Air, and plenty of it, is one of the most important -conditions for the successful treatment of typhus. The patient is to be removed, when possible, from an infectious locality, and placed in a large, airy room, from which the carpet, hangings, and all unnecessary articles of furniture have been removed, and in which thorough ventilation is secured by open doors and windows. The temperature ought to average 60° Fahr., and it may be well not to expose the patient to a draught of cold air ; but, of the two evils, cold is much less injurious than close au\ By supplying abundance of fresh air, a ready escape is afforded to the noxious emanations by which the disease is propagated to others, and the inhalation of which aggravates the disease in the patients themselves. The relative advantage of isolating cases of typhus, or interspersing them in the wards of a general hospital, is a subject on which diffei'ence of opinion exists, and Brit. Med. Journ. 1869, i. 144, 535. * Peery, 1866; Maclagan, 1867, Xo. r. T 2 2/6 TYPHUS FEVEK. of sucli importance that it will be dealt with in a separate chapter. Meanwhile, it may be said that there is ample e\ddence of the good effects of fresh air in the treatment of typhus. In Edinburgh,^ Glasgow, ° and Dublin,*^ the mortality has been found to be considerably less among patients treated m temporary sheds and even in tents, than among those treated at the same time in crowded hospitals ; and in more than one Irish epidemic it has been noticed that the poor laid at the- roadside recovered, while those in hospitals and private houses died. 2. Diluents ought to be given largely in typhus. An exces- sive quantity of drinking water increases the flow of urine, and helps to wash avray the products of metamorphosis. Patients are often capricious in their choice of drinks, and in private practice the medical attendant must be prepared to humour them with a variety. Barley-water, toast-water, gruel, orange- ade, lemonade, apple-water, tamarind-water, currant-water, raspberry vinegar, seltzer, soda-water, or cold tea without sugar or milk, may be tried ; but after a few days the patient usually loathes all except pure water. While encouraged to drink often, the patient ought not to be permitted to distend his stomach by drinking large quantities at a time. 3. Diuretics. From what has been already stated (see pp. 152, 170), the importance of maintaining the action of the kid- neys, so as to ensure the elimination of the products of the exaggerated disintegration of tissue, must be obvious. With this object 5 grains of nitrate of potash, or 15 minims of spirit of nitrous ether, or a small dose of digitalis may be added to each dose of the acid mixture. 'Sf, Acid. Hydroclilor. dil. 5ss. Sp. Aeth. Nit. n^xv. Tinct. Digitalis ni_iv-»n_x. Tinct. et Syr. Aurant. aa 5ss. Aq. ad |jss. Ft. haust. 3a qq. honi sum. Nitre-whey, prepared by boiling 5ij of nitre in a pint of milk and straining, or the potus iiiijierialis, prepared b}' dis- solving 5J to 5ij of bitartrate of potash in a pint of boiling water, and flavouring with lemon and sugar, may also be used for the same purpose. Any remedy which may be found to promote the elimination of urea, without increasing the destructive metamorphosis of tissue, will deserve a trial in typhus. Tea and coffee perhaps deserve to be included under this head. Both have long been " E. Pateksok, 1S48. « Steele, 1848. ^ O'Bkiex, 1S2S. TEEATMENT. 2/7 xecommencTecl as expergefacients in the stupor of typhus ; ^ and there is some reason for beheving that this property is due to their power of ehminating urea from the body. Parkes found that, after administering 120 grains of extract of coffee to a patient on the tenth day of typhus, the total amount of urea excreted by the kidneys in twenty-fom" hours, which for two days before, and for eight days after, varied from 507 to 552 grains, rose to 723 grains. At the same time the patient ex- pressed himself as much better, his headache ceased, and his pulse became fuller and stronger.^ Theine and caffeine are well worthy of trial in cases where there is much stupor. 4. Salines. It was at one time the practice to administer .salines in fever, on the supposition that febrile symptoms de- pended on a loss of the saline ingredients of the blood.^ Common salt, or chloride of sodium, was especially commended in typhus, when the disease presented putrid or typhoid symp- toms, such as great prostration, dry brown tongue, numerous petechise, stupor, etc.^ Its reputed good effects are not to be explained by its supplying the deficiency of this substance in the blood (see pp. 153, 259), but are possibly due to its antiseptic properties, and to its property of increasing elimination. Bis- choff, Boussingault, Knapp, and others have shown that the effect of chloride of sodium in health is to increase slightly the quantity of urea.^ It is also to be borne in mind that the quantity of salt taken with the food is much diminished in fever. Wundt's observations show that the total removal of salt from the food « In 1S17, Dr. E. Percival stated that he had found an infusion of green tea of great service in comatose affections, and especially in that of typhus [Trans. K. cH Q. Coll. of Pht/s. 1818, ii. 44). His observations were confirmed by Dr. Stoker (1826, p. no) and by Dr. Graves (1848, i. 123). Strong coffee has long been used on the Continent for the same purpose. In 1834, a French physician, clinical assistant to M. Petit, published a number of observations showing the excellent effects of coffee in the stux^or and other cerebral symiDtoms of ' Typhoid Fever.' [Bib. 1834.) Since the above was written. Dr. Grimshaw has used tea largely in the treatment of typhus, and ascribes its good effects to its power of eliminating urea. (Geimshaw, 1866, No. 2.) ' Pakkes, 1857 ; also Pakkes On the Urine, i860, p. 259. s Cheistisox, 1840, p. 183 ; Tweedie, i860, p. 589. ^ Chloride of sodium was first recommended in the treatment of fever by Dr. Eobert Eeid of Dublin in 1827. In 1835 Dr. Graves reported to the British Asso- ciation that he had tried it in many hundreds of cases, and that when there was great prostration with numerous petechife and other symptoms of putridity, no remedy acted so energetically. He prescribed 1 5 to 20 drops of a saturated solution every four hours (Geaves, 1835). Two years later. Dr. Hudson, then of Navan, reported that he had given it in 47 case§, ' in every instance with the best effect.' (Hudson, 1837, p. 351.) Salt was also at one time highly praised by Chomel {i834)> Dr. Dor of Marseilles {Gaz. Med. cU Paris, Fev. 28, 1835), and by other French practitioners, in the treatment of enteric fever ; but, on the whole, it appears to have been of less service than in typhus. (See also B.iETLETT, 1856, p. 161.) i Paekes, 1857 ; also Paekes On the Urine, i860, p. 65. 2/8 TYPHUS FE-VTEE. reduces greatly the quantity of urinary water, and after a few days renders the urine albuminous. J For these reasons, I have been in the habit of ordering large quantities of salt to be mixed with the patient's beef-tea, and have found it in most cases greatly relished, and apparently beneficial. 5. Diaplioretics were formerly much employed in the treat- ment of typhus, but are rarely given at the present da3\ In 3^oung persons, when the skin has been unusually dry and hot- in an early stage of the fever, I have sometimes found them useful in reducing the pulse and temperature, but under other circumstances they ought to be avoided. The natural process of recovery is not by elimination from the skin, and copious diaphoresis is a symptom to be dreaded. (See p. 184.) As a rule, the action of the skin will be sufficiently promoted by frequent sponging. 6. Emetics have been recommended in the early stage of typhus by most writers, and in later times particularly by Hil- denbrand, Graves and Barrallier, with the object of cutting short the fever, or of rendering its course milder. It is very doubtful, however, if true typhus has ever been cut short by an emetic. Graves admits that the remedy is only of service for this object if given within the first twenty-four or thirty-six hours of the disease,'' and at this early stage, before the appearance of the eruption, it is impossible to predict that a febrile attack will run the course of typhus. It is not uncommon for persons exposed to the poison of typhus to be seized with febrile symptoms of some severity, terminating spontaneously in three or four days ; if an emetic had been given in such a case, the cure would be attributed to it (p. 228). ki the same time, an emetic of ipeca- cuanha Oj)^ and antimony (gr. j), or of carbonate of ammonia (gij), is often of undoubted service in relieving symptoms during the first five or six days of the disease. Its good effects are often most marked in mitigating or removing the headache and general pains, in reducing the temperature, quenching the thirst, and quieting any gastric disturbance. It is contra-indicated when the patient is unusually weak, or when the disease has advanced beyond the first week. 7. Purgatives. The systematic employment of ^Durgatives in the treatment of tj'phus was first introduced b}^ Dr. James Hamilton of Edinljurgh at the commencement of the present century,' and for many years it was an almost universal jDractice J Pabkes On the Urine, iS6o, p. S5. ^ Graves, 1848, i. 13S. ' Hamilto>-, 1805, pp. 14, 159. TREATMENT. 2/9 among British physicians. It was thought that, by the free evacuation of the offensive contents of the bowels, the fever was reduced and the other symptoms reheved. The bad effects of excessive purging were exposed by Graves, Corrigan, and others, and the practice is now obsolete. Throughout the attack it is well that the bowels should act regularly and to secure this object if necessary by a small dose of rhubarb and calomel, or of castor oil, or by a simple enema ; but strong purgation often induces alarming prostration and an aggravation of all the symptoms. An active purge, however, may do good when con- vulsions have occurred, or wiien, with deep coma, there is albuminuria or suppression of urine. III. Reduce the Temperature and the Frequency of the Action of the Heart. I. Bloodletting. As typhus is essentially a disease of debility, it may appear surprising that general bloodletting to a large amount was for many years a favourite remedy with many prac- titioners in this country. Most modern physicians would regard such a practice as almost fatal ; and probably none of its former supporters would venture to have recourse to it at the present day. Modern observation has shown that the effect of blood- letting in typhus is to increase the mortality ; while, in the patients who recover after it, the nervous symptoms occur sooner and are of greater intensity and longer duration, the eruption is darker and more copious, and convalescence is greatly retarded.""^ The great revolution in medical practice within the last twenty years, both in idiopathic fevers and in acute inflammations, has lately attracted much attention, and it has been the fashion to' ascribe it to a change in the type of disease, necessitating a corresponding change in the principles of treatment. Continued fevers have been the chief field on which the battle of change of type has been fought ; but a careful study of their history fails, in my opinion, to lend any support to the theory in question. In the first place, it is well to observe that, prior to the com- mencement of the present century, the practice of all the best observers did not indicate any change of type in typhus. If we turn to the accounts given by^ Fracastorius, Hoffmann, Eogers, Strother, O'Connell, Wall, Pringle, Lind,. Smyth, "Willan, and See, for example, Hallee, 1853. 280 TYPHUS FEVER. many others,'' we find that bloocllettmg was almost universally condemned. The practice of bleeding originated in the erro- neous theories of Clutterbuck and Armstrong, already aUuded to (p. 42) ; and the success of the jDractice appeared to be esta- blished from the circumstance that it was proposed shortly be- fore an epidemic consisting for the most part of relapsing fever, the mortality from which, with or without bloodletting, is much less than that of typhus. After this, practitioners were un- willing to relinquish a remed}^, which in the epidemic of 1817- 19 appeared to have been attended with signal success, as comj^ared with the previous treatment of true t}-phus believed to be the same disease. But, by-and-by, as t}-phus was again substituted for relapsing fever, and more especiaUy as the study of morbid anatomy exposed the erroneous doctrines of Clutterbuck and Armstrong, bleeding was again condemned in the treatment of typhus, and practitioners attributed the change in their practice to a change in the type of the disease." The change, however, was not one of type, but of disease. In the next chapter it will be shown that even relapsmg fever is best treated without bleeding. In typhus, prostration is one of the chief dangers to be apprehended, and this will certainly be hastened and aggravated by the loss of even a small quantity of blood, while the greatest depletion has never succeeded in arresting the disease. That headache and other distressing symptoms may sometimes be alleviated by bloodletting there can be no doubt ; but the powers of the sj'stem must not be lowered for such an object. Even local depletion is never per- missible, except for the relief of distressing symptoms hereafter mentioned. 2. TJie Cold Water Treatment. Towards the end of last century (1787), cold affusion was proposed by Dr. Currie p of Liverpool both for arrestmg and mitigating continued fever. The patient was seated naked in an empty tub or bath, and several buckets of water of a temperature of 40° to 50° Fahr. were poured from a height of one to three feet, or more, over the head and chest. He was then hastily dried and restored to bed, and in most cases the operation was repeated once or twice daily. It was stated, that m man}- cases, if resorted to during the first three days, this treatment arrested the disease, while in others it reduced the pulse and temperature, relieved " See Historical Account. " Mcrchisox, 1S5S, No. 2. p CrEEiE, 1797. In the seventeenth century, the brothers Hahn of Leipzig treated fevers by the external use of cold water. TEEATMENT. 28 1 many of the distressing symptoms, and particularly tlie head- ache, restlessness, and delirium, and conducted the disease to a safer and speedier issue. The affusions were employed at any stage of the fever ; but the effects were always most salutary at an early stage. They were said to be contra-indicated when the temperature of the skin, ascertained by the thermometer, was not much above the normal standard, or when, notwith- standing an elevation of temperature, the patient complained of chilliness, or suffered from severe diarrhoea or profuse sweating. The wonderful results obtained by Currie were con- firmed by numerous observers in different parts of the world, whose testimony is recorded in the thh'd edition of his work, published in 1805. But in the British epidemic of 18 17-19 the practice was followed by many with great perseverance, and the general result, according to Sir Eobert Christison, was that in very few cases, if any, was the disease arrested by it ; that although an abatement of febrile heat and restlessness occm-red almost invariably, it w^as of short duration, and not to be made permanent by any frequency of repetition ; that as much good eventually was attained by frequent cold or tepid sponging together with cold applied to the head ; and that often the cold affusion occasioned, for a short time after each application, an intense feeling of pressure and weighty pain in the brain, which could not be regarded without some uneasiness.*! These state- ments, backed by professional and popular X3rejudice, account perhaps for the subsequent neglect of the cold-water treatment of fevers.'" But the observations which have been made of late years by Brand of Stettin,® Jlirgensen of Leipzig,*^ Liebermeister of Bale," Ziemssen of Erlangen,^ and H. Weber "^ and Wilson Fox "" of London, &c., show that, although the practice may not shorten the fever (see Biag. Y.) and is often inapplicable, yet that, under certain circumstances, it is useful not only for reducing the temperature first of the surface and then of the interior of the body, but for relieving headache and other distressing symp- toms, removing congestion of the kidneys, warding off delhium and coma, and rousing the nervous system in cases of excessive stupor.^ The circumstance perhaps has been too much lost 9 Cheistison, 1840. ' Kotwithstanding, the practice was still commended by different observers. See Eoss, 1820 ; Shith, 1830, p. 400 ; Armitage, 1852 ; Babeallier, 1861, p. 164. » BeAND, 1868. ' JtJEGENSEN, 1868. " LlEBEEMEISTEE, 1 868. " ZlEJISSEN, 187O. '" Brit. Med. Journ. 1867, ii. 183. ^ W. Fox, 1871. y The cold douche was strongly commended by Armitage in 1852, and subse- 282 TYPHUS FEVER. sight of, that cooHiig the body may not influence the conditions, on which the development of heat depends, but with reduced heat it may be assumed that there will be diminished metamor- phosis, to the non-elimination of the products of which many of the dangers of fever are due. In point of fact Schroeder of Dorpat has ascertained that cold baths effect a marked diminution in the excretion of carbonic acid and urea in fever,^ and as this was not attended by any aggravation of the general symptoms, it is fair to attribute it to a retarded metamorphosis of tissue. Statistics have been appealed to, to prove the great success of the cold-water treatment of fevers (particularly of enteric fever) as contrasted with that of the expectant method,^ and although other conditions not stated may have helped to mfluence the result,^ they suffice to show that the practice is not beset with the dangers commonly imagined. But the most conclusive facts in its favour are those observed m certain cases of hyperpyrexia by Dr. Wilson Fox and others, where its em- ployment was followed by recovery from an elevation of tem- perature (iio° Fahr.) which under every other method of treatment has been speedily followed by death. At the same time there are many cases of typhus in which the cold affusion or immersion would be unsuitable or injurious. Niemeyer,'' in whose clinic the hydrotherapeutic treatment of enteric fever was first introduced and carefully observed, states that in- certain cases the bath is followed by protracted exhaustion ending in death, so that he was led to fear that in removing, one danger he had induced another. This exhaustion is no- doubt due to the increased production of heat, which a great, reduction of the temperature of the body entails. The cold water treatment is chiefly adapted to cases in which the tem- perature rises to 104° Fahr. or upwards; and it is contra-indi- cated in aged persons, or when the extremities are cold, although the temperature of the central parts of the body be high ; and it must be employed with caution when there are the signs of ' weakened cardiac action, or of stagnation of blood in the capil- laries, although it may be noted that in one of Dr. Fox's patients,. who was apparently rescued from death, befo;-e the bath the face was cyanotic and the radial pulse imperceptible. quently by Trousseau, as most effectual in rousing the patient from stupor.. (AeMITAGE, 1852, TeOUSSEAU, I861, p. 168.) ' SCHKOEDEE, 1869. " Taking the results of six different observers, the mortality of enteric fever on the cold-water treatment was 57 p. c. (847 cases, 48 deaths). Lancet, 1869,. ii. 439. ■> See Ed. Med. Journ. March 1869, p. 845. "= I'ext Book of Pract. Medicine, Amer. Trans. 1869, ii. 599. TEEATMENT. 283, There are different plans for employing cold in the treatment of pyrexia, such as the cold affusion practised by Currie, packing in a cold wet sheet resorted to by Brand, or immersion in cold baths. The last is the method now most in fashion. The patient, as soon as his temperature reaches 104°, is placed in a bath having a temperature of from 50° to 70° Fahr., or better, as Ziemssen recommends, in one with a temperature of about 10° below that of the body, but which after the patient's immer- sion is gradually cooled down to 68° by adding cold water. He should remain in the bath for half an hour, or until shivering comes on, and all the time he is in the bath his limbs ought to be rubbed by assistants. He is then to be hastily dried and put into a warm bed. For some time after the bath the temperature in the rectum continues to fall as the trunk parts with its heat to the extremities ; but as soon as the temperature in the rectum rises again to 103° or 104°, the patient ought to have another bath. In the early stages of the fever as many as seven or eight ■ baths in the day may be necessary, so that the practice entails a large staff of experienced assistants. [The treatment of the continued fever by cold bathing will be considered more fully under the head of enteric fever. My own experience of it in typhus has been too limited to enable me to draw positive conclusions as to its effects on the rate of mortality, but it is far more efficacious in relieving many of the urgent symptoms, as delirium, sleeplessness, headache, and stupor, than any of the other remedies recommended for these conditions. The opinions of continental physicians who have largely used it, though agreeing in its safety and the relief it gives to the symptoms, are somewhat conflicting as to its in- fluence on the mortality. Dr. Pastan states that in the epidemic at Breslau in 1868-9, of 498 cases treated on the expectant system 82 died, giving a mortality of 16-47 per cent., while of 246 cases treated by baths of 15 minutes duration of a temperature of 66° Fahr. 29 died, giving a mortality of ii-i8 per cent. Dr. Kichter, in his report of the typhus epidemic in Upper Silesia in 1826-^ ('Berlin. Med. Wochen.' 1878), states that this mode of treat- ment promoted euphoria, but exercised no appreciable influence on the mortality. I have only had the opportunity of treating I o cases, 2 of which died, but both were in a hopeless condition when the treatment was begun. One was a man admitted into the London Fever Hospital on the sixth day in a state of ex- treme prostration, with his fauces and soft palate covered with 284 TYPHUS FEVER. a diplitheritic membrane ; but for the presence of a characteristic typhus rash, the case would have been regarded as mahgnant diphtheria. The other case was that of a woman aged fifty-two, admitted on the ninth day, also completely prostrated, and who died on the eleventh day. She only had two baths. The other cases recovered. The largest number of baths given was twenty- two. The object of the treatment being to keep the temperature at a moderate level throughout the whole course of the fever, its good effects can only be expected when it has been applied from the commencement and steadily persevered with. As adjuncts occasional full doses of quinine or salicylate of soda may be ad- ministered, and also digitalis. Under ordinary circumstances I prefer baths of a temperature of 70° Fahr., of 1 5 minutes duration.] When cold affusion or immersion is contra-indicated or in- expedient, frequent sponging of the surface with cold or tepid water will hel^^ to cool the body, and is often a source of much comfort to the patient ; in all cases especial care must be taken that the genitals are frequently sponged and kept clean. Iced drinks will also contribute to cooling of the body. [Case XXXIII. — Typhus. — Early Delirium and Prostration. — Treatment hy Tepid Baths. — Becovery. E.G.; female; 34. Nurse at a workhouse ; admitted into London Fever Hospital September 16, 1881. Was taken ill on September 14 with severe headache, epigastric pain, and feelings of great debility. The next day she had to take to her bed. The following day she was pronomiced to have scarlet fever, and sent to the Fever Hospital with a certificate to that effect. State on admission. — A moderately stout, rather flabby woman, with a heavy confused aspect, flushed face, and great febrile oppres- sion. She complained of severe headache and pains in the back and epigastrium, and was very prostrate. Pulse no; very weak. Tongue coated, not red ; no sore throat. There was a rash present on the trunk and limbs, consisting of irregular pinkish spots in parts running together, and fading on pressure ; this during the next two days became converted into a well-marked dusky livid typhus rash. Towards even- ing she became very delirious and noisy, trying to get out of bed. She was ordered a bath at 70°, to be repeated whenever the tem- perature exceeded 102° in the axilla ; six ounces of brandy daily, and tinct. opii n^xx. She had one bath during the night, and three the next day. The baths had the effect of quieting the delirium and inducing sleep. The accompanying diagram shows the range of temperature, and the number of the baths : — f\ /f / / / / / / D 6 ? , / / / o i /? j^ n R r A /\ / \ \ / \ / \ / \ / * / \ / \ / \ / / \/ \ / \ / \ d V \ 0. / \ / \/ \ /S/ P Q CJ'\ J/ V \ / \ r \ O \/ \ _ y \ !/ \ /^\( \ CI \ \ \ \ 1. ^Sy^ 1 IX x^^ XVT XVII WestNev. cm-a-n. &. C!?Jilli-. 106° 105° 104.° 103° S 102° ! 1 101° 100° B f 1 1- -^ -^ B ?■ B — -4- 9 ^ If -^r jf - — t B- ■ 8 —\e- / — Pi ^ f 1 l\ — 1 — /- f — H — f- /- \ L — 14 — — i- . ....../ 1 \ — h 1 — j- / i_ H B m * — p~* n n 8- i H * h k ^-^ r h H h h UJ 99° Tu»ptr-a.t. y ofBody ) 98° 97° Ill w - V H vr VI] 1 VIII - IX X XI XII XIII xrv^ XV — v^ w XVI m XWI BIAGRAM VIII.A.'Tfn./,.raia,v n, Typhus, Trea,iment by T.pU baths. CaseXXXlU. TKEATMENT. 285 18. Pulse no ; delirious during a great part of the day. 19. Pulse 112; seems more prostrate, delirious at times; brandy increased to eight ounces. 20. Less delirious, and slept better, but is more prostrate. Pulse 112 ; brandy ten ounces. 21. Pulse 128; respiration 28; tongue getting dry; delirious at times. 22'. Pulse 130 ; was delirious and restless in the night ; this morn- ing is sensible ; tongue brown and dry. 23. Pulse 136; respiration 30; tongue brown and dry; tendency to stupor. 24. Pulse 136 ; respiration 28 ; restless and delirious in the night. Urine had to be drawn off ; is highly albuminous. 25. Can with difficulty be roused to put out her tongue. Pulse 136. 26. Pulse 140; a black patch has appeared on left buttock; is very prostrate ; urine has to be drawn off. 27. Pulse 130; condition somewhat improved; has passed water ; mind rambling, but is more conscious, is extremely prostrate. 28. Pulse 131 ; condition much the same ; passes less urine, which continues very albuminous. 29. Pulse 138; aspect much improved ; answers questions intelli- gently, but still rambles. 30. Pulse 112 ; slept well ; no delirium ; is decidedly better. From this time she continued steadily to improve. In the accompanying chart, Diagram VIII. A, the temperatures at intervals of four hours are shown. B. indicates a bath at 70° Fahr. for 15 minutes ; the following temperature was in every case taken half an hour after.] 3. Quinine in large doses. Cinchona was recommended in the treatment of typhus by Dr. Miller of London in lyyo,^ and afterwards by John Clark/ Hildenbrand/ Gerhard,^ &c. Bate- man,'^ however, denounced it as positively hurtful. In 185 1 Dr. Piobert Dundas announced that typhus, like intermittent fever, might be cut short by large doses of quinine. His plan was as follows : — After an emetic, ten grains of quinine were given every two hours until the symptoms subsided, or until deafness and ringing in the ears supervened, when the remedy was discontinued, to be resumed after an interval of twenty- four hours.* This treatment was tried extensively, and very conflicting statements were published respecting it ; J but it is ■^ Obs. on the Dis. of Ot. Britain, 1770. " Claek, 1802. ' HiLDBNBEAND, 181I. » GeEHAKD, 1837. '' BaTEMAN, 1819. ' Dundas, 1851 and 1852. ^ Eeferenees to some of these experiments will be found in the Bibliography. Goolden (Dundas, 1852, No. 2, p. 417), M'Evei's (1852), Hayward (1852), Gee and 286 TYPHUS FEVER. now generally admitted that quinine, however administered, has no power of cutting short an attack of typhus. Dr. Dundas's recommendation was accounted for by his belief that typhus and malarious fevers were the same disease. He maintained that in Brazil, where his experience had been gained, typhus, remittent and intermittent fevers merged insensibly into one another, but he probably committed the common error of mis- taking remittent fever with typhoid symptoms for typhus. As yet, there is no reliable evidence of the occurrence of true typhus in Brazil, and none is to be found in Dr. Dundas's work. I have made many careful observations on the effects of large doses of quinine (lo to 20 grs.) in typhus, and I am bound to .admit that noises in the ears, temporary acceleration and ir- regularity of the respiration, and occasional vomiting are the only disagreeable symptoms which I have known to result. At the same time I have seen no evidence that, at whatever stage it was given, it shortened the course of the disease or diminished its danger. One power it certainly has over typhus in common with other pyrexia. A large dose (15 or 20 grs.) causes within an hour or two a fall of the temperature, and to a less extent of the pulse. I have repeatedly known the temperature reduced in this way three or four degrees. But the effect is transient. Within twelve, or at the utmost eighteen hours, unless the disease has reached its normal limit, the pulse and temperature are as high as before (see Diag. V.), and although the result may be kept up by repeating the dose, I have seen no decided good from such a course, while occasionally delirium and collapse are induced.^' At the same time, from its undoubted power of reducing temperature, one or more large doses of quinine may be useful when the disease is at its crisis, and when the tempera- ture is rising instead of falling. In more than one instance, when given at this stage, I have had reason to think that it was instrumental in saving life.' Edclowes (1853), Fletcher (1853), Fuller {Med. T. and Gaz. 1863, i. 74, and 1865, i. 195) and Barrallier (1861, pp. 153, 258) obtained highly satisfactory results from the use of quinine in typhus and enteric fever. On the other hand, Bennett (1852), Christison (Bennett's Clin. Lcct. 2nd ed. 1858, p. 881), W. Eobertson (Ibid.), Peacock (1856, No. 2), Barclay (1853), Corrigan (1853, p. 78), Haller (1853). Huss (1855, p. 180), and Jacquot (1858, p. 260) came to the conclusion that large doses of quinine never arrested typhus or enteric fever, and often gave rise to alarming symptoms. k For details of some of these experiments, see Eeport of a Committee on the value of quinine in i^yrexia. (Trans, of Clin. Soc. of Loiul. in. p. 201.) 1 ' Warburg's Tincture ' has been strongly recommended in typhus as well as in malarious fevers. This remedy is said to contain aloes, camphor and saffron, with a bitter alkaloid, either bebeerine or quinine. I have tried it in several cases TEEATMENT. 287 4, Cardiac Sedatives. Digitalis, Aconite, and Veratrum viride have an undoubted power in reducing the frequency of the pulse, and to a less extent the temperature, in typhus, enteric, and other fevers. Veratrum is largely used for this purpose in America, and its effect upon the pulse is speedy and most decided. The only objection to its use is its liability to induce nausea and faintness, but these effects soon cease on suspending the drug, and exhibiting a stimulant. Aconite is too much neglected in this country in the treatment of pyrexia, especially that depend- ent on local inflammations ; but digitalis is the remedy of this class of which I have had most exjDerience, and on which I place most reliance in idiopathic fevers. While increasing the force of the cardiac contractions, it diminishes the frequency of the pulse, reduces the temperature, and increases the flow of urine, and it often appears to have a beneficial effect upon the general symptoms. Wunder 11011,"^ Ferber," and other observers ° have strongly recommended digitalis in enteric fever, and maintain that it not only reduces the pulse and temperature, but quiets delirium, and diminishes the severity of the other symptoms. From 15 to 20 minims of the tincture, or from 6 drachms to 3 ounces of the infusion may be given in the twenty- four hours. Dr. Grimshaw ('Dub. Journ. Med. Sc' 1874) and Dr. Macnaghton Jones ('Dub. Journ. Med. Sc' 1875) also strongly recommend the use of digitalis as a cardiac stimulant and anti- pyretic. The latter prefers it to alcohol, and finds it much diminishes the rate of mortality. He gives 20 minims of the tincture or 3 grains of the infusion every four hours. Ergot and Belladonna, from their known power of inducing arterial constriction, might be expected to relieve the local con- gestions so common in continued fevers. Belladonna is said by Dr. J. Harley to have the power of reducing the pulse, moistening the tongue, and ameliorating the general symptoms in j)yrexia. He recommends 15 or 20 minims of the tincture every four hours, or injects beneath the skin p from gL- to -^ gr. of sul^Dhate •of atropia. According to Dr. B. Kelly, belladonna (20-minim doses of the tincture every four hours) reduces the j^yrexia. according to Mr. Warburg's instructions. Half an ounce was given and repeated in three hours, and afterwards one drachm every three hours. Profuse perspiration usually followed the second large dose^ but in no ease did it reduce the pulse or temperature, or shorten the disease. ■" ArcJt,. d. Heilk. 1862, iii. 97 ; and Wunderlich, 1871, p. 325. " Fekbee, 1864. ° Thomas, Arch. cl. Heilk. 1865, vi. 329 ; Hankel, Arch. d. Hcilk. Ap. 1869. '' The. Old Vegetable Neurotics, 1869, p. 247. 288 TYPHUS FEVEK. delirmm, and congestions of enteric fever, so as to be almost a specific.^ Antimony reduces the frequency of the pulse in pyrexia, and at one time was largely used in typhus and other fevers ; but the fact of its weakening the contracting power of the heart is a contra-indication to its use in typhus. It is now rarely used in fevers, except in the form of ' Graves's Mixture ' for procuring sleep. Certainly no practitioner of the present day would think of prescribing it in typhus, to the extent of 6 or 8 grains in the twenty-four hours, according to the contra- stimulant method of Easori.^ 5. Certain hygienic measures may contribute to keep the patient cool. He ought to be on a hair-mattress, or spring-bed, with a moderate amount of bed-clothes ; and the temperature of the surrounding atmosphere ought not to exceed 60° Fahr. It is a subject for inquiry how far the body might not be advantageously cooled by placing the patient in an atmosphere of a still lower temperature without draughts, instead of im- mersing him in cold baths. IV. Sustain the Vital Poivers hy ajjj^rojniate food and stimtdants,- hut in doing so avoid exciting congestion, or increasing the icork of the already overtasked glandidar organs. I . Diet. One of the many evils which sprang from the notion that the symptoms of typhus were due to cerebral inflammation was a starving system of treatment. No one helped to over- throw this system more than the late Dr. Graves. ' If,' said he, ' you are at a loss for an epitaph to be placed on my tomb, here is one for you : " He fed fevers." ' So far from delirium and other cerebral symptoms in typhus contra-indicating food, these symptoms may result from starvation.^ Nourishment must be pressed on the patient, even if he seem to have little or no inclination for it ; the patient himself is not in a state to decide what is best for him. But, inasmuch as the digestive powers are impaired, care and judgment are required in the selection and administration of food. After the fourth day of the fever, nourishment ought to be given often at fixed intervals — every three hours or every hour. If tlie patient remain long in a state of stupor, he ought to be roused to take food and stimu- lants ; but if, after much restlessness, he falls into a quiet sleep, he ought not to be aroused simply because the hour for food 1 Med. T.ancl Gaz. 1870, i. 146. ■■ Rasobi, 1S13, pp. 25, 37. • GiJAVHS, 1S48, i. 119. TREATMENT. 289 lias come round. The tendency of modern practice in England, in my opinion, is not to starve fevers, but to overfeed them. Injury, I believe, is often inflicted by forcing food upon the patient every half or quarter of an hour, or oftener. The patient is not permitted to have a moment's peace, while the food is not assimilated.* At the same time, when the patient clenches his teeth and absolutely refuses all food, or appears unable to swallow it, life may sometimes be saved by pouring liquid nourishment into the stomach by a long tube passed through the nares ; '^ or by enemata of brandy with milk or beef-tea. The food ought to be both nutritious and digestible, and may consist of such articles as the following : milk, eggs, beef-tea, veal- or chicken-broth, to which may be added vermi- celli or arrowroot, meat-essences,^ meat-jellies, custard, bread and milk, arrowroot, sago, tea or coffee diluted freely with milk, &c. In all fevers a large quantity of farinaceous food will probably be undigested, owing to the diminution of the salivary and pancreatic secretions. Of all these forms of nourishment I agree with Dr. W. T. Gairdner ^ in thinking that milk is the best. I have for many years been in the habit of giving it in preference to beef-tea. Parkes "^ also has recently shown that there are theoretical objections to a purely nitrogenous diet in fevers. It is doubtful if the disintegrating nitrogenous tissues can be fed ; and if this be so, albuminous food must be disposed of by the already overtasked glandular organs. For these reasons Parkes suggests an oleaginous diet in fevers. I have not as a rule found milk disagree with the acid treatment ; milk is coagulated by the acid of the healthy stomach. 2. Alcoholic Stimulants. . Most physicians of the last century recommended alcoholic stimulants in the treatment of typhus, and some prescribed them in large quantities.^ During the reign of blood-letting, extending over the first quarter of the present century, they were seldom and sparingly employed, but for the last forty years, mainly through the teaching of Alison, Graves, Stokes, and Todd, they have again come to be an * On this see Cokrigan, 1853, p. 24 ; and Gull, Med. Times and Gaz. August 20, 1864. " See Glasg. Med. Journ. Nov. 1869. " For example, the ' Essence of Beef ' prepared by Brand of Little Stanhope Street, the ' Preserved Meat Juice ' of Messrs. Gillon of Leith, and Liebig's ' Extract of Beef.' According to Sir K. Christison, Gillon's meat-juice differs from ordinary beef-tea in consisting principally of osmazome, with the salts and sapid principles of meat, and -it not only acts as a nutrient, but diminishes the waste of the tissues. {Edinb. Monthly Journ. Med. Sc. Jan. 1855.) " Gaihdnek, 1865, No. 2. " Parkes, 187 i, p. 530. ^ See p. 36. U 290 TYPHUS FEVER. important part of the treatment by most practitioners. Of late years there has, in my opinion, been a tendency to order them too frequently and in too large quantities, the mere existence of pyrexia being often regarded as an indication for their use, while it has been not uncommon for 18, 24, or even upwards of 36 ounces of brandy to be poured into the patient in the course of 24 hours. This practice is mainly founded on the view that alcohol is an article of food, which can prevent the strength from failing and the body from emaciating ; and there is still much difference of opinion as to whether its action in fevers is to be regarded in this light, or in that of a medicinal stimulant. On the one hand, it is contended that alcohol undergoes chemical trans- formation in the system, and contributes to nutrition and the maintenance of animal heat ; that it directly nourishes and preserves nerve-tissue ; that when large quantities in divided doses are given it cannot be smelt in the breath ; and that in acute diseases it is capable of sustaining life without the help of any other food.^ On the other hand, it is argued that it is not transformed in the body, but that it is eliminated michanged with the various excretions, and that consequently it acts not as a food, but as a medicine.^ In the present state of our knowledge it would be unprofitable here to enter into a discus- sion as to which of these two views is the more probable. My own opinion, founded on considerable experience of its use in fever, is that alcohol acts as a medicine rather than as food — more allied in its action to opium and quinine, than to milk and beef-tea. Fourteen years ago I employed brandy very largely from the commencement of a number of cases of enteric fever, the symptoms of which were noted with great care, and on comparing the results with those of my present practice, I am satisfied that the brandy did not prevent emaciation or failure of the muscular strength ; the prostration was as early, and the emaciation as great, with the brandy as without it. More recent observations make it very doubtful if alcohol has the power commonly attributed to it of saving the nitrogenous tissues fi-om disintegration,^ but there can be little doubt that it can increase the force of the heart, promote the capillary circulation, and thus in many cases help to remove delirium depending upon ^ Todd, i860, p. 459 ; also Anstie On Stimulants and Narcotics, 1864 ; Lond. Med. Rev. 1862 ; Lancet, 1867, ii. 385; The Practitioner, 1872. » E. S^nxH, Brit. Med. Journ. Nov. 1861 ; Trans. Med. Soc. Lond. Jan. 14, 1861 ; and Journ. Soc. of Arts, Jan. 18, 1861. * Paekes, 187 1, p. 527. TEEATMENT. 29 1 impaired cerebral nutrition. Hence, as Stokes long ago pointed out,'' the phenomena of the radial pulse and of the heart are the grand criteria for guiding us in the administration of alcohol in fever. When they flag, alcohol is our best and surest remedy ; but when they show no tendency to fail in strength, alcohol is unnecessary and may be injurious. Moreover, it must be re- membered that, as in the case of other medicines, alcohol in over-doses is a poison. It deranges nutrition, lessens the secre- tions, diminishes the amount of urinary water, and impedes the elimination of urea and carbonic acid ; it is also apt to induce a state of coma, indistinguishable from that of the disease, and which, when added to that of the disease, must increase greatly the dangers and difficulties of the case. While it has been shown by statistical data that the systematic treatment of fevers with large quantities of alcohol is not re- markable for its success,"^ there is abundant evidence that typhus may be treated successfully with little or no alcohol.'' The chief advocates of an alcoholic treatment of fever have rarely watched the progress of typhus treated without alcohol. Six years ago I made the following experiment at the London Fever Hospital. All typhus patients over twenty-five years of age who were ad- mitted on alternate days had from 4 to 12 ounces of brandy, while those admitted on the intervening days had milk and beef- tea without any alcohol. The results were almost identical, and although the experiment was not continued sufficiently long to make them of much value, they satisfied me that good effects are often ascribed to alcohol in typhus which are not fairly due to it. At the same time, I am no advocate for the plan of treat- ing typhus without alcohol. While believing that its ordinary employment as food in fever is a dangerous practice, I am certain that many cases are benefited by its occasional use as a stimu- lant. My experience leads me to suggest the following rules for the guidance of others in its employment. a. Patients under twenty years of age do best as a rule with- out any alcohol. b. Most patients over forty are benefited by alcohol from the commencement of the second week of the illness or earlier. c. Persons of intemperate habits require alcohol earlier and in greater quantity than others. d. In individual cases, the chief indication for the use of <= Stokes, 1839. '' Brit, and For. Med. Chir. Rev. Oct. i860 ; and Lancet, Nov. i860. "= Gaikdnek, 1865, Nos. I and 2, and 1868 ; J. B. Eussell, 1867. -a 2 292 TYPHUS FEVER. alcohol is derived from the state of the pulse and heart. A soft compressible pulse, and still more an undulating, irregular or intermitting pulse, or even an abnormally slow pulse (40 to 60), are stronger indications for stimulants than mere rapidity, and so also is a weakened impulse of the heart, or an impaired or absent first sound. If stimulants quicken the pulse, they are contra-indicated; if the pulse is made slower they may be expected to do good. e. The darker and more copious the eruption, the more is alcohol demanded. /. A burning dry skin is in itself an indication against alcohol ; whereas profuse perspiration, wdth no contemporaneous improvement in the general symptoms, calls for an increased supply. Coldness of the extremities is an indication for alcohol, especially when at the same time the temperature of the trunk is considerably elevated. f/. A dry, brown tongue is an indication for stimulants ; if under their use the tongue becomes clean and moist at the edges, it may be inferred that they are doing good. }i. Delirium must not be regarded as of necessity calling for the use of alcohol. The propriety of giving alcohol in delirium depends on the state of the pulse. If the patient becomes more restless and delirious under its use, it is probably doing harm ; if more tranquil, it is doing good. i. Alcohol, as a rule, is contra-indicated, if there be severe darting or throbbing headache, or acute noisy delirium, espe- cially when these symptoms co-exist with great heat and dryness of the skin, flushing of the face, suffusion of the eyes, and little or no impairment of the cardiac and radial pulse. Wlien alcohol is given under such circumstances, it should be restricted to the intervals of the paroxysms of delirium. h. The more the typhoid state {i.e. stupor, low delirium, tremor, subsultus, involuntary evacuations, &c.) is developed, the more will alcohol be demanded. I. Scanty urine of low specific gravity, containing little urea or much albumen, and suppression of urine are in themselves indications against the use of alcohol. m. The presence of complications, as a rule, increases the necessity for stimulants. Port, sherry, brandy, gin, and whisky are the forms in which alcohol is best given; but when a weaker stimulus is wanted, claret answers well. Malt liquors are best adapted for convalescence. Spirits contain from 50 to 60 per cent, of TREATMENT. 293 alcohol; sherry and port, from 17 to 24 per cent.; and good porter and ales from 6 to 8 per cent. Although some prac- titioners prefer wine to spirits, it is not certain that the former possess any advantages, apart from the alcohol which they contain. Spirits ought to be given diluted in cold water or milk ; but where there is great prostration, and especially where the skin is cold and covered with perspiration, the best stimu- lant is hot brandy or whisky-punch, or wine-whey. Stimulants ought to be given in divided doses frequently repeated. In urgent cases, the dose may be repeated every hour, and, as a rule, a larger quantity will be required during the night and towards morning than in the day-time, for it is usually m the early morning that the vital powers are at the lowest ebb. Many patients are lost from negligence of their attendants at this time. It is impossible to give any positive instructions as to the quantity of wine or spirits required in each case. It is very rarely necessary to give more than eight ounces of brandy at any period of the fever. Occasionally this allowance may be ex- ceeded, but from my own experience I am inclined to think that the cases must be very exceptional where it is advisable to give more than 12 ounces, or half an ounce every hour. If, not- withstanding this amount, the patient die, it is doubtful if any amount of brandy would have saved him ; and a larger amount would probably only have contributed to the fatal event. As soon as the symptoms for which alcohol is given begin to recede, the quantity ought to be reduced and smaller doses ordered at longer intervals. 3. Medicinal Stimulants and Tonics. In cases of great pros- tration, it is well to combine other stimulants with the wine or spirits. Those chiefly recommended for the purpose are carbo- nate of ammonia, the different ethers, camphor, and musk. Of these the carbonate of ammonia is the most commonly em- ployed ; and it is often prescribed through the whole course of the fever. Although ammonia is unquestionably a powerful stimulant, my experience of it in typhus has not been favour- able ; and if typhus may be simulated by a super-ammoniacal condition of the blood (see p. 144), the propriety of giving am- monia as a medicine is doubtful. Moreover, I can confirm the statements made by Drs. Kennedy,^ Joseph BeB,^ and Lyons,^' that in repeated doses it is apt to irritate the bowels and produce diarrhoea. For these reasons, I prefer the different ' H. Kennedy, i860, p. 227. s j. Bell, i860. •> Lyons, 1861, p. 211. 294 TYIHUS FEVER. ethers, ten to thirty minrnis of which may be added to each dose of the acid mixture. With these remedies it may be advan- tageous to combine bark or quinine in some such prescriptions as the following : R Acid. Hydrochlor. dil, ir|xx. Sp. Aetli. Nit. nxxv. Spirit. Chloroform. ni.xx. Tinct. Cinchon. Co. 5ss. Aq. Cinnam. ad ^jss. Ft. liaust. 3a qq. lior. sum. Or:— R Quin. Sulph. gr. ij. Acid. Sulph. Arom. nxxx. Aetheris ti|^xx. Syrup. Aurant. 5ss. Aq. ad fjss. Ft. haust. 3a qq. lior. sum. Musk and camphor are stimulants which, under circum- stances to be referred to presently, are of service. In cases of extreme prostration Zuelzer has obtained good results from injecting diffusible stimulants, such as 30 to 40 drops of the spirit of sulphuric ether, beneath the skm.^ 4. Steps must be taken to prevent the patient exhausting his muscular and nervous poiver. As soon as the disease has declared itself he must be put to bed, and every exertion of mind or body regarded as a drain upon his strength. Patients who struggle against the disease at the commencement usually suffer from great prostration afterwards. After the first week in severe cases, they ought to be provided with a bed-pan, and on no ac- count get out of bed ; and, except in extreme cases, mechanical restraint should be avoided in acute delirium. The feeling of restraint often increases the patient's efforts to get loose, while his fruitless efforts augment the muscular debility and add to his mental sufferings. Kind words and firmness will often avail more than physical force. In rare cases, however, it will be necessary to prevent the patient leaving his bed by folded sheets fastened to the bed on either side, and passed over the chest and extremities. V. Relieve Distressing Symptoms. I. Headache is often the first source of distress to the patient. It is sometimes relieved by an emetic, or by an action of the bowels, or, failing these, by evaporating lotions applied to the forehead. Wlien very severe and associated with flushing of the face and redness of the conjunctivae, the hair ought to be cut, or the head shaved, and a bladder of ice tied over the scalp, or recourse must be had to the cold affusion, which may be ad- ministered in the manner already described (p. 281), or by ' Berlin, klin. Wochenschrift, 1871. TEEATMENT. 295 simply placing the patient's head over a basin at the edge of the bed, and pouring cold water (40° to 50° Fahr.) on it, from a height of two or three feet. The relief thus obtained is often immediate and complete ; if the headache returns, the affusion must be repeated. When these measures fail, a blister or sina- pism to the forehead or nape will sometimes do good. In aged and infirm patients of feeble cu-culation, caution must be exer- cised in applying cold to the head, which has often too depressing an effect, and it will be better to try the effect of warm fomenta- tion. A double fold of lint, moistened in warm water and vinegar, is to be laid over the scalp and covered with oiled silk, the application being renewed every three or four hours. Graves strongly recommends warm fomentations as the best and most efficacious application for the ordmary headache of fever.J Lastly, in cases of intense headache, when the patient is young and robust, three or four leeches ajjplied to the temples do no harm, and often give complete and permanent relief.'' 2. Sleeplessness, Nervous Excitement, and Delirium are among the most important symptoms that require treatment. Sleeplessness is often complained of from an early stage of the disease, and, if not relieved, greatly exhausts the patient, and is apt to be followed by much delirium. The practitioner cannot be too forcibly impressed with the fact, that loss of sleep, at any stage of typhus, if it continue for two or three nights, is of itself sufficient to kill ; and that even the shortest sleep is an advantage to the patient. At the same time, it must be borne in mind that sleeplessness, as well as the other cerebral symptoms of typhus, is independent of inflammation of the brain, or of its membranes, and is not to be combated by antijDhlogistic treatment. The proper treatment for sleeplessness varies with the stage of the disease and the nature of the other symptoms. In every case the practitioner should satisfy himself that the symptom really exists. (See p. 164.) When sleeplessness occurs during the first week of the disease, it is usually accompanied by headache ; and the J Graves, 1848, i. 163. ^ Two remedies have been recommended by Barrallier for the headache of typhus : quinine in large doses, and the muriate of ammonia (Bakkallieb, i86i, pp. 153, 288). After an emetic, he orders 2^ or 5 grains of quinine to be given every quarter or half an hour, until 1-5 or 30 grains have been taken ; and if this fail, he gives 46 grains of muriate of ammonia, in three or four doses, at intervals of half an hour, dissolved in water with a little syrup of orange. I have tried Barrallier's treatment in several cases without ever observing the slightest benefit. In estimating the effects of remedies on the headache of tyi^hus, its natural abate- ment or cessation about the eighth day must be borne in mind. 296 TYPHUS FEVER. measures recommended for the relief of the latter symptom often suffice to procure sleep. If they fail, and the patient has slept little or none for thirty-six hours, recourse should be had to opiates. Fifteen minims of Battley's Solution, or 30 minims of the solutions of the muriate or acetate of morphia, or 5 grains of the compound soap pill, may be given at night ; followed in two hours by half the dose, if the patient does not sleep. If there be great headache, a dry, hot skin, and a pulse of good strength, the opiate will be advantageously combined with digitalis or antimony, in the manner stated below. When opium fails, or is for any reason contra-indicated, recourse may be had to the hydrate of chloral ; but as a rule at this early stage, when the patient is in much pain, opium is preferable as being more certain in its action. When delirium and other cerebral symptoms are associated with sleeplessness, sleep will often be secured by a proper man- agement of the sick-room. Bright light is to be excluded from the patient's eyes ; but his room ought not to be too much darkened during the day ; the proper alternation of day and night conduces to sleep.' In private practice sleep is sometimes favoured by having two beds in the room, and changing the patient from one to the other. The room is to be kept well- ventilated and perfectly quiet, and the patient must not be too often disturbed for the sake of giving nourishment. All neces- sary communications are to be made in a clear and distinct voice, for nothing annoys or excites sensitive patients more than to hear whispering in the room. If the hearing be very sensitive, which is rarely the case, the patient's ears may be stuffed with cotton-wool, as suggested by Sir D. Corrigan. The patient ought not to be contradicted in his delirium ; to do so, or to attempt to reason with him, only increases his excitement. Every effort also should be made to cheer him and prevent him desponding. In the slighter forms of delirium no further interference is ne- cessary ; but when sleeplessness co-exists with much delirium, recourse must be had to other measures, which must vary according to the state of the circulation, and as the patient's condition approaches more to delirium ferox on the one hand, or to typhomania or delirium tremens on the other. (See p. 160.) In the former case, when the patient is young and robust, and the cardiac and radial pulses are of good strength, much benefit will often be derived from the cold affusion or ice-cap to ' The mischief resulting from the injudicious exclusion of light has been strongly- insisted on by Cullen, Corrigan, and Hudson. (See Hudson, 1S67, p. 113.) TREATMENT. 29/ the shaven scalp, or from the frequent use of the ether-spray all over the head for four or five mmutes at a time, from clearing out the bowels, and, in persons who are very plethoric, from the application of from two to six leeches to the temples. A nurse ought to be in constant attendance, to prevent the patient getting up and doing himself injury. But in most cases some drug will be necessary to secure sleep, and the one which of all others is the most safe and certain is the hydrate of chloral,"^ which may be prescribed as follows for an adult : — Bo Chloral Hydrat. gr. xx. Syrup. Aurant. 3j. Aq. Mentb. Pip. This draught will often act like a charm, the patient falling at once into a quiet and natural sleep. But sometimes it fails, or even, like an insufficient dose of chloroform, renders the patient more excited ; and then the dose must be repeated after an interval of two hours. More than two doses are rarely necessary. In some patients, however, the chloral, even when repeated, does not succeed ; and then recourse must be had to opium or morphia in combination with digitalis, or with anti- mony as recommended by Graves." The following prescription may be ordered : — R Liq. Op. Sed. 3j. Tinct. Digit. 5j. Sp. Aeth. Nit. 5ij. Aq. Camph. ad §vj. M. Sumat cocli. mag. ij. statim, et cocli. mag. j. 2a qq. hora usque ad sommim. Graves's prescription is as follows : — R Tinct. Opii 5j. Ant. Tart. gr. iv. Aq. Camph. ^viij. M. Sumat cocli. mag. j. 2a qq. liora usque ad somnum. The opium in these prescriptions is assisted in its action by the sedative influence on the circulation exercised by the digitalis and antimony, which at the same time overcome one of the main objections to opium — that it tends to lock up the secretions. There can be no doubt that by these combinations sleep will often be induced when opium alone, even in larger doses, would fail, but for reasons already stated (p. 287), and also from the circumstance that it increases elimination by the kidneys rather than by the skin, digitalis appears to me to be preferable to antimony. Bromide of potassium, in drachm doses repeated every two hours, will sometiriies induce sleep in this form of delirium; when the patient is very violent, it may be advan- See also J. B. Eussell, 1870. " Gravks, 1836 and 1848, 1. 207 298 TYPHUS FEVER. tageously combined with opiates." In obstinate cases, the action of these remedies appears to be sometimes assisted by the apph- cation of blistering fluid to the forehead. When with sleeplessness the delirium approaches to typho- mania or delirium tremens, the case becomes one of the most difficult which a medical man is called upon to treat. If the patient get no sleep, his general condition will certainly become worse ; while, on the other hand, there is danger lest the means adopted to procure sleep still further weaken the cardiac con- tractions, or interfere with elimination. The hydrate of chloral is perhaps the most generally useful remedy in such cases, but it must not be given indiscriminately. It possesses this great advantage over opium that it does not impede the depuration of the blood. Its hypnotic properties are believed to be due to the liberation of chloroform in consequence of the chloral being de- composed by the alkalies of the blood, and this decomposition is all the more likely to be effected when the alkalinity of the blood is increased as in typhus. It is also much more rapid in its action than opium ; the pupils are contracted during the chloral- sleep, but dilate as soon as the patient awakes, which is not the case in the narcosis of opium ; and lastly, there is no difficulty in rousing the patient out of the chloral-sleep, as there is from the sleep of opium. Still, when it is remembered that an over- dose of chloral may produce alarming depression and irregularity of the heart's action, it must be given cautiously, if at all, when there are any of the signs of acute softening of the heart already described (pp. 141, 200). Under these circumstances I have certainly seen bad effects from its use, and with certain restric- tions I prefer resorting to opium in conjunction with diuretics and stimulants.P Twenty minims of sulphuric ether may be added to each dose of the digitalis and opium draught already recommended, or a pill with opium (gr. ^) and camphor (gr. iij) may be given every two or three hours until sleep is induced. Barrallier has found Scotch paregoric, or the Tinctura opii ammoniata very useful in these cases. According to Baron " See Amcr. Joiirn. of Med. Sc. 1869, Iviii. 43. p Graves recommended antimony and opium even in cases of this nature, and in fact wherever sleeplessness and delirium of any form co-existed in typhus ; but the circumstances in which I have found the combination most useful are those above indicated ; and antimony is obviously contra-indicated in asthenic delirium with a weakened heart. Other writers have recommended large and repeated doses of alcohol for all forms of delirium in typhus. The distinction which I have drawn has however been recognised by almost all recent observers of the disease on an extensive scale ; and among others by Dr. Clifford AUbutt, who has favoured me with the result of his large experience at Leeds in 1865-6. TEEATMENT. 299 Dupuytren and Graves,'! opiate enemata will sometimes produce sleep after opiates have been given in vain in large and repeated doses by the mouth, and on several occasions I have made a similar observation in typhus. The action of these remedies will be assisted by stimulants in accordance with the instructions already laid down, by warm fomentation or sponging of the scalp and of the legs and feet, and by the affusion of tepid water on the head. But opium in any form is contra-indicated : a, when there is evidence of extensive pulmonary engorgement ; h, when the pupil is persistently contracted ; ^ c, when the urine has become very scanty, or contains blood or much albumen ; and d, when the patient, although sleepless, is in a profound typhoid condition, and quite unconscious. Other sedatives have been recommended for the delirium and sleeplessness of typhus, some of which may be useful when the hydrate of chloral and opium are contra-indicated. These are belladonna, henbane, Indian hemp, chloroform, bromide of potassium, musk and camphor. Many years ago Graves proposed the use of belladonna as a sedative and hypnotic in cases of typhus where opium was con- tra-indicated, inferring from its action on the pupil that it was less likely than opium to aggravate the injurious effects of the typhus-poison upon the brain ;^ and this inference has been strengthened by the more recent observations of Mr. Benjamin Bell on the antagonistic therapeutic effects of atropia and mor- phia,* and of Dr. John Harley, according to whom belladonna is a direct stimulant of the heart, and a powerful diuretic." I can confirm Graves's observation as to the occasional utility of belladonna in such cases. It may be prescribed as follows : — R Tinct. Belladon. 5jss. Sp. Aeth. 3iij. Syrup. Zingib. gvj. Aq. ad §YJ. M. Sumat part, sext, 3a qq. hora. Or:— R Ext. Bellad. gr. j. Ext. Hyoscy. gr. iv. Pil. Hydrarg. gr. viij. M. Div. in pil. iv. Sumat j. 3a qq. hora. Henbane is similar in its action to belladonna, but is less reliable, and, to be of any use, must be given in large doses. Graves, 1848, ii. 529. '■ Dr. Hudson does not consider a contracted pupil and injected conjunctiva in themselves contra-indications of opium, provided there be a copious flow of urine and no stuj)or. (Hudson, 1867, p. 240.) ' Geaves, 1838. ' Eclin. Med. Jouru. July 1858, iv. i. " Brit. Med. Journ. Ap. 4, 1868. 300 TYPHUS FEVEE. Two drachms of tlie tincture may be given at once, and one drachm repeated every third hour. Cannabis Indica sometimes acts well when opium is contra- indicated, although, like henbane, it is uncertain in its result. One grain of the extract, or twenty minims of the tincture, may be given for a dose, and repeated if necessary. Chloroform, in half-drachm doses every 2 hours, has been re- commended by Sir D. Corrigan and Dr. Gordon as an occasional substitute for opium in cases of typhus and delirium tremens, where sleeplessness is combined with great restlessness, nervous agitation, and delirium.^ It is contra-indicated, however, by the same circumstances as chloral, whose mode of action is similar if not identical. Chloroform -inhalation Corrigan found to be useless in procming sleep, and not free from danger, but Hudson has occasionally found it effectual after opium has failed.^' Bromide of potassium I have not found to be of any use in sleeplessness with low muttering delirium. Musk and camphor have fallen into neglect of late years, perhaps owing to the expense of the one, and to the fact of the other not being prescribed in sufficiently large doses. They have been recommended as remedies of great value when there is nervous excitement with great debility, low muttering delkium, tremors, subsultus, carphology, feeble pulse, and inaudible first sound of the heart. Although I have occasionally had reason to attribute good results to these remedies, my experience of them has not justified the expectations which I was led to entertain by the statements of other observers. Gerhard tehs us that he found camphor one of the most useful and powerful remedies in the Philadelphia epidemic of typhus in 1836. He gave it in emulsion in doses of five grains every two hours, and in enema in doses of a scruple. ' The immediate effect was the lessening of the subsultus and tremors, and sometimes the diminution of delirium. In some cases, we possessed a complete control over the subsultus, which was immediately checked by a camphor injection.' "^^ Huss speaks in the highest terms of both musk and camphor, under the circumstances m question. Barrallier also testifies to their great utility in the delirium tremens of typhus.-^' Graves was in the habit of combining musk and camphor with tartar emetic and opium, in cases where there was subsultus in ' Gordon and Corrigan, 1S54. " Hudson, 1867, p. 241. ' Gerhard, 1837, xx. 320. » B.arr.\lliee, 1861, p. 292. TEEATMENT. 3OI addition to the usual symptoms of cerebral excitement. In one case, given in his lectures, where there was likewise complete sleeplessness, he prescribed a draught every two hours, contain- ing half-a-grain of tartar emetic, ten grains of musk, five grains of camphor, and ten drops of laudanum. After taking three doses, the patient fell into a quiet sleep and awoke quite rational.^ 3. Siiqwr. A slight amount of drowsiness is the natural mode of termination of tj^Dhus, and requires no treatment ; but when difficulty is experienced in rousing the patient, there is danger of the stupor passing into profound and fatal coma. As already stated, this stupor is independent of any anatomical lesion of the brain or its membranes, but is probably due to the weakened circulation and the presence in the blood of the products of dismtegrated tissue. Accordingly, the treatment which suggests itself is to promote elimination, more especially by the kidneys, to improve the condition of the blood, to rouse the patient by stimulants applied to the external surface, while at the same time we support the action of the heart. A dangerous degree of stupor is probably often prevented by the early adoption of the general principles of treatment already recommended, which are still api^licable when stupor is present. In this condition, benefit is often derived from a strong infusion of coffee, a small cupful of which may be ordered every three or four hours (see p. 277). At the same time, it is well to employ measures which have a derivant action on the kidneys, such as dry cuppmg and mustard- poultices to the loins, followed by the ' wet compress,'* particu- larly when the presence of albumen or blood in the urine points to a hjrpersemic condition of the kidneys, or when the urine is scanty or suppressed. The bowels are to be opened by a pur- gative or by a cathartic enema, and the action of the skin is to be encouraged by frequent tepid sponging. If the skin be dry, the warm bath, the hot air-bath, or packing in a hot, wet blanket, deserves a trial. An attempt should also be made to rouse the jDatient by stimulants to the external surface. For this purj)ose, blisters to the shaven scalp or forehead are often most efficacious. Painting with acetum cantharidis is much preferable to the ordinary blistering plaster, which takes effect slowly and is aj)t » Graves, 1848, i. 185. ^ Wet compresses are often of great utility in relieving hyijeraemia of the kidneys. Thick flannel folded two or three times is to be wrung out of hot water, passed round the loins, and covered with a piece of mackintosh or oiled cloth, retained in its place by a bandage or towel. 302 TYPHUS FEVER. to be torn off by the patient. The hqnid ought not to be apphed to the occiput, which is subjected to pressure. A piece of Imt saturated Tvith Liquor ammonise fortior, ai^phed to the scalp under oiled silk for live or six minutes, and followed by a bread poultice, blisters rapidly and effectually, without the risk caused by cantharides of h-ritating the kidnej^s. I have known cases of deep coma, where life seemed to be saved by its use. If blisters to the head fail to rouse the patient, sinapisms may be applied to the inside of the thighs, the soles of the feet, or the epigastrium. The cold affusion has been recommended as a stimulant in cases of great stupor, provided there be considerable elevation of temperatm-e. Dr. Armitage ascertained, by careful observation, that the effect of this treatment was to diminish the temperature and the frequency of pulse and respiration and to moisten the tongue, while the stujDor dimmished and sometimes disappeared enth'ely durmg the affusion.^ ' The douche,' says Dr. Todd, ' sometimes acts like a charm ; it is most applicable to cases m which a lethargic state supervenes early, and before there is great exhaustion.' " The action of the heart is to be supported by alcoholic and other stimulants, according to the instructions already laid do'^T:!. In all cases of cerebral oppression, attention must be paid to the state of the bladder. The practitioner must not be satisfied with the nurse's report that the patient has passed water in bed, for a small quantity often dribbles away and makes a great show when the bladder is enormously distended. The h^^Dogastric region must be exammed at least twice daily b}^ manipulation and percussion, and if there be the slightest doubt, the catheter ought to be introduced. Fatal convulsions or protracted cystitis I have known to result from inattention to the state of the bladder.*^ Two other remedies have been recommended for the coma of typhus, viz. : — Valerian and phosphorus. The essential oil of valerian was given by Barraliier in 172 cases of tv^phus, charac- terized by stupor and coma, and its effects are said to have been almost marveUous. ' Des individus plonges dans une profonde somnolence, dont rien ne pouvait les tirer, iuseusibles a tout ce qui se passait autour d'eux, apres avoir pris le matin I'essence ^ Armitage, 1852, p. 55. " Todd, 1S60, p. 160. '' Corrigan relates a case where violent convulsions, followed by coma, resulted from inattention to the bladder in a case of fever under the care of a homceopath. Corrit-'an drew off the urine, and the patient recovered, but suffered from cystitis for more than a year. (Corrigan, 1853, p. 42.) TREATMENT. 303 de valeriane, etaient le soir reveilles, repondaient aiix questions qu'on leur adressait ; et ce cliangement etait si imprevu, si etonnant, que plusieurs fois j'ai entendu les personnes qui suivaient mes visites prononcer le mot de resurrection.' The remedy was successful in 135 of the 172 cases ; unsuccessful in 24; and the results were doubtful in 13. About one minim in a little syrup and water was ordered every half-hour, until five or eight minims had been taken.® My experience does not jus- tify these high encomiums. I have given the Tinctura Valerianae ammoniata, in drachm doses frequently repeated, without any marked result. Phosphorus is highly praised by Huss in cases of extreme torpor and prostration : ' when the patient lies upon his back, quiet, without any delirium, indifferent, and not easily roused ; when the pulse does not exceed 100, and is small and feeble ; when the first sound of the heart, though audible, is feeble and short, and the respiration slow and unimpeded, and when the temperature does not exceed 101° Fahr.' It is given dissolved in almond-oil, in doses of j\ of a grain every two or three hours. ^ 4. When convulsions occur in typhus, treatment is seldom of much avail, but still the case is not altogether hopeless. Dry cupping and sinapisms over the loins, the hot air-bath, or the hot-pack, may be expected to relieve the congestion of the kidneys, while their action is promoted by saline diuretics, nitrous ether and digitalis. At the same time the bowels are to be freely acted upon by a cathartic enema, and by a large dose of calomel or a di'op of croton oil given by the mouth, and the external treatment for rousing the patient out of stupor already spoken of must be enforced. In every case the state of the bladder must be looked to. 5 . HypercBsthesia of the integuments is sometimes relieved by warm fomentation, or by the occasional application under oiled silk of lint saturated with Linimentum belladonnse. If these measures fail, anodynes may be given internally according to the instructions already laid down for procuring sleep. Bar- raUier observed great relief follow the internal administration of chloroform in doses of from 10 to 25 minims every hour for four hours.s 6. For the muscular and neuralgic pains which chiefly occm- during convalescence, recourse must be had to quinme and « Barrallier, 1861, pp. 168, 376. ' Huss, 1855, p. 178. t- Barrallier, iS6i, p. 298. 304 TYPHUS FEVEE. opiates, and anodyne liniments. Barrallier strongly recommends the inhalation of chloroform.'^ 7. Thirst is to be assuaged by cold drinks. "V\Taen insatiable, a weak infusion of some bitter substance such as cascarilla or quassia will often do good. According to Lyons, camphor is often a specific against thirst ; it may be given in the form of camphor water or of Murray's fluid camphor.^ 8. Vomiting at the commencement of typhus is usually checked by an emetic and an aperient. When concm-ring with severe cere- bral symptoms, treatment must be directed against the latter. In the few cases where there is persistent vomiting with much prostration, the acid treatment is to be suspended, and ice, lime water, bismuth, magnesia, or an effervescing mixture substituted ; the bowels are to be cleared out by rhubarb and blue pill ; and sinapisms applied to the epigastrium. 9. Tympanites will usually be relieved by tm-pentine-stupes to the abdomen, or by an enema of turpentine, assafoetida, and rue. If these measures fail, turpentine may be given inter- nally in the manner recommended for pulmonary congestion, or in combination with the tincture of perchloride of iron and minute doses of strychnia. 10. Hiccup, attended by abdominal derangement, is amen- able to the same treatment as tympanites ; but both these symptoms have often a cerebral origin, and must be treated on the same principles as the other cerebral symptoms which they accompany. Sucking small pieces of ice will sometimes relieve the hiccup. 11. Albuminuria (see p. 301). 12. Puhnonari/ congestion is usually associated with more or less bronchitis, but from its frequency must be regarded as a symptom rather than a complication of typhus. It is so often the chief cause of death that in every case with the slightest cough or quickness of breathing, the chest ought to be examined at each visit. Care must be taken not to confound ' cerebral respiration ' with the dyspnoea resulting from pulmonary disease. As soon as any signs of congestion are discovered at the back part of the lungs (see p. 142), mustard poultices or turpentine- stupes are to be applied to the chest once or twice daily, and during the intervals the chest ought to be enveloped in linseed poultices covered with oiled silk, or in a wet compress.-" These applications are preferable to blisters, as their action can be kept *■ Babealliek, 1861, p. 173. ' Lyons, 1861, p. 202. J See p. 301, note TREATMENT. 305 up longer, while blisters to the chest are apt to degenerate into troublesome sores. With this local treatment it will usually be necessary to combine alcoholic stimulants. When, along with congestion of the dependent parts, there is evidence of catarrh of the bronchial tubes throughout the lungs, one or other of the following mixtures will usually act well : — R Ammon. Carb. gr. v. Vin. Ipecac. ni.vj. Syrup. Tolutan. 5j. Aq. ad gjss. M. Ft, haust. 4ta qq. hora sum. Or:— R Amnion. Carb. gr. v. Sp. Aeth. Nit. trixx. Tinct. Scillse ni.x. Mucilag. 5j. Infus. Senegffi ad §jss. M. Ft. haust. 4ta qq. hora sum. When, notwithstanding these measures, the pulmonary con- gestion persists or extends, recourse ought to be had to dry cupping of the chest, and in cases of threatened asphyxia the withdrawal of a few ounces of blood by cupping will sometimes do good, stimulants being given at the same time. In this condition also, the internal administration of turpentine or creasote is often of the greatest service. Huss speaks of turpen- tine for this condition as one of the greatest treasures in modern medicine,'' and certainly its good effects in the bronchitis and j)ulmonary congestion of adynamic fevers are often most decided. It may be given in doses of ten or fifteen minims every three hours in yolk of egg or almond emulsion, or according to the following formula : — R Olei Terebinth, ntx. Spirit. Chloroform. t»txx. Spirit. Aeth. tr^xx. Spirit. Junip. rri.xv. Mucilag. 5j. Aq. Menth. Pip. ad §j. M. Ft. haust. 3a qq. hora sumend. After a few doses of this medicine, the patient often coughs and expectorates viscid mucus, with much relief to the respira- tory symptoms. Creasote seems to act in a similar manner to turpentine, but is less generally useful. One ounce of the Mis- tura creasoti may be given every three or four hours. In ex- treme cases a mustard-emetic sometimes appears to rescue the patient from asphyxia, by promoting free expectoration, and permitting free ingress of air into the bronchial tubes.' •^ Huss, 1855, p. 162 ; see also Ltons, 1861, p. 170. ' Lyons, 1861, p. 169. X 306 TYPHUS FEVER. VI. Counteract Complications and Sequelce. In the treatment of these complications we must be guided by general principles and by the symptoms in the individual case, never forgetting that the primary disease has a tendency to induce great nervous prostration and depression of the heart's action, which forbid all depleting or lowering measures. 1 . Pulmonary complications are the most common, and espe- cially bronchitis. More or less bronchitis is constantly associated with the hypostatic congestion of the lungs which is a constant symptom in bad cases of typhus, and the treatment of which has been already considered. The slighter forms of bronchitis occurring in the early stage of the disease or in convalescence may be treated by poultices to the chest, and five grains of Dover's powder night and morning. The Pilula ipecacuanhae c. scilla, and the Pil. conii comp. are also useful. True pneumonia must be treated by the same measures as pulmon- ary congestion. Occasionally I have seen good effects from the acetate of lead as recommended by Professor Strohl "^ of Strasburg, and the late Dr. Joseph Bell" of Glasgow. Two or three grains, with or without opium according to circum- stances, may be given every four hours. Persistent pneumonia during convalescence is to be treated with blisters and iodine to the chest, and the internal use of iodide of potassium and bark, or of quinine and iron. When pneumonia passes into gangrene, the case is almost hopeless ; but large doses of chlorate of potash and bark, the inhalation of carbolic acid and tar- vapour, and the free use of stimulants and food will occasionally save the patient. When pletirisii occurs, there is always danger of liquid accumulating insidiously in the chest. The proper treatment consists in digitalis and other diuretics, quinine and iron, and blisters and iodine to the chest ; if these measures fail, recourse must be had to paracentesis. 2. Acute oedema of the glottis is always to be dreaded when the voice and cough become husky. The patient must be kept in a warm moist atmosphere, carefully watched ; and sinapisms are at once to be applied to the throat, while the tincture of the perchloiide of iron, or the glycerole of tannin, or finely pow- dered alum by insufflation, are to be applied to the rima glotti- dis. If, notwithstanding these measures, there seems danger of asphyxia, the larynx must be opened without delay. "• Gaz. des Hop. Feb. 28, 1861. ° Bell, i860, ix. 55. TEEATMBNT. 307 3. Partial paralysis following typhus must be treated with a generous diet, mineral tonics, and small doses of nux vomica or strychnia, the cold shower-bath and sea-bathing, and by friction, shampooing, passive movements, and galvanism of the affected muscles. Where incontinence of urine persists during conva- lescence, the best remedy is the tincture of the perchloride of iron, and in the female immediate rehef will often be derived from cauterizing the orifice of the urethra with nitrate of silver. 4. When mental imbecility or mania persists during conva- lescence, a generous diet and tonics with change of air will in time almost certainly effect a cure. Sudden paroxysms of mania •occurring during convalescence are best treated with stimulants and chloral or opium. 5. Diarrhoea and Dysentery. Diarrhoea is to be treated with astringents, and if necessary by an opiate enema. Towards the termination of the disease it may be due to paralysis of the howel, and then benefit will be derived from the tincture of perchloride of iron and strychnia. For dysentery a combination of ipecacuanha, Dover's powder, and Hydrargyrum cum creta may be given four times a day, and an astringent draught after each motion of the bowels. 6. Bed-sores. In all severe or protracted cases of typhus, the back ought to be examined daily, and means adopted to prevent undue pressure on those parts where bed-sores are apt to form, especially the sacrum and hips. This may be done by an annular air-cushion or a water pillow, but when practicable, the patient ought to be laid on a water-bed,- spring-bed, or strap-bed.° As soon as the slightest redness is discoverable, the parts should be ■ kept dry and painted twice daily with a mixture of collodion and castor-oil, or with the white of egg beaten up with an equal quantity of rectified spirit, or with a solution of gutta-percha in chloroform (one drachm of sheet gutta-percha in one fluid ounce of pure chloroform). These applications stimulate the cutaneous capillaries, and form a protecting film on the surface. When bed-sores have formed, stimulating poultices ought to be applied until the sloughs separate. An excellent application under such circumstances is composed of two parts of castor-oil and one of balsam of Peru spread on pieces of lint, or pieces of lint saturated with carbolic oil, which are laid on the sore and covered with a • An excellent strap-bed has been invented by Dr. Corrigan (see Coerigan 1853, p. 84). X 2 308 TYPHUS FEVEE. linseed-poultice, to be changed three or four times a day- Yeast-, carrot-, chlorine-, and charcoal-poultices, or a few drops of carbolic acid or turpentine in the ordinary linseed-poultice, are also very useful. To correct fetor the parts are to be washed each time that they are dressed with a lotion of carbolic acid (gr. XV. ad Ij.), sulphm-ous acid (i in 6), chlorinated soda (Liq.. sod. chlorat. siv., aq. .fixss,), or the permanganate of potash (Liq. pot. permang. 5vj., aq. ad .fx.). After the sloughs have separated, the sores are to be dressed with some stimulating lotion, and if sloughing return, strong nitric acid must be applied, followed by poultices. 7. Spontaneous gangrene. When the feet are cold and livid,, external warmth ought to be applied by means of hot water bottles, or bags of hot sand or bran ; and as soon as gangrene threatens the limb should be enveloped in cotton wool, over which a few drops of turpentine or spirit of camphor are sprinkled. After gangrene has commenced, the same treatment is applic-^ able as for bed-sores, until a decided line of demarcation has formed ; and then, as soon as the patient's strength permits, amputation must be performed a considerable way above. In cancrum oris, strong nitric acid must be applied freely and without delay over the ulcerated surface inside the mouth ; poultices are to be applied over the cheek, and the mouth fre- quently washed out with one of the antiseptic lotions mentioned under the head of bed-sores. Sloughing and ulceration of the cornea are best prevented by wet compresses over the closed eyelids, whenever the patient lies with his eyes constantly open. When ulcers have formed, warm fomentations of belladonna or poppy-heads ought to be applied, and if there be much pain in the eye j)aracentesis of the cornea must be performed. Slough- ing in any part of the body indicates a low state of the system, and calls for large quantities of stimulants, quinine, the mineral acids, and other tonics. As soon as the primary fever has ceased, malt liquors and abundance of nourishment in a diges- tible form ought to be allowed. Opium is usually required to relieve pain and procure sleep. 8. Erysipelas is best treated by stimulants and by the tincture of the perchloride of iron and spirit of chloroform, or quinine and the mineral acids, and by the application to the part of flour and cotton wool, or of a warm fomentation of lead and opium (Plumb, acet. et Pulv. opii aa. gr. iv. ad §j. aq.). In ery- sipelas of the face we must always be on our guard against a similar condition of the pharynx and larynx ; and when either TEEATMENT. 3O9 of these parts become affected, the fauces, back of the pharynx, or the entrance to the larynx, ought to be freely painted with the glycerole of tannin, a solution of perchloride of iron (equal parts of the tincture and water), or a solution of nitrate of silver Oj ad 5J). When the patient is unable to swallow, brandy, beef-tea, ether, and quinine ought to be given by the rectum, or introduced by a long tube into the stomach. When apncea is imminent from obstruction of the rima glottidis, laryngotomy must be performed without delay. 9. For diffuse cellular inflammation and pycemia the same constitutional treatment is required as in erysipelas. I have tried the hyposulphites in several cases of this sort without any good result. Opium is often necessary to relieve pain and procure sleep. As soon as matter forms, it ought to be freely evacuated, the cavity washed out with a strong solution of chloride of zinc ( 9 j ad 5J), and the wound dressed with carbolic oO. 10. Inflammatory sivellings in the parotid region and else- where are to be treated internally in the same manner as gan- grene, erysipelas, and pyaemia. The swellings are to be covered with cotton-wool or poultices. I have never seen any benefit from leeches, but blisters applied in the early stage seem some- times to prevent suppuration. As soon as pus has formed, it is to be evacuated by free incisions ; and even before pus can be felt, when the swelling continues to increase for several days and is tense and painful, one or more incisions often give great relief, and prevent the spread of the inflammation. 1 1 . When thromhosis of the femoral vein occurs during conva- lescence, the patient must lie on his back with the foot raised above the level of the trunk. A flannel-bandage is to be applied from the toes to the hip, so as to keep up gentle pressure and maintain the temperature, and be worn for some time after the swelling has disappeared. If a hard painful cord be felt in the situation of the femoral vein, strips of lint smeared with equal parts of belladonna and glycerine may be laid along the coarse of the vessel before applying the flannel-bandage. When the pain and tenderness are unusually severe, warm anodyne foment- ations, or even leeches, along the course of the vein will often give relief. 12. For oedema of the lower extremities during convalescence, ionics, especially iron, and a generous diet are to be prescribed. 3IO TYPHUS FEVEE. Treatment during Convalescence. As soon as the fever ceases, most patients convalesce rapidly^ unless there be some complication ; and the chief duties of the physician consist in preventing premature exertion and exposure to cold, and in checking the inordinate appetite. Although there is probably no acute disease in which the appetite returns more speedily, and may be gratified with greater impunity, it is well to restrict the diet, for the first two or three days of conva- lescence, to animal soups and farinaceous articles with milk and eggs. On the third day, if the tongue be clean and moist, the pulse slow, and the rash gone, a piece of boiled white fish or chicken, or the lean part of a mutton chop, may be allowed. As soon as convalescence is established, porter or ale ought tO' be substituted for the wine and brandy, as they are more fitted for promoting the transformation of food, and at the same time furnish nutriment themselves in the form of gluten and sugar. The bowels are usually costive, and are to be kept oj)en by mild laxatives and enemata. The mineral acids, with bark^ quinme, and iron, may be given as tonics, and are particularly caUed for when the pulse is abnormally slow, in which case also the patient should be cautioned against assuming the erect posture" too soon, as sudden and fatal syncope has sometimes, been the result. Opiates or the hydrate of chloral may be re- quired to produce sleep ; and in every case great benefit will be derived from a change of residence and exercise in the open air. 311 CHAPTEE III. RELAPSING OR FAMINE FEVER. Sect. I. Definition. A CONTAGIOUS disease, characterized by the presence in the blood of a spiral bacterium, the spirillum or spirochsete. It is chiefly met with in the form of an epidemic, during seasons of scarcity and famine. Its symptoms are : a very abrupt invasion marked by rigors or chilliness ; quick, full, and often bounding pulse ; white moist tongue, rarely becoming dry and brownish ; tenderness at the epigastrium ; vomiting, and often jaundice ; enlarged liver and spleen ; constipation ; skin very hot and dry ; no characteristic eruption ; high-coloured urine ; severe headache, and pains in the back and limbs ; restless- ness, and occasionally acute delirium ; an abrupt cessation of all these symptoms, with free perspiration, about the fifth or seventh day ;— after a complete apyretic interval (during which the patient may get up and walk about) an abrupt relapse on or about the fourteenth day from the first commencement, running a similar course to the first attack, and terminating on or about the third day of the relapse ; sometimes a second, or even a third, relapse ; — mortality small, but occasionally death from sudden syncope, or from suppression of urine and coma ;— after death, no specific lesion, but usually enlargement of liver and sx3leen, and if death takes place during a paroxysm the spirochsete will be found in the blood. Sect. II. Nomenclature. I. — Names derived from its duration and peculiar course. A Five Days' Fever with Eelapses {Butty, 1770); Short Fever, Five Days' Fever [var. 1817-19) ; Five, or Seven Days' Fever {Wardell, dc. 1843, Irish Writers, 1847) ; Remittent Fever {Craigie, 1843, Purefoy, 1853) ; Eelapsing Fever (Paterson, Steele, dc. 1847 ; Jenner, 1849 ; Lyons and "Anderson, 1861) ; Typhus recurrens {Hirsch, 1859) ; Das recurrirende Fieber ; der Eiickfallstyphus {German Writers) ; Fievre k recliute and Typhus a recliute {French Writers). 312 EELAPSING OR FAillNE FEVER. 2. — Names derived from its Prevalence in Epidemics. The Epidemic Fever {auct. var.) ; Epidemic Eever of Edinburgh {Welsh, 1819) ; Epidemic Fever of Ireland pro parte [Barker and Gheyne, 182 1); Scotch Epidemic of 1843 [Alison, Wardell, JR. Cormack, Jackson, Henderson, H. Douglas, D. S^nith, Craigie, <&c.) ; Epidemic Eemitteut Fever [Mackenzie, 1843); ^^6 Silesian Fever of 1847 [Brit, and For. Med. Ch. Bev. July, 185 1). 3. — Derived from the supposed Inflammatory Nature of the Pyrexia. Dynamic or Inflammatory Fever [Stoker, 1835 ; and Dublin Journal, 1848); Synocha [Cullen, 1769; Christison, 1840 and 1858); Ke- lapsing Synocha [Seaton Beid, 1848).? 4. — Derived from the Common Occurrence of Jaundice as a Symptom. Yellow Fever [Graves and Stokes, 1826 ; Arrott, 1843) ; Bilious Ee- lapsing Fever [Steele, 1848) ; Gastro-hepatic Fever [Bitohie, 1855) ; Bilioses Typhoid [Griesinger, 1864). Has also been designated Bilious Eemittent Fever, Eemitting Icteric Fever, Biliary Fever, and Bilious Typhoid Fever. 5. — Derived from its connection with Famine. Famine Fever [Stoker, 1826, and Irish Writers generally) ; Armen- typhus [Geivnan Writers, 1848) ; Die Hungerpest [GrcevelVs Notizen, 1848). 6. — Other Synonyms. Fever of the New Constitution [O'Brien, 1828) ; Miliary Fever [Ormerod, 1848; Watson, 1848); Typhinia (i^arr, 1859); Spirillum Fever [Garter, 1882). Sect. III. Historical Account of Eelapsing Fever. EELAPSING Fever, like typhus, is not a new disease. Hippocrates ; described a fever prevailing upwards of two thousand years ago in the island of Thasus, off the coast of Thrace, which resembled it very closely in most of its characters, including an intermission of five or seven days between the febrile attacks, jamidice, epistaxis, tendency to miscarry, &c.i In the accounts of many epidemics of typhus, mention is made of relapses, which in some instances probably referred to relapsing fever, as this fever prevails often as an epidemic in conjunction with typhus. Strother, in describing the fever epidemic in London in 1729, speaks of frequent relapses ; "^ and Lind, in his account of the contagious p Eelapsing Fever probably constituted one of the varieties of the ' Inflamma- tory Fever,' or ' Synocha ' of the writers of last century ; more recently, it has often been considered a variety of typhus. <« Spittal, 1844, p. 177 ; Hippocrat. Op. Syd. Soc. ed. i. 389. ' yTBOTHER, 1729, p. 121. HISTORY. 313 typhus of tlie fleet, observes : ' In tlie fevers concerning whicli we are treating, the patients are very subject to relapses.' ^ The earHest mention, however, of relapsing fever, on which reliance can be placed, occurs in Eutty's ' Chronological History of the Diseases of Dublin.'* Speaking of the year 1739, he says: 'The latter part of July, and the months of August, September, and October were infested with a fever, which was very frequent during this period, not unhke that of the autumn of the preceding year ; with which compare also the years 1741, 1745, 1748. It was attended with an intense pain in the head. It terminated sometimes in four, for the most part in five or six days, sometimes in nine, and commonly in a critical sweat : it was far from being mortal. I was assured of seventy of the poorer sort at the same time in this fever, abandoned to the use of whey and God's good providence, who all recovered. The crisis, however, was very imperfect, for they were subject to relapses, even sometimes to the third time. In some, there succeeded pains in the limbs.' Again, at p. 90, after speaking of the typhus of 1741, he says : ' Through the three summer months, there was frequent here and there a fever, altogether without the malignity attending the former, of six or seven days' duration, terminating in a critical sweat ; but in this the patients were subject to a relapse, even to a third or fourth time, and yet recovered.' Huxham described frequent relapses in the fever prevalent at Plymouth in this same year.'* Eelapsing fever also appears to have been observed by Dr. John Clark at Newcastle in 1777.'^ During the epidemic of 179 7-1 801, many cases of relapsing fever were observed. ' Certain it is,' remarked Barker and Cheyne, ' that the fever in 1801 very generally terminated on the fifth or seventh day by perspiration, and that the disease was then very liable to recur ; and that the poor were the chief sufferers by it."^ There is evidence of the occasional occurrence of relapsing fever, during the first sixteen years of this century, in Ireland and elsewhere,^ while the next great epidemic of fever (1817-19) was chiefly com- posed of it. It is needless to recapitulate the circumstances under which this epidemic originated, or the extent of its prevalence (see p. 39). Typhus and relapsing fever were then regarded as modifi- cations of one disease, and, according to Christison, ' there was a general impression that the relapsing fever could produce the common typhus.' Hence it is not surprising that the records of the epidemic do not show the period at which each fever was most prevalent. But the circumstance that the rate of mortality increased at many places with the advance of the epidemic makes it probable, that the propor- tion of typhus to relapsing cases was greater towards the close of the epidemic, than at its commencement. Thus, of 28,514 cases of fever " LiND, 1763, p. 63. ' EuTTY, 1770. " Huxham, 1752. " Claek, 1780, pp. 36, 132. ^ Bakker and Cheyne, 1821, i. 20. "^ Ibid. p. 213. In 1813 it was observed in Berlin in conjunction with typhus (Zuelzer, 1869, p. 131). 314 RELAPSING OR FAMINE FEVER. admitted into the Dublin Hospitals from September 181 7 to November 1818 inclusive, 1,242 died, or i in 23; while of 9,419 cases admitted during the first six months of 1819, 525 died, or i in iy94.y In the Cork Street Fever Hospital, of 7,613 cases admitted in 181 8, thera died 256, or i in 30 ; but of 3,920 cases admitted in 1819, 226, or i in i7'34.2 Again, of 1,741 cases admitted into the AVaterford Fever Hospital durmg the first nine months of 181 8 only 51, or i in 34* 13, died, while of 2,050 cases admitted during the last three months of 1818 and the first three months of 1819, there died 122, or i in i6"8.* From Dec. i6th, 181 7, to -June i6th, 181 8, there were admitted into the Fever Hospital at Ennis 206 patients, of whom 10, or i in 2o'6, died,, while from Jmie i6th to Dec. i6th, 1818, 22 died out of 281 cases, or i n i2'77.^ In Aberdeen we are told that in January 18 19, towards the end of the epidemic, the disease assumed a worse aspect and the number of fatal cases increased. ° It would not be difficult to multiply these results, and, in fact, an mcrease in the rate of mortality with the advance of the epidemic was all but universal.'' After 1 8 19, relapsing fever seems to have almost disappeared until the subsequent epidemic of 1826, which consisted of both typhus and relapsing fever, but in which the proportion of typhus was greater than in the preceding epidemic. Now, for the first time, a distinction was drawn between the two fevers, and there is conclusive evidence that the proportion of relapsing cases was greatest at the commence- ment of the epidemic, and progressively dimmished as the epidemic advanced. Dr. O'Brien, who published an account of the epidemic as it appeared in Dublin, states that at the commencement there were ' two fevers, the ordinary typhus, or fever of the old constitution,' which was very fatal, and ' a fever of the new constitution,' lasting only a few days and seldom fatal, but frequently relapsing. At first, he says, most of the cases were of the latter form, but as the epidemic advanced, the proportion of relapsing cases greatly decreased."^ This statement is confirmed by comparing the rate of mortality of the epidemic at different stages of its progress. Thus, of 8,607 cases admitted into the Dublm Fever Hospital from May to December 1826,. only 249 died, or i in 34*56 ; whereas, of 3,658 cases admitted from January to May, 202 died, or i in i8*i. A similar observation was made by Alison with regard to the epidemic in Edinburgh. He states that the symptoms generally were more asthenic than in the epidemic of 1817-19, and that this was more especially the case in 1827 than in 1826.^ It also appears from Alison's memoir, that the rate of mortality from fever in the Eoyal Infirmary was greater in 1827 than in 1826. From 1828 to 1842 relapsing fever may be said to have disappeared from Britain, It formed no component part of those extensive y Haety, 1820, 6th Table of Appendix. ' Ibid. p. 40. » Baeree and Chetne, 1821, ii. 48. * Ibid. p. 108. "= Haety, 1820, p. 115. ■' It is well known that in epidemics of pure typhus the mortality is greatest at the commencement. (Seep. 241.) " O'Beien, 1S28. ' Alison, 1827. HISTORY. 3 I S outbreaks of fever in Glasgow and Edinburgh in 1831-2 and 1840-1, or of the more general epidemic of 1836-38. Its cessation was so complete, that when it again broke out in 1843 it was regarded by- many as a new disease. In Ireland, its disappearance was perhaps not equally complete, but even there, little or no mention was made during this period of a fever presenting its peculiar characters. Towards the end of 1842 and in 1843 appeared that remarkable epidemic in Scotland, and, to a less extent, in England, which has already been described (p. 47). This epidemic resembled that of 181 7- 19 in consisting mostly of relapsing fever. True typhus, however, was not absent ; in some places, as in Dundee, s it preponderated over relapsing fever ; and everywhere it increased in prevalence with the advance of the epidemic. This fact is clearly brought out by the returns of the Glasgow Eoyal Infirmary, where, as in Edinburgh, the two fevers were now recognised as distinct diseases, and the numbers of each carefully recorded. Thus :— Relapsing Fever. Typhus. In 1843, were admitted, 2,871 and 142, or 20-2 E. F. to i Typhus In 1844, ,, ,, 432 and 711, or i ,, to i"64 ,, In 1845, ,, ,, 37 and 266, or i ,, to 7-18'^ ,, The following rates of mortality from fever, during the same epi- demic, in the Edinburgh Infirmary, also show a considerable increase towards the close of the epidemic : — Oct. I, 1842, to July I, 1843, 817 admissions, and 6"85 p.c. died. July I, 1843, to Oct, I, 1844, 4,642 ,, and 7*77 p.c. ,, Oct. I, 1844, to Oct. I, 1845, 679 ,, and ii'34p.c.^ ,, Prom Warden's Tables also it appears that of 330 patients m the Edinburgh Infirmary in October 1843, only 10, or i in 33, had the eruption of typhus, which was present in 24 of 450 patients (or i in i8f ) in the hospital during the following January .J Dr. Kose Cormack, who in December 1843 published a memoir on the epidemic as observed in Edinburgh, thus wrote : ' As the season advanced, all the cases have been more characterised by depression and general typhoid symptoms. The cases of Continued Fever, with and without measly eruption, are becoming more and more common in Edinburgh, and also in Glasgow, as Dr. Weir of the Lifirmary there informs me.' "^ In the Medical Gazette for April 1849, ^^^ same writer observes : ' Towards the close of the epidemic (of 1843), ^^^^ ordinary Edinburgh typhus with measly eruption began to rage.' In the London Fever Hospital, ' the peculiar typhus-eruption ' was noted in only i of 61 cases admitted in January 1844, but in 22 of 39 cases admitted in August ; again, of 1 1 1 cases admitted in December 1843, only 3 (or i in 37) died, whereas of 39 cases admitted in August e Aeeott, 1843, p. 131. '' M'Ghie, 1855, p. 161. ' Statistical Reports of the Hospital. ' Wabdell, 1846, xxxvii. pp. 229, 774. ^ Coemack, 1843, p. 107. 3l6 RELAPSING OE FAMINE FEVER. 1844, II (or I in 3'54) died. The Eeports also state that relapses occurred in almost all the cases admitted in the latter part of 1843, ^^^ were rare in 1844. After the epidemic of 1843, a few cases of relapsing fever continued to be observed in both Ireland and Britain, until the end of 1846. The epidemic of 1847-8 presented a greater proportion of typhus cases, and in this respect bore very much the same relation to the epidemic •of 1843, that the epidemic of 1826 had borne to that of 181 7-19. The greater preponderance of relapsing fever at the commencement of the epidemic was a matter of general observation. Thus, Dr. Steele, in his report of the cases admitted into the Eoyal Infirmary of G-lasgow, observes: 'It will be seen, by reference to Table XIII., that the two diseases kept steadily advancing, somewhat in an inverse ratio. At the beginning of the year, the cases of relapsing fever averaged about three-quarters of the whole admissions. The disease advanced, though very gradually, till the month of July, after which the number began to decline, and at present (April 1848) they form but a small proportion of the cases under treatment. The number of typhus cases admitted in January 1847 was so low as 66. The admissions increased rapidly till July, when they outnumbered those of the rival epidemic. After this period, typhus cases began to decline very slowly, at the same time always keeping ahead of the relapsing cases ; so that, at the close of the year, the former averaged about two-thirds of the whole fever cases under treatment.' ^ The following are the actual numbers of admissions of each fever into the Glasgow Eoyal Infirmary : — In 1846 . . 777 Eelapsing Fever . 500 Typhus. In 1847 • • 2,333 .> .' • 2,399 In 1848 . . 513 „ „ . 980 In 1849 • • 168 ,, ,, , 342 "^ ,, Mr; James Paterson, speaking of the Barony Fever Hospital in Glasgow, which was opened for eleven months from August 5, 1847, remarks : ' The relative proportion of the two principal forms of fever varied much at different periods of the Hospital's history. At its opening, the number of cases of fever with relapse doubled that of the tj^hus cases. At the close of the year they were nearly equal, and during, and after, February, the number of the typhus cases doubled that of the relapse cases.' ^ The same sequence of events was noticed in Edinburgh. From statistics of the epidemic, published by Dr. E. Paterson, it appears that, from May i, 1847, to January 31, 1S48, 589 cases of relapsing fever and 422 cases of typhus came under treatment ; whereas, during the two months of February and March 1848, the numbers were 58 of relapsing fever and 73 of typhus." Agam, the Official Statistical Tables of the Infirmary show that, from October i, 1848, to October i, ■ Steele, 1S48, p. 166. '" M'Ghie, 1855, p. 161. " J. Paterson, 1848, p. 361. " E. Patekson, 1848, p. 397. HISTORY. 317 1849, there Avere admitted 203 cases of relapsing fever and 349 of typhus; whereas, from October 1849 ^0 October 1850, there were only 25 cases of relapsing fever to 468 cases of typhus. Similar observations were made in London by Dr. Ormerod p and others. Of 64 cases of ' fever ' admitted into the London Fever Hospital in April 1847 at the commencement of the epidemic, only i died; whereas, of 104 cases admitted in December, 12 (or i in 8"6) died; and of 967 cases admitted in the year 1848, 166 (or i in 5'8) died. On the whole, however, eases of relapsing fever were few in London in proportion to typhus. The cases in the London Fever Hospital did not exceed 100. The Irish records of this epidemic make it probable that the same order of events took place in that country. Although the accounts are less clear, inasmuch as few Irish physicians recognised the distinc- tions between the different forms of fever, the following extract from Dr. H. Kennedy's account of the epidemic in Dublin is to the point r ' Cases of genuine typhus were through the whole epidemic very rare. Occasional cases did occur, and these became more numerous with th& advance of the epidemic' 1 Throughout the epidemic, the proportion of true typhus cases appears to have been much less in Ireland than in Scotland, and in Scotland than in England. The years 1846 and 1847 were marked by severe famine, not only in this country, but in some parts of the Continent, more particularly in the Prussian province of Upper Silesia and in some other parts of Germany. There an epidemic broke out, which was the counterpart of that in the British Isles. The investigations of many accurate observers, such as Virchow, Diimmler, and Suchanek,^' leave no doubt that this epidemic consisted partly of relapsing fever, and partly of typhus. It commenced in Upper Silesia, where the effects of the famine were felt most severely, and where the condition of the inhabitants singularly resembled that of the Irish. The following paragraph is extracted from a review of the epidemic by an English "writer : — ' The province of Upper Silesia is a dependency of Prussia. It is inhabited, however, not by Saxons, but by a race of Poles, who have been severed from their nation for 700 years, and yet have preserved their language, their religion, and their unwillingness to labour, although they have lost the inventive genius and the chivalrous spirit of their parent stock. Separated thus from Prussia by differences of blood, of religion, and of language, the utmost efforts of that en- lightened country have failed to teach them Saxon industry, or to give them Saxon comfort. The schoolmasters, who have been sent among them, have learned Polish, but have not taught German ; the Pro- testant teachers have only excited in them a more fanatic zeal for their Catholic priests : the profound literature of Germany awakened p Orjierod, 1848, p. 217. 1 Irish Report, Bib. 1848, vii. p. 54 ; also viii. p. 67 ; H. Kennedy, i860, p. 217. ^ See Bibliogra2ohy, 1S49. 3i8 RELAPSING OR FAMINE FEVER. in tliem no response ; and amidst the clasli and tumult of modern progress, tliey remain silent and unmoved in their antique isolation. Like the Irish, the potato is their staple article of food, to which they add butter-milk and sauerkraut. Their dwellings are the prototypes of the Irish cabins, and in the smallest and dirtiest huts persons of all ages and sexes are crowded together. Nor does the parallel to Ireland end here. The relations between landlord and tenant appear to be on as false a footing as those which exist in Ireland, only that here a still more oppressive state of servitude may be found. The aristocracy also, as in Ireland, adopt a system of absenteeism, and spend in Berlin or Vienna the small portion of wealth which the labour of their miserable dependants creates. The Silesians, like the Irish, are ex- cessively intemperate.' ^ After the epidemic of 1847-8, relapsing fever gradually subsided. In London it increased considerably in 1851, the patients being almost exclusively Irish, of whom many had been but a short time in London, and all were m a state of extreme destitution. This increase occurred at a time when typhus was comparatively rare, but gradually the number of relapsing cases diminished (see Table XXIIL), In Glasgow there was also an increase of relapsmg fever in 185 1, followed by a great increase of typhus, as the relapsing cases became fewer. In Ireland, relapsing fever was a common disease in 1853.* But in 1855 relapsing fever disappeared, and for more than fourteen years not a case of it was observed in any hospital of Great Britain, while in Ireland it seems also to have been unknown."^ TABLE XXIIL London Glasgow 1 London Glasgow Years Fever Roj-al Tears Fever Royal Hospital Infirmary Hospital Infirmary 1848 13 513 1 1855 I 22 1849 30 168 : 1856-67 1850 32 174 1 1868 3 1851 256 255 1869 768 1852 88 192 1870 903 704 1853 r6 72 1871 69 755 1854 5 68 Eelapsing fever was next heard of in St. Petersburg. In the spring of 1865 Europe was startled by the announcement of a great ' Bemew Bib. 1851, p. 28. ' Pukefoy, 1853. >■ Cases of ' relapsing fever ' were erroneously reported as occurring during this time in Scotland. For example, the Eegistrar-General for Scotland (Stark, 1865, p. 313) stated that in 1864, iS cases of relapsing fever had been treated by the medical practitioners of Perth, but I have their authority for saying that not one of them had seen or heard of a case of true relapsing fever in that year, although they had met with a few cases of enteric fever followed by a relapse. So also with regard to the deaths from ' relapsing fever ' reported at Midcalder in 1869 by the Eegistrar-General, it was shown that the disease was not true relapsing fever (Ed. Med. Journ. Jan. 1870, p. 670). HISTORY. 3 1 9 Eussian pestilence, wliich on enquiry turned out to be relapsing fever and typhus. In 1863 relapsing fever had been observed at Odessa,^ and in the summer of 1864 it appeared in St. Petersburg, where all accounts agree m stating that it had before been \mknown. The opinion generally arrived at by the scientific physicians who investi- gated the matter was that the disease origuiated in St. Petersburg, and was not imported. The liberation of the serfs had driven multitudes of labourers to the capital in search of work. Overcrowd- ing was the result, while at the same time provisions of all sorts were unusually dear and bad. The potatoes were diseased or destroyed by frost, and much of the flour contained ergot of rye. The epidemic was confined to the poorest and most wretched of the population. It reached its acme in the spring of 1865, and m the autumn of the same year it rapidly declined. The proportion of relapsing fever to typhus was much greater at the commencement of the epidemic than towards the close. The mortahty of the relapsing fever was unusually high ; of 12,382 cases admitted into the different hospitals of St. Petersburg there died i2"7 per cent.'^ Towards the end of 1867 relapsing fever with typhus became epidemic in East Prussia, and in its old hamit Silesia. Whether or not this was an offshoot of the Piussian epidemic is not very clear, but it was generally ascribed to ' great destitution and want of food.' ^ In 1868 the disease spread to Berlin, Breslau, and other large towns, and many excellent descriptions of it were published by German physicians.y Epidemics of relapsing fever have continued to recur in Eastern Germany and Piussia up to 1880. In 1876-77 there was an extensive one in Finland. In 1868 relapsing fever reappeared in Britain.^ The first, patient observed came under my care at the London Fever Hospital on July 4, a female aged 20, of Irish birth, but who had resided eight years in London, and was not very destitute. The second patient was a Polish Jewess, who came four days later from a house about a quarter of a mile distant from that of the first, who could not speak English, and whose length of residence in London was not ascertained. From the same house a Polish family, consisting of father, mother, and child, was admitted on the same day, who, during the seven days they were in hospital, had no fever, but were in a state of extreme prostration. Three weeks afterwards a third patient, a girl aged 14, who had lived all her life in London, came from the house next to that of the Polish Jewess. During the last four months of 1868 eight German Jews with relapsing ^ Bernstein, 1865. " Hee3l\nn and Kuttner, 1865 ; Whiteley, 1865 ; Mill.u;, 1865 ; Zuelzer, 1867 ; EcK, Gaz. des Hop. May 18, 1865 ; Med. Times and Gaz. 1865, ii. 413. There is evidence of relajDsing fever at Moscow in 1840, and at New Archangel in 1857-8. "^ Letter from Dr. Zuelzer of Berlin, .January 2, 1868. y Wtss and Bock, 1869; Obermeier, 1869; Pastau, 1869; Lebert, 1870. ' MuKCHisoN, 1869. 320 EELAPSING OR FAMINE FEVER. fever were admitted into the German Hospital in London,^ but no case was observed at the London Fever Hospital, after the three in July 1868, until May 1869, and the disease cannot be said to have become epidemic in London until the autumn of 1869, although, strange to say, a singularly severe outbreak of the disease commenced at Trede- gar, in South Wales, in October 1868.^ It may be added that not one of the first 70 cases admitted into the London Fever Hospital in 1869 came from the same houses or even streets as the patients admitted into the Fever and German Hospitals in 1868, and that during 1869 and 1870 the patients were almost exclusively natives of England; very few were L-ish. In September and October 1869, relapsing fever appeared in Liverpool and Manchester, and in March 1870 in Leeds, Edinburgh, and Glasgow. The epidemic in London rapidly attained its height in December 1869, and then it gradually declined until June 1871, when it finally ceased. (See Table XXVIII.)*' As in former epidemics, the disease was restricted to the poorest of the population. A large proportion of the patients were tramps and hawkers, in an extremely destitute condition. Li three respects, however, the epidemic differed from most that preceded it. First, it appeared towards the close, instead of at the commencement, of a great typhus epidemic ; secondly, a comparatively small proportion of the patients were Irish (seep. 321); thirdly, it was not preceded by famine, or by any very unusual causes of general distress among the poor, although the number of paupers in the metropolis and elsewhere had for years been rapidly increasing. But in connexion with these discrepancies it is right to remember, that for the first time there was reason to suspect that the disease was not of indigenous nor of Irish growth, but was imported from abroad. No deaths from relapsing fever have been registered in England since 1872, but a few have occurred every year in Scotland up to 1879. One death was registered in Ireland in 1881. From the above remarks, and from the observations formerly made in the historical account of typhus, the following conclusions are arrived at : — 1. Eelapsing fever is an epidemic disease, in a stricter sense than even typhus. It may disappear entirely for years from those places where at other times it rages most fiercely. 2. Epidemics of relapsing fever have usually co-existed with epi- demics of typhus, and have always appeared under circumstances of distress or famine. 3. In mixed epidemics, the relative proportion of typhus and re- lapsing cases has varied at different times and places ; but, as a rule, the proportion of relapsing cases has been much greater at the commencement than towards the close of the epidemic, and with the advance of the epidemic typhus has taken the place of relapsmg fever.. » H. Webek, Med. Times aiid Gaz. December 19, 1868, and Lancet, February 1869. " Official Bep. on Sanitary State of Tredegar by J. N. Eadcliffe. * A few cases were again observed in December 1872. GEOGKAPHICAL RANGE. 32 I Sect. IV. Geographical Eange. The geographical range of relapsing fever is much wider than it was once imagined to be. Ireland and Britain are the comitries in which epidemics of it have been chiefly observed, and most of the British epidemics have been of Irish origin. Take, for example, the epidemic of 1847. ^11 accounts agree in stating that it did not commence in Glasgow, Liverpool, and other towns until after the immigra- tion of large numbers of destitute Irish, "^ According to Dr. E. Pater son, ' at the commencement of the epidemic in Edinburgh, almost every case admitted into the Infirmary was from Ireland, and for nearly three months they continued so.' Large numbers had come direct from Ireland. With the increase in the pro- portion of cases of true typhus, the proportion of Irish patients diminished, and that of the Scotch increased (see. p. 48).® It is clear that the cases of relapsing fever, of which this epidemic was at first mainly composed (see p. 316), were, for the most part, Irish. Similar observations were made in London. Of the patients admitted into the Fever Hospital at the commence- ment of the epidemic, the majority were suffering from relaps- ing fever (see p. 315), and a considerable proportion were poor Irish, who had not been in London many days, and who had reached the metropolis with fever on them, or destitute of food and clothing, and in an extreme state of exhaustion.^ Dr. Ormerod, from his experience at St. Bartholomew's, stated that the cases of relapsing fever in 1 847 were ' mostly Irish newly arrived in London,' and added : ' At first the residents still continued to suffer from the better-known form of the disease in all its severity (typhus), whereas the newly-arrived Irish had mild relapsing (miliary) fever.' s Again, of the cases admitted into the London Fever Hospital between the years 1848 and 1855, more than two-thirds were natives of Ireland (see Table XXIV.). Taking the census of 185 1 as a basis of calculation, it follows that during the period in question there were admitted with relapsing fever into the I^ever Hospital i in every 386 of the Irish inhabitants of Londcm; i in every 8,351 foreigners ; i in every 15,200 of the Scotch inhabitants; and only i in every " See p. 48. * R. Paterson, 1848 see also Orb, 1847, p. 374. ' Report for 1847, P- n. ^ Ormerod, 1848, p. 217. Y 322 RELAPSING OR FAMINE FEVER. 16,465 of the English inhabitants. Moreover, a large proportion of the patients born in London or the rest of England were the children of Irish parents, or were of Irish extraction. Many also of the Irish patients had only recently arrived from Ireland ; of 250 Irish cases, whose length of residence in London was ascertained, 20, or 8 per cent., had left Ireland within three months; 36, or 14*4 per cent., within six months; and 81, or 32-4 per cent., within a year. But two of the British epidemics of relapsing fever have not owed their origin to Ireland. The Scotch epidemic of 1843 originated in Scotland, and scarcely, if at all, implicated Ireland. Of 150 patients in Edinbm'gh, observed by Wardell at an early stage of the epidemic, only 25 were natives of Ireland, and they had caught the disease by lodging in houses or localities where it prevailed. As the epidemic advanced, the proportion of Irish TABLE XXIV. Places 1848-55 1868-70 Natives of London „ rest of England . ,, Scotland ,, Ireland ,, rest of World 83 or 1976 per cent. 50 or 11-9 „ 2 or '47 „ 281 or 66-9 ,, 4 or -95 1,071 or 65-86 per cent. 366 or 22-51 „ 20 or 1-23 ,, 145 or 8-91 „ 24 or 1-47 „ Total whose birth-place noted 420 or 99-98 ,, 1,6260199-98 „ increased.^ (See p. 48.) When the last epidemic also com- menced in London in 1868 there was no relapsing fever in Ire- land, there was no evidence of any of the patients having come recently from Ireland, and throughout the epidemic less than 9 per cent, of the patients were of Irish birth. Calculating from the census of 1861 (see p. 58), i in every 1,805 of the English, and I in every 737 of the Irish inhabitants of London were admitted with relapsing fever into the Fever Hospital during the two years 1869-70. Eeference has already been made to extensive epidemics of relapsing fever in Poland and Germany, and in Eussia from Archangel to Odessa (see p. 319); but there is no evidence of its occurrence in any other part of the continent of Europe. In June 1844 relapcing fever was observed at Philadelphia by Dr. M. Clymer among Irish emigrants landed from a Liver- pool packet, but the disease did not spread.' Under similar '' Wardell, 1S46, xxxvii. 229. Clymek, 1870. GEOGRAPHICAL EANGE. 323 circumstances it was observed at New York in 1848,^ and at Buffalo in 1850-1,'' but on neither occasion did it spread among the population. In 1869 it again appeared in America, the first cases being observed at Philadelphia in September, and at New York in November ; the patients were chiefly poor Irish and Germans, and the disease was believed to have been im- ported, although the channel of importation was not determined ; on this occasion the fever spread to a limited extent among the inhabitants.' Eelapsing fever can scarcely then be said to be indigenous in America. Contrary to the opinion expressed by Morehead and in the first edition of this work, it must now be admitted that relapsing fever occurs in India and other tropical countries. It is true that some writers have confounded tropical yellow fever, or "' bilious remittent fevers ' of malarious origin with relapsing fever, yet it is now clear that a disease identical with the relaps- ing fever of this country was observed by Griesinger ™ in Egypt in 1 85 1, and prevails in conjunction with typhus in India and in the Punjab. It is said to have been recognised as far back as 1852 in the valley of Peshawur by Drs. Farquhar and Lyell, and excellent descriptions of it have been published by Drs. H. Clark, De Eenzy, E. Gray, and others." One remarkable outbreak of it occurred among the Punjab muleteers. They had been sub- jected to severe privations, long marches without shelter from the rains, and short rations, and they had become so emaciated as to resemble the sufferers from the Orissa famine," An extensive epidemic, described by Dr. Vandyck Carter,p occurred in 1 877-8-9 in Western India, coinciding with a period of famine due to prolonged drought. i Dubois, 1848. ^ Flint, 1852. ^ Flint, 1870; A. CLAr^K, 1870; Parry, 1870. "■ Geiesinger, 1864, p. 2^] T„ footnote. " See H. Clark, 1869 ; also Sanitary Reports of the Punjab for 1868 and 1869, and Lancet, 1869, ii. 648. Parkes regards the fever described by Dr. W. Walker (see p. 60) as relapsing fever (Army San. Rep. ii. 361). " While fully conceding that relapsing fever may occur in India, I must record my dissent from the view expressed in a recent work by Dr. E. T. Lyons of the Bengal Medical Service (E. T. Lyons, 1872). According to this writer all the fevers regarded as ' malarious remittent fever ' in Lidia are really relapsing fever, and the origin of any fever from malaria is absolutely rejected. Dengue and yellow fever he seems also to look upon as identical with relapsing fever. It ap- pears to me that in very many of the epidemics to the records of which he apjjeals, the diagnosis of relapsing fever is baspd upon very meagre and unsatisfactory data, while in some there is positive proof that the disease was not relapsing fever. Exceptional cases of relapsing fever may resemble many other diseases, but in most cases the range of temperature, which Dr. Lyons considers to be quite ' un- imnortant as a character for classification,' Avill suffice for a diagnosis. p Carter, 1882. T 2 324 EELAPSING OR FAMINE FEVER. Lastly, relapsing fever, or a disease very similar to it, has' been observed in Algeria,i and in the island of Reunion/ Sect. V. Etiology of Eelapsing Fester. A. Predisposing Causes. I. Sex. Of 2,115 cases admitted into the London Fever- Hospital in twenty-three years (1848-70) 1,279 were males, and 836 females. The difference is the more remarkable, considering the excess of females in the population and among the typhus patients drawn from the same sources. (See p. 62.) Published statistics of other institutions show for the most part a similar excess of males, and never any great preponderance of females, as appears from the following tabular statement. TABLE XXV. Places Males Females Total London Fever Hospital .... Edinburgh, 1843'* 1847-8' 1848-9" Glasgow, 1847-8^ St. Petersburg, 1864-5*' .... Breslau, 1868-9^ Total 1,279 683 no 1. 159 2,310 278 356 545 93 1. 174 889 265 2,115 712 1,228 203 2,333 3,199 543 6,175 4,158 10,333 It is not to be supposed that anything in the male sex specially predisposes it to suffer from relapsing fever, but the difference referred to is probabty attrilmtable to the fact that far more males than females belong to the class of tramps and vagrants, who constitute a large proportion of the cases of relapsing fever. 2. Age. Table XXVL (p. 325) shows the ages of 2,111 cases admitted into the London Fever Hospital in twenty-three years (1848-70). The youngest cases were two boys aged 5 months, and the^ oldest, a man aged 75. ^ Arnould, 1867. ■■ Union Med. July 1865, p. 54. " Wardell, 1846 ; CoRMACK, 1843 ■> Douglas, 1845. * Robertson, 1848; E. Paterson, 1848. " Edin. Infirm. Eep. '' Steele, 1848. •" Zuelzer, 1867, p. 647. "" Lebert, 1870, p. 487. ETIOLOGY PREDISPOSING CAUSES. 32s TABLE XXVI. 1 No. of Cases Percentage A 1 at eacb A„e . period of Males Pemales Total life Under 5 years 1 19 20 39 1-84 From 5 to 9 years 59 67 126 5-96 , 10 to 14 ,, 129 105 234 11-08 , 15 to 19 „ 266 139 405 19-13 , 20 to 24 „ 244 III 355 i6-8i , 25 to 29 „ 130 77 207 9-80 , 30 to 34 „ 100 78 178 8-43 , 35 to 39 „ 80 64 144 6-82 , 40 to 44 „ 73 69 142 6-72 , 45 to 49 .. 65 25 90 4-26 , 50 to 54 „ 45 35 80 3-78 , 55 to 59 „ 28 11 39 1-84 , 60 to 64 „ 30 24 54 2-55 , 65 to 69 „ 5 7 12 •56 , 70 to 74 „ 3 2 5 •23 , 75 to 79 .. I I •04 Age not specified . 2 2 4 Total, omitting doubtful cases 1,277 834 2,111 99-85 TABLE XXVII. Ages Per cent, of Typhus Cases Per cent, of Relapsing Cases Under 1 5 years there were From 15 to 25 years .... 25 years and upwards .... 30 >. >. .. .... 50 „ „ „ .... 19-94 29-39 50-57 41-05 10-64 18-88 35-94 45-03 35-23 9-00 From this it would appear that relapsing fever attacks all ages, but that the proportion of patients between 15 and 25 years to those more advanced in life is greater than in the case of typhus. The contrast between the ages of the two fevers is apparent from the foregoing tabular comparison (Table XXVII.), and also from the fact that while the mean age of the typhus patients was found to be about three years above that of the total population, or 29-33, ^^^^.t of 437 patients admitted prior to 1868 was only 24-4-1, or two years under that of the population (see p. 62). Although the male patients outnumbered the females at all ages excepting under ten, a somewhat larger proportion of the 326 EELAPSING OE FAMINE EEVEE. females were advanced in life. Thus 3777 per cent, of the females, but only 33'65 of the males, were over thirty, and while the mean age of 206 females (admitted prior to 1868) was 26-01, that of 231 males was only 22-98. The number of patients between the ages of 40 and 45 almost equalled that in the preceding lustrum, but in females only was there the absolute increase noticed in typhus (see p. 64). These results agree with most of the statistics of Eelapsing Fever, which have been published. Of 203 cases admitted into the Edinburgh Infirmary during the years 1848-9, 45, or 22-16 per cent., were under 15 years of age; 50, or 24-63 per cent., above 30; and only 9, or 4-43 per cent., above 50."^ Of 215 cases under Halliday Douglas in 1843, 'j'j were under 20, 135 under 30, 80 above 30, and 28 above 50.^ Lastly, of 2,333 cases in Steele's report of the Glasgow epidemic of 1847, 302, or 12-94 pel' cent., were under 15; 795, or 34-07 per cent., were above 30; and 153, or 6-55 per cent., were above 50.^ 3. Months and Season of Year. Table XXVIII. (p. 327) shows the~ number of cases of Eelapsing Fever admitted into the London Fever Hospital in each month during twenty-three years (1848-70). The largest number of cases has been admitted into the London Fever Hospital during the winter and autumn months ; but the undue preponderance in these months was caused by the epidemic of 1869-70. Eelapsing Fever is an epidemic disease, on the prevalence of which season of the year has little influence. In one epidemic, the largest number of cases occurs during one season ; in another epidemic, during a different season. In Edinburgh in 1843, the epidemic was at its height during the autumn and winter; the St. Petersburg epidemic of 1864-5 was at its climax in winter and spring; the Glasgow epidemic of 1847, in spring and summer. The Edinburgh epi- demic of 1843 commenced in January or February, the Dublin epidemic of 1826, and the London epidemic of 1869, in May; the Leith epidemic of 1843, in September; and the Glasgow epidemic of 1843, in December 1842. Epidemics of Eelapsing Fever appear then to commence, progress, and decline, quite irrespectively of the season of the year. Eelapsing Fever differs from Enteric Fever, in not being always most prevalent in autumn ; and from Typhus, in not being usually most prevalent during and towards the end of winter. Statistical Bciwrts. " Douglas, 1845. " Steele, 1848. ETIOLOGY — PREDISPOSING CAUSES. 327 1-1 ro ro u-i 00 HI : m c<3 ro VO t^ On ON vo 1-0 •i3*niA\. ^ rn Tj- "-o u-1 ■* • w ; »J^ : H-l 00 unm^ny M 00 t^ ON • M : CN ^ On VO jaiaumg • cr> ■* "^ ■rh ■* N : CO w . : m >-o ^o Suuds IT) 00 \o 1-1 00 W u-i ro : : VO N ro -taqniaoad W M W 00 10 • - 1-1 a : : : • VC) 1-1 : M rh '' ro ON ro jaqmaAOij ►H On fO "* M : CO : : : : • «3 11 M 00 VO ro jaqo^oQ 1-1 M ro 00 ro • rt en : : : : 1-1 . 00 ro jgqura^dag : : N 10 ■* : N ; : : I-. On ^jstigny cT) : : : : « m On mr : : ro 00 00 "H ii : : fo 1^ 10 ro N VO 3mX£ " *0 • ^0 M 1-1 • • : : ro : : : ro 00 ^ t— 1 Seyi : T}- : a^ N " : • : . rr> : ; ; >* : vo t~^ lucly On ro M 1-1 • 2 ! : : vo qojBH N : w Tj- t--. ro : ; ; : : 'o . 00 ro iiBruqg^j ■* i-i CO ■* - CO CO CO 00 328 RELAPSING OR FAMINE FEVER. 4. OccujJatioji. No occupation, in itself, predisposes to Ee- lapsing Fever. A large proportion, however, of the cases admitted into the London Fever Hospital have heen hawkers, street-musicians, beggars, or tramps, with no fixed residence, and this has been a common observation at all times and places. 5. Recent Residence in an Infected Locality. The annexed Table shows the length of residence in London of all the cases of relapsing fever admitted into the London Fever Hospital smce 1847, in which the circumstance was noted. TABLE XXIX. Less than 14 days ,, 3 months ,, 6 „ Longer than 12 ,, Total . 61 or 3*05 per cent. 141 ,y Tos 199 M 9'95 267 „ 13-36 1,731 „ 86-63 1,998 „ 99'99 From these figures it might seem that recent residence in London does predispose to relapsing fever. The result, how- ever, is not attributable to any local cause, for durmg fourteen years, not a case of relapsing fever was observed in London. It is due to the circumstance that a large number of persons attacked with relapsing fever are vagrants, who, after wandermg over the country in search of work or food, arrive destitute and exhausted in the crowded dwellings of large towns, where the disease is already prevalent, or to the fact that not a few of the patients have been actually ill at the time of their arrival. This has been a common observation in all epidemics ; and not unfrequently the patients, coming from no locality where the disease was known to prevail, have sickened at the wayside, the disease being apparently generated by the privations and exhaustion to which they have been subjected (p. 336). 6. Over-crowding and Destitution. Eelapsing fever being, like typhus, communicable from the sick to the healthy, over- crowding of course favours its propagation. Accordingly, it is found to prevail chiefly in the most crowded localities of large cities, inhabited by the poorest of the population. Of 1,212 cases admitted into the London Fever Hospital, 735 came from the central and eastern divisions or most crowded parts of the Metropolis, and considerably more than one-seventh from the single parish of Holborn. (See Table VIII. , p. 74.) The subject of over-crowding and destitution, in relation to ETIOLOGY— EXCITING CAUSE. 329 the prevalence of relapsing fever, will be again referred to in greater detail (p. 337). The remarks already made as to the effects of cold and wet, intemperance, bodily and mental fatigue, depression of spirits, &c., as predisposing to typhus, apply with equal force to re- lapsing fever. (See pp. ^J and 69.) B. Exciting Causes. I. Contagion.^ All observers, with the exception of Craigie and Yirchow, have believed relapsing fever to be contagious. Craigie, writing in the midst of the Edinburgh epidemic of 1843, when the disease was for the first time beginning to be regarded as dis- tinct from typhus, and before sufficient evidence had been collected as to its contagious character, stated that the belief that it was contagious was a * presumption rather than a well- founded inference.' ® Virchow, whose experience of the disease was then limited to a fortnight's visit to Silesia during the epidemic of 1847, came to the conclusion that the disease was not contagious, but was the result of local causes endemic in Silesia.^ All the medical men, however, practising in Silesia believed it to be contagious.^ That there is a poison in relapsing fever, communicable from the sick to the healthy, is proved beyond doubt by similar evidence to what has been adduced in the case of typhus. a. When rela'psing fever commences in a house or district, it often spreads with great rapidity. Thirty cases have been ad- mitted into the London Fever Hospital from the same house, and 66 cases from the same court, within a few months ; and similar observations have been made at all times and places, when the disease has been epidemic. h. The prevalence of relapsing fever in single houses, or in limited districts, is in direct proportion to the degree of inter- course hetween the healthy and the sick. This was observed to be the case at Glasgow and in other parts of Scotland, in 1843. In many houses inhabited by several families, when the disease appeared in one apartment, it first attacked all its occui^ants, and then spread to the rooms adjacent, and afterwards sought '' See note ', p. 80. ^ Ceaigie, 1843, P- 4i7' ' ViKCHOw, 1849, p. 263. s Ibid. p. 254. 330 EELAPSING OR FAMINE FEVER. its victims in the other rooms on the same floor, in the order of vicinity and intercourse. The two following instances, recorded by Mr. Eeid of Glasgow,^ are to the point, while at the same time they demonstrate the importation of the disease into localities before exempt. The first has reference to the introduction and propagation of the fever at the Dalmarnock colliery, in 1843. This was a large tenement, standing alone and surrounded on every side by open fields. It consisted of three stories, entered by three separate stairs, and inhabited by forty different families. In May, an Irish family removed to a single apartment on the uppermost story, the youngest child being at the time sick of the fever. On the 2nd of June the father sickened, and m suc- cession the whole family. The disease then spread from room to room, and in the space of two months attacked twenty- two persons on this story, the other inhabitants of the building being all this time exempt. The absence of the fever before the arrival of the infected family and its subsequent propagation, first in the infected family, and afterwards among those only in closest communication with them, are facts quite inexplicable on the supposition of a local origin, and indeed in any other manner than on the supposition of contagion. Secondly, ' the disease was introduced by a person from a neighbouring village into a house of two apartments, situated in Mile-end, and containing within its narrow walls eleven human beings. All of these were attacked, and every one relapsed ; but in the next house, with a similar entry, and separated only by a brick partition, where the occupants were nearly equally numerous and, from their circumstances and habits, equally susceptible, all escaped.' Now, if relapsing fever were not contagious, and arose from malaria in the atmosphere, as many have maintained, why was it confined to the one house into which it was introduced, and did not extend to other houses in the immediate vicinity ? But again, most observers testify to the great liability of the attendants on the sick to contract the disease. In 18 19, Dr. Welsh, of Edinburgh, wrote thus : ' Since Queensberry House was opened on February 23, 1818, my friends, Messrs. Stephen- son and Christison, the matron, two apothecaries in succession, the shop-boy, washerwoman, and 38 nurses, have been infected ; four of the nurses have died. With the exception of two or ^ W. Eeid, 1843, P- S^o. ETIOLOGY EXCITING CAUSE. 331 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.'^ Cor- mack, in his account of the epidemic of 1843, at Edinburgh,, observed : ' Almost all the clerks and others exposed to the contagion have been seized. Dr. Heude, and his successor Mr. Eeid in the new Fever Hospital, Dr. Bennett my successor there, Mr. Cameron and his successor Mr. Balfour in the ad- joining fever house, as well as most of the resident and clinical clerks in the Eoyal Infirmary, have gone through severe attacks during the past summer and autumn. Hardly any of the nurses, laundry-women, or others coming 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.' J Similar observations were made in Glasgow and other Scotch towns in, 1843, in Silesia in 1847, ^^ St. Petersburg in 1865,. in Germany in 1868-9, and in Great Britain during the recent epidemic. In the London Fever Hospital, during the years 1869-70, 27 of the nurses and officers and 5 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 admitted. It is to be noted also, that in general hospitals, only those nurses and medical attendants who have been in close relation with cases of relapsing fever have contracted the disease. The nurses in the surgical wards, and in medical wards into which fever cases have not been admitted, have escaped. If the fever had depended on local causes, all ought to have suffered alike. c. Persons living in comfortable circumstances, and in localities tvhere the disease is unknoivn, are attacked on visiting infected persons at a distance. Pielapsing fever is a disease peculiar to the destitute, and only attacks persons in easy circumstances who have had direct communication with the sick. Medical men, living in localities where the disease is unknown, have often been attacked immediately after exposure to the poison. A remarkable illustration is recorded by Wardell. Within a space of five months, in 1843, the resident physician in one of ' Welsh, 1819, p. 45. J Coemack, 1843, p. 115. 332 EELAPSING OR FAMINE FEVER. the fever hospitals at Edinburgh had to be re-ai3pointed six different times, five of the gentlemen who held the post having in succession been attacked by the raging epidemic. All of these gentlemen had, previous to their attack, resided in dif- ferent and distant parts of the new town, where the epidemic was scarcely known, yet, as soon as they were exposed to contagion, they contracted the fever .^ d. Relapsing fever has often been imported by infected persons into localities before exempt. Certain localities have been ob- served to become foci for the propagation of the disease, imme- diately after, but not before, the introduction of infected persons. Two illustrations have already been given on the authority of Mr. Eeid of Glasgow. Many others might be added. In 1865, relapsing fever was imported into Cronstadt and other parts of Eussia from St. Petersburg ; ' while its appearance in New York in 1847 and in 1870 seemed due to Irish and English immigrants. In hospitals, it has always been found that the nurses and attendants never contracted relapsing fever, until after the admission of patients suffering from that form of fever. In 1870 relapsing fever was communicated to 5 nurses and patients in St. Mark's Hospital for Fistula by a nurse from the Fever Hospital, and by a ward-maid of St. Mark's who had visited the Fever Hospital ; this ward-maid and the Fever Hospital nurse were the two first persons attacked with relapsing fever m St. Mark's.^ From the foregoing evidence it is clear that relapsing fever is communicable by the sick to the healthy. So far as our knowledge extends, its contagium appears to be governed by the same laws as that of typhus. 1. The mode of communication is probably the same as in typhus, that is to say, the poison is conveyed through the air, or by fomites, from the sick to the healthy, and actual contact is not necessary. 2. The distance to which the poison tcill travel through the atmosphere. The remarks made on this subject, under the head of typhus, apply with equal force to relapsing fever. It is only they who are in close communication with the sick, or who visit, or reside in, their badly ventilated dwellings, that suffer. With free ventilation, the disease almost ceases to be communicable. Cormack states that in 1 843 there were many instances where relapsing fever was imported into houses in the new town of ^ Wabdell, 1846, xxxvii. 775. ' Zuelzer, 1867, p. 646. ™ Leaeeli, Lancet, June 11, 1870. ETIOLOGY — EXCITING CAUSE. 333 Edinburgh by medical students and others, who had contracted it by visiting the sick, but that he had never known an instance of its spreading in these locaHties. He also mentions an instance, where a single case of relapsing fever was treated in a general ward ; only one of the other patients, a man suffering from epi- lepsy, contracted the fever : this man, and this man only, had been in the habit of sitting on the fever bed." 3. Fomites. The poison of relapsing fever is communicable by clothes. At least, it is difficult in any other way to account for the fact mentioned by Cormack, of the large number of laundry- women who contracted the fever in the Edinburgh Infirmary during the epidemic of 1 843 ; ° they had no communi- cation with the sick, except through their clothes and bedding, and their circumstances were not such as to render an independent origin probable. Cormack' s statement has been confirmed by many subsequent observers and by the experience of the London Fever Hospital. Parry relates two remarkable instances in which relapsing fever was transported to a distance by infected clothes.P^ According to Wyss and Bock, there was evidence at Breslau in 1868 that the disease could be transmitted from the sick to per- sons at a distance, through the medium of third persons who themselves escaped.^ No fact confirmatory of this statement has come under my notice. 4. Length of exposure necessary in order to contract the disease. If the poison be concentrated, its effects may be manifested at once, but few instances of this nature have been recorded. A medical friend visited the Union Workhouse of the City of London, during a period of 1845 when upwards of 100 cases of relapsing fever had been sent from that building to the Fever Hospital. He was attacked on the spot with nausea and headache, and took to bed at once with the fever. A similar case is mentioned by Zuelzer.'' When the poison is more diluted, the danger seems to increase with the length of exposure, and, on the whole, a longer exposure appears necessary than in the case of typhus. According to Cormack, very few of the numerous medical officers of the Edinburgh Dispensary in 1843 contracted the disease, in comparison with the number of the medical attendants at the Infirmary. The former were much exposed to the fever in the badly ventilated dwellings of the poor, but were usually with their patients for short periods only, and had constant oppor- tunities for inhaling an uncontaminated atmosphere. " Cormack, 1843, p. 116. " Ibid. pp. 115, 117. p PaePvY, 1870, p. 341. « Wyss and Bock, 1869, p. 56. ' Zuelzer, 1867, p. 647. 334 RELAPSING OR FAMINE FEVER. 5. Tlie latent 'period of relapsing fever has been variously estimated, but there are few facts for fixing it accurately. Cases have been recorded to show that the effects of the poison may be instantaneous, while on the other hand the Silesian physicians in 1847 made the latent period vary from 14 to 21 days.^ Ac- cording to Lebert, it varied at Breslau from 3 to 7 days, but was oftener over than under 5 days, and sometimes extended into the second week.* Partly from my own observations, but mainly from other sources," I have collected 32 cases which bear more or less upon the point,^ and the results of which may be vsummed up as follows : — I. Period exactly fixed — 12 cases. 14, 13, 12, 9, 7, 5, 5, 4, 2 days — attack immediate on exposure, 3 cases. 11. Both limits of period fixed — 6 cases. Between i and 12 days — 3 cases. ,, I and 16 ,, I case. ,, 14 and 16 ,, 2 cases. III. One limit only of period fixed — 14 cases. a. Maximum — 11 cases. 2, 3, 4, 4, 5, 5, 8, 9, 9, 10, 10 days. h. Minimum — 3 cases. 6, 6, 9 days. Hence it appears that : i . The period of incubation is even more variable than that of typhus. 2. It is on the whole shorter than that of typhus. In 9 of the 12 cases in which it was ac- curately determined, it did not exceed nine days ; in none was there reason to believe that it exceeded sixteen days ; in only 4 did it certainly exceed twelve days, and in only 4 others was it possible for this period to have been exceeded ; while in 1 3 of the 32 cases, it did not exceed five days. 3. Occasionally, as in typhus, there is no latent period at all, the symptoms commenc- ing almost immediately after the first exposure to the poison. [When communicated by inoculation of the blood the period of incubation varies from 5 to 8 days in man, from 30 hours to 5 days in monkeys. (See p. 401-) ' ViRCHow, 1S49, p. 262. ' Lebekt, 1870, p. 469. ° CoKMACK, 1843, p. 117; JjF-.Aimn, Lancet, June ii, 1S70 ; Zdelzkk, 1867, p. 647 ; Wyss and Bock, 1869, p. 65 ; Muiehe.uj, 1870 ; A. Clark, 1S70, p. 28 ; Paery, 1870, p. 341- " MuECHiSON, 1 87 1. ETIOLOGY— EXCITING CAUSE. 335 In all probability apparent periods mucli exceeding or falling short of these are due to errors of observation.] 6. Proportion of persons liable to he attacked, on exposure to the poison of relapsing fever. This is probably about the same as in typhus. During 23 years, i case of typhus originated in the London Fever Hospital, for every 62 typhus patients admitted (288 to 18,000) ; and i case of relapsing fever for every 65 ad- missions (32 to 2,083). 7. Immunity from subsequent attacks. Contrary to what was found to be the case with typhus, one attack of relapsing fever confers little or no immunity from subsequent attacks. Welsh tells us that, in the epidemic of 18 17-19, there were several instances of i)ersons having two, and even three, attacks ; '^ and Christison observes that during this same epidemic, he experi- enced no fewer than three separate attacks within fifteen months in his own person.^ Wardell ^ and Mackenzie,^ in the epidemic of 1843, met with several examples of persons having a second attack, after some months ; Jenner, from his experience of relapsing fever in London in 1847-50, arrived at the same con- clusion ; ^ and in the Irish epidemic of 1847, many individuals had a second, or even a third attack, at intervals of a few months.^ Similar observations were made at St. Petersburg in 1865,° and at Prague in 1867,*^ and at least two well-marked instances of a second attack after an interval of several months have come under my own notice (see Diag. IX.). 2. Indejjendent Origin.^ Although relapsing fever is undoubtedly contagious, it is highly probable that it can be generated de novo. A large num- l)er of patients are unable to trace their illness to contagion. Of 440 cases admitted into the London Fever Hospital prior to 1868, 171 (or 38-86 per cent.) ascribed their illness to contagion, mostly in consequence of other cases occurring in the same house, while the remainder were not cognisant of any exposure to the disease. It is quite possible, however, that a disease may \)Q due to contagion where the source is not traceable, while, on the other hand, the occurrence of many cases simultaneously in one house is no proof that a disease is contagious. A stronger " Welsh, 1S19, p. 46. "" ^ Cheistison, 1858, p. 583. y Wabdell, 1846, xxxvii. 230. ' Mackenzie, 1843, p. 226. » Jennek, 1850, xxiii. 119. " h-ish Report, Bib., 1848, viii. 65. " ZuELZEE, 1867, p. 652. '' Peibeam and Eobitschek, iS69,p. 248. ' See p. 8. 336 EELAPSING OE FAMINE FEYEE. argument in favour of the independent generation of relapsing" fever is the fact, that after it has been entirely absent for many years it again breaks out, on each occasion under precisely similar circumstances, and occasionally, as in Scotland in 1843, without any traceable importation, or source frorn which it could have been imported. Professor Christison, no advocate for the independent origin of other fevers, speaks of the ' spontaneous generation ' of relapsing fever from ' penm-y pent up in airless dwellings ' as a matter beyond doubt/ For the same reasons, Zuelzer^ and other writers declare that the disease was developed de novo at St. Petersburg in 1 864. Lebert observes that at Breslau in 1868, although it was currently believed that the disease must have arisen by contagion, there was no shadow of a proof that it did so, and every circumstance of the epidemic was opposed to such a view.^ From the fact that epidemics of typhus and relapsing fever often co-exist, it may be assumed that the conditions under which both originate are similar, and these conditions may be summed up in two words— destitution and over- crowding. Accordingly, in all accounts of both typhus and relapsing fever, it is stated that the cases have been confined to the poorest of the population, and for the most part to the most crowded localities of large cities. A closer investigation by the process of elimination renders it probable that, while the poison of typhus is generated by over-crowding, and destitution favours its exten- sive propagation, that of relapsing fever is more intimately con- nected with, if it be not generated by, destitution, and is pro- pagated by over-crowding. In the first place, it may be well to demonstrate the intimate connection between relapsing fever and destitution. Of 2,115 cases admitted into the London Fever Hospital in twenty-three years, 2,057, or 97*26 per cent., were paid for by the parochial authorities, and totally destitute. Of the remaining 58 cases, 15 were also in a most destitute state, 25 were hospital nm*ses, and for only 1 8 was an admission-fee paid.' A large proportion of the patients, for some time previous to their attack, had been literally starving. Before the outbreak of the epidemic of relapsing fever in Ireland in 18 17, the inhabitants, owing to a succession of bad ' Chkistison, 1863, p. 440. « Zuelzer, 1S67, p. 640. ^ Lebekt, 1870, p. 462. ' The reader is referred to the corresponding remarks nnder the head of Typhus and Enteric Fever. ETIOLOGY — EXCITING CAUSE. 337 liarvests and other causes (see p. 39), had for a long time been reduced to extreme starvation ; and many had been compelled to feed on indigestible articles, such as grass and the roots of trees. Similar observations were made in Silesia in 1847; prior to the outbreak of the epidemic, a succession of three bad harvests had reduced the inhabitants to such a state of starva- tion, that numbers died from this cause alone, and many subsisted on clover, grass, inushrooms, the roots of trees, kc) The state of misery and destitution, under which the epidemic of 1847 broke out in Great Britain and Ireland (where a large proportion of the cases were also at first relapsing fever), has been already referred to (p. 48). Speaking of Glasgow, in 1847, Dr. Orr writes : ' The fever-hospitals were crowded to overflowing with houseless wanderers. . . . Many poor, starved, destitute, and diseased creatures were brought and laid down before the gates of the Infirmary, their relatives, if they had any, not knowing what to do with them ; and, in numerous instances, it was desti- tution and starvation more than fever which was their chief affliction. To destitution, therefore, we are principally to look for the cause, which during the last year has filled our fever- hospitals to overflowing.' ^ These remarks applied with equal force to every locality in the kingdom, where the epidemic was observed. But, admitting all these facts, it may be argued that the famine and the fever are both the results of one common cause — of inclement weather, or of some subtle atmospheric influence. Weather, however, is found to have no influence over the origin or propagation of relapsing fever. It prevails alike in seasons remarkable for the amount of rain (Silesia, 1847), and in seasons remarkable for their drought (Edinburgh, 1843), in unusually hot summers (Edinburgh, 1843), and in the cold of winter (Glasgow, 1842-3, and Leith, 1843-4). {Vide ante, p. 326.) Destruction of the crops from any sort of weather has sufficed to produce it. With regard to an atmospheric influence capable of destroying the fruits of the earth, and at the same time of inducing relapsing fever, its existence is in the first place a gratuitous assumption, while it is known that relapsing fever may appear quite irrespectively of failures of the crops, and under circum- stances where the destitution and misery of the population have, so to speak, an artificial origin. One of the most remarkable epidemics of relapsing fever on record — the Scotch epidemic of •I ViBCHOw, 1849, p. 177. " Orb, 1848, p. 371. 338 RELAPSING OR FA3IIXE FEVER. 1843 — was not preceded by failures of the crops. (See p. 47.) It did not affect Ireland, but was confined to Scotland, where its connection with destitution was proved by Alison and many other observers. In 1840, Alison called the attention of the authorities to the deplorable condition of the poor in Scotland, and to the inadequate measures provided by law for their relief.^ Owing to the construction of railways, which, it is said, attracted numbers of Irish labourers, and caused the inhabitants of the small villages and towns along the lines to flock into the large towns and to swell their pauper j)opulation, and to other causes, the misery and want of the poor, year by year, increased. Between the spring of 1840 and 1843, four public subscriptions, amount- ing to 20,oooL, were raised in Edinburgh alone, to relieve their immediate necessities. A charity fund was subscribed in Edinburgh to find employment for the poor, and the coincidence between the progress of the fever and the cessation of the opera- tions of this fund was remarkable. No. of Admissions Men employed by for Fever into Charity Pund. Royal Infirmary .» February (1843) • 933 • 74 March 556 83 April 320 96 May 119 113 June 35 161 July 25 251 August . 392 September 531 October , 638 n During the months of September and October, from thirty to fifty applicants had to be sent away daily from the gates of the Infirmary. The disease was entirely confined to the poor. We are told that some of the medical men in Edinburgh, whose practice lay among the better classes, did not see a single case ; while, on the other hand, it was calculated by Alison that of the destitute poor of Edinburgh scarcely one escaped. In Glasgow, it is stated that for two years before the appearance of the fever, the poor had been in extreme privation ; and it is added, that the epidemic ' made its appearance, and began to spread, in those localities where poverty and wretchedness of every description most abounded ; and that during the whole season of its prevalence, the pauper population were almost its only ■ Alison, 1S40. «■ Ibid. 1S44 (I). D. Smith, 1844 (2), p. 79. ETIOLOGY— EXCITING CAUSE. 339 victims.' Of 1,768 cases collected by Alison," Halliday Douglas,? and MuiTay,i 1,179, 01* about two-thirds, were out of employ- ment and utterly destitute at the time of seizure, and many of the remainder had also been out of employment, and had only got work a few days before. Moreover, it is important to observe, that the proportion of the very destitute among the patients attacked diminished as the epidemic -advanced. Of 177 patients in the Edinburgh Infirmary on July 22nd, 127 were out of employment, wdiereas on September 30th this remark applied only to 184 out of 330 cases. There are no data for determining the precise proportion at the commencement of the epidemic. Similar observations were made in London, as shown by the following extract from the Annual Keport for 1 843 of the Fever Hospital : ' The present epidemic has "' afforded striking and extensive evidence of the close connection between fever and destitution. A large proportion of the subjects of fever received into the hospital during the past year were agricultural labourers and provincial mechanics (not Irish), who had been induced to leave their native counties in search of work, and who, either on their road to the Meti'opolis, or soon after their arrival in it, were seized with the disease. The causes assigned for their illness by these poor creatures themselves were various, some stating that it was owing to sleeping by the sides of hedges, others to want of clothing, many being without stockings, shirts, shoes, or any apparel capable of defending them from the inclemency of the weather ; while others, and these constituted a very large pro- portion of the number, attributed it to want of food, being driven by their intense hunger to eat raw vegetables, turnips, and even rotten apples ; and certainly their appearance, in many instances, fully corroborated the truth of their representations.' Compare with this the following extract from the Eeport of the London Fever Hospital for 1869: 'With rare exce^Dtions the patients admitted with relapsing fever have been in a de- plorable state of destitution — far greater than that of the average of typhus patients. Even the nurses were strongly impressed with this fact. A large proportion of the patients were tramps, who had travelled long distances in search of work, and many of whom appeared to have arrived in London with the fever upon them. Many admitted during Sei^tember and October had only just returned from hop-picking in Kent, where they had been Alison, 1844 (i). * Douglas, 1845. " Murray 1843. z 2 340 EELAPSING OR FAMINE FEVER. sleeping in barns and under hedges and eating unwholesome^ food ; several patients, for instance, stating that they had eaten nothing for weeks excepting raiv turnips and unripe fruit.' In Eussia in 1864-5, and subsequently in Germany, relaps- ing fever was found to be restricted to the very poOr and destitute, and if occasionally both in these countries and elsewhere the disease has attacked a few of the better class in virtue of its contagious character, it has never spread to any extent among them. Throughout the recent epidemic in London I have not seen one case of relapsing fever in private practice. The intimate connection between the origin and progress of" relapsing fever and destitution being thus clear, I proceed to adduce some arguments in favour of the opinion, that in its origin it is more independent of over- crowding than typhus,, and that it is the result of destitution alone. I. It is not easy to isolate destitution from over-crowding. The two conditions almost invariably co-exist. Accordingly, in many of the accounts of relapsing fever it is stated, that not only were the patients most destitute, but that they inhabited localities which were densely crowded.'' But relapsing fever is found also to prevail where destitution alone could operate, which is seldom, if ever, the case with typhus. In Ireland, during great epidemics, it has attacked the inhabitants of the country villages and the houseless poor by the wayside, as well as the inmates of the crowded lodging-houses of the large towns. The Scotch epidemic of 1843 did not commence in the large towns, as typhus almost invariably does, but in the country- districts of Fife. In Edinburgh, in 1843, we are informed by Dr. Craigie, that the epidemic prevailed, not only in the crowded localities of the Grass-market and in the closes of the High- street, the Canongate and the Cowgate, but that ' a number of cases were sent from Musselburgh, Tranent, Penicuick, Had- dington, Dunbar, and similar situations, where the population was not dense and where ventilation was excellent.'* Mr. Bottomley described an outbreak of relapsing fever among Irish reapers at Croydon in 1 847 ; they had suffered greatly from privations consequent on the famine, but had not been subjected to over-crowding, for they had been in the habit of sleeping on the roadsides and under hedges. Even on the supposition that the fever in this instance was due to a contagium imported from ■■ See for example, Wardell, 1846, xxxvii. 153; R. Jackson, 1844, p. 418;, D. Smith, 1844 (2), p. 79 ; Phkry, 1844, p. 85. ' CK.UQIB, 1843, p. 417. ETIOLOGY EXCITING CAUSE. 34 1 Ireland, it is to be observed that true typhus, whose poison, from all we know of it, is much more active, rarely, if ever, makes its appearance under such circumstances.* (See p. 88.) In London, both in 1843 and in 1869, it was noted that tramps, on their road to the Metropolis, were often seized with relapsing fever. 2. But, secondly, it has been typhus, and not relapsing fever, which was observed in the crowded hospitals, ships and prisons of former days, and which is met with as a consequence of over- crowding in the intervals of great epidemics, when there is no general famine. 3. Conversely, it is Eelapsing Fever, and not Typhus, which has been observed to result more directly from starvation. To the evidence already given on this point, the following state- ments by Irish observers of the epidemic of 1847 ^^J be added. Dr. Lynch of Loughrea reported : ' Most of the cases of fever supervening upon the starvation-state were characterised by repeated relapses and short febrile attacks. I saw no instances of the short relapse fever amongst the gentry, except in clergy- men and physicians.' " Dr. Falkiner of Kilkullen reported his experience in almost the same words.'' 4. The voracious appetite often observed during the parox- ysms, and peculiar to Relapsing Fever, indicates its more intimate <3onnection with starvation,'^ as do also the anaemic cardiac mur- murs and the leuchsemia present in many cases. 5. The fact, already dwelt on, that, in mixed epidemics of Typhus and Relapsing Fever occurring during seasons of famine the former fever chiefly prevails at the commencement of the outbreak (p. 320), points to its more intimate connection with destitution. The result of famine has usually been, that the poor have flocked from the country districts to swell the pauper population of the large towns, which become more crowded the longer the famine lasts. As this crowding increases, the fever, which results from crowding (typhus), is gradually substituted for that which is more immediately the result of destitution. 6. Lastly, some of the appellations bestowed on Relapsing Fever in different countries indicate the popular opinion as to its origin. It is essentially the Famine-Fever of the British Isles, and the Armentyphus and Hungerpest of Germany. (See p. 312.)'' t BoTTOMLEY, 1847. " Iris/i i^e/jorf, jBi6. 1848, vu. 393- ^ Ibid. viii. 84. '' See under 'Symptoms.' " Eeferring to the origin of eiDidemics of Eelapsing Fever in India, Dr. E. T 342 KELAPSING OR FAMINE FEVER. [In the previous editions Dr. Murcliison here discussecl the question of the non-identity of typhus and relapsing fever ; but as their specific distinction is now universally acknowledged, it has not been considered necessary again to insert at length the arguments. An attack of one disease does not protect against an attack of the other, though it is much more common for relapsing fever to be followed by typhus than for typhus to succeed relapsing fever : nevertheless, many instances of the latter have been observed both in this country and on the Conti- nent ; and though the two diseases are often epidemic at the same time, and in the same house, transition forms are never observed, while convalescents from relapsing fever are often attacked by typhus,, and occasionally the reverse.] That grave objections may be raised to the suggestion that a contagious fever can be generated by mere destitution is readily conceded. It may be well, then, to refer to the phe- nomena known to be exhibited by the living body in consequence of starvation. The effects of starvation on birds and mammals have been studied by Chossat,^ and on the human subject, by Holland,'' Donovan,* and others.^ Chossat found that animals rapidly diminished in weight, while at the same time the tem- perature of their bodies decreased. The fat was almost com- pletely removed, and the blood was reduced to one-fourth of its normal amount ; whilst the nervous system experienced scarcely any loss. Death appeared to be coincident with the consump- tion of all the disposable combustible material, and to be really caused by cold ; in some cases it was preceded by cerebral symptoms showing that ultimately the nutrition of the nervous centres became impaired. In Chossat's experiments the reduc- tion of food was more sudden and complete than it usually is in the human subject. Holland, who investigated the effects of starvation on the poor of Manchester, mentions, among the earliest symptoms, emaciation, exhaustion, languor, listlessness, despondency, and giddiness. These symptoms were sometimes succeeded by others of a cerebral character, such as staggering, dimness of sight, delirium, stupor, and coma. At other times, the exhaustion was followed by symptoms of reaction — quick pulse, flushing of the face, dry tongue, intolerance of light, pains in different parts of the body of a neuralgic character, and delirium. At the same time he observed that all the secretions Lyons observes : ' The view maintained by Murcliison receives strong confirmation from the history of epidemics whicli have happened in this country ' ilnd. Ann. of Medi Sc. July 1872). y Chossat, 1843. '■ Holland, 1839. " Donovan, 1848. '' Cabpentek's Principles of Human Physiology, 5th ed. p. 57. ETIOLOGY — EXCITING CAUSE. 343 of the body became vitiated. Similar effects were witnessed bj^ Dr. Donovan among the Irish peasantry in the district of Skibbereen, dming the famine of 1 846-7. In addition, he says : ' The skin exhaled a peculiar and offensive fetor, and was covered with a brownish filthy-looking coating, almost as in- delible as varnish ; this I was at first inclined to regard as incrusted filth, but further experience has convinced me that it is a secretion poured out from the exhalants on the surface of the body.' Other observers have noticed that during starvation the body exhales a putrid odour, not unlike that of a corpse, and that after death putrefaction is immediate and rapid.*^ Under prolonged abstinence then, the human body seems to become the subject of purely chemical changes, the processes of vital renewal not taking place as in health ; ^ febrile symptoms are developed ; while at the same time the deficient supply of new histogenetic materials appears to check the elimination of those which have become effete, for in no other way can we account for that tendency to putrescence, manifested during life in the fetid exhalation and peculiar secretion from the skin, and after death in the rapidity with which putrefaction super- venes. Mr. Kelly, in his report of relapsing fever at Mullingar in 1 847, wrote as follows : ' Its smell was peculiar, not fetid or heavy, but something like burning straw, with a musty odour; and, strange to say, there was not a single pauper in the work- house, with whom I had any intercourse, that did not evolve a similar odour when heated, even by the slightest exertion.' *" It is not unreasonable to suppose that under such circumstances a contagium should be generated capable of lighting up fever in the system, and communicable by the sick to those who are in health. It may be argued, that persons are constantly exposed to want, without fever resulting. But, under ordinary circum- stances, the means provided for the relief of the poor prevent that degree of want necessary to give rise to the phenomena above described, which are only produced during seasons of famine or of public calamity, when the ordinary means of relief are inadequate. Even then, the effects may often be warded off by extraordinary exertions on the part of the rich, as was the case for a time in the Edinburgh epidemic of 1843. (See p. 338.) Again, there may'^be other circumstances conducive Cabpenteb, Op. cit. p. 57. See Liebig's Letters on Chemistry, Eng. ed. 185 1, p. 323. Irish Bepoi-t, Bib. 1848, viii. 65 ; see also Muirhead, 1S70. 344 RELAPSING OR FAMINE FEVER. to, or necessary for, the production of relapsing fever from de- stitution. In most accounts of epidemics of relapsing fever, it is stated that the inhabitants have not only been starving, but that they have subsisted on unwholesome articles of diet, such as the roots of trees, grass, fungi, &c. (See pp. -39, 336, 339.) Or, it is possible, that personal uncleanliness may contribute towards the production of the results in question. Eelapsing fever has been for the most part confined to the lower Irish, and to the poor of those nations who most resemble the Irish in their habits. Personal squalor, however, will not alone generate relapsing fever ; for, while the former is constant, the latter only appears during seasons of great distress. With regard to the view that relapsing fever is due to malaria, or to some subtle and obscure atmospheric agency which is the cause of both famine and fever, it has been shown that artificial famine has sometimes been followed by the same consequences as that from failure of the crops, and it is unintelligible that any atmospheric agency or malaria should only attack the desti- tute, and leave those who are well fed exempt. Of all the causes that can be assigned for the origin of relapsing fever, it seems to me that destitution is the most tenable. ' We give the name,' says Brown, ' of cause to the object, which we believe to be the invariable antecedent of a particular change ; ' ^ and such appears to me to be the relation of destitution to relapsing fever. This much at all events may be asserted with confidence, that as long as there is no great destitution in a population, relapsing fever will not become epidemic, and that an epidemic will cease when the poor are well fed. These facts are most important, even if the theory founded on them be not accepted. Sect. VI. Symptoms of Eelapsing Fever. A. Clinical Description. The patients, while walking about, or engaged in their ordi- nary avocations, or on first awaking in the morning, without any premonitory symptoms, are suddenl}' seized with a sense of chilliness or with rigors, oftentimes severe, and accompanied by frontal headache and pains in the back and limbs. There is slight prostration of strength from the first, but it rarely ap- ' Inquiry into tlie Relation of Cause and Effect, 3rd ecl.Edin. 1818. SYMPTOMS. 345 proaches in severity to that of typhus ; the patients usually take to bed at once, owing to extreme giddiness rather than to weak- ness ; very often they are able to walk to hospital two or three days after their seizure. After a period, varying from a quarter of an hour to several hours, the cold stage is succeeded by a dry burning skin, great increase of the headache and of the pain in the back and limbs, and violent thirst. Occasionally on the second or third day there is sweating, in some cases profuse and lasting for several hours, but not attended nor followed by any relief to the head- ache and other symptoms. In a few cases this sweating occurs earlier : no well-marked hot stage intervenes between it and the primary rigors, but the sweat breaks out on the face and upper part of the body, while the patient is yet in his initiatory rigors. In many cases the sweating alluded to is not observed. After the primary cold stage, or after the above-mentioned -sweating when it occurs, the skin continues dry and hot (104 to 108-5° Fahr.), this condition being occasionally interrupted by irregular short rigors, or slight sweating. No characteristic eruption appears at any time ; but in a varying proportion of the cases, there is decided jaundice. The pulse almost invariably exceeds no ; as a rule, it reaches 120 ; and, in not a few cases, it is as high as 140 or 160; it is not rarely 140 on the second day of the disease ; at the same time it is often full, and of con- siderable firmness. The tongue is at first moist, and covered with a white or yellowish fur ; it may continue in this state throughout the illness ; but in rare cases, after three or four days, it becomes dry all over, or exhibits a dry brownish streak along the centre. The thirst is excessive ; the appetite is often absent ; occasionally it is voracious ; the bowels are constipated. In the jaundiced patients there is no absence bf bile from the stools, which either retain their normal hue, or are unusually dark. In many cases, there is more or less tenderness on pressure over the epigastrium and in the splenic and hepatic regions ; while percussion indicates obvious enlargement of both liver and spleen. Nausea and vomiting are not uncommon ; sometimes they are amongst the earliest symptoms, and continue incessant. The vomited matters consist of a green bilious fluid, or rarely they are black, like coffee-grounds. The urine is high- coloured, and in the jaundice cases contains bile. The head- ache continues severe, and is often of a throbbing character, while the pains in the muscles and joints are intense. Sleep- lessness is almost invariably a distressing symptom ; the mind 34^ EELAPSING OR FAMrNB FEVEE. is usua clear, but now and then delirmm occurs about the fifth or sixth day. About the end of the first week, sometimes as early as the third, or as late as the tenth, but in most cases on the fifth or seventh day, there is an abrupt cessation of all the symptoms. At one moment, the patient may be groanmg with pain, with his pulse at 120 or 150, and a dry burning skin, and within a few hours, the pulse may have fallen to below 70, and the tem- perature from 108° F. to several degrees below the normal standard ; the skin is moist, and the tongue clean, and the patient, free from pain, declares himself perfectly well, with the exception of a certain amount of languor and exhaustion. This sudden amelioration is almost invariably ushered in by profuse jDer- spiration, but in rarer cases by diarrhoea, epistaxis, catamenial discharge, or hsemorrhage from the bowels. Occasionally improve- ment is immediately preceded by brief, but violent delirium. The patient has now a good appetite ; and, day by daj, he gains strength, and there are all the indications of permanent convalescence, except that the pulse is often unusually slow — ■ 40 to 60. In many cases he is up and walking about, or he is discharged from hospital. But, after a week's interval, mostly on the seventh day from the crisis, or on the fourteenth (twelfth to the twentieth) day from the commencement of the first attack, without any warning or cause to account for it, what is called ' the relapse ' sets in. The patient is suddenly seized with rigors, followed by headache, pains in the back and limbs, burning skin, rapid rise of temperature, quick pulse, furred tongue, vomitmg, tenderness at the epigastrium, constipation, and occasionally delirium. The rise of the pulse and tempe- rature are as rapid as were their fall in the preceding crises.. In a few hours the pulse may rise from 50 or 60 to 120, or up- wards. The relapse is, in fact, a repetition of all the symptoms observed in the primary paroxysm : sometimes the symptoms are more severe ; at other times, they are less so. The relapse usually lasts three days ; in some cases, it lasts only one or two days, and in others, five or more. Now and then, there is a second relapse, coming on about the twenty-first day, and lasting two or three days ; and in rare instances, even a third or fourth relapse occurs. On the other hand, there may be no relapse at all, the patient continuing to convalesce after the crisis of the first paroxysm. Eelapsing fever is far from being mortal. Uncomplicated oases almost invariably recover ; and the total mortality rarely SYMPTOMS. 347 exceeds i in 25, or i in 50. Great prostration and sinking, however, are apt to come on suddenly in the course of some cases ; the face assumes a purpHsh hue ; the extremities are cold and livid ; the patient cannot be roused, and there are all the phenomena of profound collapse, which may terminate in death ; sometimes a fatal termination occurs in this way within a few hours after there had been no evidence of danger. At other times, death occurs at the end of the first or second paroxysm from suppression of urine, with delirium, coma, and occasionally convulsions. Pregnant females invariably abort in the course of relapsing fever, sometimes in the first, but oftener in the second, paroxysm. Abortion is sometimes, but not invariably, a cause of death. Convalescence is often retarded by the occurrence of dysen- tery, severe muscular and arthritic pains, or ophthalmia. B. Illustrative Case. Case XXXIV. Belapsing Fever. First crisis on 6th day. Belapse on 14th day. Second crisis on iSth day. Second Belapse on 24th day. Third crisis on 2'jth day. Erysipelas of Face on ^oth day. Eliza P , aged 26, a nurse in the Fever Hospital, was seized at noon on Nov. igth, 1869, with rigors, headache, and severe general pains preventing sleep. Occasional retching, but no jaundice. Tongue moist ; no appetite ; much thirst ; bowels confined. Spleen and liver both enlarged and tender. Perspired profusely on night of Nov. 24th, and next morning [6th day) was much better, and hungry. Continued better till Dec. 2nd {14th day), when she again lost her appetite, and the pains returned. Dec. 4th. Constant retching and no sleep. Dec. 6th [iSth day). Has perspired profusely, and is again much better, and hungry. Continued to improve till Dec. 12th {24th day), when she had rigors, followed by fever and vomiting. These symptoms subsided with copious perspiration on Dec. i^th {2'jth day). A fourth paroxysm of fever on Dec. i8th ushered in an attack of erysipelas of the face, which lasted five days, and was followed by an uninterrupted convalescence. The following Table shows the pulse, respiration, and temperature throughout the illness. (See also Diag. XL) 348 RELAPSING OR FAMINE FEVER. TABLE XXX. Day 9 A.M. 2 P.M. 9 P.M. of Dis- ease Pulse Resp. Temp. Pulse Eesp. Temp. Pulse Resp. Temp. 2 120 24 104-2 3 120 36 104- 120 36 104- ' 108 36 104- 4 120 34 104- 120 ... 104- ' 112 24 103- 5 112 34 I02- 120 32 103-8 114 32 103-8 6 108 32 I02-8 100 28 102-6 108 36 105- 7 72 20 95-4 72 20 96-8 76 24 98- 8 76 28 97*4 80 36 98- 68 32 98-2 9 68 32 98-4 68 30 98-2 72 28 98-4 lO 80 36 98- 98 32 98-6 72 28 98-2 II 68 28 97-8 80 28 98-2 68 20 97-8 12 68 28 98- 72 28 98-8 72 28 98- 13 64 28 98- 64 30 99-4 64 32 98-4 14 92 32 98-4 104 44 IOI-6 114 40 103-8 15 1x6 32 103-6 112 24 104- 112 20 105- 16 132 40 104-6 120 36 104-2 128 36 101-2 17 120 28 104- 128 32 104- 120 52 105- 18 98 28 99-4 98 28 ... 84 28 97- 19 64 24 97-4 72 36 97- 1^ 40 97-4 20 92 20 97-6 80 36 98- 24 J 20 36 104-8 ... ... ... 25 ... 120 32 105- .„ ... ... 26 120 30 105-2 . . • 1 112 30 102-4 27 96 24 99-2 ... ... 72 20 98- C. Analysis of Principal Symptoms. a. The Physiognomy. The countenance is often flushed and the eyes injected during the febrile paroxysms ; but the flushing is rarely of that dingy, earthy hue so common in typhus, and not circumscribed as in enteric fever. The vascularity of the eyes is also less marked than in typhus. Death by sinking is often preceded by duskiness of the face and a deep purple colour of the nose. When the paroxysms subside, the face may be unusually pale. During the febrile state, the countenance is often expressive of pain. The stupid, confused expression, so common in typhus, is rarely met with in relapsing fever; but in the few cases where cerebral symptoms sujpervene, the countenance may assume all the characters of the typhoid state, common to many diseases. The presence of jaundice in many cases im- parts a peculiarity to the countenance not observed in other fevers of temperate climates. Cormack described as one of the most remarkable ]3eculi- SYMPTOMS. 349 arities of the epidemic in 1843, 'a bronzing, leadening, or purpling of the countenance, before and after seizure.' In the ordinary mild cases, the countenance of the patient, according to him, had a peculiar appearance, which might be designated * bronzed,' for want of a better term ; whereas, in the severe cases, * a deep, persistent purple colour of the face appeared before or immediately after the invasion of the disease.' ^ These phenomena were chiefly observed at the commencement of the epidemic. After the epidemic had reached its climax, Cormack stated that facial bronzing ceased to be met with. Other ob- servers of the epidemic failed to recognize it,'^ and it was not a notable symptom in the London epidemic of 1868-69. h. Morbid Phenomena referable to the Skin. I. Eruption. Eelapsing Fever is not characterized by any definite eruption. Neither the measly eruption of typhus, nor the lenticular rose spots of enteric fever are present. The existence of the latter has never been asserted ; and as to the eruption of typhus, Alison,^ Henderson,-" and Craigie ^ all testified to its universal absence in the Eelapsing Fever at Edinburgh in 1843 ; while Wardell examined upwards of 1,200 cases,^ and Douglas 220, without ever detecting it. Jackson failed to find it once in upwards of 800 cases which came under his notice at Leith ; ™ and, with one exception, Arrott did not see any- thing resembling it in 672 cases observed at Dundee. Jenner never found any eruption in the cases examined by him in London, between 1847 and 1850." But in exceptional cases of relapsing fever, the surface of the trunk is covered with numerous small roseolar spots, or with a reddish mottling, varying in its characters, sometimes resembling the eruption of measles, but more commonly indistinguishable from that of typhus at an early stage, yet always disappearing on pressure, never becoming petechial, and fading after a few hours or three or four days at the longest. This eruption may appear on the third day, or immediately before the crisis, of the first paroxysm ; it may, or may not, recur with the relapse ; or it may be present in the relapse only. Cormack," W. Eobertson,P and •5 Cormack, 1843, pp. 3, 23. ^ See, for example, Douglas, 1845, p. 209, and Wabdell, 1846, ' Alison, 1843. J Hjendeeson, 1843. ^ Ceaigie, 1843. ' Waedell, 1846. " Jackson, 1844, p. 430. ° Jenner, 1850, xxii. 647. " Cormack, 1843, pp. 73, 106. p Eobertson, 1844. 350 RELAPSING OR FAMINE FEVER. Douglas ^ in Edinburgh, Watson in Leith,'" and Arrott in Dundee,^ each noted an instance of this eruption in the Scotch epidemic of 1843.^ In the recent epidemic I have noted it in. at least 8 out of about 600 cases ; ° while it has been also observed by Shaw in London/ Muirhead in Edinburgh,"^ and Tennent in Glasgow.'^ Several continental observers have also recently called attention to its occurrence, and more especially Zorn,y Zuelzer,^ Wyss and Bock,'' Pribram and Eobitschek,^ and Obermeier.° It appears to be more common in some localities than in others. Thus Tennent found a rash in 24 out of 352 cases at Glasgow ; while Obermeier at Berlin observed a mottling reminding one of typhus in the majority of cases. This may account for the statement made by Virchow, Diimmler, and other German observers, to the effect that an eruption was far from uncommon in the relapsing epidemic of Silesia in 1847, which differed from that of typhus in the foUowmg particu- lars : it appeared as early as the second or third day, and after one or two days disappeared ; it was rosy or pale red, effaceable by pressure, followed by desquamation, and not obvious after death."! 2. General Hyperamia. Lividity of the surface of the body is much rarer than in typhus. But, in cases where there are pulmonary complications, cerebral oppression, or sudden sink- ing, lividity of the face and entire surface may be observed. (See Physiognomy, p. 348.) 3. Petechics, Purjmra- Spots, and Vihices. True petechias (see p. 131), varying in size from a pin's head to a split pea, but in most cases very minute, are not uncommon. Smith noted them in 314 out of 1,000 cases at Glasgow;^ and in London they have been noted by Jenner*' and myself. In many in- stances, these minute petechias are evidently flea-bites. Alison was of opinion that even the larger spots 'originated in flea- bites and extended by little ecchymoses.' They cannot always, however, be thus accounted for. They often make their first appearance in large numbers in one night after the patient's admission into hospital ; their size is occasionally much larger 1 Douglas, 1845, p. 218. "■ Jackson, 1844, p. 430. " Arrott, 1843, p. 129. ' These cases were the source of much discussion. See Wardell, 1846, xxxvii. ■653, and CoRJUCK, 1849. " Lancet, January 22, 1870. "' Brit. Med. Jonrn. April 23, 1S70. ■" Muirhead, 1870. '^ Tennent, 1871. ^ Zuelzer, 1867, p. 660. » Ibid. " Wyss and Bock, 1869, p. 121. * Pribram and Eobitschek, 1869, iii. 151. ' Obermeier, 1869, p. 175. '' See ViRCHow, D^mmler (p. 349), &c., 1849; also Review, Bib. 1851, p. 35. ' Smith, 1844 (2), p. 70. ' Jenner, 1853, p. 259. SYMPTOMS. 351 than flea-bites ; while Wardell, Henderson, and Smith examined them carefully with a lens in a number of instances, but could not discover a central punctum. Jackson also caused two patients suffering from the fever (a severe attack in both in- stances) to be bitten by a number of fleas confined in a bottle. The bites went through the ordinary stages of a flea-bite in a healthy person, and did not enlarge. There can be little doubt then that these petechia are often the result of a hsemorrhagic tendency, engendered by the fever, or by the previous anaemic condition of the patients. Paterson met with petechias chiefly in persons who had been in the greatest destitution. s They differ from the petechise of typhus in not being developed in the centre of exanthematous spots. They do not appear on any specific day, but they are more common in the first paroxysm than in the relapse, and in cases where there is jaundice than when jaundice is absent ; of 21 petechial cases observed by Jackson, 14 had jaundice.^ Occasionally they co-exist with haemorrhages from the mucous surfaces; and Alison mentions one instance where the serum in a blister-vesicle was perfectly black.' Vibices are occasionally observed, and then the case is usually severe ; but the minute petechiae are probably not of much importance in prognosis. Although Kilgour, Alison, and Jackson thought that they were more frequent in fatal than in mild cases, they are far from uncommon in the mildest cases ; while Douglas at Edinburgh J and Smith at Glasgow'' were both of opinion that they added in no way to the danger or severity of the disease. 4. Sndamina. An eruption of miliary vesicles often accom- panies perspiration at the period of crisis. Ormerod found this eruption so common in London in 1847, that he designated the disease ' Miliary Fever.' ^ Few other observers have noted their occurrence, and they were present in only 12 of 220 cases ex- amined by Douglas,™ and in 14 of 95 eases observed by Wyss and Bock." 5. Desquamation. Relapsing fever is occasionally followed by extensive desquamation. Dr. Gueneau de Mussy tells me that he once removed from the body of a young lad, conva- lescent from relapsing fever at Dublin, a piece of epidermis fully ten inches square. During the febrile state the nutrition 8 R, Paterson, 1848, p. 404. '' Jackson, 1844, P- 428. ' Alison, 1843. J Douglas, 1845, P- 217. ^ Smith, 1844 (2), p. 70. ' Okmeeod, 1848, p. 217. ■" Douglas, 1845, p. 218. " Wyss and Bock, 1869, p. 123. 352 EELAPSING OR FAMINE FEVER. of the nails is impaired ; white marks are developed upon them coincidently with the attacks of pyrexia, but not with the apyretic- intervals. (See p. 136.) 6. The Temperature (see Case XXXIV. and Diagrams IX., X., and XI.) rises higher than in typhus or in most other fevers, and its course is pathognomonic of the disease. Christison long ago pointed out that in the epidemic of 18 17-19, it ranged from 102° to 105° Fahr., and at times even reached 107°;° while Cheyne, who took the temperature in 250 cases during the same epidemic, found that in 15 it reached 106° or 107°.^ More re- cently numerous accurate observations of the temperature, in some instances every two hours throughout the attack, have been made at the London Fever Hospital and elsewhere in Britain, and by many excellent observers in Germany.'^ The chief facts ascertained are these. The temperature commences to rise before the initiatory rigor, and before there is any rise of the pulse, and within twelve or twenty-four hours reaches i04°-io6°. It usually reaches its acme (io5°-io8-7°) shortly before the crisis, and occasionally at this stage it rapidly runs- up several degrees in a few hours. In one case Obermeier noted a rise of 4° in half an hour just before the crisis. During the paroxysm there are daily remissions of 1° or 2°, most marked in children, and mostly in the morning. At the crisis, which is sometimes ushered in with a rigor, the temperature suddenly falls, often to below the normal standard. A fall of 8°, or 9°, or 10° in a few hours is not uncommon (see Diagram XI.) ; and falls of 13'' in six, and of 14-4° in twelve hours have been noted.. For two or three days after the crisis the temperature may be as low as 96°, 94°, or even 92°, and in one case where collapse supervened Tennent found the temperature in the rectum not to exceed 90'6°. A subnormal temperature after the crisis is so constant as to be useful in diagnosis. After two or three days, the temperature occasionally shoots above the normal standard for a few hours ; but in any case it soon regains this,, and remains normal until the advent of the relapse, when the same phenomena are repeated as in the first paroxysm. The maximum temperature, as a rule, is higher in the relapse. A circumstance of some importance in the pathology of pyrexia is the fact, conclusively established by many independent " Chkistison, 1858, p. 583. ' Hudson, 1867, p. 274. 1 MuiBHEAD, 1870 ; Tennent, 1871 ; E. L. Fox, Med. Times and Gaz. March 5, 1870; DuFFiN and Kelly, IT?. October 9, 1869; Wdndeklich, i87i,p.333; Zuelzeb, 1867,' p. 662 ; Wyss and Bock, iS68, p. 105; Obeemeibr, 1869, p. 175; Pastau,. 1869 ; Peibbam and Robitschek, 1869. I # ^ t 1 i : i . 1. .; , 1 i i i I'M MM Ml ' M j i ; ! i i ; i ; 1 1 1 ! 1 1 i i ; ! ! i i : i 1 i 1 ! : 1 : : 1 MM 1 I 1 . ' ' I ' I 1 1 ! ! ! j 1 . \ \ \ i M ! : ' 1 i 1 1 1 ■| 1 1 ill 1 i i j i 1 MM < \'\ ]"' 1 : ! ! 1 1 i i i M Mil i i i H 1 1 'Mi \ t en ^~ ' ! ' i MM i ■ MM hm ! ■ I 1 ^ ; ' n ! 1 i ; i J ! ! M \ \ ■ \ ' - Mm ill i 1 -(^ ; 1 1 CO 1 — 1 - . ; ! ! i ' ! ' i ! ! 1 M ' ' ^ll M ' \ i i Jr> ' 1 ! ■ ! 1 ■■ 1 Mil ' ' j ; i 1 MM Mi 1 : 1 MM i 1 ^v ' i M 1 1-- ■ , : ; i 1 i ! Mi' \\ \^ ^ 1 i i i 1 i i [ i I ' Mil 1 M ! 1 T^ p, ^ i 1 i i_J_ : i i i 1' i — H :—i— J — •-yT j ^M i 1 ^^. \\\\ i 1 i i 1 ! M i ' 1 ^^ 1 h f— J- rn^ i i ! 1 ! ! — H 1 r- 1 ^ • i 1 1 ! M ; M j { ! i ! ■ ! ! ! j ' -r-r ; 1 1=* -« J ! 1 1 i j j M 1 1 1 i i 1 r ~~ H I 1 i 1 ! li . I n 1 ■. « - ^ ' J— i'l ll i ^ \L 1 1 1 i ' 1 i 1 i i ji 1' (N ! 1 1 I 1^ -III - - I _ |_ ^ : i ! M 1 M ^ 1 i 1 1 1 ! 1 1 1 j 1 i ! r—] 1 ' i 1 1 1 -. I ! i 1 ' 1 1 M...: ! M I ^ kl ! i i [ j I i 1 ! 1 i ~M ! I \ 1 — 1 — *"" i j i 1 1 1 ! ! 1 1' < i 1 i 1 i 1 r- 1 i 1 ' ) s V i iH - f CD - - - v ...- ' 1 "s: - — — M U-) ^ ( -1-1 _ - -4 ^ ' i j ■ ■ -p ■" M =Fh i ^~ ^Ji T"' 1 ^ --^ P „ . J M S| ^ h^ M CO " - - -bj >i i~j ■> < Si IN - y > r— 1 1 I ^ ' - - = — ^ i _ - "^ ^ }— — 1 — u 1 ^ -t 1 4fl o L o _ _ CO O c o ■ _ O ^ O O <35 05 t ^ 00 _, 3 fti I ! ! ! r 1 h - i T ■■f [— i 1 1 1 i ,-^ 1 1 j (M 1 ' i 1 i 1 1 i 1 1 1 O 1 ! j \ j 03 j i i 1 1 j j 1 OJ i i I i > 1 1-1 1 1 1 1 1 • > ( i 00 1 1 1 ! y\ 1 1 rH i 1 t 1 i _ _ 1 _ -4- 1~ ^ !> ■"■"■ :^' l|" - 1 1- 1 1 ! j i 1 r 1 O^ >• 1 1 ! 1 1 CO < t-n i 1 i 1 1 ! -* s rri ' 1 1 ' ' '^ i 1 i i ! \ \ '"" ^ ^^ i i ^ "" ■•■ - » 1 i I .—1 1 1 i j "1 -H CO . . . 1 ! j i ! V 1 > CM |L i J_ 1 - —4 II i 1 i 1 i: > ,—1 J_ 1 i K i ^^ i i > ! i O — ^_- - i i < > i 1 1 i ,"' 1 1 1 < 1 j i i.. "] j 00 1 1 ! K i I ! ..> i> f^ 1 i 1 < . 1 I H ^ ^ 1 r— i— _. ___ _ Z; :=>« •• r'~ ^ =a » ■" ! 1 ■ 1 ■ 1 ~ i Ln i ^ 1 j ! i «^ b" \ i 1 i j 1 1 rj 1 ■%: j j 1 i 1 ^- S I , ! i . 1 1 P 1 . CD - - - -^ = ^ 1 1 1 j s= • 1 i ?^ "^^^ 1 „ " j 1 1 j ~^ • ! 1 i 1 i 1 1 '<--^ ' --- - -■ 1 \ 1 1— — ~ — — — - -- — -+4 Is \- o o L CO o i L. c c O _ O Ql c< b o cn ^ ?, 00 L. J I I I I 'I I I i 1 !i ! Hi i^ M^IIM lii SYMPTOMS. 353 observers, that these high temperatures in relapsing fever entail little or no danger to the patient and do not produce serious cerebral symptoms. Of Obermeier's patients, the temperature of three rose to 107 "6°, of six to 1077°, and of two to io8'5°. * In all these cases, no special danger attributable to the high temperature could be discovered, nor even a single circumstance in which they differed from the rest.' ' During the attacks,' says Tennent, * the height attained by the temperature was on an average between 104° and 106°. In many cases, however, it was found to be as high as 107°, while in two cases 108° was noted. In these cases of very high temperature, the condition otherwise was not in any way notably different.' 7. Moisture. One of the most characteristic features of re- lapsing fever is the profuse perspirations which in most cases usher in and accompany the crisis. The patients for some hours are literally bathed in perspiration. Slighter perspira- tions are occasionally observed in the course of the paroxysm, as for instance on the second or third day, or immediately after the primary rigors. The perspiration which accompanies the crisis is sometimes preceded by a slight rigor, and in rare in- stances by a slight fall of the pulse. As a rule, however, the pulse does not fall until the sweating begins. The perspiration has an acrid reaction, and, according to Cormack, ' a charac- teristic disagreeable smell.' ' 8. Odour from the Skin. (See p. 343.) c. Morbid Phenomena presented by the Organs of Circulation. I. The Pulse almost always exceeds no; it may vary from 90 to 112, and usually reaches 120 or upwards; while in not a few cases, as the disease advances, it is 140 or 160, and in rare instances 170 or 180. Of 220 cases examined by Douglas in 1843, the pulse exceeded 120 in 105. In 20 of these 105 cases the pulse exceeded 140 in the minute ; in 29 it was above 130, but under 140; and in 56, above 120, but under 130.^ This remarkable rapidity of the pulse, although most marked in children, is common in adults ; of the 20 patients observed by Douglas in whom the pulse exceeded 140, several were above 40 years of age. Again, the pulse attains this great rapidity very early in the disease ; within a few hours of the initiatory rigor it may be as high as 120; and in this respect relapsing CoEMACK, 1843, p. 4. " Douglas, 1845, p. 213. A A 354 RELAPSING OR FAMINE FEVER. fever presents a marked contrast to typhus. In 15 cases of typhus observed on or before the fifth day, Henderson found the average frequency of the pulse to be exactly 100, whereas in 38 cases of relapsing fever the average frequency of the pulse during the first five days vs^as 123 ; in the 15 cases of typhus, the pulse exceeded 104 in only two instances ; in the 38 cases of relapsing fever, it did so in 37.* Moreover, the high pulse does not in itself indicate danger. Of the 220 cases noted by Douglas 19 died; but only one-third of the deaths occurred among patients in whom the pulse exceeded 120, and not one among those in whom it exceeded 140. Of 9 cases observed by Hender- son where the pulse exceeded 135, only one died. On the sup- position that relapsing fever is but a mUd variety of typhus, it is not a little remarkable that a symptom, which in typhus is thought to indicate danger, is so common in relapsing fever where the mortality is so small. The rapidity with which the pulse falls at the period of crisis is also remarkable. As a rule, the pulse begins to fall before the temperature. In a few hours, it may fall from 140 to 54. In the first half of the apyretic stage, however, the pulse usually continues a little above the normal standard, but for some days before the relapse, when the temperature has regained its normal height, the pulse is in many cases singularly slow, often not exceeding 44 or 50, but assuming the erect posture will sometimes raise it from 50 to upwards of 100. The slow pulse is not due to slowness in the contraction of the heart, but to a prolongation of the pause. There is not always a direct ratio between the pulse and temperature ; and usually there is less correspondence between them in the relapse than in the first paroxysm. The temperature may be 106°, while the pulse does not exceed 90. During the febrile paroxysms, the pulse is often at first full and bounding, and at the height of the fever there may be visible pulsation of the superficial arteries ; but at and after the crisis, the pulse may be small and feeble, jerking, undulatory, or irregular, and according to Obermeier a systolic murmur is sometimes audible over the arteries. After the crisis, the pulse is weak, and markedly dicrotous. 2. Action of the Heart. Towards the crisis temporary im- pairment of the impulse and first sound of the heart is not uncommon, but within a few days, or more speedily under the Hendekson, 1843, p. 206. SYMPTOMS. 355 use of stimulants, these symptoms usually disappear, so that they are probably clue to temporary weakness, and not to granular softening. Stokes,*" Lyons,^ and Heslop "^ first drew attention to the fre- quent occurrence in relapsing fever of a systolic bellows-murmur, loudest at the base of the heart and along the great vessels, and always diminished in intensity, or becoming imperceptible, when the patient sits up. The frequent occurrence of this sound has been noticed by many recent observers.^ In some cases, it is heard in both paroxysms and remains during convalescence ; but it always disappears as the patient regains strength. From these characters it is obviously a blood-murmur, and, as such, it is interesting in reference to the connection shown to exist between starvation and relapsing fever. Often, when there is no distinct murmur, the first sound is prolonged to almost double its normal length. 3. Blood. (See Post-Mortem Appearances.) d. Morbid Phenomena presented by the Organs of Respiration, 1. The Respiratory Movements are usually quickened, some- times out of proportion to the acceleration of the pulse, so that occasionally they amount to 40 or 48 in the minute, and are laboured, independently of any pulmonary complication. With much painful enlargement of the liver and spleen the respirations may be for the most part thoracic. When the pulse faUs to below the normal standard {e.g. 40 or 50), the respirations may remain as high as 20, so that the ratio of the resi^irations to the pulse may then be as i to 2. 2. Hypostatic Congestion of the lungs occasionally, but rarely, occurs. (See p. 142.) 3. The Expired Air. Leyden has shown in two cases that though the percentage of carbonic acid in the air expu-ed during the pyrexia is diminished, the total quantity exhaled is in- creased, the proportion being as 1*5 to i in the non-febrile state (see p. 143).^ When typhoid symptoms supervene, the breath has often an ammoniacal smell, and contains ammonia. (See P- 145.)' " Diseases of the Heart, 1854, p. 423. ^ Lyons, 1861, pp. 105, 161. " Ibid. "^ Texxent, 1871 ; Zuelzer, 1867, p. 665; Obeejieiee, 1869. J Leyden, 1870, p. 544. '■ Zuelzee, 1867, p. 667. A A 2 356 RELAPSING ,0R FAMINE FEVER. e. Morbid Phenomena j^resented by the Organs of Digestion. 1. The Tongue is usually slightly swollen so as to show the impressions of the teeth, and from the first covered with a white, yellowish, or brownish fur, of varying thickness ; but a clear triangular space is sometimes observed at the tip. The edo-es and tip are occasionally redder than natural, and the papilla somewhat enlarged; in rare instances the tongue is red and glazed. In the majority of cases it continues moist through- out the attack ; but in some, about the third or fourth day, it presents a dry brownish streak along the centre, or it becomes dry all over, or, in rare instances (3 per cent.), dry, brown, and crusted. The last appearance is only seen in very severe or fatal eases. 2. Broum Sordes on the teeth, lips, and tongue only occur in very rare cases (5 in 160, Zuelzer), with other typhoid symptoms, 3. The Appetite usually ceases with the supervention of the paroxysm, returns during the intermission, and ceases again during the relapse. But not uncommonly it has been observed to be voracious during the febrile paroxysms, and especially during the relapse. It is sometimes extraordinary to see a patient with a temperature of 105° or more craving for solid food, and, what is more, eating it and being none the worse. The following extract from the Eeport of the London Fever Hospital for 1843 has reference to the Eelapsing Fever of that year : — * A peculiarity, very novel in its character, was an inordinate desire for food ; this desire, so very unusual in fever, was all but universal. In some instances it was so uncontrollable, that no representation of the danger of indulgence produced the slightest effect in pacifying the minds of the patients ; but many insisted on leaving the hospital long before their convalescence was suffi- ciently advanced, declaring that they preferred running all risks to enduring their constant sense of starvation. Several of these were brought back to the hospital in a few days, having relapsed into a hopeless state of fever.' Observations to the same effect were made in Ireland in 1847. Thus, Dr. Eussell of Enniskerry, in his description of relapsmg fever, remarked : * One of the most anomalous symptoms of the epidemic, one which marked its true character (a famine fever), and impressed on the mind of the attendant the source and origin of the disease, was the SYMPTOMS. 357 importunate calls for food by all pauper patients, even during the first days of the attack.' ^ Since the above paragraph appeared in the first edition of this work, many cases of relapsing fever presenting the pecu- liarity referred to have come under my notice, and similar observations have been made at Berlin,'' Prague," and elsewhere. 4. Thirst is an almost invariable symptom, and is excessive far oftener than in typhus. 5. Nausea and Vomiting are among the most common symp- toms. Vomiting occurred in 643 of 1,000 cases observed by Smith, at Glasgow.*^ It is often one of the earliest symptoms, as in 56 of 80 cases observed by Wardell,® and then it may subside after two or three days, or recur more or less frequently. Some- times it is incessant throughout the paroxysm, everything swal- lowed being immediately ejected. Occasionally it does not appear until the paroxysm has lasted for several days. It ceases with the crisis, and may or may not return with the relapse. In some cases, it is more severe in the relapse than in the first paroxysm. The vomited matters are usually scanty, and consist for the most part of green bile, or of the ingesta tinged green of various shades. ' Black vomit,' similar to what occurs in 'Yellow Fever,' has been described by several observers, but more particularly by Cormack,^ Arrott,^ and Wardell.^ It is not noted as having been observed in any British epidemic except that of 1 843 ; ' and then it occurred only in a few cases, although it seems to have varied in frequency at different places. Cormack and Wardell met with several unequivocal examples of ' black vomit' in Edin- burgh ; but Alison J and Douglas,^ who had extensive opportunities of watching the epidemic in the same city, did not meet with a single case. Craigie,^ writing at the very height of the epidemic (October 1843), stated, that up to that time only 2 or 3 cases altogether had been observed in Edinburgh ; and Wardell him- self remarked that the cases in which this symptom occurred were quite exceptional. Dr. Smith of Glasgow seemed to doubt if true black vomit ever occurred ; while Perry of Glasgow, and Kilgour of Aberdeen, make no mention of it. On the other hand. Dr. Arrott described this symptom as ' quite common ' in * Irish Report, Bib. 1848, viii. 64. * Obeemeier, 1869, p. 165. ° Peibbam and Robitschek, 1869, iii, 159. * Smith, 1844 (2), p. 69. ' WaBDELL, 1846. ' COBJIACK, I843. s Abbott, 1843. '' Waedell, 1846. * In 1869-70, I failed to observe it once in 600 cases. J Alison, 1844 (i). ^ Douglas, 1845. > Ceaigie, 1843. 358 EELAPSING OR FAMINE FEVER. the fever at Dundee. Arrott gives no detailed description of his cases ; but the cases observed by Cormack and Wardell appear to have been unequivocal examples of true black vomit, the appearance being due to blood extravasated from the capillaries of the stomach, and altered by the acid secretions. In some cases there was a fine inky sediment in the vomit : at other times the sediment was grumous, in consistence like thick hare- soup, and in colour varying from dark-brown to black. Moreover^ the opinion that these appearances were due to altered blood was confirmed by the sources of the extravasation being found after death, in the form of superficial ecchymoses and large clots of blood, in the submucous areolar tissue of the stomach and intestines. Both Cormack and Wardell looked upon ' black vomit ' as an almost fatal sign. The former only observed it in the most * malignant ' cases ; and all the few cases seen by the latter died. Of 1 6 fatal cases in the Dundee Infirmary, black vomit was noted in 6. At the same time, if true black vomit was so common in Dundee, as stated by Arrott, it is remarkable that the mortality from the disease in that town was even less than at other places. Arrott lost only 7 of 672 patients, and in i only of his fatal cases does there seem to have been black vomit. Of the 6 fatal cases of black vomit occurring in the Dundee Infirmary, it is worth noticing that the patients were mostly advanced in life; the youngest was 25; the oldest, 69; and the average age of the 6 was 44 years, or considerably above the average age at which relapsing fever usually occurs. (See p. 325.) Dr. W. Eeid of Glasgow records the case of a girl, aged 14, who vomited large quantities of clotted blood ; in this case, there was also hsemorrhage from the bowels and from the ears.™ Zuelzer refers to three cases of profuse haematemesis observed at St. Petersburg in 1864-5. 6. Meteorism is an occasional symptom, and, when accom- panied by enlargement of the liver and spleen, may be the source of some distress. 7. Gurgling may be felt in cases complicated with diarrhoea, but is rare, and not confined to any particular part of the abdomen. 8. Abdominal Pain and Tenderness. In almost all cases there is more or less pain, increased by pressure, in the epigastric and Eeid, 1843, p. 359. SYMPTOMS. 359 hypochondriac regions. The pain in many cases is shght, but in others it is so acute as to cause great uneasiness and interfere with respiration. Frequently it is confined to the epigastrium ; but at other times it is limited to either hypochondrium, or it may extend over all these regions. Severe lancinating pains in the left side are not unfrequently found associated with enlarge- ment of the spleen. Pain and tenderness in the epigastrium often accompany vomiting, but their severity is not necessarily proportionate to the urgency of the vomiting. Epigastric pain associated with vomiting was present in 273 of 450 cases observed by Wardell, and the proportion would have been greater, had all the cases been observed from the commencement. There is no tenderness on pressure over the iliac regions, except where dysentery exists as a complication. 9. Enlargement of the Liver and Spleen. More or less en- largement of the spleen is present in all cases. Very often the organ is three or four times its normal size, and in some in- stances it is so large, that its edge can be felt projecting several inches beyond the lower margin of the left ribs, or it may cause a visible bulging of the abdominal wall. This enlargement may usually be detected on the first day of the disease, and attains its maximum towards the close of the paroxysm ; in most cases it subsides with the crisis and returns with the relapse ; but now and then it persists after the fever has ceased. Enlargement of the liver also occurs in most cases, but is less common and extensive than that of the spleen. 10. Constipation. As in typhus, the rule is that the bowels are constipated, although diarrhoea coming on late in the disease is an occasional complication, or may be critical. 11. Characters of the Stools. The stools may retain their natural colour and consistence ; more commonly, they are darker than natural. In severe cases, black coffee- ground matter similar to what is occasionally vomited, or black stools, are sometimes passed per anum. At Glasgow Gibson met with 9 instances (out of 202 cases), where haemorrhage took place from the bowels ; " two similar cases were noted by Tennent ; " while Hudson states that in the Irish epidemic of 1848 haemorrhage from the bowels was not unfrequent.P 12. Jaundice is a symptom noticed by almost all writers on relapsing fever, but is not so frequent as might be inferred from the importance attached to it by some observers. It was observed Gibson, 1843, p. 332. ° Tennent, 1871. •" Hudson, 1867, p. 91. 360 RELAPSING OR FAMINE FEVER. by Welsh in the Edinburgh epidemic of 18 17-19. 'Decided yellowness of the skin and eyes,' he remarks, ' occurred in 24 of 743 cases (or i in 30|-|) ; and in all those cases where the experiment was tried, the urine tinged linen yellow.' '^ This estimate was probably under the mark, as the total included a few cases of typhus. Jaundice was also noticed in the epidemic of 1826; "■ but, although there are no data for ascertaining its precise frequency, it does not seem to have been more common than in the epidemic of 1843. Many observers of the latter epidemic furnish precise information on the point. Thus, jaun- dice was present according to : — Wardell^ (Edinburgh) in 78 of 955 cases, or in i of i2'24 Douglas* ,, ,, 29 ,, 220 ,, ,, I ,, 7-58 Jackson" (Leitli) ,, 31 ,, 300 ,, ,, i ,, 9-7 Gibson^ (Glasgow) ,, 13 ,,. 114 ,, ,, i ,, 8-77 D. Smith '^ ,, ,, 384 ,, 1,000 ,, ,, I ,, 2-6 Total . . 535 of 2,589 „ ,, I of 4-84 In 1847-8, Eobertson "^ says that in Edinburgh jaundice was less common than in 1843, and Paterson noticed it only in 4 of 141 cases ; ^ but at the same time, in London, Jenner met with it in nearly one-fourth of his cases.^ Eecent observations make jaundice less common than in 1843. Thus it was present according to : — Zuelzer (St. Petersburg, 1864-5) in 222 of 1,065 cases, or in i of 4-8 Parry (Philadelphia, 1869-70) ,, 4 ,, 37 ,, ,, i ,, 9*25 Wyss and Bock (Breslau, 1868) ,, 9 ,, 95 ,, ,, i ,, 10-5 London Fever Hospital, 1869-70 ,, 153 ,, 1,671 ,, ,, i ,, 10*92 Tennent (Glasgow, 1870) ,, 30 ,, 352 ,, ,, i ,, 11-73 Muirbead (Edinburgh, 1870) ,, 3 ,, 40 ,, ,, i ,, 13-33 Total . . 421 of 3,260 ,, ,, I of 7-74 9 Welsh, 1819, p. 73. " Geaves and Stokes, 1826. " Waedell, 1846. 34 cases of typhus have been deducted from Wardell's calculation. It is possible that Wardell's estimate as regards Edinburgh was too small, in consequence of his observations not commencing until the epidemic was at its height. His own tables show that there was a progressive diminution of the yellow cases, as the epidemic advanced. Thus, of 320 cases in the Edinburgh Infirmary in October 1843, when the epidemic was at its height, 37, or i in 8-65, were yellow, but of 426 cases admitted in January 1844, 28, or i in 15, were yellow, and of 80 iDatients in April, wheir the epidemic had nearly ceased, only 2 had jaundice. In the early part of the epidemic jaundice was apparently more common, although Henderson and Craigie speak of the symptom as being even then excep- tional. In other places jaundice appears to have been more frequent than in. Edinburgh. In Glasgow, according to Dr. D. Smith, it occurred in 2 out of every 5 patients, and in Dundee it is also said to have been more common than in Edinburgh. ' Douglas, 1845. " Jackson, 1844. ' Gibson, 1843. " Smith, 1844, p. 69. == EoBEBTSON, 1848, p. 373. y E. Patekson, 1848. ' Jennek, 1850, xxii. 646. SYMPTOMS. 361 It would thus appear, that although jaundice varied in frequency at different times and places, it has rarely occurred oftener than once in 5 cases, and it is usually less frequent. It is met with at all ages, but is most common at the middle period of life. It rarely appears before the third or fourth day of the primary paroxysm. It may occur during the first paroxysm only, or in the relapse only, or in both paroxysms, and in rare cases it does not disappear in the interval. It may commence at the height of the pyrexia, or at the crisis. Of 28 cases observed by Douglas,'^ the jaundice occurred in the first paroxysm only in 16 ; 2 of the 16 patients became jaundiced on the fourth day, and none earlier than this. In 10 cases the jaundice only occurred in the relapse, and in 2 cases it was present in both paroxysms. Jackson found jaundice in the first attack only in 1 3 cases ; in the second, only in 1 8 cases ; m the third, only in 2 cases ; and in both the first and second attacks, in 2 cases.'' As a rule it does not last more than a few days. The intensity of the jaundice varies from a slight tinge to a deep yellow. Of 29 cases, Douglas noted it as intensely bright in II, complete but less intense in 9, and very faint in 9.^= In my experience the proportion of intense cases has been much less. The conjunctivae are first tinged, and then the skin. In the intense cases, the serum in a vesication contains bile, and the urine may be so loaded with it as to resemble porter. There is no impediment, however, to the flow of bile into the intestine, for the faeces retain their natural colour, or are unusually dark, and the bile-ducts after death are found to be pervious. Dr. Alison stated, on the authority of Dr. Peacock, that in some instances the bile was thick and viscid so as apparently to cause obstruction ; but this condition is exceptional, for in most in- stances the bile is perfectly fluid and is found in the duodenum and stools in abundance. Most observers have agreed in making jaundice a formidable symptom in relapsing fever. In the epidemic of 1817-19, Welsh observed jaundice in 4 out of 34 (i in 8^) fatal cases, but only in 20 of 709 (i in 35) cases which recovered. In 1826-27, jaundice was looked upon bj Graves and Stokes as a very fatal fiymptom. In 1843, Cormack regarded it as characterizing the Douglas, 1845, P- 216. " Jackson, 1844, p. 426. •= Douglas, 1845, p. 216. 3^2 RELAPSING OR FAMINE FEVER. most malignant cases ; 4 out of 8 jaundiced cases under Craigia died ; Alison observed jaundice in most of the cases which proved fatal under his care ; and this symptom was present in all the 16 cases which were fatal during the epidemic in the Dundee Infirmary. Among the symptoms which accompany the jaundice, vomiting and more or less pain in the epigastric and hypochondriac regions are the most common ; while in the more severe cases, * black vomit,' albuminuria, haemorrhages, tendency to collapse, delirium, coma, subsultus, and other cerebral symptoms are occasionally met with.*^ Delirium was noticed by Douglas in 6 out of 29 jaundiced cases (i in 5), but only in 12 of 191 ( I in 16) non -jaundiced cases. On the other hand, jaundice is met with in a number of instances, which differ in no other circumstance from the mildest cases, far larger than that in which it is attended by dangerous symptoms. Welsh spoke of jaundice as * a very trifling occurrence ; ' of 6 cases that came under Henderson's notice, i patient died from a totally different complication, and the other 5, in all of whom the jaundice was well marked, 'had not a single symptom that made them differ from the ordinary cases, excepting thie yellowness,' According to Douglas, * vomit- ing was not more frequent or troublesome in the cases with jaundice than in the ordinary cases;' of 35 cases of jaundice under Jackson, only 2 died ; while at Dundee, where jaundice was said to have been more frequent than elsewhere, the total mortality was very much less, or only i in 96. Alison remarked that ' many jaundiced cases had the crisis at the usual time, and went on quite favourabty with little treatment.' Moreover, jaun- dice is far from being a constant accompaniment of delirium and other cerebral symptoms. Of 18 cases in which Douglas observed delirium, only 6 were jaundiced. It follows that, although jaundice has been observed in a large proportion of severe and fatal cases of relapsing fever, the presence of bile in the blood and tissues is not in itself a dangerous symptom. Since the days of Galen, it has been the custom to look on the bile as possessed of narcotic properties, and as capable of producing coma, delirium, and other cerebral symptoms, when absorbed into the blood; and even at the present day this opinion is commonly entertained. Yet it is well known that in jaundice from obstruction of the ducts the ^ To these cases the term ' Bilious Tyi^hoid ' has sometimes been applied. See Sec. IX. ' Varieties.' SYMPTOMS. 363 above-mentioned symptoms are rare, while the experiments of Frerichs show that the artificial introduction of bile into the blood is not followed by the symptoms usually attributed to it, and that its presence in the blood is harmless.^ Moreover, cerebral symptoms and death are common in fevers where jaundice is rarely observed, whereas in relapsing fever, where jaundice is so common, cerebral symptoms are comparatively uncommon and the mortality is peculiarly small. Indeed, the observations of Henderson ^ and Dr. Michael Taylor^ render it very probable that in relapsing fever, as in typhus, it is to urea (and other products of tissue-metamorphosis usually excreted by the kidneys), and not to bile, that the dangerous cerebral symp- toms which occasionally supervene must be attributed.^ In the only fatal case complicated with jaundice that occurred under Henderson's care, death was preceded by cerebral symptoms, and urea in considerable quantity was found in the serum of the blood. From observations on other cases, Henderson was in- clined to believe that cerebral symptoms in relapsing fever were always due to a similar cause. More recently Pribram and Eobitschek have found albuminuria in severe cases of relapsing fever with jaundice, and I have repeatedly made the same obser- vation. The jaundice occasionally observed in relapsing fever is merely one of the results of a morbid state of the blood. The poisons of other fevers, such as those of yellow fever, remittent and intermittent fevers, typhus and enteric fevers, as well as those of pyaemia and of certain snakes, may also give rise to jaundice. These poisons appear to act by interfering with the normal metamorphoses of the bile-pigment, which in health is being constantly reabsorbed from the bowel.^ /. Morbid Phenomena presented by the Urinary System. Important observations on the urine of relapsing fever have been made, in 1843, by Henderson,J Michael Taylor,'' and other physicians, and within the last few years by Wyss and Bock,i Eiesenfeld,"! Huppert," 0. Schultzen," and Pribram and = Klinik der Leherhranhlieiten, Syd. Soc. Transl. i. 187, 395. ' Hendeeson, 1843. ''' Taylok, 1844. '' Even in true yellow fever, the cerebral symptoms admit of a similar explana- tion. (See page 181). * See my Clin. Lee. on Dis. of Liver, 1868, p. 312. •• Henderson, 1843, p. 224. "^ Tailob, 1844, p. 293. ' Wyss and Bock, 1869, i^. 146. "' Eiesenfeld, 1869. " HuPi>EET, 1S69. ° CCHULTZEN, 1869. 364 RELAPSING OR FAMINE FEVER. Eobitschek.P The principal facts elicited by these writers and observed by myself may be summed up as follows : — The quantity of urine during the paroxysms varies with that of the fluid ingesta, but as a rule it exceeds the normal standard, especially in the relapse. During the crises the quantity is reduced ; but for several days after the crises it is much in- creased ; the patient may pass 60 or 80 ounces, or more, in this twenty-four hours. The colour and specific gravity vary with the quantity ; the reaction is almost always acid. The daily amount of urea is increased during the paroxysms and diminished in the interval, although much less food is taken in the former periods than in the latter. The greatest increase is in the first paroxysm. Pribram and Kobitschek found 74 grammes (1,142 grains) voided in 24 hours by a man aged 41. During the crisis, the quantity diminishes ; and for the first two or three days of the interval it is again considerably above the normal standard, but during the latter half of the apyretic interval it sinks below this, until immediately before the relapse, before any rise of the pulse or temperature (Pribram and Eobitschek), when it again rises. The increase during the relapse is less marked than in the first paroxysm, as there has been no time for the store- albumen to be replaced in the interval, but the quantity still keeps up for a day or two after the second crisis. This post-febrile elimination of an increased amount of urea is to be accounted for by a portion of the nitrogenous matter broken down by the febrile process being retained in the system, not perhaps all in the form of urea, but in that of sub- stances from which urea is formed.^ When, from disease of the kidney, or from any other cause, the quantity of disinte- grated nitrogenous matter retamed in the system is unusually large, cerebral symptoms, such as delirium, stupor, coma, or convulsions, are apt to supervene. This is most likely to occur about the periods of crisis. In fact, while it admits of demon- stration that cerebral symptoms in relapsing fever are indepen- dent of inflammation or of obvious organic lesion within the cranium, there are grounds for believing that they are due to the retention in the system of urea or other products of disinte- grated nitrogenous matter. A brief recapitulation of a portion of the evidence in favour of this view may not be out of place ; while at the same time it is well not to forget an observation of p Pkibeam and Eobitschek, 1869. 9 '^his view, advocated by Biesenfeld, Huppert, and others, is opposed by Schultzen. SYMPTOMS. 365 Henderson's, to the effect that the blood-serum of relapsing fever may contain urea, although there be an excess of this material in the urine. 1. Henderson mentions the case of a gentleman who was seized on the day of crisis with uneasy sensations in the head and confusion of mind, and for eighteen hours passed no urine. Ten grains of nitre were prescribed every hour. He began immediately to pass abundance of urine, and the symptoms were at once relieved. 2. In a second case under Henderson, the commencement of cerebral symptoms was accompanied by suppression of urine, and death was preceded by several attacks of convulsions. Urea was obtained by Dr. Douglas Maclagan in considerable quantity from the blood, and in smaller quantity from the serum of the cerebral ventricles. 3. In a third case, also under Henderson, the commencement of cerebral symptoms was marked by a reduction of the urine to one-half of its former amount. Dr. Michael Taylor ascertained that the total urea excreted in the urine did not exceed 109' 3 grains (the normal average, according to the lowest estimate, being 286 grains) ; and Dr. Maclagan obtained urea in blood taken from the arm. 4. In a case under Dr. Wardell, the occurrence of cerebral symptoms was accompanied by suppression of urine, and abun- dance of urea was found in the blood by Dr. M. Taylor.*" 5. In a fifth case of relapsing fever with cerebral symptoms, recorded by Dr. Taylor, the urine did not exceed 16 ounces, and urea was discovered in considerable quantity in the blood. 6. In another case observed by Dr. Taylor, the development of cerebral symptoms was accompanied by a reduction of the urine to 16 ounces, the total amount of urea in twenty-four hours not exceeding 174 grains. 7. Cases of suppression or diminution of urine with cerebral symptoms were observed by Jackson at Leith,^ and by other writers on the epidemic of 1843.* Suppression of urine was also noted as a very fatal symptom of relapsing fever in 1 847.'* 8. Zuelzer states that at St. Petersburg in 1864-5 cerebral symptoms commonly supervened on a diminution or suppression of urine, and that frequently such patients recovered after a copious discharge from the kidneys.^ ' Wardell, 1846, xxxix. 547. ' Jackson, 1844, pp. 423, 431. * See Wardell, 1846, Case vii., &c. " Irish Report, Bib. 1848, viii. 300. ' Zuelzer, 1867, p. 677. 366 BELAPSING OR FAinNE FEVER. 9. I have never known typhoid symptoms in relapsing fever without albuminuria, or some other evidence of retarded elimi- nation by the kidneys. The uric acid is sometimes increased, and sometimes dimin- ished. The urine at the crisis occasionally deposits lithates. The chlorides about the third day of the first paroxysm begin to diminish, and before the crisis they may have entirely disap- peared, and they may continue absent, or nearly so, for one or more days after the fall of the temperature. A copious excretion of them then takes place until the relapse, when they again sink rapidly, and do not return until the second, thh^d, or fourth day after the second crisis. Wyss and Bock have shown that the ingestion of salt during the paroxysms makes no difference in the chlorides of the urine ; and their researches also make it probable that the salt is absorbed but retained in the system. (Seep. 153.) The inliospliates and sulphates vary with the ingesta, but ac- cording to Kiesenfeld the phosphates are increased and follow the same course as the urea. The presence of an excess of phosphoric acid in the blood he imagines may help to account for the severe muscular and arthritic pains. Crystals of oxalate of lime are said to be common in convalescence. Albumen is occasionally present (in 6 of 14 cases, Zuelzer ; in II of 70, Pribram and Eobitschek). The quantity is usually small, but now and then considerable, and in severe cases the urine may contain much blood. In one case I met with copious hsematuria in both paroxysms, although the urine in the interval contained not a trace of albumen. (Case XXXV.) Case XXXV. Belaimng Fever. Hcematuria in both Paroxysms. James C , aged 25, admitted into L.F.H. Jan. 26th, 1870, on third day of ilhiess. Pulse at 120. Temp. 105°. No rash. Severe headache and pains in back and limbs ; mind clear ; tongue moist and fm-red ; great thirst ; no appetite ; bowels confined ; no jaundice nor vomiting. Says that smee ilhiess commenced, urme has been black. Jan. 2'jth. Pulse 130. Temp. 106°. Severe headache, and slept none. Urine scanty and very dark from admixture of blood, and deposits epithelial and blood-casts. Not the shghtest oedema, and mind clear. Ordered large doses of nitrate of potash and acetate of ammonia, and mustard and Imseed poultices to kidneys. Ja7i. 28th. Pulse 130. Temp. 106°. Tongue dry and brown ; much thirst, and severe headache. Jan. 2gth. Pulse 120. Temp. 105°. Less pain. Slept well. Urine more copious and paler. Moderate diarrhoea. Jan. soth {ith day). Pulse 84. Temp. 96-5°. Has perspired freely, SYMPTOMS. 367 and is free from pain, and has some appetite. Jan. ^ist. Urine is now almost normal in colour, but still contains much albumen. Feb. yrd {nth day). Going on well, and urine now contains not a trace of albumen. Feb. 8th. Still feels well, and urine contains no albumen. Feb. gth (I'jth day). After dinner was suddenly seized with severe pain in head and loins, and soon after noticed his water to be again dark. Feb. loth. Pulse 132. Temp. 106°. Much pain in head and limbs. Urine dark brown and smoky, contains much albumen, and deposits a brownish sediment containing epithelial and blood-casts. Feb. nth. Pulse 136. Temp. 106*5°. Pains are more severe, but mind clear, Feb. 12th {20th day). Much better. Perspired freely. Pulse 90. Temp. 97°. Pains are gone, and is hungry. Feb. i^th. Urine is clear and contains not a trace of albumen. From this date convalescence was uninterrupted. Tube-casts — epithelial, blood, and hyaline — may be present along with albumen. They are figured by Obermeier, who found them in 32 out of 40 cases, and inferred that an acute desquamative nephritis was one of the ordinary phenomena of relapsing fever ."^ Leucine and tyrosine have been found in some cases by Pribram and Eobitschek ; while Schmidt has detected bile-acids in the urine of jaundiced cases. Sugar is sometimes present in small quantity. g. Morbid Phenomena presented by the Nervous and Muscular Systems. 1. Headache is almost invariably complained of, and is usually one of the first symptoms. The pain is mostly frontal, but sometimes it is general. In a few cases it is slight and continues only for a day or two ; but, as a rule, it is severe, and lasts throughout the paroxysm, subsiding with the crisis, but returning with the relapse. It is much more severe, and oftener of a shooting, darting, or throbbing character, than the headache of typhus. 2. Vertigo. Most patients suffer from great giddiness from the commencement of the attack until convalescence. (See pages 345 and 372.) 3. Muscular and Arthritic Pains. A remarkable and most distressing symptom of relapsing fever is the severe pains in the muscles and joints complained of by most patients. They occur in many cases during the paroxysms, but they are Obeemeier, 1869, p. 170. 368 RELAPSING OR FAMINE FEVER. often most severe in the apyretic interval and during conva- lescence, when the patient in other respects is going on well. They were very common in the relapsing fever of 1817-19^ and in that of 1826/ and they are mentioned by almost every writer on the epidemic of 1843. They were said to be more common at the commencement of the epidemic of 1843 than subsequently. Wardell found that 438 of 536 patients, or up- wards of 4 in 5, suffered from these pains.^ They are some- times seated in the muscles of the trunk or extremities ; at other times in the larger joints, or in the feet. During con- valescence, they may take the form of sharp stitches in the sides. In character they are not unlike the pains of acute rheumatism ; they are increased by pressure or movement, and are often most excruciating. They are not attended, except in rare instances hereafter referred to, by any swelling or redness of the joints ; whilst the fact of their shifting from one place to another makes it improbable that they are due to any tissue- change in the muscles. Their cause is obscure, but they pro- bably depend on the presence in the blood of some abnormal substance, such as uric, lactic, or phosphoric acid. (See p. 365.) Eelapsing fever is attended altogether by more pain than typhus, and the pains are also more impressed on the memory, from the circumstance that the mind is usually clear and the perception unimpaired. Persons who have passed through both fevers invariably look back on the former as the source of the greater suffering. 4, Impairment of the Mental Faculties. — Delirium. In re- lapsing fever delirium is an exceptional symptom, met with chiefly in the intemperate and hysterical ; in most cases the mind remains clear throughout the attack. Occasionally the patient talks a good deal in his sleep and has frightful dreams, but he is easily roused and gives rational answers. Of 220 cases observed by Douglas, delirium occurred in only 18, or about 8 per cent. : of these 18 cases, in 6 the patients had pre- viously been intemperate ; and in i case the delirium was apparently due to opium.^ Decided delirium was present in only about 12 of my 600 cases, and in 7 of 352 cases observed by Tennent.^ When delirium does occur, it is oftener acute and noisy than in typhus. About the period of crisis, or after the termination of the paroxysm, the patients sometimes become stupid and confused ' Welsh, 1819, p. 18. ^ O'Brien, 1828, p. 530. * Wabdell, 1846, xl. p. 107. " Douglas, 1845, p. 211. * Tennent, 1871. SYMPTOMS. 369 and show a tendency to stupor ; in rare cases, they become suddenly and violently delirious and cannot be kept in bed. These symptoms may persist, and gradually merge into those of the ' typhoid state ' (dry brown tongue, muttering delirium, and more or less unconsciousness), or they may speedily pass off. The connection between these cerebral symptoms and diminished excretion by the kidneys has been already referred to. The delirium which occurs at or after the period of crisis is sometimes remarkable for its sudden outbreak, its violent character, and its very short duration.'' Dr. Eobertson mentions an instance, where the patient had conversed with him ration- ally at the time of his visit, but scarcely had Dr. K. left the ward, when he became suddenly outrageous, screamed, raved, abused his attendants, could with difficulty be restrained in bed, and passed his stools and urine involuntarily. Within fifteen minutes he was again calm and collected, bathed in per- spiration, and in perfect oblivion as to what had just passed. Eobertson met with 5 or 6 instances of this nature in Edinburgh in 1847-8, and in Dublin they were said to be more common."^ In 4 cases I have observed a similar paroxysm, the patients staring widely with their eyes, screaming and plunging about their limbs, these symptoms ceasing as suddenly as they had commenced. One patient in this state struck his nurse with a poker ; a second smashed a window with a spittoon ; while a third laboured under the hallucination that his bed was full of snakes. This form of delirium does not appear to be ursemic in its origin, but resembles the maniacal delirium from inanition observed sometimes during convalescence from typhus and other acute diseases. (See p. 204.) 5. Wakefulness, Somnolence, Coma, etc. Sleeplessness is a very common and distressing symptom, both in the paroxysms and in convalescence, in the latter case being usually due to the severity of the muscular and arthritic pains. Stupor and coma, so common in typhus, are rare in relapsing fever. Their occasional appearance in connection with sup- pression of urine has been already referred to. Under such circumstances, they usually supervene at, or after, the period of crisis, and their advent may then be sudden. When they come on before the cessation of the paroxysm and do not speedily pass off, there is no well-marked crisis, and all the phenomena of the * typhoid state ' may be developed. • Jackson, 1844, p. 420; Eobertson, 1848. ^ Eobertson, 1848, p. 373. B B 370 EELAPSING OE FA3IINE FEVER. 6. Prostration, more or less, is present in all cases from the first, but it is usually slight in comparison to that of typhus, and it is rarely so complete as to prevent the patient getting out of bed, or helping himself, except in those instances where collapse or cerebral symptoms supervene at the crisis. It is vertigo, rather than muscular prostration, that causes patients to take to bed at an early stage of the disease. 7. Muscular Paralysis. Eetention of urine and the involun- tary passage of urine and faeces are rare, except in cases charac- terized by sudden syncope or by cerebral symptoms. Involuntary evacuations were noted by Douglas in only 6 of 220 cases, and in several of these the discharges were due to extreme diarrhoea, rather than to paralysis ; all 6 died.*^ 8. Tremors, Suhsultus, Carphology, and Rigidity of the muscles are also rare symptoms. Tremors mostly occur in persons of dissipated habits ; the other symptoms are only observed in those rare instances where the disease passes into the typhoid state. 9. General Convulsions are in rare cases observed to occur at or after the crisis with other head-symptoms, or sometimes independently of them in cases which seemed to be progressing favourably. The cases where they occur are usually fatal. Of 4 cases alluded to by Henderson, 2 died ; and the result in the other 2 is not stated.^ Jackson records the case of a boy who recovered, after having had ' two convulsive fits on the day of crisis, in which for twenty minutes the limbs became rigid, the body motionless, and the eyes turned upwards.' The pathology of convulsions in relapsing fever is probably the same as in typhus. (See p. 167.) In a case observed by Henderson, urea was found in considerable quantity in the blood and in the fluid of the cerebral ventricles, although the urine was not coagulable by nitric acid ; after death, the kidneys were found to be ' of ordinary size and consistence, moderately loaded with blood, and, when washed, seemingly a little paler than usual in some places.' ^ h. Morbid Phenomena referable to the Organs of Siiecial Sense. I. Organs of Vision. The ' ferrety eye,' or the injected con- junctivae, so characteristic of typhus, is comparatively rare in relapsing fever. The pupils are for the most part natural ; but Douglas, 1845, P- 210. ' Hendekson, 1843, p. 221. « Ibid. p. 222. SYMPTOMS, 371 in cases where stupor and other cerebral symptoms supervene, they may be contracted. 2. Organs of Hearing. Tinnitus aurium is often present, but deafness is not a common symptom. In 220 cases, Douglas met with it only 12 times ; and in 8 cases it was very slight and only lasted a day or two. Of the 4 cases in which it was decided, it occurred early in the attack in i, and in the remaining 3 it only came on in convalescence.^ 3. Organs of Smell. Epistaxis is not uncommon and is occa- sionally profuse, necessitating plugging of the nares. Some- times it is one of the earliest symptoms ; but it is most common at the period of crisis, when it now and then appears to take the place of the ordinary perspirations. Douglas noted epistaxis in 13 of 220 cases in Edinburgh, and many of the other patients stated that they had bleeding from the nose before admis- sion.' In many of the Irish epidemics, epistaxis has been very common. (See p. 178.) It was noted in 74 of 613 cases at St. Petersburg.^ Twice I have found it necessary to plug the posterior nares. Case XXXVI. Belajysing Fever. Epistaxis in both Paroxysms. Joseph D , aged 17, admitted into L.F.H. Oct. 1st, 1869, ill five days with fever, headache, vomiting, pain and tenderness in hypo- cliondria, and occasional profuse epistaxis. Pulse 108. Temp. 104°. Oct. ^rcl. Epistaxis continues, and patient is very low. Posterior nares to be plugged. Oct. 4th. Pulse 88. Temp. 97°"6. Oct. 6th. Appetite good. No bleeding. Plug removed. Oct. loth [i^th clay). Fever returned. Pulse 108. Headache ; moderate epistaxis. Oct. nth. Pulse 140, Temp. 106°. Vomiting and decided jaundice. Oct. 14th. Pulse 132. Oct. i^th {20th day). Has perspired profusely, and is much better. Pulse 84. Temp, normal. 4. Cutaneous Sensibility. Hypersesthesia is rarely met with in relapsing fever (see p. 178); but occasionally the jaundiced patients complain of itchiness, which is an accompaniment of jaundice under other ch'cumstanees. Sect. VII. Stages and Duration of Eelapsing Fever. Unlike typhus, relapsing fever is divisible into well-marked stages. In ordinary cases, there are four : — The primary paroxysm, the intermission, the relapse, and convalescence. The ^ Hendeeson, 1843, P- 210. ' Ibid. p. 220. J Zuelzee, 1867, p. 679. B B 2 372 EELAPSING OK FAMINE FEVER. paroxysms are again subdivisible into the accession, the pyrexial stage, and the crisis. 1. The Mode of Accession. The mode of accession is in most cases sudden, without any premonitory symptoms. The patient, on awaking in the morning, or when sitting at the fireside, or walking, or engaged in his ordinary avocations, is suddenly seized with a sense of chilliness, or with rigors, which are much more severe than those some- times observed at the commencement of typhus. These rigors are often accompanied by a sensation of cold trickling down the back, frontal headache, severe pains in the back and limbs, and nausea or vomiting. From Wardell's observations on the epi- demic of 1843, '^^ would appear that in 103 out of 120 cases the invasion was marked by distinct rigors ; in 31 out of 40 cases, by headache ; in 56 out of 80, by nausea or vomiting ; and in 52 out of 80, by arthritic or muscular pains.*" In some few cases, sickness is the first symptom, and this, with headache, pains in the back and chilliness, precedes the attack of rigors for two or three hours. In a few cases, there are no well-marked rigors, but only a sense of chilliness. Premonitory symptoms are far from frequent ; they were noted by Douglas in 5 only out of 220 cases, although it was admitted that in some of the cases they may have been over- looked. These symptoms were anorexia, general pains, and a feeling of debility and malaise,^ lasting for a few hours or several days before the rigor. Owing to the suddenness of the invasion, patients not un- frequently apply for admission into hospital on the first or second day of the disease. In 500 patients admitted into the London Fever Hospital, the average duration of the fever before admission was 4-9 days ; "^ the average of 80 cases observed by Wardell was 47 days. At the same time, the prostration is not so great as to prevent many patients from going about for two or three days, and when patients take to bed on the first day, it is oftener from giddiness than from weakness. 2. The Primary Paroxysm. The duration of relapsing fever has been spoken of by all observers as short when compared with that of tyi^hus; and k Waedell, 1846. > Douglas, 1845, p. 11. >» The average would have been shorter, had not the admission been delayed in several cases until the second paroxysm. Compare with typhus (pp. 165, 185). STAGES AND DUKATION. 373 hence the names ' Short Fever,' 'Five Days' Fever,' and ' Seven Days' Fever ' have been given to it. These designations, how- ever, apply only to the first paroxysm and exclude the relapse, which occm's so frequently as to justify its being regarded as part of the disease. As to the primary paroxysm, in the epidemic of 1739-41 Eutty " fixed its ordinary duration at five, six, or seven days ; Welsh ° and Christison p assigned five days as the usual limit to the fever of 18 17-19; and O'Brien five or seven days to that of 1826.1 In the epidemic of 1843 Cormack made five days the ordinary limit ; "^ but most other observers thought seven days the more common duration,'' and Jackson at Leith found that the crisis occurred in most cases on the eighth day.* In the epidemic of 1847 the common duration at Edinburgh, according to Paterson, was five days," and according to Eobertson, seven.'^ Elaborate statistics bearing on this point are given by the authorities referred to."^ It suffices here to state, that the most common duration of the primary paroxysm is from five to seven days ; that in rare instances it does not exceed three or four days, and that probably in no case, except where complications exist, does it exceed ten days. Of 100 cases ^ under my care, the duration of the first paroxysm was 3 days in i, 4 days in 9, 5 days in 20, 6 days in 46, 7 days in 14, 8 days in 7, and 9 days in 3 ; the average of the 100 was 5-96 days. Douglas's observa- tions seem to show that the average duration is less below thirty years than at a more advanced period of life, and less in females than in males. Craigie,y Cormack,^ Smith ^ and other writers on the epidemic of 1 843 allude to a slight remission on the third day of the first paroxysm, consisting in a slight abatement of the headache and thirst, with slight perspiration, but rarely with any fall in the pulse. This remission is not constant, and not a characteristic feature of the disease. Douglas failed to observe it. " Eutty, 1770, pp. 75, 90. " Welsh, 1819, p. 78. p Chkistison, 1858, p. 582. 9 O'Beien, 1828, p. 527. ■■ Cormack, 1843, PP- 5i io°' ; Alison, 1843, p. i; Douglas, 1845, P- ^2; Waedell, 1846, xxxviii. pp. 155, 5; KiLGOUK, 1844, p. 322. ' Jackson, 1844, p. 421. " E. Pateeson, 1848, pp. 391-5. ^ EoBEETsoN, 1848, p. 373. ■" " See also Feantzel, 1870. ^100 consecutive cases in my Case-Books where the facts were noted. 5" Ceaigie, 1843, P- 416. ^ CoEJUCK, 1843, p. 5. " Smith, 1844 (i), p. 70. 374 RELAPSING OR FAMINE FEVER. 3. The Intermission. After the cessation of the first paroxysm, the patient usually expresses himself as in perfect health, and in uncomplicated cases, with the exception of debility, an abnormally slow pulse, or muscular and arthritic pains, he is free from all complaint. Day by day he recovers strength, and by the end of a week he may be up and going about, or may have resumed his work. He often feels so well, that it is difficult to persuade him that he has not yet shaken off his malady. Sir K. Christison relates an anecdote in reference to his colleague, Dr. Bennett, who was attacked with relapsing fever on the first outbreak of the epi- demic of 1843, when the disease was unknown except to the older members of the profession. Sir E. Christison saw him after the termination of the first paroxysm : ' Though still con- fined in a great measure to bed from debility, he was well other- wise, and enjoying the genuuie pleasures of a fever convalescent. When he had detailed to me his case, I told him he had sus- tained, to all appearance, an attack of my old acquaintance synocha (relapsing fever), whose face I had not seen for a good many years ; that he was not yet done with it, and that he would have another three days' attack, commencing with rigor on the fom'teenth day. Dr. Bennett, surprised — I will not say incredulous — replied, that the relapse had no time to lose, as there were only three or four hours of the fourteenth day to run. It did, indeed, lose no time, for I must have scarcely reached home from his house, before the rigor set in with violence ; and he had three days of fever again, terminating, as the primary attack had done, with an abrupt crisis by sweating.'^ The ordinary course of events, then, is, that after an interval of a week from the crisis of the first paroxysm all the febrile symptoms return. In many cases the interval is exactly seven days, so that the relapse occurs on the twelfth or fourteenth day, according to the duration of the primary paroxysm, and can be predicted with tolerable certainty. Of 100 cases under my care, the duration of the intermission was 7 days in 37, 8 days in 22, and 9 days in 13 ; the shortest was 5 days, and the longest 12 ; the average of the 100 was 7-82 days. The average duration from the commencement of the first paroxysm until that of the relapse, was in the 100 cases 1374 days. At the •> Christison, 185S, p. 591. STAGES AND DUKATION. 375 same time, the intermission occasionally may not exceed two or three days, while sometimes it exceeds twelve days. Douglas states that the relapse does not occur sometimes until after the twenty-first day from the primary seizure.'^ Lyons states that in the cases of relapsing fever observed in the Crimea, the period of intermission was remarkably inconstant, varying from two to many days.*^ According to O'Brien ^ and Douglas,^ the cases where the primary paroxysm is longest have also the longest intermission; and, as a rule, Douglas found the intermission longer in males than in females. Occasionally the intermission of febrile symptoms is not quite complete, or there is a remission rather than an intermission. The pulse does not fall to its normal standard, the appetite does not return, and the patient complains of lassitude, slight head- ache, and giddiness, and has occasional chills and perspirations. Such cases, however, are exceptional (in only 15 of 220 cases observed by Douglas) ; and in most, if not all, there is probabl}^ some local complication. Again, in those cases where cerebral symptoms supervene at the period of crisis, the intermission may be masked, and the fever more protracted ; but even then the crisis is often indicated by sweating and a considerable fall in the pulse and temperature. Lastly, in some cases permanent convalescence follows the crisis of the first paroxysm, and there is no relapse. 4. Relapses. On or about the fourteenth day from the primary seizure, subject to the variations already mentioned, the patient is a second time attacked with rigors, followed by a repetition of the symptoms which characterized the first paroxysm. The second attack, like the first, comes on suddenly and without warning. Kilgour remarks that at Aberdeen it was preceded by loss of appetite and sleeplessness ; ^ but Perry tells us that in Glasgow he found the appetite before the relapse unusually acute ; '' and in most instances, according to my experience, there are no premonitory symptoms. The second attack may be milder or more severe than the first. In some cases the first attack is mild, while the second is characterized by delirium, diarrhoea, dysentery, or other grave ' Douglas, 1845, P- ^9- * Lyons, 1861, p. 107. ^ O'Beien, 1828, p. 528. ' Douglas, 1845, P- ^S- s KiLGouE, 1844, p. 322. '' Pekey, 1844, p. 82. 376 KELAPSING OR FAMINE FEVER, symptoms. But more commonly the second attack resembles the first, or runs a milder course. Occasionally it is indicated by nothing more than a slight increase of the pulse and tem- perature, with general malaise. The duration of a relapse varies from a few hours to several days ; the average is usually from three to four days, or less than that of the primary paroxysm. In some cases it lasts less than twenty-four hours ; and in a few, it is prolonged to seven or eight days ; but it is rarely longer than this in uncomplicated cases. Of lOO consecutive cases under my care, the duration of the relapse did not exceed i day in 4 ; it was 2 days in 9 ; 3 days in 46 ; 4 days in 24 ; 5 days in 1 5 ; and 7 days in 2 ; the average was 3*45 days. In the Crimea, according to Dr. Lyons, the relapse was occasionally protracted to twenty-one days.' As stated already, a relapse is not invariable. Of 182 cases under Dr. Craigie,^ relapses occurred in no. Of 300 cases under Jackson of Leith, 3 died during the first attack, and of the re- mainder all save 21 relapsed.'^ Of 1,000 cases under Dr. D. Smith at Glasgow, 7 1 2 relapsed ; ^ and of 946 cases observed by Wardell at Edinburgh, 603 had one or more relapses."^ Adding these results together, it follows that in 1843, of 2,425 cases, relapses occurred in 1,701, or in upwards of seven-tenths. Several observers of the epidemic of 1843 remarked that the relapses became less frequent towards its close. Thus Wardell found that in October 1843, 72 out of 80 had relapses, but in April 1 844, only 40 out of 80." Steele also observed that towards the termination of the epidemic of 1847 in Glasgow, relapses became less frequent, until at last they formed the exception rather than the rule." Eelapses, however, are probably much more common than might be inferred from the above data. Some patients are only admitted into hospital in the relapse ; a still larger number are dismissed before the relapse occurs ; while in others the relapse is so mild that it is apt to be over- looked. Douglas and Cormack were disposed to think that even in 1 843 few or no cases escaped without relapsing ; p and of 1 00 consecutive cases under my care in 1869, all but four had a relapse. Zuelzer noted a relapse in 568 of 597 cases in St. Petersburg, and Tennent in 337 of 352 cases in Glasgow in 1870. Occasionally a second relapse, lasting three or four days, ' Lyons, 1861, p. 107. J Cbaigie, 1843. '' Jackson, 1844, p. 421. ' Smith, 1844 (i), p. 72. '" Wabbbll, 1846, xxxix. 274. " Ibid. " Steele, 1848. p Douglas, 1845, P- '5; Cokmack, 1S43, P- ^7- STAGES AND DURATION. 37/ occurs between the twenty-first and the twenty-fourth day (count- ing from the primary seizure), sometimes, however, as early as the eighteenth or as late as the thirtieth day. A second relapse was observed by War dell in 6"] of 946 cases ; by Jackson, in 28 of 297 ; by Douglas, in 1 1 of 220 ; by Parry 1 in 3 of 37 — altogether, in 109 out of 1,500 cases, or in i out of 14. The second relapse commences and terminates in the same way as the two preceding paroxysms. The symptoms are almost invariably mild in their character. The attack may last from one to ten days, but rarely exceeds forty-eight hours. A third, fourth, and even a fifth relapse, making in all six paroxysms, has occasionally been observed. In the a.bove 1,500 cases, a third relapse occurred nine times, or in i out of 166 cases, and a fourth relapse, once. These relapses usually re- semble a common febricula. From what has been stated it follows that, under ordinary circumstances, when there are but two paroxysms, the duration of relapsing fever to the commencement of permanent convales- cence amounts to about eighteen days. The average of 100 of my cases was i7'9 days. No satisfactory explanation of the relapse has been given. Hudson has suggested that it is due to the commingling with the circulation of a quantity of non- depurated blood which has been laid by in the spleen, and states that in the epidemic of 1847-8 a relapse followed every case in which there was a persistence of splenic enlargement after the first crisis.'" On the other hand, it has been argued that the relapse is really a second attack of the fever, resulting from re-absorption of poison eliminated by the patient himself in the sweat of the first crisis, the apyretic interval being the second period of incubation.^ This view seems even more improbable than that commonly held, according to which the relapse and the first paroxysm are both believed to result from the same dose of poison, and in this respect to re- semble the successive paroxysms of pyrexia in ague. [The relapse must in all probability be ascribed to the repro- duction of the spirochete in the blood.] 5. Defervescence or Crisis. The paroxysms of relapsing fever usually terminate by a well-marked crisis, which in the majority of cases is charac- 1 Parry, 1870. ■ Hudson, 1867, p. 175. ■ A. W. Blyth, Med. Times and Gaz. 1870, i. 22. 37^ KELAPSING OR FAMINE FEVER. terized by copious perspiration. In many instances the sweat- ing is preceded by chilliness, or a shght rigor. It lasts for some hours, and is attended by sudden and marked relief to alltha symptoms, the pulse falling perhaps from 140 to 70, and the temperature from 108° to 96° Fahr. (See p. 352.) Other dis- charges, such as diarrhoea and dysentery, epistaxis, copious menstruation, or in rare instances haemorrhage from the bowels, may occur at the same time ; but it is seldom that they entirely displace the sweating. The crisis is sometimes accompanied by great languor and prostration approaching to collapse, or by the cerebral phenomena already alluded to (p. 368). In aged persons the attacks sometimes terminate by lysis rather than by crisis. 6. Convalescence. Although relapsing fever is a much less formidable disease than typhus, convalescence is usually much slower. Many patients remain for a long time very weak, and complete re- covery is more apt to be retarded by the occurrence of distress- ing sequelse than in typhus. The average stay in the London Fever Hospital of 500 patients was the same as in typhus, or 23 days. (See p. 185.) Sect. VIII. Complications and Sequels of Eelapsing Fever. a. Diseases of the Respiratory Organs. The complications in the respiratory organs are the same as in typhus, but are less frequent and severe, and seldom inter- fere much with recovery. 1. Bronchitis is not uncommon, but is usually slight, except when of old standing. Smith noted it in 132 out of 1,000 cases at Glasgow in 1843, the cases being most numerous in winter and spring.* According to Arrott it was very common in the same epidemic at Dundee." 2. Pneumonia is said to be more common than in typhus. According to Jenner, it is the next most common lesion after enlargement of the liver and spleen."^ Smith met with 3 cases ; Alison with i case;"^ Zuelzer with 9 in 160 cases ;"" and Douglas with 6 in 220 cases. Of the last 6 cases, 5 died ; but in 4, there ' Smith, 1844 (i), p. 70. " Arrott, 1843, P- ^'32- "" Jennee, 1850, xxii. 647. " Alison, 1843, p. 2. == Zuelzer, 1867, p. 684. COMPLICATIONS AND SEQUELS. 379 was also inflammation of the bowels. Pneumonia occurred only four or five times in my 600 cases. 3. In rare instances, pneumonia terminates in gangrene. One case was observed by Douglas, and two by Pribram and Eobitschek. 4. Pleurisy is also an occasional complication.^ On the left side it may occur in conjunction with splenic abscess. 5. Laryngitis or oedema of the glottis was observed by Smith in 9 (of 1,000) cases about the period of crisis. It is usually slight, but may require tracheotomy.^ b. Complications referable to the Organs of Circulation. I. Sudden Collapse comes on in some eases, and may prove rapidly fatal. It may occur in the primary paroxysm, in the intermission, or in the relapse. The pulse becomes small, irregular, or imperceptible, and the heart's impulse and sounds more or less obliterated ; the whole surface is cold and livid, and the patient is often perfectly unconscious. The most extra- ordinary circumstance is, that these symptoms may come on suddenly in cases previously mild, and may terminate in death within a few hours after the patient has been looked upon as in no danger. Douglas mentions three instances. In one, death occurred a few hours before the first crisis ; in a second, death occurred suddenly during the intermission without any pre- vious complaint, the patient being found in the morning, lying in an easy posture, and dead, as if for some hours ; the third patient was found dead about the period of the first crisis, without any warning, and within half an hour after having expressed herself as feeling easy."" Occasionally the syncope is due to haemorrhage, as in two cases recorded by Cormack^ and by Eeid of Glasgow,^ or to rupture of the spleen ; while in many other cases the patient has been the subject of chronic organic disease. Four of my patients died in this manner. In three the heart was found to be fatty (Cases XXXVII., XXXVIII.), and in two of these there was also fatty degeneration of the liver and kidneys ; the fourth patient had Addison's Disease. All excepting the last were over fifty years of age. y Robertson, 1844; Smith, 1844 (i), p. 70. ^ Pateeson, 1848; Bkgbie, 1866, 1^. 651. " Douglas, 1845, p. 274. *> Coemack, 1843, p. 41. " Eeid, 1843. 380 RELAPSING OR FAMINE FEVER. Case XXXVII. Belapsing Fever. Fatal Collapse on 1 1 th day. Dilated Fatty Heart. Charles H , aged 59, was seized with relapsing fever on Dec. ze^th, 1869. The attack was not of unusual severity. On Dec. ^ist the crisis occurred, the pains ceased, and the patient felt better. He ate meat, and seemed to be doing well, but remained low. At noon on Jan. 4th he became suddenly collapsed, and was dead within fifteen minutes. Autopsy. — The only evidence of organic disease was in the heart, which was dilated and fatty ; the right cavities were filled with soft dark coagulum. The spleen was large and congested. • , Case XXXVIII. Relapsing Fever. Fatal Collapse on 8th day. Fatty Heart, Liver, and Kidneys. Jessie S , aged 63, admitted into L.F.H. Dec. 10th, 1871, on 2nd day of relapsing fever. Pulse 120. Temp. 105°. Severe general pains ; little sleep ; tongue dry ; much vomiting. Dec. i^th [jthday). Crisis. Pulse 60, very feeble. Temp. 97'5° ; profuse sweating; still much vomiting and decided jaundice ; extremities cold and livid. Stimulants were administered freely, but patient did not rally, and died at 4 p.m. on Dec. i6th, retaining consciousness till the last. Autopsy. — Advanced fatty degeneration of heart, liver, and kidneys. Great congestion of lungs. 2. Palpitations are sometimes complained of during conva- lescence. They may, or may not, be accompanied by the anaemic cardiac mm-mur already described (p. 355). 3. Peiicarditis. In one of my patients there was typical pericardial friction dm-ing the relapse, followed by erythema nodosum in convalescence. 4. Hmnorrhages from various parts are by no means un- common. The most common variety is epistaxis (see p. 371). Haemorrhage from the uterus (p. 388), from the stomach (p. 357), from the bowels (p. 358), from the kidneys (,p. 366), and from the ears,*^ may likewise occur. These haemorrhages may appear at any stage of the first paroxysm, or of the relapse, but oftenest at the crisis. Dr. Gibson of Glasgow met with haemor- rhages in 2 1 out of 202 cases ; in 8, the bleeding took place from the nostrils ; in i, from the lungs ; in 3, from the stomach ; and in 9, from the bowels.*^ Douglas observed haemorrhages in 14 out of 220 cases; in i, the bleeding was from the uterus, Reid, 1843, p. 359. ' Gibson, 1843. COMPLICATIONS AND SEQUELiB. 38 I and in 13, from the nostrils: epistaxis had also occurred in several other cases prior to admission/ 5. Venous Thrombosis (see p. 195) I have not met with as a sequel of relapsing fever. 6. Arterial Thrombosis. In Case XXXIX., gangrene of both feet, * embolic ' masses in the spleen and kidneys, and softening of the brain, resulted from arterial thrombosis. Cases were observed in St. Petersburg in 1864-5, where all four extremities, nose, ears, and lips, became gangrenous, probably from a similar cause. = (See p. 199.) Case XXXIX. Belapsing Fever. General Arterial Thrombosis. Gangrene of Feet. Softening of Brain, dx. George C , aged 20, admitted into L.F.H. Dec. i^th, 1869, on third day of a severe attack of relapsing fever. Pulse 120 ; skin hot, 106° F. ; no eruption ; distinct jaundice ; no vomiting ; tongue dry ; much thirst ; bowels confined ; severe headache and general pains. On the 22,1x1 {nth day) the pulse had fallen to 76, the temperature was normal, and the appetite was returning, but the tongue remained dry and the jaundice persisted. On 28th (16th day) the fever returned, and did not subside after the usual period of three or four days. On Jan. jth, the fever persisting, the left foot and leg were found to be cold and livid, and there was no pulsation in the left femoral artery. Gangrene gradually extended over the lower third of left leg, with much pain; but on Jan. nth a line of demarcation had formed, and the patient's general condition was much improved ; he slept and ate and drank well. This improvement continued until the morning of the ijth, when he became rather suddenly unconscious. He was unable to swallow, had stertorous breathing, divergence of both eyes to the left, and clammy sweat. These symptoms continued until death at 1*30 a.m. next morning. The existence, or not, of hemiplegia was not noted. Autopsy. — The left femoral artery for five inches at its upper part was occluded by a firm, white, adherent coagulum. Both ventricles of heart contained a solid white coagulum, entangled among the fleshy columns and extending into the aorta and pulmonary artery, but there were no vegetations on any of valves. Both lungs congested. Spleen weighed 31 oz. ; its tissue soft, except at either end, where there was a firm, pale infarctus as large as a small orange. Kidneys weighed together i6|- oz.; externally they were smooth, and their capsules separated readily ; embedded in the cortex of both were several large pale infarct!, producing slight bulges on the outer surface, and surrounded by rims of injected renal tissue. Left middle cerebral ' Douglas, 1845, P- 219. ^ Zuelzer, 1867, p. 6S4. 382 RELAPSING OR FAMINE FEVER. artery obstructed by adlierent coagulum, and softening of central parts of corresponding liemispliere. 7. Enlargement of the Spleen occasionally persists for several weeks after the second crisis, and is either painless and asso- ciated with great anaemia, or tender and accompanied by febrile symptoms of a remittent type,^ which often subside under treat- ment directed against the spleen. In the latter case, the spleen is probably the seat of inflammatory masses resulting from thrombosis. 8. Piuptiire of the Si^leen now and then occurs during the paroxysm when the organ is greatly enlarged. Haemorrhage takes place into the peritoneum, and sudden and acute pain in the left hypochondrium followed by collapse, fatal within a few hours, is the result. Two examples are recorded by Zuelzer/ and one by Hudson.^ 9. Abscesses of the Spleen, for the most part due to thrombosis, may occur during the paroxysms, but oftener in convalescence. They give rise to the febrile symptoms already referred to. Sometimes they excite acute peritonitis or left pleurisy. Cases have been observed in which these abscesses have burst into the descending colon, or upwards through the diaphragm.^ 10. AncBinia. Great ansemia is common for weeks or months after the attack. c. ComjMcations referable to the Nervous System. I. Partial Palsy, lasting for a few days or weeks after re- covery, is occasionally noticed. Cormack mentions the case of a female, aged 36, in whom loss of power in both deltoids con- tinued for about ten days, after restoration to health in every other respect had taken place. ^ In 2 (of 220) cases Douglas observed partial paralysis of the fore-arms ; in one, it came on during the intervals between the attacks ; in both cases, the attack was sudden, with accompanying numbness, but with no head-symptoms ; the paralysis lasted for several weeks.™ Tempo- rary paralysis of the upper and lower extremities was observed by Dr. Parry in several cases at Philadelphia in 1869-70.'^ In a man aged 44, Tennent observed paralysis of the portio dura supervene six days after the second crisis." i' Wtss and Bock, 1S69, p. 19S. ' Zuelzee, 1867, p. 670. J Hudson, 1867, p. 95. '' Zuelzer, 1867, p. 696. ' CoRsiACK, 1843, p. 148. ■" Douglas, 1845, p. 272. ° Pabrt, 1S70, p. 348. o Tennent, 1S71. COMPLICATIONS AND SEQUELJB. 383 2. Muscular, Arthritic, and Neuralgic Pains are more fre- quent and severe during convalescence than in the paroxysms. They are, in fact, the most common sequelae, and often cause great suffering and prevent sleep ; but they usually cease after a few days, when the strength is regained (p. 367). d. Complications presented by the Organs of Special Sense. I. Post-febrile Ophthalmia. One of the most remarkable features of relapsing fever is the frequent occurrence during convalescence of a peculiar disease of the eyes. This sequela has been observed in almost all epidemics, but is never met with after typhus or enteric fever. The first cases were described by Mr. T. Hewson in his work on Venereal Ophthalmia,^ and occurred in his practice as long ago as 18 14. Mr. Wallace,i Dr. Jacob,*" and Dr. Eeid ^ gave an account of the affection as observed in Dublin during the epidemic of 1 826. It is alluded to by almost all writers on the epidemic of 1843, ^^^^ ^^i excellent description of it was published at that time by Dr. Mackenzie of Glasgow.*^ It was again observed in the eijidemic of 1847, when Dr. Dubois of New York " also described it as occurring among the Irish immigrants recovering from relapsing fever. Within the last few years it has been investigated anew by Estlander of Helsingfors, who observed it in Finland in 1867-8.'^ The disease, as described by Mackenzie, presents two distinct stages, the amaurotic and the inflammatory. During the first stage, the patient complains of more or less dizziness of vision, of musccs volitantes, and luminous stars. The inflammatory stage is characterised by lachrymation without injection of the conjunctivae, and by intense pain in and around the eye, aggra- vated at night and preventing sleep ; the pulse is quick, and rigors are frequent. In some cases the amaurosis commences with convalescence, and even before the cessation of the febrile paroxysms, and yet the inflammatory stage does not supervene for weeks or months ; but still oftener the dulness of vision does not commence for several days, weeks, or even months after the febrile attack, and is then almost immediately followed by the symptoms of inflammation. As a rule, the inflamma- tion commences from three weeks to three months after the p Observations on theHistory and Treatment of Ophtlialmia, London, 8vo. 1814, pp. 34, 119. ■> Wallace, 1828. ' Jacob, 1828. • Beid, 1828. ' Mackenzie, 1843. ° Dubois, 1848. ■' Estlander, 1869. 384 RELAPSING OR FAMINE FEVER. cessation of tlie fever. Occasionally its advent is protracted to four, five, or eight months after the fever, while Douglas men- tions two cases where it appeared as early as the second day of the relapse. According to Mackenzie, the inflammation commences in the retina, and from this spreads to the iris and sclerotic, the capsule of the lens and choroid ; but from the more minute observations of Estlander it would appear that the start- ing point of the disease is in the choroid, and especially in the ciliary body. Inflammation is lighted up here by some morbid state of the blood, and spreads thence to the vitreous body, causing the ' amaurotic ' symptoms, and subsequently, but not always, to the iris, the iritis corresponding to the ' inflammatory stage.' Eecoverj^ is tedious ; in most cases two months have been necessary to effect a cure, and unless carefully treated, the disease may end in permanent loss of sight. Both eyes are rarely attacked, and the right suffers more fre- quently than the left. Jacob never met with a case in which both eyes were affected. Of Wallace's 40 cases, the right eye alone suffered in 36, the left in 2, and both in 2. Of Mac- kenzie's 36 cases, the right only was affected in 18, the left in 10, and both together or consecutively, in 8. Of 29 cases under Dubois, the right only was affected in 15, the left in 11, and both in 3. Adding these results together, there are 105 cases, of which the disease was limited to the right eye in 69, to the left in 23, and attacked both in 13. On the other hand, of Est- lander's 28 cases, the left eye only was affected in 14, the right in 8, and both eyes were involved in 6. This ophthalmia occurs at all ages, but most frequently between 10 and 30. Of Wallace's 40 patients the youngest was 10, and the oldest 36. Jacob met with no case above 45, and only 3 of 30 cases were above 25. Of Mackenzie's 36 cases, 26 were between 10 and 30. Dubois and Jacob, however, met with cases, aged only 2^ or 3, and Mackenzie mentions others up- wards of 50. There are no data for ascertaining the proportion of cases of relapsing fever which are followed by ophthalmia, as the local disease rarely appears until long after the patient has been dis- charged from hospital. Occasionally the patient seems to have quite recovered from the effects of the febrile attack before the ophthalmia commences, but far oftener considerable debility remains. Jacob and Mac- kenzie both state that ophthalmia was most common in the very poor, who had insufficient nourishment during convalescence ; COMPLICATIONS AND SEQUELiE. 385 and the latter observes that many of his patients were wan and extremely weak at the time of their attack. These observations point to insufficient nom*ishment as one of the main causes of the ophthalmia ; and if this be so, it explains why the affection in question succeeds no other fever than relapsing. In some instances, exposure to cold has seemed to be the immediate exciting cause. 2. Epistaxis. (Seep. 371.) 3. Otorrhoeci. A purulent discharge from one or both ears sometimes occurs during the fever, or more commonly in conva- lescence, especially in scrofulous children. e. Diseases of the Organs of Digestion. 1. Pharyngitis. Welsh ^ states that in the epidemic of 1817- 19, 'in 181 of 743 cases the fauces or tonsils were more or less inflamed ; but in most cases, the affection was slight.' 2. Diarrhoea and Dysentery are common complications or sequelae of relapsing fever, and are among the chief causes of death in some epidemics. They were often observed in the Scotch epidemic of 1843, especially during autumn; in winter and sjDring they were comparatively rare. Smith met with them in 167 out of 1,000 cases at Glasgow,^ and Douglas in 33 of 220 cases at Edinburgh : y putting these results together, they were present in 200 of 1,220 cases, or in one-sixth. In my experience these complications have been rare (about 6 in 600). Most commonly, the diarrhoea comes on in the relapse, or after the cessation of both paroxysms. Of Douglas's 33 cases, looseness came on in the first paroxysm in only 3, and in 2 of the three it was very trifling ; in 30 it did not commence until after the day of relapse, and one- half of the 30 were not attacked until after the second crisis. Occasionally the diarrhoea appears to have a critical character; in 6 of Douglas's 33 cases, it occurred at the precise time of the crisis, and in 4 of the 6 it lasted only for a single day. At the same time, the diarrhoea does not appear to be substituted for the sweating ; in the 6 cases alluded to sweat- ing was also noted in 4, and in the other 2 its absence was not positively ascertained, while in 2 it was unusually profuse. These attacks occur at all ages with about equal frequency. Their accession is mostly sudden, and is occasionally preceded by rigors ; at other times it is gradual. They vary in severity ; in " Welsh, 1819, p. i. -^ Smith, 1S44 (i), p. 70. ^ Touglas, 1845, p. 269. C C 386 EELAPSIXG OE FA3IINE FEVER. II of Douglas's 33 cases the looseness was trifling, and easily restrained; of the remaining 22 cases, 8 "were fatal; in all the fatal cases the attack did not commence until after the cessation of the relapse. In some cases there is great pain and tenderness over the lower part of the abdomen, or the patient complains of tenesmus and griping pains. Vomiting, sometimes of an urgent nature, is a common accompaniment. In the milder forms the stools are fluid, f^eculent, dark, and very offensive, and rarely contain blood ; but in the more severe forms they are scanty, and consist almost exclusively of blood and mucus. The pulse is seldom quick, except in the paroxj^sm, and occasionally does not exceed 60. The purging may last only a few hours, or several weeks. Douglas mentions one patient who died within seven hom's of its commencement, and another whose death occurred on the 25th day of the pm-ging, or the 48th from the accession of the fever. 3. Peritonitis is fortunately a rare complication, as it is alwaj^s fatal. Of 2,846 cases of relapsing fever in the Glasgow Infirmary in 1847-8, 7 died from peritonitis.^ Paterson men- tions a case where death resulted from peritonitis on the sixth day,^ and Douglas another, where it was fatal on the 38th day: in the latter case the peritoneal surfaces of the bowels adhered at all then points of contact, leaving circumscribed interspaces filled with pm"ulent fluid.^ The peritonitis is almost always traceable to dysentery, or to an abscess or rupture of the spleen. (See p. 382.) /. Complications referable to the Integuments and Joints. 1. Erysipelas is an occasional sequela of relapsing fever, and is sometimes fatal. It was noted in 4 of 1,671 cases at the London Fever Hospital ; all recovered. 2. (Edema of the Lower Extremities is not an uncommon sequela, and appears to depend on debility of the organs of circulation, or an impoverished state of blood. It is chiefly met with in persons who have been starving before the attack, or who have been subjected to lowering treatment. It is usually slight, rarely extends so high as the hips, and seldom lasts longer than two or three weeks. 3. Ganfirene from pressure is rare in relapsing fever, which is not surprising, considering the short duration of the febrile IDaroxj^sms. '- Steele, 1848 and 1849. ■" E. Pateeson, 184S, p. 394. '' DorcLAS, 1845, p. 273. COMPLICATIONS AND SEQUELS. 38/ 4. Gangrene incleijendent of iwessure. (Seep. 381.) 5. Accidental Cutaneous Eruptions. (See also p. 350.) Perry at Glasgow "" and Arrott at Dundee ^ noted the frequent occur- rence of herpetic eruptions around the nose and mouth, espe- cially about the period of relapse, and in a few cases Cormack observed a pustular eruption around the mouth, immediately after, or simultaneously with, the crisis.® Wardell mentions an mstance where several bullae containing a sanguineous fluid appeared over the body. The patient died with m'femic symptoms, and urea was found in the blood. ^ A case is mentioned by Douglas where the fever was followed by an abundant eruption of lichen.^ Urticaria has been noted in a few instances by myself and other observers.'' One of my patients who had pericarditis in the relapse, got erythema nodosum of the legs dm"ing convalescence. Lastly, boils sometimes break out over the body during con- valescence, and may retard recovery. 6. Subcutaneous Inflammatory Swellitigs or Buboes are oc- casionally met with in the relapse, or in convalescence ; but on the whole they are rare, and do not often give rise to much constitutional distm'bance. They may be developed in the parotid, submaxillary, or inguinal region. Wardell records one instance where an inflammatory swelling in the parotid region appeared with the relapse, and was apparently the cause of death } Parotid swelling was noted in only one of my 600 cases ; the patient recovered. In the St. Petersburg epidemic of 1864-5, buboes are said to have been common, and to have been a frequent cause of death.'' 7. Effusion into the Joints. In most cases the severe articular pains which occur during convalescence are unattended by swelling, but there are exceptions. Cormack met with three in- stances in which severe pains in the knee-joint were followed by- effusion, and with several cases where there was swelling of, tB^' ankle-joints.^ Douglas observed two instances where the joints of the hand, during convalescence, presented pain, swelling, redness, heat, and stiffness ; the attack lasted a few days only. The same writer mentions a third case, where a rigid state of the masseter muscles prevented the movements of the lower jaw; and a fourth, where the same effect was produced by inflam- " Peery, 1844, p. 82. " Akkott, 1843, p. 132. ' CoEjiACK, 1843, p. 147. ' Waedell, 1846, xxxix. 548. e Douglas, 1845, p. 273. ^ Tennent, 1871. ' Waedell, 1846, xl. 200. J ZuELZEE, 1867, p. 686 ; Whitlet, 1865. •= Coemack, 1843, p. 147. c c 2 388 RELAPSING OR FAMINE FEVER. mation of the right maxillary articulation, which was tender and presented a circumscribed swelling.^ g. Comiolications referable to the Uterine System. 1. Menstruation may occur at any stage of relapsing fever.. At the crisis it is sometimes profuse, and apparently critical. Jackson noticed that copious menstrual discharge took placa occasionally at the invasion of the fever."^ 2. Abortions. A very remarkable feature of relapsing fever is that pregnant females, no matter at what stage of pregnancy, almost invariably miscarry. All observers agree on this point. For example, of 41 pregnant patients under the care of Smith," Jackson," and Tennent,? all miscarried but one. Ten out of 12 pregnant patients in the London Fever Hospital miscarried. The exceptions, indeed, are extremely rare. According to Cor- mack, abortion occurs most frequently in the relapse ; but of 19 cases under Jackson at Leith, 12 aborted during the first paroxysm ; 6 during the second ; and i during the third. Occa- sionally it takes place as early as the second day of the fever. Delivery is sometimes followed by copious haemorrhage, or by rapid sinking and death ; but, as a rule, the mother recovers, although, even when pregnancy is advanced, the child is always still-born or only survives a few hours. This circumstance makes it probable that the abortion is due to the foetus being poisoned by the maternal blood, aided, perhaps, by the inanition of the mother before and during the fever. Albrechfi reports a case where a woman gave birth to a seven months child on the third day of the relapse. The child died in 8 hours, and on j)ost-mortem examination, 38 hours after, the spirochsete was found in large numbers in the blood of the heart; some were still moving, and the body presented other signs of relapsing fever ; the spleen was greatly enlarged, there was granular infiltration of the heart, parenchymatous swelling of the liver and kidneys, and sub-serous ecchymoses. Sect. IX. Varieties or Eelapsing Fever. Eelapsing fever presents varieties according to its degree of severity and the presence of certain symptoms or complications, such as jaundice, vomiting, cerebral symptoms, hfemorrhages, ' Douglas, 1845, p. 273. '" Jackson, 1844, p. 423. " Smith, 1844 (i), p. 71. " Q2J. cii. p. 423. p Tennent, 1S71. 1 St.Pctersh.Med.Woch.i'i'&i.- VARIETIES. 389 diarrhoea, or dysentery. The most remarkable and formidable varieties are, on the one hand, that characterized by a dry tongue, delirium, stupor, subsultus, coma, or convulsions, or the ' typhoid state ; ' and, on the other, that which proves fatal by sudden syncope. Again, there are varieties according to the duration and number of the paroxysms, and the length of the intermissions. As a rule, there are two paroxysms ; occasionally there is but one, or there are three ; and in rare cases there are four or more. In the severer forms, where typhoid symptoms come on at the time of the first crisis, there may be no well- marked intermission and the paroxysm may appear unusually protracted. Cormack, in his monograph on the epidemic of 1843, made two varieties of the disease, i, ' The ordinary, or moderately congestive form,'' which consisted exclusively of the ordinary mild cases, and was scarcely ever fatal ; and 2, ' The highly congestive form,'' the chief characters of which were intense jaundice, a deep persistent purple colour of the face appearing immediately before or after the invasion of the disease, enlarged liver and spleen, hsemorrhages sometimes from the mucous membranes, somno- lence, delirium, subsultus, &c. ; and lastly, a remission, rather than an intermission, between the paroxysms. This second variety, which was comparatively rare but often fatal, corre- sponds to the form which has since been described by Griesinger and other writers ^ under the designation ' bilious typhoid.' The proportion of cases of this sort varies in different epidemics, and thus accounts for variations in the rate of mortality. In the Eussian epidemic of 1864-5 examples of this form were very common, but in the recent epidemic in London they were ex- tremely rare. Case XL. Belapsing Fever. Jaundice and Hematuria. No marked Apyretic Interval. (' Bilious Typhoid.') George W , aged 28, admitted into L.F.H., Nov. ijih, 1869, ill 3 days with severe fever and general pains. Pulse 104. Temp. 104° ; no rash. Tongue moist, with white fur ; great epigastric tenderness ; occasional retching. Ordered nitre-mixture. Nov. i8th {^th day, 10 A.M.). Was delirious in night, and, notwithstanding an opiate, slept little ; is still delirious. Pulse 132. Temp. io4'5°. Tongue dry and cracked. Whisky 3 oz., 4 p.m. Pulse 72. Temp. 100°. Still very delirious. Ordered opiate every four hours till sleep. Nov. igth. Pulse 112. Temp. ioo"2°. Slept at intervals, but still very delirious. ■■ Geiesingek, 1864, p. 285 ; Lebeet, 1869. 390 EELAPSING OE FAMINE FEVEE. Tongue diy and brown. Dulness of liver increased downwards, and mucli tenderness along lower margin. Nov. 20th. Pulse 140. Temp. 103°. Tongue very dry. Bowels only once opened since admission. Marked jaundice and occasional bilious vomiting. Urine retained, and what was drawn off by catheter contained a large quantity of blood. StiU much dehrium, but slept during night.- Ordered aperient draught, whisky 6 oz., sinapism to epigastrium, gr. x. acid, gallic. every 4 hours. Nov. 21st. Pulse 100. Temp. 102°. Very delirious in night. Bowels open. Nov. 22nd. Pulse 92. Temp. 101°. Still very delirious and requires catheter. Urine contams much less blood. Tongue dry and rough. Nov. 2^rd {loth day). Pulse 80. Temp. 100°. Tongue still dry, but was quiet during night, and passed urine without catheter. Urine contains no blood and only a trace of albumen. Skin stiU yellow. Nov. 25^/^. Pulse 100. Tongue stiU dry. Patient is heavy and stupid, without much delirium. Is hungry. Nov. 2'jth {14th day). Has been improving, but tongue has kept dry and skin yellow, and to-day is not so well. Pulse 112. Temp. 102-5°. Face flushed. Nov. 2Uli. Pulse 108. Nov. 2,0th {I'jth day). Pulse 90. Temp. 99°. Tongue moist. Appetite returning. No albumen in urine. Jaundice almost gone. From this date convalescence was unmterrupted. Sect. X. Diagnosis of Eelapsing Fevee. The diseases with which relapsing fever is apt to be con- founded are : — Typhus, enteric fever, febricula, remittent fever, yellow fever, incipient small-pox, bilious headache, and cerebral diseases. I. Typhus. Prevailing, as they do, together in great epi- demics, typhus and relapsing fever have natural^ been regarded as varieties of one disease. Yet, in their clinical histories, no two diseases can present a greater contrast. The characters which distinguish relapsing fever from typhus are mainl}'- the following : — a. The suddenness and severity of the primary rigors (see pp. 179 and 372). h. The absence of that heaviness or stupidity of countenance, so characteristic of typhus (see pp. 129 and 348). c. The much greater frequency of the pulse and elevation of the temperature as early as the first or second day of the disease (see pp. 136 and 352). d. The frequent occurrence of an anaemic cardiac murmur, and the absence of the cardiac phenomena indicative of softening of the left ventricle (see pp. 141 and 353). e. The greater heat of skin, and the absence of the typhus eruption (see pp. 132 and 352). DIAGNOSIS. 391 /. The frequency of jaundice, of vomiting, and of tenderness and enlargement of the hver and spleen (see pp. 148, 210, 357, and 359). g. The presence of epistaxis and other hfemorrhages (see pp. 178, 143, and 380). h. The severe muscular and arthritic pains (see pp. 157, 367, and 383). i. The rarity of delirium and other cerebral symptoms (see pp. 158 and 368). k. The almost invariable occurrence of abortion in pregnant females (see pp. 212 and 388). L The common occurrence of ophthalmia as a sequela (see P- 383)- m. The sudden subsidence of the pyrexia about the fifth or seventh da}^, accompanied by a copious critical sweat, and fol- lowed by apparent convalescence (see pp. 185 and 373). n. After a complete intermission of about a week, the occur- rence of a relapse on or about the fourteenth day (see pp. 188 and 373). 0. The remarkable difference in the rate of mortality (see pp. 234 and 394). As a rule, the characters of the two diseases are so different, that there can be no difficulty in diagnosis. But those cases of relapsing fever in which cerebral symptoms, and especially the 'typhoid state,' are developed when the patient first comes under observation, may closely resemble typhus, and then, in forming an opinion, we must rel}^ chiefly on the history of the case, the presence or absence of eruption, and the nature of other cases occurring in the same house or family. 2. Enteric Fever. {See Diagnosis of Enteric Fever.) 3. Simple Fever or Febricula. (See Diagnosis of Fehricula). 4. Piemittent Fever. Eelapsing Fever, on its appearance in 1843, "^^^ regarded by Craigie, Mackenzie, and other observers, as a variety of the remittent fever of tropical countries, and hence several of its designations (see p. 311). Both diseases commence suddenly, run a short course, have a tendency to relapse, and are often complicated Avith sickness, jaundice, and haemorrhages. Tropical remittent fever, however, originates from malaria, affects all classes of the community alike, and is not infectious ; whereas relapsing fever often occurs in districts free from malaria ; ^ all the circumstances marking its origin and "" Only 3 cases of ague were admitted into the Edinburgh Infirmary during the whole epidemic of 1843-4 {Official Report, p. 2). 392 EELAPSING OR FAMINE FEVER. progress oppose the idea of its depending on malaria ; it is confined, for the most part, to the poor and destitute ; and it is infectious. Moreover, there is no resemblance between the in- termissions of relapsing fever and the remissions of remittent fever. In no form of ' remittent fever ' does the febrile paroxysm last almost continuously for five or seven days, is then followed by a complete intermission of a week, and afterwards, with tolerable regularity on a certain day, by a return of the fever for three or five days. It is true that Craigie, Cormack, and others mention the occurrence of slight irregular remissions in the course of the paroxysms of relapsing fever ; but these remis- sions are far from constant, and from the rigors to the crisis the paroxysms usually exhibit as continued a course as typhus ; even if they were more common, relapsing fever would not correspond with any form of remittent fever yet described. (See also P- 3230 5. Yellow Fever. The frequency with which relapsing fever is complicated with jaundice has caused it to be mistaken for true yellow fever. In 1826 Drs. Graves and Stokes* published an account of the yellow fever of .Dublin, and the 21st chapter of the first volume of Graves's Lectures is entitled ' Yellow Fever of the British Islands.' The cases described by these writers appear to have been relapsing fever complicated with jaundice and cerebral symptoms ; and the fact that they differed from true yellow fever was pointed out at the time by O'Brien." The Scotch epidemic of 1843 was likewise regarded as closely allied to, if not identical with, yellow fever by Cormack of Edinburgh, Arrott of Dundee, by several physicians in Glasgow, and by Dr. Graves of Dublin. In Glasgow it was even fancied that the disease had been imported by merchant vessels from the West Indies, although, in truth, it had been prevailing on the east coast of Scotland for some time before it appeared in Glasgow. (See p. 47.) There is, no doubt, a strong resemblance between the severe form of relapsing fever, known as ' bilious typhoid,' and true yellow fever, so that, as far as symptoms go, it might be difficult to distinguish them.'*' But we have here an illustration of the mistakes which are apt to result from founding analogies or differences between acute specific diseases on symptoms alone. ' Graves and Stokes, 1S26. See also article 'Enteritis,' in Cyclop, of Pract. Med. 1833, ii- 59- " O'Bkien, 1S28, p. 532. " See on this subject a Lecture by the Author on Yellow Fever {Brit. Med. Joiirn. December 8, iS66). DIAGNOSIS. 393 and of neglecting the circumstances under which they appear, or, in other words, their causes. As ah-eady remarked, the * typhoid state,' seen in its typical form in true typhus, is not peculiar to that disease, but is liable to be developed in many others. So it is with jaundice, which occasionally appears in- dependently of any mechanical obstruction of the bile-ducts, as a result of other poisons besides that of true yellow fever. Without entering at present into the much-vexed question of the etiology of ' yellow fever,' it may be said to differ from relapsing fever in the following particulars : — a. Yellow fever exhibits no predilection for the poor and destitute, but attacks all classes alike. Indeed, according to some writers, feebleness of constitution prevents rather than favours an attack.'^ h. Yellow fever attacks the same individual only once ; re- lapsing fever confers no immunity from subsequent attacks. c. Jaundice is an almost constant symptom in yellow fever, whereas it is much oftener absent than present in relapsing fever. d. Yellow fever does not cause great enlargement of the spleen. e. Yellow fever is a most mortal disease ; relapsing fever is rarely fatal. [But in the form known as bilious typhoid the rate of mortality has been observed to be as high as 66 per cent.] /. Death in yellow fever is usually preceded by '^ black vomit,' which in relapsing fever, even when fatal, is so rare, that some of the most experienced of observers have doubted its occurrence. g. Lastly, the yellow fever of the tropics never follows the peculiar course of relapsing fever — a febrile paroxysm lasting for a week, terminating in a critical sweat, followed by a com- plete intermission of a week, and then by a second paroxysm. Eelapses of any sort are rare in yellow fever. 6. The severe rigors and pain in the back, coupled with head- ache, vomiting, quick pulse, and hot skin, may at the onset lead to the suspicion of Small-Pox. Although the lumbar pain and vomiting are rarely as severe as in the early stage of small-pox, a diagnosis during the first two days may be difficult, especially if there be any possibility of the patient having been exposed to the poisons of both diseases. 7. The headache is usually less than that of Dyspeptic or Bilious Headache, which is also not ushered in by rigors, nor Copland's Med. Diet. iii. 394 RELAPSING OR FA3IINE FEVER. accompanied by the quick pulse and hot skin of relapsing fever. 8. The suddenness of the attack, the rigors, the hot skin, and pains aU over the body, as well as in the head, distinguish the onset of relapsing fever from incipient cerebral affections. [The demonstration of the spu-ochgete in the blood will now distin- guish relapsmg fever h-om all other febrile diseases.] Sect. XL Prognosis and Mortality. As in typhus, the prognosis is based on the rate of mortality, the circumstances known to influence that rate, the presence and severity of certain symptoms and complications in individual cases, and the mode of fatal termination. a. Rate of Mortality. Eelapsing fever is far from being a fatal disease. As com- pared with typhus or enteric fever, its rate of mortality is ex- tremely small. The following table shows the rate of mortality of all the cases admitted into the London Fever Hospital, since 1847. TABLE XXXI. Years ; Admissions 1 1 Deaths | lyiortality per cent. Years Admissions Deaths Mortality per cent. 1 1848 13 1849 i 30 1850 32 1851 256 1852 1 88 1853 16 I 2 7 i I i 7-69 o-oo 6-25 2'73 I-I3 o-oo 1854 1855 1S68 1869 1S70 5 I 3 768 903 17 II O-OO 0-00 0-00 2-21 I-2I Total 2,115 39 1-84 Deducting 2 cases fatal within 2 hours of admission 2,113 37 175 Deducting 8 additional, who died within 48 hours 2,105 29 1-38 Thus, out of 2,115 cases, only 39 proved fatal, making 1-84 per cent., or about i in 54 ; or deducting 10 cases fatal within 48 hours after admission, the mortality was only 1*38 per cent., or I in 72. This small mortality from relapsing fever has been a matter of general observation. Thus, in the Scotch epidemic of 1843, t^i& mortality according to different observers was as follows : — PROGNOSIS AND MORTALITY. 395 TABLE XXXII. Locality Authority Cases Deaths Mortality per cent. Edinburgh . Ditto. Glasgow Ditto. Dundee Aberdeen Leith .... 1 Wardel^ Douglas^ McGhie^ Smith^ 1 Arrott'' Kilgour" Jackson'^ I20 220 2,871 1,000 672 1,201 216 5 19 129 43 7 47 10 4-16 8-63 4*49 4-30 1-04 3-91 4-63 Total 6,300 260 4-12 or I in 24*23 Similar observations have been made since 1843, as shown by the following results : — TABLE XXXIII. Locality Authority Cases Deaths Mortality per cent. Dundee, 1843-55 . Edinburgh, 1847-8 . Ditto do. . Ditto 1848-9 . Glasgow since 1843 Belfast, 1847-8 Dr. T.J.Maclagan^ Paterson*' Robertsons Official Eeport McGhie" Dr. Eeid' 3,066 639 589 203 4,933 1,014 61 20 23 8 276 74 1-98 3-13 3-90 3'94 5-59 7-29 Total 10,444 462 4-42 or I in 22*6 Adding all these results to those observed at the London Fever Hospital, we have 18,859 cases, and 761 deaths, or the rate of mortality of relapsing fever in this country has been 4*03 per cent., or i in 2478. In the epidemic in Bombay in 1877-8 9 Carter observed a mortality of 18*02 per cent. h. Circumstances influencing the rate of Mortality. I. Age. As in typhus, the rate of mortality increases as life advances. (See Table XXXVI.) In early life relapsing fever is scarcely ever fatal. Of 717 male patients under 25 years of age ^ Waedell, 1846. ^ Arrott, 1843. " Private Letter. '' McGhie, 1855. 5' Douglas, 1845. ^ McGhie, 1855. " Smith, 1844. <= KiLGouR, 1844. "^ Jackson, 1844. *■ E. Paterson, 1848. e Eobeetson, 1848. ' Irish Report, Bib. 1848, viii. 301. 396 KELAPSING OR FA3IINE FEVER. admitted into the London Fever Hospital not one died. Taking both sexes together, there were — Under 30 years, 1,366 cases, 7 deaths, or -51 per cent. Above 30 „ 745 ,, 32 „ „ 4-29 „ „ 191 >> 18 ,, ,, 9-42 ,, 72 ,, 9 >: „ 12-50 ,, ,, 60 Again, of the admissions into the Fever Hospital from 1848 to 1855, the mean age of the fatal cases was much greater than that of those which recovered. TABLE XXXIV. Cases Total eases, in which age known Cases which recovered Fatal cases .... 437 426 II 24-41 24-14 35-09 These results agree with what have been observed elsewhere. J TABLE XXX V.k Age Males ' Pemales Total -^'-^ '$^ >>^- 3 s c = CS S 3 -g ^ ce -tf '^ < " fl «a ^ " P % 0- < " O-QO Under 5 years . 19 o'oo 20 o'oo 39 From 5 to 9 years 59 o'oo 67 o'oo 126 O-QO ;, 10 to 14 ,, . 129 o'oo ' 105 1 o'95 234 I 0-42 „ 15 to 19 ,, . 266 o'oo ! 139 2 1-43 /05 2 0-49 „ 20 to 24 „ . 244 0-00 in I o'9o 355 I 0-28 ;, 25 to 29 „ . 130 I 0-76 77 2 2-59 207 3 1-44 ,, 30 to 34 ., . 100 2 2-00 78 2 2'56 178 4 2-24 „ 35 to 39 „ . 80 2 2-50 64 2 3'12 144 4 2-77 ,, 40 to 44 „ . 73 o'oo 69 3 4-34 142 3 2'II » 45 to 49 ji • 65 2 307 25* 4 '00 90 3 3-33 „ 50 to 54 „ . 45 4 8'88 35 2-85 So 5 6'2S ,, 55 to 59 „ . 28 4 14-28 II o'oo 39 4 10-25 „ 60 to 64 „ . 30 4 i3'33 24 4'i6 54 5 9-25 „ 65 to 69 „ . 5 I 20'00 7 14-28 12 2 i6-66 „ 70 to 74 „ . 3 I 33-33 2 jO'OO 5 2 40-00 ,, 75 to 79 „ . I I Age doiibtful . 2 2 4 Total, including 1 1-64 I doubtful cases [ 1,279 21 2-15 2,115 39 2. Sex. According to the experience of the London Fever Hospital, the mortality among males suffering from relapsing fever is somewhat less than that among females. Of 1,279 J See, for example, Douglas, 1845, P- 278; Official Rep. of Edin. Infirm, iov 1848-9; and Zuelzer, 1867, p. 691. ^ In this and the following Tables, the cases fatal within two hours of admission (see p. 394) have laeen included. PEOGNOSIS AND MOETALITY. 397 males 21, or 1*64 per cent., died ; and of 836 females, 18 or 2-15 per cent. ; but this result is attributable to a larger proportion of the males being under 30 years of age. Under fifty -the mortality was greater among females, but above fifty it was much greater among males. Thus : — Under 25 years . From 25 to 50 years Above 50 years . Almost all published statistics agree in making the mortality somewhat greater in the male sex.' 3. Times and Seasons. The mortality, according to season, of the cases admitted into the London Fever Hospital since 1847 is shown in the following table : — ■ Males Femat.-rs Cases Deaths Mortality Cases Deaths Mortality 717 o"oo 442 4 •90 448 7 1-56 313 10 3"i9 112 14 12-50 79 4 6-33 TABLE XXXVL Months and Seasons Admissions Deaths Mortality per cent. January February March April . May . June . July . August September October November December 269 159 103 113 no 1 104 76 92 90 238 368 i 393 6 I 3 I I I 4 6 15 2-23 0-62 Q-OO 2-65 •90 O-QO 1-31 i-o8 i-ii 1-68 1-63 3-8i Spring Summer ..... Autumn ..... Winter 326 272 696 821 4 2 II 22 1-22 073 1-58 2-68 Total 2,115 39 1-84 From this, it would seem that the mortality is greatest in winter. This result, however, was not uniform for each year. As in typhus, the mortality appears to be greatest at the ' For example, in epidemic of 1843, see Douglas, 1845, P- ^73^ ^^^'^ Re}), of E din. Infirm, for 1843-4; for epidemic -of 1847-8, see Eobertsox, 1848, E. Pateeson, 1848, p. 398, and Sep. of E din. Infirm, for 1847-8 ; and for St. Petersburg ei^idemie of 1864-5, see Zuelzer, 1867, -p. 691. The aggregate of these statistics makes the mortality among males 7-44 per cent. (5,040 cases and 375 deaths), and among females 5-82 per cent. (3,881 cases and 226 deaths). 398 EELAPSING OE FAMINE FE"V^R. commencement and height of an epidemic. Thus, of 1,147 cases admitted into the London Fever Hospital dm'ing the first ten months of the recent epidemic (May 1869 to Feb. 1870), 23 died, or the mortahty was 2 per cent., whereas, of 524 patients admitted in the subsequent ten months, only 5 died, or '95 per cent. In the Scotch epidemic of 1843, it was com- monly noticed that the cases were most severe and fatal on the first outbreak of the disease. Although in both tjqphus and relapsing fever the cases become milder and the mortality diminishes towards the close of an epidemic, in mixed epidemics of the two fevers the total rate of mortality has often been noticed to increase progressively as the epidemic advanced. As alread}" explained, this circumstance is due to a gradual increase in the ratio of typhus to relapsing cases (see p. 320). 4. Station in Life. The statistics of the London Fever Hospital furnish no information on this point, as all the 2,115 cases admitted since 1847, with the exception of 18, were of the poorest class. It has been a common observation in Ireland, that ' continued fever ' has been more severe and fatal among the rich than among the poor ; but, as before stated, this cir- cumstance has been mainly due to the fact, that most of the cases occurring in the upper class have been tj'phus or enteric fever, while a larger proportion of the poor have had relapsing fever. 5. Place of Birth and Race. Of the cases admitted into the London Fever Hospital since 1847, the rate of mortality accord- ing to bh'thplace was as follows : — TABLE XXXVII. No. of Cases D-*^« 1 ^^^ EngUsh Irish Scotch . . . ■. Foreigners . . ' . Birthplace not noted 1,570 426 22 28 69 27 10 2 ^^2 2-34 o-oo o-oo 2-90 From this it appears that the mortality among the Irish was I in 42 ; among the English, i in 58 (see p. 243). Among the Eussians in 1864-5, the mortality was much higher than has ever been observed in this country. It was as high as 127 per cent. (1,574 deaths in 12,382 cases). This was due, however, more to the dissipated habits of the patients and their PROGNOSIS AND MORTALITY. 399 extreme prostration before the attack, than to the mere influence of race. 6. The Previous Habits of the patients influence the progress and mode of termination of the disease. In 6 of Douglas's 19 fatal cases, the health had been greatly impaired by dissipation. 7. There are no data for determining the influence of consti- tution, mental depression, fatigue and privation, or neglect of treatment on the rate of mortality ; but the remarks made on these points under the head of Typhus are probably equally applicable to relapsing fever (p. 244). c. Presence of certain Symptoms or Complications. 1 . A very rapid pulse on the first or second day of the disease is not, as in typhus, a cause of alarm. 2. Profuse perspiration, accompanied by a rapid pulse, is not, as in typhus, a dangerous symptom. 3. Jaundice and minute petechia do not, in themselves, indicate danger, unless they be accompanied by cerebral symp- toms. 4. Purpura-spots and vibices, however, are only met with in severe cases. 5. Copious haemorrhages, particularly from the stomach and bo"wels, are dangerous symptoms. 6. Suppression, or great diminution of the quantity, of urine is usually followed by cerebral symptoms of a dangerous character. 7. Cerebral symptoms, such as stupor, delirium, coma and convulsions, tremors, and subsultus, are only observed in the most severe cases, and often terminate in death : even convul- sions, however, are not necessarily fatal. 8. It must be borne in mind that fatal collapse, or dangerous cerebral symptoms, occasionally supervene suddenly and unex- pectedly at or after the crises. 9. The presence of complications, and especially of peritonitis, pneumonia, diarrhoea, dysentery, abortion, or erysipelas, always increases the danger. 10. Chronic organic diseases, and particularly fatty degene- ration of the heart, favour the occurrence of fatal collapse (see p. 379). 1 1 . The interval between the paroxysms must not be mis- taken for permanent convalescence. 12. After the second crisis, the liability to certain sequelas. 400 EELAPSING OE FAMINE FEVEE. and particularly to severe muscular and arthritic pains, dysentery and ophthalmia, must be kept in view. Dysentery supervening during convalescence sometimes terminates fatally. d. Mode of Fatal Termination. In fatal cases, death is due to collapse (p. 379), or to uraemic poisoning (p. 365), or to some complication, such as dysentery, peritonitis, pneumonia, abortion, hemorrhages, &c. The fatal event may occur in either paroxysm, in the inter- mission, or in convalescence. Of 16 fatal cases observed by Douglas, death took place in the primary attack in 4 ; in the intermission, in i ; in the relapse, in 5 ; and during conva- lescence, in 6; in one, death occurred on the 38th day after the accession of the fever from peritonitis, and, in another, as late as the 48th day from dysentery. Sect. XII. Pathological Anatomy. The most important pathological change in relapsing fever is the presence in the blood of actively moving spiral filaments, which were first found by Obermeier °^ in 1873. They only differ in size from similar filaments originally discovered in stagnant water by Ehrenberg in 1838, and named by him spirochsete pli- catilis {airstpa, a coH ; %atT77, hair). Another spirochaete was found in the mucus of the gums by Steinberg in 1862 ; this he termed spirillum buccale. It has since been described by F. Cohn,° and the name spirochgete denticola given to it. Accord- ing to Arndt ° it is actually derived from the protoplasm of the salivary corpuscles (?). These three forms are closely allied, and may be regarded as different species of one genus or different varieties of one species. The spirochsete of relapsing fever has received various names, as spirillum, spirotrix, &c., but the one originally given to it by Ehrenberg should be preferred, and from its discoverer in the blood it may be fitly termed spirocheete Obermeieri, the name adopted by Cohn. It has since been carefully investigated and experimented upon by numerous observers, among whom may be enumerated Heydenreich, p Mottschutkoffsky,"! F. Cohn,'' Koch,* Pdess,* Albrecht," Vandyke Carter.' Although these observers ■" Obeemeieb, 1873. " CoHX, 1872 and 1S75. ° Arxdt, 1879. p Heydenreich, 1877. ' Mottschutkoffskt, 1876 and 1879. "■ CoHX, 1879. ' Koch, 1879. ' EiEss, 1879. " Albrecht, 1880. ' Vandyke Caetee, 1882. PATHOLOGICAL ANATOMY. 4OI disagree in some points the following maj' be regarded as a brief summary of the conclusions most generally acce^jted. The spirochfete Obermeieri (Plate VI.) is an extremely slender colourless spiral filament, homogeneous in structure, varying in length from y-^th to y-^o-o^h inch, in breadth from ^^^ ^^ th to 5-ooiro^^^ inch. It i^resents active vibratile and rotatory move- ments, and progresses in the direction of its long axis either forwards or backwards. Its numbers vary greatly in different cases and at different times in the same case ; as many as 40 or 50 may be visible in each microscopic field, or they may be so few as to be detected with difficulty ; when very numerous they may become aggregated into little clumps. There does not appear to be any constant relation between the numbers and the severity of the symptoms. According to most observers they are only present during the paroxysms, often not appearing till the second day, and they usually disappear before the temperature falls. Heydenreich and Carter, however, could always detect them some time before the rise of temperature in the relapse, and in inoculated monkeys before the primary paroxysm, the intervals varying from -^ to 21 hours. They retain their motility for one or two days after withdrawal from the body, and when kej)t in sealed tubes as long as 130 days (Heydenreich). Dr. Mottschutkoffsky, of Odessa, found that by inoculation of the blood during the paroxysms, though not during the remis- sions, relapsing fever could readily be communicated to man, the disease in all respects resembling that contracted in the usual manner, being neither more or less severe. He also found that blood from the malignant form, known as bilious typhoid, invariably gave the ordinary and never the malignant form. The disease has also been communicated by accidental inoculation in making post-mortem examinations. Vandyke Carter and afterwards F. Cohn also found that the disease could be readily communicated by inoculation to monkeys, but experi- ments on other animals have never succeeded. Mottschutkoffsky found that the period of incubation of the inoculated cases was never more than 8 or less than 5 days. In monkeys Vandyke Carter found it to vary from 30 hours to 5 days, and the spirochaete could always be detected in the blood. In 24 monkeys in whom the experiment succeeded in only two did a relapse take place ; by transmission through the monkey the poison seemed to increase in virulence. Koch and Vandyke Carter have succeede d m cultivating the parasites out of the body, when they become hypertrophied. D D 402 RELAPSING OR FAMINE FEVER. elongated and form a dense network. With regard to the mode of thek development and decay in the blood little is known. Small round bodies found in the blood are believed by some to be their spores, and there seems reason for believing that some kind of spore persists after the spirochsete itself has disappeared. Albrecht found that the spirochaete developed in blood drawn during the intermission and kept in the moist chamber of the microscope. With regard to their behaviour to various reagents, it is found that neither quinine nor salicylate of soda administered by the mouth have any effect on them. Drs. Moller"^ and Kiess,"" how- ever, found that salicylate of soda given in large doses during the intermission rendered the relapses less frequent. Mottschutkoffsky found that when blood was diluted with a O'l per cent, solution of quinine, the spirochsete was rendered motionless, but nevertheless did not lose its power of commu- nicating the disease by inoculation. When lo parts of blood were mixed with one of spirit of a strength of 66°, the spirochaete became motionless and the inoculation failed. Heydenreich attributes their disappearance before the crisis to the high temperature, which he considers causes their death, but it is found that out of the body they will stand a tempera- ture of 1X0° Fahr. without losing their motility. Mottschutkoffsky found that by inducing profuse diaphoresis by jaborandi the dis- appearance of the parasite was hastened and the paroxysms shortened. And from this and their behaviour with reagents he considers that inspissation of the blood at the crisis may be the cause of their disappearance. Owing to their extreme tenuity and colourlessness, the de- monstration of the spirochaste in the blood is attended with some difficulties, and the blood should be examined fresh and with the aid of reagents. Vandyke Carter recommends for permanent pre- servation drying the blood after exposing a thin film to the fumes of osmic acid, effected by inverting the thin glass cover and placing it for a few minutes over the mouth of a phial containing a 2 per cent, solution, and then drying. Another method which he recom- mends is to add to the thoroughly dried blood a drop of glacial acetic acid and allow it to remain about a minute and then to trickle off, and afterwards to wash with a few drops of distilled water and again dry. The preparation will now show only the Spirochaete and the nuclei of the white blood corpuscles. " ViRCHow and Hirsch, Jahresbericht, 1879. ^ Deiitsch. Med. Wochen. 1879. PATHOLOGICAL ANATOMY. 4O3 According to Heydenreich the best staining fluid is fuchsin. Carter recommends the film of dried blood to be treated with a clear aqueous solution of fuchsin for 3 or 4 minutes, the super- fluous staining fluid to be then washed off with distilled water and the specimen again dried ; an improvement on this method being first to heat the blood at a temperature of 250° Fahr. by leaving the slide for a minute or two on a metal plate made hot by a lamp. The specimens may be mounted in Canada balsam or glycerine. Eelapsing fever is characterized by no other constant ana- tomical lesion. The principal morbid appearances are as fol- lows : — a. Geiieralities. Emaciation. The body is usually much emaciated, except when persons in easy circumstances have contracted the disease by direct communication with the sick. The emaciation is due not so much to the disease, as to previous want. h. I7itegiime7its, Muscles, and Bones. 1. Discoloration. Large patches of livid discoloration are often observed on various parts of the body, more particularly on the back, the scrotum, and the pinnae of the ears. The jaundiced tint of the skin is often more marked after death than during life. 2. Spots. The petechise, purpura-spots and vibices, observed during life, persist after death. 3. The Muscles do not usually exhibit the abnormal colour ob- served in typhus. In cases characterised by the most severe mus- cular pains during life, the tissue of the muscles may exhibit no microscopic change ; but in some cases, especially those where death has been preceded by cerebral symptoms, granular and fatty degeneration is met with, as in typhus (see p. 249). 4. The Bones and the white tissues of the body generally are tinged yellow in the jaundiced cases. c. Organs of Digestion. 1. The PJiarynx and (Esoplvagiis rarely present any abnormal appearance. 2. The Stomach. The mucous membrane is usually perfectly normal, or only slightly injected ; but when death has been D D 2 404 EELAPSING OR FAMINE FEVER. preceded by urgent vomiting, and more especially when the rare symptom of ' black vomit ' has been present, the lining membrane is much injected, and here and there exhibits patches of ecchy- mosis and submucous extravasations of blood. Cormack mentions one case where the stomach, over one-third of its surface, was very black from blood effused on the surface of, and beneath, the mucous membrane. Similar appearances were noticed by Wardell, Douglas, and others, during the Scotch epidemic of 1843. In most cases, the ecchymosed patches do not exceed one or two inches in diameter. The membrane over these patches is softened and lacerable. In rare cases the stomach contains black blood similar to what has been vomited during life : more commonly it contains only a little yellowish bilious fluid. 3, The Small Intestines. In those cases which have been complicated with diarrhcea, the mucous membrane is often more or less injected, particularly towards the lower part of the ileum, and patches of ecchymosis, similar to those found in the stomach, may sometimes be observed. Neither Peyer's patches nor the solitary glands are ever ulcerated, nor do they contain any ab- normal deposit ; and, indeed, in most cases the small intestines are in every respect healthy, or only slightly injected. 4. The Large Intestines are usually healthy, except in those cases which have been complicated with diarrhcea or dysentery. In the slighter forms of this affection, irregular patches of arborescent and punctiform injection are found scattered irre- gularly over the surface of the membrane, which in the vicinitj^ of these patches is healthy in appearance and consistence. In the more advanced forms, the mucous membrane of the whole of the large intestine and of the lower two or three feet of the ileum presents tlie most intense vascular injection, of a deep red, purple, or dingy-brown colour. The surface also is covered with a pale membranous pellicle, which here and there has the ap- pearance of having been separated in patches. Occasionally a few small ulcers with thickened edges are found in different parts of the large intestine.^ In one case, Cormack found patches of blood extravasated beneath the mucous membrane of the rectum, and altered blood in the faeces. 5. The Mesenteric Glands are not enlarged, and present no abnormal appearance. 6. The Liver, especially when death occurs during the febrile paroxysms, is usually found enlarged, firm, and loaded with r CoKMACK, 1843, p. 49; Douglas, 1845, p. 271. PATHOLOGICAL ANATOMY. 4O5 blood; but even in the jaundiced cases it often exhibits no alteration of structure. Occasionally at St. Petersburg the liver was found to be in a state of acute atrophy, and in two cases of this sort, Zuelzer found it to contain crystals of leucine and tyrosine.'' These were probably examples of the form known as ' bilious typhoid.' 7. The Gail-Bladder and Bile. The bile is often dark, thick, and viscid. It has been thought that its inspissated condition might obstruct the ducts and account for the jaundice. But in almost all the jaundiced cases the bile- ducts are perfectly pervious, abundance of bile is found in the duodenum and faeces, and in some cases the bile is even thinner than natural. In two cases Pastau traced the jaundice to catarrh of the bile- ducts.^ 8. The Pancreas is normal. 9. The Spleen is perhaps of all the internal organs the one most frequently altered. It is almost always enlarged, and the enlargement is greater than that observed in typhus or enteric fever. Kiittner, in one instance, found it weigh four and a half pounds.'' It is largest when death occurs during the febrile paroxysms ; when the fatal event is due to some complication during convalescence, the spleen may be of normal size. In consistence, the spleen is often softened, and in some cases diffluent ; at other times, it is firm, and the Malpighian bodies are unusually distinct. Occasionally pale, red, fibrinous infarcti • are found in its substance and near the surface, and sometimes these are broken down into abscesses with signs of recent inflammation of the superimposed peritoneum. In rare cases the spleen has been found ruptured (see p. 382). 10. The Peritoyieum. Extensive recent peritonitis is occa- sionally met with (see p. z^6), usually associated with an in- flamed colon or spleen, but independent of any perforation of the bowel. d. Organs of Circulation and Blood. I. Hhe, Heart often presents no abnormal appearance. In one case Cormack observed considerable effusion of blood beneath the endocardium of the left ventricle. The muscular tissue of the heart is often pale and flabby, and in a state of granular or fatty degeneration. These changes are rarely absent when death " ZuELZEE, 1S67, p. 698. " Pastau, 1869. *" Zuelzer, 1867, p. 695 ; see also Hudson, 1867-, p. 95. 406 EELAPSING OR FAIMINE FEVEE. has been due to collapse, but sometimes they seem to have been antecedent to the attack of fever (p. 379). 2. The Blood drawn during the febrile paroxysms is often buffed," although there has been no local inflammation. De- colorised fibrinous coagula are found in the heart and large vessels more frequently than in typhus. But in other cases, and especially in those where haemorrhages or cerebral symptoms have been present, the blood drawn during life coagulates imperfectly, and after death is dark and fluid as in typhus. In several cases, urea has been detected in the blood in considerable quantity (see p. 365). The spirochaete has been found in the blood after death. In 1843, Dr. Cormack and Professor Allen Thompson found the blood in 1 2 cases to contain an increased number of white corpuscles ; *^ and although this observation has been called in question by Wardell,® and more recently by Pastau,^ it has been confirmed by the independent researches of Zuelzer and others at St. PetersburgjS and of Muu-head at Edinburgh.^ e. Organs of Resjiiration. 1. The Larynx and Trachea usually present nothing abnor- mal (p. 379). 2. The Bronchi are usually healthy, but occasionally present the signs of bronchitis. 3. The Pleurce rarely exhibit signs of recent inflammation (see p. 379). 4. The Lungs, on the whole, are much oftener normal than in typhus. The most common morbid appearances are those of bronchitis. Hypostatic consolidation is comparatively rare. True pneumonia is more common than in typhus, and indeed is a common cause of death. Gangrene of the lungs is rare (see p. 379). /. Nervous System. 1. "^hQ Cerebral Membranes may exhibit increased injection, or may be normal. There is no relation between the amount of vascularity and the severity of cerebral symptoms during life. 2. The Cerebral Serosity. An excess of the sub-arachnoid serosity and of the fluid in the lateral ventricles is occasionally met with. This serosity is colourless or of a pale straw colour; = Welsh, 1819; Arrott, 1843; Jennkr, 1850. '' Cormack, 1843, p. 113; and 1S49. '' Wardell, 1S43, p. 113. ' Pastau, 1869. - Zuelzer, 1S67, p. 666. '' MuiRHEAD, 1870. TEEATMENT. 40/ in the jaundiced cases it may be yellow. In one case where there had been suppression of urine followed by cerebral symp- toms during life, Dr. D. Maclagan found it to contain urea.' 3. The Brain and Cerebellum exhibit no signs of recent disease. Their substance is of normal consistence, and the number of vascular points may, or may not, be increased. Occasionally when there is a large quantity of fluid in the ventricles, the surrounding brain substance is slightly softened. There is no proof that inflammation of the brain, or of its membranes, has ever resulted from the relapsing fever. g. Urinary System. The Kidneys are frequently more or less loaded with blood ; while the cortex is softened, and* there is cloudy swelling of the renal epithelium. The post-moriem appearances of relapsing fever may be summed up as follows : — 1. There is no specific or constant lesion. 2. The most common lesions are enlargement and infarction of the spleen, slight leuchaemia, congestion of the liver and kidneys, jaundice, dysentery, and pneumonia. 3. In most cases nothing can be discovered in the liver, or in the bile-ducts, to account for the jaundice. In exceptional cases only there is acute atrophy or catarrh of the ducts. 4. No lesion can be discovered in the brain or its membranes, even when cerebral symptoms have been most marked. Sect. XIII. Treatment. The treatment of relapsing fever, like that of typhus, is both prophylactic and remedial. A. Prophylactic Treatment. The remarks made on the prophylactic treatment of typhus (p. 267) apply also to relapsing fever. Eelapsing fever is the appanage of poverty and destitution ; and the more completely we succeed in ameliorating the condition of the poor, particu- larly in times of famine, the more successful shall we be in averting the disease. When an epidemic has broken out, a due supply of nourishment to the poor, attention to ventilation and the prevention of overcrowding in their dwellings, the providing of baths and public wash-houses, and the timely ■ Henderson, 1843, p. 223. 408 RELAPSING OR FA:MINE FE^TR. isolation of the sick, are the measures on which we must chiefly rely for arresting its progress. The abolition of the Corn- laws, and the liberal manner in which the English public of the present clay respond to appeals in behalf of real distress in any quarter, promise to prevent a recurrence in this country of those frightful epidemics of famine fever described in former pages. B. Curative Treatment. It is important to bear in mind that most cases of relapsing fever recover without treatment of any sort. As Eutty long ago observed, those who are abandoned to the use of whey and God's good providence for the most part recover. The disease may be treated on the same principles as those laid down under the head of typhus, but in carrying them out we must beware of doing anything which would thwart the natural tendency to recovery, while we endeavour to obviate the known modes of death. I. Neutralize the Poison and Improve the State of the Blood. (See p. 273.) As yet we know no means of rendering the poison of relaps- ing fever inert in the system, but the mineral acids which have been already commended in typhus are also useful in relapsing fever, and particularly in cases characterized by cerebral symp- toms. From the condition of the blood the acid preparations of u'on might be expected to be of even more service than in typhus (see p. 275). No known treatment, however, has the power of shortening the paroxysms or of j^reventing their recur- rence. Allthe various antiseptic remedies have been tried but have failed to destroy the spirochsete in the blood. O'Brien, in 1826-7, thought that quinine might prevent the relapse ;J but in the Scotch epidemic of 1843 the remedy was tried persever- ingly by many practitioners, and found to be inefficacious.'' Douglas gave it in 24 cases, in doses of from two to four grains three or four times a day; of the 24 patients, 22 relapsed in hospital, and the remainuig 2 were discharged on the fifteenth day, one having all the appearances as if he was about to have a second paroxysm ; moreover, the average date of the relapse was ascertained in 2 1 cases, and was found to be exactly the same as in the cases treated without quinine.' In Edinburgh, in 1847, J O'BkIEN, 182S, p. 530. ^ COKMACK, I843, p. 168. ' Douglas, 1845, P- 277. TREAT3IENT. 409 * much attention was paid, especially towards the beginning of the epidemic, to cut short the disease, and to save the patients from a relapse. Strict confinement to bed, a strict regulation of diet, low diet, common and full diet, quinine, bibeerine, and arsenic, were all tried in a certain series of cases, but without the least effect in warding off the relapse, not even in prolonging its recurrence for a single day. It came like a fit of ague, almost to an hour.™ Eobertson, in the same epidemic, believed that an emetic given on the fourteenth day often postponed the relapse for several days, or lessened its violence. He mentions one instance in which it seemed to be deferred by this means for four days," but this postponement is not uncommon independently of treatment. In the last epidemics of relapsing fever quinine, and more re- cently salicylate of soda, have been extensively tried both in this country and on the Continent. In September 1869, I gave 20 grains on the 13th and again on the 14th day, in 6 cases ; in 4 the relapse occurred between the 1 4th and 1 8th days ; in 2 there was no relapse. A seventh patient took 20 grains of quinine on the 3rd, 4th, and 5th days ; the crisis occurred on the 7th and the relapse on the 15th day. In February 1870, an account was published of 3 cases treated in St. Bartholomew's Hospital, in which the relapse was said to have been prevented by quinine, which was given in lo-grain doses on the 13th da}', and afterwards in doses of 5 grains twice a day.° Subsequently, I treated 9 cases on this plan ; in 8, the relapse occurred between the 14th and i8th days; in the 9th there was no relapse, but this is not invariable even when no quinine has been taken. Muu'head found large doses of quinine taken by the mouth and injected subcutaneously, and also arsenic, of no use in preventing the relapse ; p while Obermeier proved that quinine in repeated small doses, and both in single and repeated large doses, in no way modified the temperature or course of the disease. "^ (See p. 402 for the effects of salicylate of soda and jaborandi.) II. Promote elimination, not merely of the Fever-poison, hvt of the products of metamorphosis. (See also p. 273.) When the patient is seen early in the attack, it may be well to commence with an emetic of ipecacuanha and antimony, or of mustard. The act of vomiting unloads the liver, and often affords great relief to the ^severe pains in the hypochondria. Pateeson, 1848, p. 406. " Robertson, 1848, p. 273. Brit. Med. Jowii. Feb. 26, 1S70. p Muirhead, 1870, ■i Obeemeier, 1869. 41 EELAPSING OR FAMINE FEVER. Throughout the febrile paroxysms, constipation is to be counter- acted by means of castor-oil, or by some other mUd aperient. Active purging, however, is to be avoided, and the risk of diarrhoea or dysentery supervening is to be kept in view. At the same time, the action of the kidneys is to be kept up by the frequent exhibition of small doses of nitre. Many years ago, Dr. Boss of Leith published a paper on the use of nitre in the relapsing fever of 1818, and spoke of it as 'an invaluable remedy for increasing the urine.' ^ In 1843, Dr. Henderson ex- pressed the opinion that head-symptoms might be averted by nitrate of potash and other saline diuretics.* Similar testimony in favour of nitre is borne by Drs. Cormack ' and Wardell.** By keeping up the action of the kidneys from the first, my experi- ence has led me to think that the occurrence of uraemic poison- ing, which is one of the main causes of death, may often be avoided. From one to two drachms of nitre, with one drachm of dilute nitric acid and half a drachm of tincture of digitalis, may be taken in solution in the course of 24 hours. Acetate of potash and nitric ether may be used for the same purpose ; but the nitre has the additional advantage of keeping the bowels open. III. Reduce the Temperature and the Frequency of the Action of the Heart. (See p. 279.) The measures which deserve a trial for this object have already been discussed under the head of Typhus. Patients often experience great relief from frequent sponging of the surface with cold or tepid water, and from cold affusion to the head. From the high temperature so often attained, relapsing fever appears particularly well adapted for immersion in the cold bath. This is found to give marked relief to the distressing symptoms. Under this head it may be well to make, a few remarks on the subject of blood-letting, which was formerly commonly practised in relapsing fever, and which some physicians still believe to have been beneficial. In the epidemic of relapsing fever in 18 17-19 blood-letting was practised largely. The profession was misled by the doctrines of Ploucquet, Clutterbuck, and Beddoes, who taught that there was no such thing as idiopathic fever, but that pyrexia was always dependent on local inflammation ; and this error ■" Eoss, 1820. Baglivi long ago wrote: 'In ardentibus febribus sal prunell '^ Hendekson, 1843, P- 222. ' Cormack, 1843, p. 161. " Wakdell, 1846. TREATMENT. 4I T was confirmed by the remarkably small mortality which followed the new method of practice. The fact was lost sight of that re- lapsing fever naturally terminates in recovery ; and the mortality after blood-letting in relapsing fever was compared with the mor- tality of typhus under the opposite mode of treatment. This is evident from the writings of Welsh, the great advocate of blood- letting. Thus, the following extract from his work contains one of the chief arguments in favour of his practice : — ' From the registers of the Eoyal Infirmary it appears that, from January 1812 to January 1817, 506 fever patients were dis- missed cured, or died. Of these, 457 were discharged cured and 49 died, or the proportion of deaths to recoveries was as I in lo^f. From the ist of January 18 17 to the ist of January 18 18, there were 478 fever patients dismissed cured, and 33 died; thus the deaths to recoveries were as i in I5^-|. From the ist of January 181 8 to the ist of January 18 19, there were 784 patients discharged cured, and 41 died, or the deaths were to the recoveries as i in 204^. . . . Now, it must be remarked, that it was towards the end of the year 18 17 that the practice of /rec venesection began to be employed in the Eoyal Infirmary; but it did not come into general use till the spring of 1 8 1 8 ; and since that time the mortality has been steadily diminishing.' " The facts admit of another explanation. Welsh made no distinction between typhus and relapsing fever. The cases during the first of the above periods were mostly typhus ; those during the latter were chiefly relapsing fever (see p. 313). The rate of mortality diminished, not from the substitution of venesection for other treatment, but owing to the partial displacement of typhus (a very mortal disease) by relapsing fever, which is rarely fatal. If Welsh, in place of comparing the mortality of relapsing fever with that of typhus, had compared the mortality among the cases bled under his own care with that of cases not bled, he might possibly have arrived at a different conclusion. No allusion to such a comparison is made in the body of the work ; but it appears from the Tables in the Appendix that the mortality was much greater in the former class than in the latter. The number of patients under Dr. Welsh at Queensberry House amounted to 743."^ Of these, during the first paroxysm, 224 were bled from the arm only; 140 were both bled from the arm and leeched ; 189 were bled by means of leeches only ; and 190 were bled neither generally nor locally. Again, of the 133 ' Wklsh, 1S19, pp. 169, 170. " Ibid. p. i^ 412 RELAPSING OR FAMINE FEVER. patients who suffered a relapse, 42 were bled from the arm dm-ing the relapse ; 20 were both bled and leeched ; 22 were bled by means of leeches only ; and 49 were bled neither locally nor generally. ' The total number of ounces of blood drawn during the treatment of the cases, both of primary fever and relapse, amounted to 10,166; and the total number of leeches applied amounted to 4,364.''' Many of the patients had been also bled before admission into hospital. One patient alone was bled to 100 ounces, and had 26 leeches applied. Now, what was the. mortality among the cases that were bled, as compared with that where bleeding was not practised '? Of 364 cases bled from the arm, 20 died, or i in i8-2. Of 189 „ leeched, 10 „ ,, i ,, 18-9. Of 190 „ not bled 4 ,, ,, i ,, 47*5.^ The mortality, therefore, was far more than twice as great among the cases which were bled, as among those which were not bled. During the epidemic of 1843, venesection was tried in several instances, but was almost universally repudiated as worse than useless. Dr. Alison stated that the cases which were bled had a slow and unsteady convalescence, in both 181 8 and 1843 ; ^ and that blood-letting is contra-indicated by what we now know of the etiology and pathology of the disease. IV. Sustain the Vital Powers by Appropriate Food and Stimulants. General instructions for carrying out this object will be found at p. 288. With regard to relapsing fever it is only neces- sary to add — 1 . That a larger quantity of nourishment is usually required after the cessation of the febrile paroxysms than in typhus, and that many patients during the fever, and especially in the re- lapse, will take a considerable quantity of nutriment with relish, and ai^parently with benefit (p. 356). 2. That alcoholic and other stimulants will often be required about the period of crisis, to counteract the tendency to collapse. They are especially indicated in persons over 45 years of age, and where there is evidence of a weak heart. Welsh, 1819, p. 186. ' Ibid. p. 184, and Table XXII. ^ Alison, 1843, p. 3. TEEATMENT. 4 1 3 V. Relieve Distressing Syiwptoms. (See p. 294.) Headache is usually the first symptom that calls for treat- ment. It is often relieved by an aperient, cold applications to the head, and the cold affusion; but if, notwithstanding, it persists and prevents sleep, recourse must be had to opium, larger doses of which are usually necessary than in typhus. Opium is also the best and surest remedy for the muscular and arthritic iMins, which are often the source of intense distress. The hydrate of chloral I have found to induce sleep in many cases, even where there was severe pain. It is less certain than opium, but is preferable when opium is for any reason contra- indicated. (See p. 298.) 2. Vomiting and pain in the Hepatic and Splenic regions are often greatly relieved by an emetic and aperient, and by dry cupping or the application of warm fomentations, poultices, sinapisms or blisters to the epigastrium. If these measures fail, relief is often derived from sucking small pieces of ice, from lime water and milk, or from bismuth, or an alkali in effervescence in conjunction with small doses of opium. Hydrocyanic acid and creasote have been tried under these cii-cumstances with less benefit. 3. The Jaundice calls for no special treatment. Mercury, which has often been recommended, is of no use except as an occasional aperient. It must be remembered also that the danger lies in the contamination of the blood, not with bile-pigment, but with urinary products. (See p. 370.) 4. In all cases of relapsing fever attention must be paid to the state of the urine, especially about the time of the crisis. When it is reduced in quantity, or contains blood or much albumen, and particularly when the patient is at the same time drowsy, or shows other signs of uraemic poisoning, the bowels are to be freely moved, dry cupping, sinapisms, poultices, or the wet compress may be applied over the loins, determination to the skin is to be promoted by the hot air-bath, or hot wet pack, while the nitrate or acetate of potash and liquor ammonise acetatis, with or without small doses of digitalis, are given internally. 5. Collapse is to be met by a free exhibition of medicinal and alcoholic stimulants. 6. Delirium, Sleeplessness^, and other cerebral symptoms are to be treated in the manner recommended under typhus. The violent delirium which occurs sometimes at the crisis is best treated with opium or chloral in conjunction with stimulants. 414 RELAPSING OR FAMINE FEVER. VI. Counteract Complications and Sequela. (See p. 306.) 1. Pneumonia and bronchitis require the same treatment as in typhus (see p. 306). 2. Various remedies have been given for the severe muscular and arthritic ixdns occurring during convalescence. Tweedie strongly recommended small doses of extract of colchicum with calomel and Dover's Powder.* Cormack, however, gave colchi- cum in both large and small doses an extensive trial, and came to the conclusion that it was of little or no use. He also tried the iodide of potassium, which he fancied sometimes to afford a little ease.^ But the remedies on which most reliance is to be placed are quinine and iron, with opium. The opium is to be given internally, and may also be applied externally in the form of liniment or fomentation. When the pain is unusually severe, the subcutaneous injection of morphia may be used. 3. CEdema of the lower extremities is best treated with steel and mineral acids, a nutritious diet, and bandaging the legs. 4. Ancemia during convalescence is to be counteracted by the different preparations of iron. 5. Small doses of laudanum in decoction of logwood, or an astringent mixture containing kino or catechu, with opium, will in most cases check diarrhoea. But when there is dysentery, the best remedies are ipecacuanha and opium. The ipecacuanha maybe given in the form of ' Twining's Pill,' which has long en- joyed great repute for the treatment of dysentery in India, and in which it is combined with blue-pill and extract of gentian, or it may be described as follows : — R Pulv. Ipecac, gr. ij. Pulv. Ipecac. Co. gr. v. Hydrarg. c. Greta, gr. iij. Misce. Fiat pulv. quater in die sumend. Or, R Pulv. Ipecac, gr. iij. Pulv. Acacise gr. v. Misce. Fiat pulv. 4ta qq. liora sumend. An enema of starch and opium ought also to be administered from time to time, especially when there is much tenesmus ; and occasional doses of castor-oil are useful if the stools are scanty and the abdomen distended. Warm fomentations are to be ap- X)lied over the abdomen, and the diet is to be restricted to articles which are nutritious but non-irritating, such as milk, farinaceous TwnEDIE, 1S60, p. 592. •> COKMACK, 1843, p. 64. TREATMENT. 415 food, eggs, &c. If the dysentery assume a chronic form, the mineral astringents, such as the sulphate of copper, the acetate of lead, the nitrate of silver, and above all the pernitrate of iron, in combination with small doses of opium ought to be substi- tuted for the ipecacuanha. 6. For peritonitis, large and repeated doses of opium (gr. j. every hour), fomentation of the abdomen, and absolute rest are the only remedies likely to be of any benefit. 7. Painful Enlargement of the Spleen is to be treated with rest, poultices, and opium. Chronic enlargement persisting during convalescence requires a combination of sulphate of iron and quinine internally, and the external application of iodine, or of the red iodide of mercury ointment. 8. For the post-fehrile ophthalmia ° in its early stages, tonics, such as quinine and iron, are evidently called for. By such remedies, with a liberal diet and blisters behind the ears, we may hope to avert iritis. As soon as this shows itself, Mackenzie recommends a few leeches to be applied to the temples, and a powder containing one grain of calomel, one or two grains of quinine, and a quarter of a grain of opium, with a little sugar, to be given every four or six hours. When the gums become affected, the quinine is to be continued without the calomel. At the same time, the pupils are to be kept dilated by dropping occasionally within the eyelids a solution of belladonna or atropine, and the leeches are to be followed by blisters behind the ears, which should be kept open for some time. These remedies must be combined with a nutritious diet. See references at p. 383. 4i6 CHAPTER IV. ENTERIC OR PYTHOGENIG FEVER. Sect. I. Definition of the Disease. AN endemic disease, generated and propagated by certain forms of decomposing organic matter. Its symptoms are : a commencement often insidious, or marked by slight rigors, a sensation of chilliness, or profuse diarrhoea ; pulse usually frequent and soft, but pulse and temperature both subject to great variations in same patient ; febrile symptoms in mild cases often remittent ; tongue red, and often fissured, occasionally becoming dry and brownish; in most cases, but not invariably, increased splenic dulness, tympanitis, abdominal tenderness, gurgling in the iliac fossae, and diarrhoea, with or without intestinal haemorrhage; skin warm, with occasional sweats ; an eruption of isolated, elevated, rose-coloured spots, vanishing on pressure, first appearing between the seventh and fourteenth days, and coming out in successive crops, each of which lasts two or more days ; frequently epistaxis ; prostration coming on late, patient rarely taking to bed before the seventh or tenth day ; headache, sometimes fohowed by stupor and active delirium, but mind often clear throughout the attack, even in fatal cases ; dilated pupils ; the disease protracted to the twenty-fourth or thirtieth day, and occasionally, though rarely, followed by a relapse of all the symptoms, including the eruption ; after death, disease of the solitary and aggregated glands of the ileum, and enlargement of spleen and mesenteric glands. Sect. II. Nomenclature. I, Synonyms derived from its su2)2)osed Besemblance to Ty pirns. Typhus nervosus {Sauvages, 1760) : Typhus mitior and Synochusp-o parte [Cullen, 1760) ; Abdominal Typhus and Darm-typlms [Aiiten- rieth, 1822, and German Writers generally) ; Synochusand Typhus with Abdominal Affection {Southwood Smith, 1830); Fievre NOMENCLATUEE. 41/ Typhoide {Louis, 1829 ; Ghoviel, 1834) ; Typhus gangliaris vel entericus {Ebel 1836 ; Schonlem, 1839) ; Typhoid Fever [Stetvart, 1840; Bartleit, 1842; Jenner, 1849); Mild Typhoid Fever {Copland, 1844) Ileo-typhus {Griesinger, 1857); Typhia {Farr, 1859) ; Typhus {many loriters). 2. — From its Mode of Prevalence. Febris non-pestilens (i^ores^'M-s, 159 1 ) ; Endemic Fever {many toriters) ; Autumnal or Fall Fever [Flint, 1852 ; and American loriters gene- rally). 3. — From its Bemittent Character. Uvperos rjixLTpLToio'; ? {Hippoc.) ; Hemitritseus ? Tritieophyas ? and Triphodes ? {auctor. antiq. var.) ; Febris semitertiana seu composita [Galen? Forestus, 1591 ; Sjngelius, 1624); Triteophya typhodes {Mangettis, 1695); Eemittent Fever {T. Sutton, 1806); Infantile Eemittent Fever {Evanson a,iid Maunsell, 1836 ; and many toriters). 4. — From its Lengthened Ditration. Febris lenta {Forestus, 1591 ; Willis, 1659; Linnceus, 1763; Vogel, 1764) ; Slow or Lent Fever {Strother, 1729; Langrish, 1735); Febris chronica? {Juncher, 1736); Common Continued Fever {Armstrong, 1816) ; Fievre continue {L erminier smdi Andral, 1823). ■ 5. — From its su2:)posed Nervous or Hysteric Character. Nervous Fever {Gilchrist, 1734) ; Slow Nervous Fever {Huxham, 1739) ; Febricula, or Little Fever, commonly called the Nervous or Hysteric Fever, Fever on the Spirits, Vapours, &c. {Manningham 1746) ; Irregular Low Nervous FeYev {Fordyce, 1791) ; Nervenfieber {German writers) ; Fievre nerveuse {French writers) ; Low Fever {many writers). 6. — From the occurrence of Putrid or Septic Symptoms. Febris putrida {Biverius, 1623) ; Febris putrida quse vulgo lenta ap- pellatur {Willis, 1659); Febris putrida nervosa? {Wintringham, 1752) ; Febris putrida aut biliosa {Tissot, 1758) ; Febris a putredine orta {A. Tralliani, quoted by Burserius as Syn. for his Fe. gastric, ac. 1785); Febris a,ta,cta,, pro parte {Selle, 1770); Fievre ataxique, pro parte, and F. adeno-meningee {Pinel, 1798); Entente septi- cemique {Piorry, 1841) ; Sepimia {Hare, 1853). 7. — From its Beseynhlance to Hectic Fever. Febris hectica {Willis, 1667) ; Infantile hectic fever {various ivriters). 8. — From the Absence of the true Typhus-Eruption. Febris petechizans vel spuria {Hoffmann, 1699). 9. — From the comjnon Occurrence of Gastric Derangement, Bilious Vomiting, dx. Febris gastrica [Ballonius, 1640; Febris acuta stomachica aut in- testinalis [Heister, 1736) ; Febris glutinosa gastrica (Sarcowe, 1765J ; E E 41 8 ENTEEIC OR PYTHOGENIC FE^^R. Febris gastrica acuta [Burser. 1785) ; Fievre meningo-gastrique {Pinel, 1798) ; Gastrisches Fieber [Bichter, 1813) ; Fievre gastrique [Diet, des Sc. med. 1816) ; Epidemic Gastric Fever [Cheyne, 1833) ; Gastric Fever {Craigie, 1837) ; Febris hiliosdij { Galen ? Biver. 1623 ; Stahl, 1700 ; Juncker, 1736) ; Bilious Fever {Pringle, 1750 ; Btctty, 1770) ; Febris biliosa putrida {Selle, 1770) ; Febbre biliosa {Benelli, 1775); Synochus biliosus (Sauvages, 1760); Bilio-gastric Fever [Copland, 1844) ; Gastro-bilious and Bilious Continued Fever {modern writers). 10. — From the Intestinal Symptoms and LesionsA Febris colliquativa ? {J. B. Fortis, 1668); Febris stercoralis ? {Qti.es- nay, 1753) ; Febris mucosa {Selle, 1770) ; Febris pituitosa {Stoll, 1785; Strack, 1789); Febris colliquativa primaria seu essentialis {B'urserius, 1785); Morbus biliosus-mucosus {Knaus, 1786) ; Febris pituitosa nervosa (/aco&i, 1793); Schleimfieber (iTaw^, 1795) ; Fievre muqueuse {French writers) ; Mucous or Pituitous Fever [Copland, 1844). Febris mesenterica maligna {Baglivi, 1696 ; Hojfmann, 1699) ; Febris intestinalis vel mesenterica [Biedel, 1748) ; Febris mesenterica acuta [Burchard, quoted by Burserius, 1785); Fievre entero-mesenterique [Petit and Serres, 1813) ; Enteritic Fever [Mills, 1813) ; Gastro- enterite (Brotcssais, 18 16) ; Entero-mesenteric Fever {Ahercromhie, 1820) ; Febris mesaraica [Wendt, 1822) ; Dotbienenterite [Bre- tonneau, 1826 ; Leuret, 1828 ; Christison, 1840) ; Muco-enteritis {various loriters) ; Fever, with Affection of the Abdomen {Alison, 1827) ; Fever, with Ulceration of the Intestines {Bright, 1829) ; Gastro- enteric and Gastro-splenic Fever [Craigie, 1837); Enterite folliculeuse {Cruveilhier, 1835 ; Forget, 1841) ; Enteric Fever {Bitchie, 1846; Wood, 1848; W. T. Gairdner, 1859; Coll. Phys. Bond. 1869) ; Febris tympanica {Bahington, 1853) ; Intestinal Fever {W. Budd, 1856). II. — From its supposed Dependence on Worms. Typhus hysterico-verminosus {Sauvages, 1760); Febris verminosa [Selle, 1770) ; Worm Yev&c, pro parte {various loriters). 12. — From its Mode of Origin. Kight-soil Fever {Brown, 1855) ; Pythogenic FeYer {Muoxhison, 1858) ; Cesspool Fever [var.). 13. — Other Designation. ]\Iiliary Fever (Pringle and De Haen, 1760). The term typhoid, commonly applied to this fever, is in many respects inappropriate. In the first place, it literally " Many of the cases described by Cullen and his successors, as ' Enteritis erysipelatosa,' were probably examjples of this fever. (See description of it by Alison, 1S44 (No. 2), p. 323.) HISTORY. 419 means like typhus, and consequently it is at variance with all precedent in the accepted nomenclature of species in science. Secondly, it is constantly employed in an adjective sense, to designate a group of symptoms which may appear in the course of any disease ; and thirdly, a large proportion of the cases of so-called ' typhoid fever ' exhibit no symptoms of a typhoid or typhus-like character. It follows, that the use of the term typhoid to designate a specific fever tends to create confusion ; and, indeed, it is probable that this very name has contributed to make many regard the fever in question as merely a variety of typhus. At the same time, it may be doubted if any of the numerous synonyms by which the disease has been known be more appropriate. For example, I am inclined to question the propriety of employing a name derived from the abdominal lesion, as most such designations are calculated to revive the exploded doctrines of Broussais. Even the term Enteric Fever, adopted by the London College of Physicians in its ' Nomen- clature of Diseases,' is apt to convey the erroneous impression that the fever is the result of the intestinal lesion ; while practically it leads to errors in diagnosis and treatment. Medical men often decline to call a fever ' enteric,' in which, as often happens, there are no enteric sj^mptoms, and hence the intestinal lesion is apt to be overlooked until it unexpectedly becomes a source of danger. This mainly accounts for the circumstance that in the returns of the Eegistrar-General deaths are weekly ascribed to ' Simple Continued Fever,' a disease which in twenty-five years has not once been fatal in the London Fever Hospital. These considerations induced me to suggest the name Pythogenic Fever, derived from what I endea- voured to show was the cause of the fever (TruOoysvys, from TTvOwv {TTudojbbaL, putresco) and ysvvdco).^ The reception which this name has met with has encouraged me to retain it in this work.^ Sect. III. Historical Account. SOME of the descriptions of the Greek writers probably referred to enteric fever. Hippocrates states that in the course of two successive autumns, he met with many cases of fever of the continual * See MuECHisoN, 1858 (3). Objections have been raised to the etymology of the word ' Tivdoyevr^s ; but in Scapula's Greek Lexicon a host of similar words will be found, e.g. ^AAiyevT^s, e mari ortus ; ^A Steothes, 1729, pp. 15, 164. 422 ENTERIC OR PYTHOGENIC FEVER. Ill 1734, Dr. Ebenezer Gilchrist of Dumfries published an 'Essay on Nervous Fever.' His description evidently refers to enteric fever. Thus he speaks of its long duration, and of its frequent occurrence in children. The symptoms varied greatly in different cases, but among the most common were diarrhoea, abdominal pain, meloena, epistaxis, partial sweats which gave no relief, and in the advanced stages delirium and other cerebral symptoms. He observes : — ' I take this fever to be very different in its nature and changes from other fevers ' prevalent in Scotland. ■' In the followmg year. Dr. Browne Langrish of London drevv^ a similar distinction between the ' Sloio Nervous Fevers ' and the ' Malignant Continued Fever,' the former being characterized by a quick but variable pulse, vomiting, purging, and a duration of from twenty to thirty days. In the treatment of nervous fever, Langrish condemned both bleeding and purging. ^ Four years later Huxham published the first edition of his ' Essay on Fevers,' in which he devoted a chapter to the differences between the ' Sloiv, Nervous Fever ' and the ' Putrid, Malignant, Petechial Fever.' His descriptions leave little doubt, that by the former title he referred to enteric fever, and by the latter, to typhus. He observes : ' I cannot conclude this Essay on Fevers, without taking notice of the very great difference there is between ihe lyutrid, malignant and i\iQ sloio , nervous fever ; the want of which distinction, I am fully persuaded, hath often been productive of no small errors in practice, as they resemble one another in some respects, though very essentially different in others.'*^ In 1746, Sir Eichard Manningham, F.E.S., gave an excellent de- scription of enteric fever, under the title of ' Febricula, or Little Fever.' This fever, he said, was popularly designated the ' Nervous or Hysteric Fever, Loiu Continued Fever, Fever on the Spirits, Vapours, Hypo or Spleen.' Among the symptoms were, a red often dry tongue, abdominal pains, diarrhoea, haemorrhages, quick but variable pulse, loss of memory, and in a few cases slight delirium. He dwelt particu- larly on its insidious origin, and said that at the beginning it was apt to be disregarded, ' till, at length, more conspicuous and very terrible symptoms arise, upon which the physician is sent for in the greatest hurry, and the little, neglected fever proves of very difficult and un- certain cure, and too often becomes fatal in the end.' He condemned the practice of bleeding, and recommended cordials and diaphoretics." Not long after, a discussion arose between Sir John Pringle and Professor De Haen of Vienna, as regards the treatment of fever. De Haen advocated the necessity of blood-letting, whereas Pringle ob- served that ' many recovered without bleeding, but few who had lost much blood,' and recommended stimulants. It turned out, however, that these two observers were dealing with different diseases. ' Gilchrist, 1734, p. 347. " Langeish, 1735, p. 343. * Huxham, 1739. " Ma^s'ningham, 1746. HISTORY. 42 3 Pringie's malignant fever of the hospital and jail with petechise was typhus ; whereas De Haen's petechial and miliary fevers were, for the most part, enteric. Pringie gives an unmistakable description of the eruption of typhus ; but the eruption in De Haen's fevers is described as consisting of isolated round elevated spots, which came out in suc- cessive crops, and which were occasionally interspersed with true petechia and vibices. This difference was pointed out by Prmgle, who, in his reply to De Haen's attack, observed that one great cause of confusion was the undefined meaning of the term petechicz, and added : ' I have never considered the jail or hospital fever and the miliary fever as similar, and indeed I may venture to say, that, as the symptoms of the two are so much unlike, they ought to be treated as different in species ; ' and again : ' The miliary fever is incident to all ranks of people, Hving in the best air and in the most cleanly manner, whereas the malignant fever, which I treat of, is scarce to be seen but among the lowest people crowded together in close and foul places, such as m military hospitals, jails, and transport ships.' ^ De Haen's miliary fever was described by his successor Stoll, under the designations of jntuitotis and. sloto nervous fever. Stoll relates the case of a boy who died on the fourteenth day of this fever. His symptoms had been vomitmg, diarrhoea, and colicky pains, associated with general fever ; but this was so slight, that until the twelfth day he was able to walk to the hospital for medicme. After death, the small intestines were fomid inflamed and gangrenous and the mesen- teric glands enlarged, and near the lower end of the ileum there was a perforation.^ Many other accounts of enteric fever on the Continent were pub lished during the eighteenth century. Eiedel described a febris intestinalis , in which the lower portion of the ileum was found gangrenous after death. '^ The same fever is also reported as very pre- valent at Stuttgart, in 1783; at Gottingen, in 1785 ; and at Hilde- sheim, in 1789.? Not a few writers pomted out the difference between it and typhus. Burserius, for example, after describing with tolerable accuracy the symptoms and post-mortem appearances of enteric fever, added, that although it sometimes simulated petechial fever, ' multum discrepare videtur.' ^ Li 1 760-1, an epidemic of fever occurred at Gottingen, which has acquired some notoriety and requires particular notice. It was described by Eoederer and Wagler under the name of morbus mucostcs, and has been regarded by most succeeding writers as identical with the pituitous fever of Stoll and the typhoid fever of modem times. But, after carefully reading the original monograph, I doubt the correctness of this view, and am of opinion tliat the fever referred to was probably for the most part typhus complicated with ' PEiNGiiE, 1750; 4tli ed. 1764, app. pp. 99, loi ; De H.ven, 1760; Eitciiie, 1855, p. 264; .Jennek, 1853, p. 416. "' Stoll, Rat. Med. ii. 407 ; Eitchie, 1855, p. 265. '^ Eiedel, 1748, p. 45. y Duncan's Annals of Med. 1796, i. 73. ' BuESEKius, 1785, p. 449. 424 ENTEEIC OR PYTHOGENIC FEVEE. dysentery. The disease broke out in a crowded, famislied garrison, during a siege in November 1760. Eoederer and Wagler regarded it as a degenerated form of dysentery, with which the garrison had been afflicted for three months before. Although the intestines were found after death ulcerated and gangrenous, these lesions were always in the large intestines. In thirteen cases, the post-mortem appearances are described with great minuteness, but in none was the ileum ulcerated ; while in the general observations on the anatomical lesions, it is re- marked concerning the small intestines : ' Tunica interna, licet inflam- mata, tamen continua est.' The enlargement of the mucous follicles figured and described were observed in the stomach, duodemim and colon, and in only one case is any mention made of enlargement of the agminated and solitary glands of the ileum. ^ Meanwhile, in England, the distinctions drawn by Gilchrist and Huxham between the slow nervous fever and the malignant fever of the hospital were not lost sight of, and were excitiiig some discussion. Dr. Vaughan of Leicester, in a letter addressed to Dr. Lettsom, speaks of the febris nervosa as ' a very different disease to the febris carcerum, in its attack, progress, termination, and cure,' and blames CuUen for not distinguishing them ; ^ and Dr. Erasmus Darwin of Derby, in another letter addressed to Dr. Lettsom, in 1787, proposes as a ques- tion for discussion at the Medical Society : ' Whether the nervous fever of Huxham be the same as the petechial or jail fever ;''' while Dr. Willan in 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.' '^ The intestinal lesions of the slow nervous fever also began to be noted. They did not escape the notice of John Hunter, as is shown by two preparations in his museum at the Eoyal College of Surgeons;^ and in 1799, one of Hunter's pre- parations was figured by Matthew Baillie.^ There is also evidence that during this century enteric fever was not unknown in Ireland. Eutty makes frequent mention of a con- tinued fever in Dublin, which prevailed for the most part in autumn, was protracted to three or four weeks or upwards, and was accom- panied by diarrhoea and haemorrhages. s Dr. Macbride of Dublin, in 1772., spoke of the febris nervosa (a protracted fever, attended by diarrhoea) as a different species from the putrid continual fever, which was contagious and accompanied by a florid eruption, gradually passing into petechite.'* Lastly, Dr. Sims, in his account of the epidemic of » EoEDEEEE and Waglee, 1762, Y>V- 4' 8, 19, 179. * Life of Dr. Lettsom, by Pettigrew, iii. 161-2. " Ibid. iii. 118. ^ Willan, 1801, p. 231. " Pathol. Catal. Nos. 1,214 and 1,219. ' Plates of Morbid Anatomy, fasc. 4, ])\. ii. fig. 3. Dr. William Stark of London lias often been referred to, as the first to localise the lesions of enteric fever in the intestinal glands ; but his drawings, and still more the clinical account of the cases from which they were taken, leave no doubt in my mind that the disease which he described was not enteric fever. Staek's Works, 4to. Loud. 1788, pp. 5, 7. K Eutty, 1770, jip. 51, 181, 187, 202, 250, &c. '' Macbride, 1772, p. 336. HISTORY. 425 typhus in Tyrone in 1771, remarked that it was different from the nervous fever of Gilchrist and Huxham, although he believed that nervous fever, in its advanced stage, might degenerate into malignant hospital fever, so that it was impossible to distinguish them,^ "With the commencement of the present century, the pathological anatomy of fever began to be carefully investigated in France. M. Prost of Paris, in 1804, announced that ' les fievres muqueuses, gastriques, ataxiques, adynamiques, ont leur siege dans la membrane muqueuse des intestins ' (vol. i. p. 23). He stated that he had dis- sected the bodies of upwards of 200 patients who had died of fever in Paris, and that he had invariably found the intestines inflamed (p. 56) ; and he added, What is now known to be erroneous, that this inflammation was always in proportion to the severity of the delirium and other febrile symptoms (p. 57).. Prost erred in mistaking every 'post-mortem redness of the intestinal canal for inflammation ; and although he described correctly the ulcerations peculiar to enteric fever, he regarded them as merely the ultimate stage of ordinary inflammation, and was unacquainted with the peculiar seat and nature of the disease. Of the 113 post-mortem examinations of different diseases recorded in his work, 16 only appear to have been well-marked examples of enteric fever.J Broussais did little more than extend the views advocated by Prost. He was aware that the ulcerations found in fever frequently had their seat in the intestinal glands, but he thought it useless to distinguish between this form and inflammations of other portions of the intestine. So little did Broussais appreciate the nature of the lesions of enteric fever, that in describing this disease as the type of his ' gastro-enterite,' he maintained that in variola, measles, and scarlet fever, death was due to the same ' gastro-enterite.' Belie-ving that the symptoms were the result of inflammation, Broussais was the advocate of copious depletion, and his writings have more or less influenced the practice of many continental physicians to the present day.^ In 18 13 enteric fever was described with far greater accuracy and precision by Messrs. Petit and Serres, under the designation of 'Fievre enter o-mesenterique.' These observers pointed out that the lesions were limited to the lower portion of the ileum, and that thus the disease differed from ordinary enteritis. They were the first to regard it as specific. They expressed the opinion that the morbid appearances in the intestine resulted from the introduction of a poison into the system, and that they were of an eruptive nature, like the pustules of variola. Still, they believed that the abdominal lesions preceded, and were the cause of, the pyrexia, and that the extent of the former determined the severity of the latter. They also failed clearly to localise the disease in the solitary and agminated glands.^ After this, Cruveilhier,"i L^rminier, and Andral" described the Sims, 1773. •> Pbost, 1804. ^ Broussais, 1816 and 1823. Petit and Serees, 1813, pp. 159, 165, and Introd. p^D. 20, 39. ' Cbuveilhier, 1816. " Lerminier and Andeai;, 1823, i. 403. 426 ENTERIC OR PYTHOGENIC FEVER. intestinal lesion as an internal exantbem, the ulcerations as preceded by 'pustules,' and the larger patches as an ' anthrax de la membrane muqueuse.' Andral, moreover, maintained that there was nothing to show that the disease commenced in the mucous follicles, and he classified Continued Fever under diseases of the abdomen. ° It was reserved for Bretonneau of Tours to prove that the disease was always locahsed in the solitary and agminated glands of the ileum. He also was the first to maintain that it depended on the action of a poison, which was communicable from the sick to the healthy. Al- though he considered the disease of the intestinal glands as inflam- matory, and accordingly named the affection ' dothienenterie ' or ' dothienenterite ' {SoOlyjv, a tumour, and ei'repov, intestine), he dis- tinguished this mflammation from all other inflammations of the bowel ; he showed that there was no correspondence between the severity of the febrile symptoms and the extent of the intestinal lesion ; and, like Petit and Serres, he insisted on the analogy of the latter to the cutaneous eruptions of the exanthemata. Bretonneau's views were made known in Paris in 1S20, but were first published by his pupils Landini and Trousseau in 1826, and by himself in 1829.P In 1829 was published the first edition of the elaborate and philosophic work of M. Louis. 1 Its appearance constituted an important epoch in , the history of continued fevers, as the work furnished a standard of comparison with other fevers. Louis gave to the disease the unfortu- nate appellation of Fievre typho'ide, which was adopted by Chomel m his ' Clinical Lectures ' published in 1834,1' and since then has come into general use. By the works of Louis and Chomel it was shown that disease of the solitary and agminated glands of the ileum was always present in the fever of Paris ; both authors, however, agreed that the severity of the fever did not correspond with the extent of the local disorder, and they described cases of latent typhoid, where the symptoms were extremely mild up to the date of fatal perforation. They also insisted on the necessity of not confounding typhoid fever with gastro-enterite. All these French observers, however, regarded the contagious typhus of camps and armies, and of English writers, as identical with the disease under their own observations. Broussais remarked : ' En effet, puisque le mot typhus est synonyme du mot gastro-enterite, chaque fois que Ton dira typhus des prisons, typhus des hopitaux, typhus d'Amerique, typhus du Levant, ce sera comme si Ton disait gastro-enterite des prisons, des hopitaux, etc' Louis, Bretonneau, and Chomel were all inclined to regard the two affections as identical, although the two last deplored the absence of careful post-mortem records of typhus cases, which, they thought, could alone decide the question. Chomel, after expressing doubts as to the contagious nature of ' typhoid fever,' remarked : ' Si des observations ultcricures dimon- " Lebminier and Axdk.vl, 2ncl ed. 1834. p Landini, 1826; Tkousseau, 1826; Bretonneau, 1829. 1 Louis, 1S29. " Chomel, 1834. HISTOEY. 427 traient dans le typlius des lesions anatomiques semblables a celles que Ton rencontre dans la maladie typlioide, I'identite de ces deux affections serait mise liors de doute, et la question de la contagion serait jugee. But, while French pathologists were thus maintaining that con- tinued fever was always associated with disease of the intestinal and mesenteric glands, British observers were making the discovery that in most fatal cases of fever these parts were healthy. At the same time, observations similar to those made in France were not wanting in Great Britain and Ireland, In 1806 Dr. Thomas Sutton pubhshed the account of a ' remittent fever ' among the troops at Deal, which was accompanied by great sickness and diarrhoea, while after death the bowels were foimcl to be inflamed and gangrenous. ^ Willan and Bateman, in their Eeports on the Diseases of London between the years 1796 and 1816, make frequent mention of the same fever as prevailing more particularly in autumn.* Many of the cases bled so largely by Mills in Dublin in 181 2 (see p. 41) were evidently examples of the same fever." To Dr. James Muir we are indebted for an excel- lent history of a limited outbreak of enteric fever in the suburbs of Paisley in 1811 ;'' and to Mr. Henry Edmonstone, for an equally lucid account of an outbreak at Newcastle in the autumn of iSiy.'"' Mr. Edmonstone's account is particularly interesting, as it forms a striking contrast to the descriptions of typhus then prevailing in many other parts of the United Kingdom, and which afterwards visited Newcastle itself. The outbreak commenced in June during extremely hot weather following much rain, and lasted only six weeks. It was believed not to be contagious, and several members of a family were observed to be attacked simultaneously. Many of the first cases occurred in the higher ranks of life and among servants in the best ventilated parts of the town, and it was scarcely known in those parts of the town where the infectious typhus was most common among the poor. Children and persons in the vigour of life were almost exclusively affected. Its duration was from 14 days to a month. Among the symptoms were vomiting, purging, melsna, epistaxis : cerebral symp- toms were rare. Abercrombie, in 1820, recorded two cases of ' entero- mesenteric fever,' in which the characteristic lesions of enteric fever were found after deatli, and stated that the so-called ' remittent fever ' of infants was often symptomatic of intestinal disease.'' In 1826, Dr. Hewett of St. George's Hospital published a number of cases, proving the frequent occurrence of ' follicular vilceration ' of the bowels in the idiopathic fever of London. Dr. Hewett's investigations have met with mimerited neglect. They were published almost simultaneously with those of Bretonneau ; and, like his, they showed that the seat of the lesion was in the solitary and agminated glands of the ileum. According to Dr. Hewett, the orifices of these glands became plugged, and the glands themselves distended with secretion, while the » Sutton, 1806. * Willan, iSoi, p. 25 ; Bateman, 1819, p. 145, etc. " Mills, 1813. ' Muie, 1811. ^ Edmonstone, 1818. "^ Abeecrombie, 1820. 428 ENTERIC OR PYTHOGENIC FEVER. surrounding tissues became disorganised partly by ulceration and partly by sloughing.y In 1827 Bright published his observations on fever in London, illustrated by excellent coloured drawings of the intestinal disease, which he spoke of as occurring occasionally.^ In the same year. Dr. Alison stated that he had met with the intestinal affection described by French authors in Edinburgh ; but he main- tained that it was not found after death from the ordinary typhus of that city; in 25 autopsies he had found Peyer's glands healthy.^ In 1830, Dr. Tweedie ^ and Dr. Southwood Smith,<= the two physicians of the London Fever Hospital, published the results of their experience. Both authors recorded a number of cases of fever in which the intes- tines were found ulcerated and the mesenteric glands enlarged after death, and other cases where these parts were healthy : both regarded the intestinal lesion as merely one of many other complications of fever. A few years later (1834-7), Craigie confirmed Alison's obser- vation to the effect that, in the fever of Edinburgh, intestinal disease occasionally ' coexisted with the fever and determined the fatal termi- nation,' but that in most cases the intestines were healthy. 'i Lastly, although Irish observers ascertained that intestinal disease was excep- tional in the fever of their own country, yet, in 1833, Dr. Cheyne described the symptoms and lesions of the fever of France under the appellation of ' ejndemic gastric fever,' and stated that he had frequently observed it in Dublin ; ® and, in the following year, Mr, Poole adopted Cheyue's appellation in his account of two outbreaks of the disease in different parts of Ireland.^ Thus the French pathologists rarely failed to find the intestines diseased in fever ; the English, on the contrary, in most cases found them healthy, and believmg, either that the primary seat of fever was in the brain, or that fever was an idiopathic or essential affection, regarded the mtestinal lesion as an accidental complication. In both countries, among the first effects of the increased study of morbid anatomy was the neglect of the distinctions drawn in the previous century between the slow nervous fever and the malignant fever of armies and jails. Somewhat clearer views on the subject prevailed in Germany. In 1810, Hildenbrand distinguished between the contagious typlius and the non-contagious nervous fever ; ^ and soon afterwards many German writers regarded the Typhus exanthematicus and the Typhus ahdoini- nalis, Typhus gangliaris, or Nervenfieber, as well-marked varieties.'^ The distinctions, however, which they laid down were not siifiicient to ensure accuracy in diagnosis, still less to establish the non-identity of the diseases in question, while in 1844 Dr. Kuchler published a memoir to prove that the two diseases were identical.^ y Hewett, 1826. ^ Bright, 1827. " Alison, 1827. " Tweedie, 1830. " Smith, 1S30. ^ Ceaigie, 1834 and 1S37. ^ Cheyne, 1833. ' Poole, 1834. ^ Hildenbrand, 181 i, p. 15. ^ Eeuss, 1814 ; AuTENEiETH, i822 ; Stannius, 1835 ; Ebel and Grossheim, 1836 ; Schonlein, 1839. ^ See Geisolle, Path. Int. 1852, i. 53. HISTOEY. 429 But the investigation of the question was soon to be renewed, and to be crowned with results w^iich even Erasmus Darwin eoukl little have anticipated. A record of the successive steps by which our present knowledge has been attained is an important chapter in the history of Medicine. Early in 1835, Dr. Peebles, who had observed the rubeoloid erup- tion in the contagious typhus of Italy, pointed it out to Dr. Perry in the Glasgow Hospital. Dr. A. P. Stewart was present on the occa- sion, and from that date the eruption, which seems to have been pre- viously overlooked in Glasgow,J was noted in the majority of cases. In January 1836, Dr. Perry published a paper, in which he correctly described many of the distinctions between typhus and enteric fever. "^ He referred to the complete absence of the ' typhus- eruption ' in ' dothienenteritis,' but did not state that the latter was characterized by an eruption of its own, although, four years later. Dr. Stewart remarked that Dr. Perry was the first whom he had heard maintain the complete difference of the two eruptions.' The following extract, however, from Dr. Perry's memoir shows that his ideas on the subject were far from clear, and that he believed the existence of intestinal lesion to be not incompatible with true typhus : — ' Dothienenteritis, or enlargement of the mucous follicles of the smaller intestines and en- largement and ulceration of the aggregated glands of the lower third of the ileum, occurs in combination toith contagious tyijJms, and is to be met with in about one in six of those who die from typhus. It also exists as a disease j;er se.' In the same year (1836), Dr. H. C. Lombard of Geneva, who had previously had ample experience of enteric fever in Switzerland and France, visited various towns in England, Scotland, and Ireland. In certain cases of fever in Glasgow and Dublin, which he had considered similar to the fever of the Continent, he was astonished to find no disease of Peyer's glands. After further investigations in Liverpool, Manchester, Birmingham, and London, he was the first to state that there were ' two distinct and separate fevers in Great Britain ; one of them identical with the contagious typhus, the other a sporadic disease, identical with the typhoid fever, or dothienenteritis, of the French.' He did not, however, determine the differences between the eruptions and the symptoms of the two fevers.™ Almost at the same time, Messrs. Gerhard and Pennock of Philadelphia were arriving at the same con- clusions from observations of an epidemic of typhus, which prevailed in that city in the spring and summer of 1836. Both had previously studied enteric fever in Paris and were familiar with it in their own country. They at once recognised the difference of the new disease, and after a time they were never deceived in their diagnosis. Their observations were published by Gerhard in February and August 1837. Gerhard maintained that the typhus of Philadelphia was identical with British typhus, and with the jail, camp, ship, petechial, or spotted ' See antea, p. 46. ^ Peekt, 1836 (i). ' Stewart, 1840. "> Lombaed, 1856. 430 ENTEEIC OR PYTHOGEXIC FE^'ER. fever, and that it was eminently contagious ; while, on the other hand, enteric fever was rarely communicated. He showed that the lesions of Peyer's patches and of the mesenteric glands, invariably present in the latter, were never found in the former, and remarked that Enghsh observers erred in regarding the intestinal disease as a mere complica- tion of tj'TDhus. He insisted on the ' marked difference between the petechial eruption of typhus and the rose-coloured spots of t}'phoid fever ; ' and he showed that a peculiar train of symptoms, very different from those of typhus, was associated with the intestinal affection, and that ' the distinctive characters of the two diseases were such as in practice could not allow them to be confomided.'" To Messrs, Ger- hard and Pennock certainly belongs the credit of first clearly esta- blishing the most important points of distinction between the two diseases. M. Valleix of Paris, in a review pubhshed in January and February 1839, thus alluded to Gerhard's observations : ' M. Gerhard etablit d'abord un fait bien important, c'est qu'il pent exister, et qu'il existe en effet, concurremment dans le memepays, deux maladies, qu'on pent parfaitement diagnostiquer, et dans lesquelles on pent predne, pendant la vie du malade, les lesions qui seront trouvees apres la mort : ce sont la fievre t}-phoide et le typhus proprement dit.' ° In 1837 the Academie de Medecine of Paris awarded prizes to the authors of two essays on the 'Analogies and Differences of Typhus and Typhoid Fever.' These essays did not contain original observa- tions, but referred chiefly to the pre%'ious records of the two diseases. One author (Gaultier de ClaubryP) expressed his comiction that the two diseases were identical ; the other (Montaulti) arrived at the con- clusion that, notwithstanding certain resemblances in their s}TQptoms, they were really distinct. It may be remarked that De Claubry, like some recent writers, although beheving the two fevers to be identical, argued from the statements of previous observers as if they had always employed the terms ' tjqihus ' and ' tjqohoid ' with strict accuracy. It was not surprising, then, that he maintained that intestinal lesions might exist in true typhus. It was De Claubry 's memoir, however, that mostly influenced pubhc opmion in France. In 1838 Dr. Staberoh of Berhn, after studying fever for four or five years in Vienna and Paris, and for six months in Britain, pointed out to the hospital physicians of Glasgow the different eruptions met with in Continued Fevers, and remarked that these distinctions would facilitate the decision of the question of the specific difference of typhus ahdominalis and typhus exanthematicusJ In February 1839, Dr. Shattuck of Boston, U.S., came over from Paris, where he had already studied enteric fever, and watched some cases at the London Fever Hospital. He v^Tote an accomit of thirteen cases, which he communicated to the Medical Society of Observation of Paris. About one-half of Dr. Shattuck's cases appear to have been typhus ; the other half were enteric. Dr. Shattuck strongly insisted " Gerhard, 1837, xx. iSg, 291, etc. » Valleix, 1839 (No. i). p De Claubry, 1838. « Moxtault, 1838. ' Staberoh, 1838, p. 427. HISTORY. 43 1 on the existence of two fevers in England, and pointed out with con- siderable minuteness the distinctions between them.^ His paper formed the groundwork for a second review on fever, published by M. Valleix in October 1S39, in which the conclusions were arrived at, that both typhus and fievre typho'ide were to be met with in England, that the latter was the same as the fever of France, and that English practitioners erred in confounding them.* In February 1840 M. Eochoux published a memoir, in which he endeavoured to show that the ' dothienenterite ' of Bretonneau differed from typhus in its anatomical lesions, symptoms, and causes. He in- sisted that nothing could be more unlike than the eruptions of the two fevers, and that while typhus was highly contagious and generally believed to result from overcrowding, the contagious character of dothienenteritis was doubtful and it was independent of overcrowding." On the 6th of the same month (February 1840) Dr. H. C. Barlow read a paper ' On the Distinction between Typhus Fever and Dothien- enterie ' before the Parisian Medical Society, which was published in abstract in the ' Lancet ' for February 29th. This paper has received less attention from subsequent writers than it deserves. Dr. Barlow maintained that typhus was an epidemic and highly contagious disease, and was usually most prevalent in winter ; whereas dothienenterie was an endemic disease, but slightly, if at all, contagious, and always most prevalent in summer and autumn along with other abdominal ajffec- tions. Although typhoid symptoms were common to both fevers as well as to other diseases, he showed that their clinical history and duration were entirely different. He carefully distinguished between the rose-coloured lenticular spots of the one disease and the petechial eruption of the other, and he insisted that the lesions of dothienenterie were never present in typhus. ' Surely,' he says, in conclusion, ' two diseases which differ in all these particulars cannot be identical.'^ Dr. A. P. Stewart studied fever in the Glasgow Fever Hospital from the summer of 1836 to June 1838, and afterwards in Paris. The results of his researches were communicated to the Parisian Medical Society on the i6th and 23rd of April 1840, and were published in October of the same year. Dr. Stewart described in a masterly manner the leading distinctions between ' typhus ' and ' typhoid ' fevers, as regards their origin, proximate causes, course, symptoms, and anato- mical lesions ; and he supported his views by a statistical analysis of cases of both fevers. He pointed out more accurately than any pre- vious observer the differences of the eruptions ; and he remarked that the characters of the two diseases, when taken collectively, were ' so marked as to defy misconception, and to enable the observer to form, with the utmost precision, the diagnosis of the nature of the disease and the lesions to be revealed by dissection.' He showed that, while there was overwhelming e"^idence to prove that the effluvia from living bodies in close and unventilated localities could generate the ° Shattuck, 1839. * Valleix, 1839 (No. 2). " Eochoux, 1840. ' Baelow, 1840. 432 ENTEPJC OR PYTHOGENIC FEVER. poison of typhus, ' typhoid fever ' often appeared in country places and in the best aired houses. The facts and arguments adduced in his memoir forced upon him the conviction that the two fevers were 'totally different diseases.'^ In November 1840 a review of Dr. Stewart's memoir appeared in the ' Archives Generales de Medecine, which the writer ended by remarkmg, that Dr. Stewart's observations demonstrated that in England there were two distinct diseases — ' typhus,' and ' typhoid fever.' In consequence of the various researches now mentioned, Louis, in the second edition of his great work on ' Fievre typhoide,' published in 1 84 1, admitted that ' le typhus fever des Anglais est necessairement une maladie tres-differente de celle qui nous occupe ; ' and he added, that although difficulties in diagnosis might occasionally arise, such difficulties were encountered in the diagnosis of the best-known diseases, and in no way detracted from the specific non-identity of the two fevers in question.-"^ Bartlett, also, in the first edition of his work on American Fevers, treated them as distinct diseases.^ In 1846, Dr. Eitchie of Glasgow accurately described the various circum- stances in which the two fevers agreed and differed \'^ and since 1846, the cases of each fever admitted into the Glasgow Eoyal Infirmary have been carefully distinguished. In the following year (1847) Dr. H. Gueneau de Mussy came over from Paris to Dublin, and after studying typhus, which was then so prevalent in that city, was convinced of its specific distinctness from the fever of Paris. On his return to Paris, his arguments induced M. Grisolle to adopt the same view.^ Dr. De Mussy observed one case in Dublin where a patient died of typhus contracted during convalescence from enteric fever ; the cicatrices of the intestinal ulcers were discovered after death. The doctrine of non-identity, however, did not remain unopposed. In a careful review of the subject, published in July and October 1841, the writer,'^ with all the evidence before him, regarded the two fevers as varieties, but not distinct species. Dr. Davidson, m the Thackeray Prize Essay on Fever (1840), came to the same conclusion.'' In June 1845 De Claubry reiterated to the French Academy of Medicine his belief in identity, although in the subsequent discussion he was strongly opposed by Eochoux. Dr. Waters, also, in his inaugural Prize Thesis, presented to the Medical Faculty of the University of Edinburgh in 1847, stated that the conclusion was inevitable, that the two fevers were identical.'^ Indeed, notwithstanding the decided opinions expressed by the several observers above-mentioned, it was the general impression, both in England and France, that the evidence adduced was insufficient to establish the specific non-identity of the two fevers, and the opposite doctrine continued to be taught in most medical schools. " Stewart, 1840 and 1858. ^ Louis, 1841, ii. 318, 324. y Bartlett, 1842. ' Ritchie, 1846. » (jKisoLLE, Path. Int. 1852, i. 55. " See Biblioijr. 1841, Rcvlciu. ' Davidson, 1841. ^ Waters, 1S47 (not published). HISTORY. 43 3 Much of the remaming doubt, however, was removed by the re- searches of Sh' "W. Jenner, pubKshed between 1849 and 185 1. Jenner confirmed and ampHfied the distmctions between the symptoms of the two diseases previously drawn by Gerhard, Stewart, and others, and did much to faciUtate their diagnosis. He supported his statements by carefully-recorded cases, and by an elaborate analysis of the symptoms and _2JOS^moriem appearances of numerous cases of both fevers observed by him at the London Fever Hospital. But the most important part of his investigations, bearing on the question at issue, was that which demonstrated the dependence of the two fevers on distinct causes. By an analysis of all the cases admitted into the London Fever Hospital during more than two years, he showed that the two fevers did not prevail together, and that the one did not communicate the other. He also adduced cases to prove that an attack of the one fever protected from subsequent attacks of itself, but not of the other Jenner main- tained that typhus and the so-called ' typhoid fever ' were as distinct as any two of the exanthemata.® During the last twenty years, many physicians enjoying independent spheres of observation have arrived at the same conclusions as Gerhard, Stewart, and Jenner. Among our own countrymen may be mentioned Dr. Peacock f of St. Thomas's Hospital, Dr. Wilkss of Guy's Hospital, Sir Thomas Watson^ and Dr. Tweedie,* Dr. W. T. Gairdner J and Dr. Anderson'^' of Glasgow, and Dr. A. Hudson^ and Dr. Lyons™ of Dublin. In an essay, presented to the Medical and Chirurgical Society of London in 1858, I endeavoured to show that the causes of the two fevers were very different." Li America, the non-identity of the two fevers has been advocated by Bartlett," Austin Flint,? and Wood,i and is generally recognised. Many Continental physicians also, who have lately had an opportunity of studying typhus, have expressed their conviction of its distinctness from the enteric fever, with which they had been more familiar previously. La 1854, Forget communicated to the French Academy of Sciences the report of an epidemic of typhus in the jail of Strasbourg. Although in his work on ' Enterite Folhculeuse, published in 1841, he had expressed his belief that the diseases were identical, his first experience of true typhus led him to an opposite conclusion, and in the memoir referred to, he uses the following words : — ' J'expose une serie d'observations avec autopsie, qui demon- trent I'absence de I'enterite folliculeuse dans le typhus. Comme corollaire des faits precedents, j'etablis un parallele entre les deux maladies, d'ou resulte qu'elles different non-seulement par les caracteres anatomiques, mais encore par les causes, les symptomes, la ma.rche, la duree et le traitement.' «■ The French physicians who met with typhus during the Crimean war adopted the doctrine of non-identity almost without ' Jennee, 1849, 1850 and 1853. ^ ' Peacock, 1856 and 1862. K WiLKS, 1855 and 1856. '' Watson, Liecturcs on Physic, 4th ed. 1857, vol. ii. ' TwEEDiE, i860. J W. T. Gairdner, i860 and 1862 (2). *" Anderson, 1861. ' Hudson, 1867. "' Lyons, 1861. " Mdkchison, 1858 (i). " Baktlett, 1856. P Flint, 1852. « Wood, Treatise on the Practice of Medicine, 4th ed. 1855. "■ Forget, 1854. 434 ENTERIC OR PYTHOGENIC FEVER. exception. Two of them may be referred to, by way of illustration. Ill 1856 Godelier communicated to the French Academy an excellent report of sixty-three cases of typhus observed at the Hospital of Val- de-Grace. He maintamed that British typhus was identical with the typhus of prisons and armies, but differed entirely from the fievre typhoule in its mode of origin, symptoms, and anatomical lesions. ' Le typhus et le typhus fever sont identiques ; ils different specifiquement dt^ \& fievre typlio'ide.'^ Jacquot summed up the evidence on the ques- tion as follows : — ' En un mot, chaque espece, typhus et fievre typhoide, presente tous les degres d'intensite, sans cesser de garder son iii- dividualite, ses caracteres, sa marche, ses symptomes, ses lesions.'* Again, M. Barrallier, in his account of an epidemic of typhus at Toulon, enters minutely into the question of its distinctness from the ordinary fever of France, and remarks : — ' EUes son separees I'une de Tautre par leurs causes, leurs symptomes, leur marche, leur duree, leurs caracteres anatomiques ; elles appartiennent reellement a la meme classe de maladies, les fievres esseiitielles specifiques, mais elles constituent des genres a part, comme la rougeole et la scarlatine dans le groupe des fie\T:es eruptives.'" Many German physicians, among whom may be mentioned Grie- smger,'^ Hirsch, and Zuelzer, have adopted the same view. The specific distinctness of the two diseases is now in fact generally recognised in every part of the world. It is true that some excellent observers continued to adhere to the doctrine of identity,'' and to maiii- taui that it is impossible to distinguish the symptoms or lesions of the two fevers, and that uideed the dothienenteritis of Bretonneau is merely an accidental complication of typhus. Looking at the past history of medicine, it would be surprising were it othervise. The arguments on both sides of the question will be discussed in a subsequent chapter. Sect. IV. Geographical Eange. Enteric fever has been known to occur in every part of the ■world. It is endemic in the British Isles, but is apparently most common in England, more common in Ireland than in Scotland, and in Scotland more common on the west than on the east coast. Of 4,565 cases of enteric fever admitted into the London Fever Hospital during twenty years (i 848-1 867), the birth-place was noted in 3,887 as follows : — " GoDfiLiEK, 1856, 13. 896. ' Jacquot, 1S58, p. 307. " B.U5R.u:;LiER, 1S61, p. 129. ' Geiesingek, 1S64. " Chbistison, 1858; Stokes, 1854; Kennedy, i860 and 1862; J. Bell, 1S60; Huss, 1855; Yates, 1857; Chambers, 1858; Barclay, On Med. Diagnosis, 1859; Baklow, Man. of Pract. of Med. 1856 ; J. H. Bennett, Clinical Lectures, 1865. GEOGRAPHICAL RANGE. 435 TABLE XXXVIII. 2,422 or 62-31 per cent. 1,175 M 30*23 24 „ -62 „ 225 „ 5'79 41 „ 1*05 Natives of London ,, of rest of England ,, of Scotland ,, of Ireland ,, of rest of World Total . . 3,887 loo'oo Taking the census of 1861 (see p. 58) as a basis of informa- tion concerning the birth-place of all the inhabitants of London, it follows that during the period above mentioned there were admitted into the London Fever Hospital — I in every 475 of the Irish inhabitants. I ,, 721 of the English inhabitants. I ,, 1,488 of the Scotch inhabitants. I ,, 1,637 of Foreigners. The contrast here presented with typhus and relapsing fever will be seen by referring to pp. 58 and 322. The experience of the London Fever Hospital furnishes no evidence of enteric fever having been at any time imported into London from Ireland or elsewhere. Medical literature abounds with records showing enteric fever to be endemic in France, Germany, Russia, Spain, Italy, and Turkey. Many of them are referred to in this work ; others are quoted by Hirsch."" The occurrence of enteric fever in Norway and Sweden has been demonstrated by Huss,^ Conradi,^ etc., and in Iceland by Schleisner and Hjaltelin.'^ There can be no doubt that enteric fever is met with in the tropics, where it has probably been often mistaken for remittent fever. In India, it is far from uncommon. Annesley^ and Twining '^ long ago jDointed out that a fever often prevailed in Bengal, which proved fatal under typhoid symptoms, and in which the small intestines were found ulcerated after death. Similar observations were made in Madras by Mouat and Shanks, "^ while the recent researches of Scriven,^ Ewart,f Edward Goodeve,^' Cornish,^ Ranking/ Peet,J and Moreheadi^ leave no doubt on the matter. These gentlemen have recorded " HiRscH, 1859. y Huss, 1855. ^ * Hiesch, 1859, p. 158. * ScHLEisNEE, 1850 ; HjALTELiN, 1862. '' Annesle^, Dis. of India, p. 547 , « Twining, Dis. of Bengal, 1832, p. 13. "^ Hirsch, 1859, p. 161. "■ ScEiVEN, 1854 and 1857. ' Ewart, 1856. s Goodeve, 1859. I" Cornish, 1862. ' Banking, 1862. J Peet, 1S62. ^ MoEEHEAD, Researches on Disease in India, 2nd ed. i860, p. 160. 436 ENTERIC OE PYTHOGENIC FEVER. numerous eases of fever occurring in various parts of the Bengal,. Madras, and Bombay Presidencies, and in Burmah, which, in their symptoms (including the eruiDtion) and iiiost-mortem . ap- pearances, agreed in every respect with the so-called 'typhoid fever ' of French and English writers. Indeed, according to Dr. J. L. Bryden, enteric fever is the one disease of India by which the young soldier dies.^ Heymann has frequently observed it in Sumatra and Java,*" and it has also been shown to prevail in Syria." In Africa it is not wanting. Haspel,° Cambay,P and other French writers have observed it in Algeria. Griesinger "^ mentions it as occurring in Egypt ; and Oelsner in the Isle of Bourbon.'' It is probably not uncommon on the West Coast of Africa.- M'William, in his account of the Niger Expedition,'' records the •post-mortem appearances of several cases of fever, as follows : — ' The jejunum was free from disease, and likewise the ileum until within three feet of its lower end, where were observed softening of the mucous lining generally and livid spots. A series of small ulcerations were seen in 4 cases. In one the membrane was thickened and rough and the ulceration had nearly perforated the bowel. The agminated glands of Peyer were distinct and enlarged in 4 cases. The morbid appearances observed in the intestines are very like those so often found in fatal cases of th& typhoid fever of this country.' Again, in the Museum of Fort Pitt there is a drawing showing the condition of the intestines in a case which proved fatal at Sierra Leone, and which was believed to be yellow fever, but which was probably enteric fever compli- cated with jaundice.* Enteric fever prevailed extensively among the British troops in the Zulu and Egyptian campaigns, and among the French troops in Tunis. In North America, enteric fever is endemic from Greenland to the Gulf of Mexico. The writings of Gerhard," Bartlett,^' Flint,^ Jackson,'' and Wood,y are often referred to in this work, and many other references have been collected by Hirsch. Martinez del Rio,^ Jecker,^ Newton,^ Strieker,"* and Gibbs,*" have described a fever as prevailing in Mexico, which presented all the symptoms^ ' Eighth An. Bep, of San. Com. of Gov. of India for 1871. '" Schmidt's Jahrb. Bd. lii. 96. " Hiesch, 1859, p. 160. • Haspel, 1850. p Cambay, 1854. 9 Griesingek, 1853. "■ HinscH, 1859, p. i62» ' London, 1843, p. 144. ' Jennee, 1853, p. 312. " Gerhaep, 1837* " Babtlett, 1842 and 1856. " Flint, 1S52, "^ Jackson, 1838. y Wood, Treat, on Pract. of Med. 4th ed. 1855. ' Louis, 1841, vol. i. pref. p. 17. » Hirsch, 1859, p. 164. ETIOLOGY PREDISPOSING CAUSES. 437 SLYid anatomical lesions of enteric fever ; while Lidel ^ and Praslow ^ have reported its occurrence in Central America and California, and W. H. Stone has observed it in the West Indies.*; According to Tchudi, it is extremely common in Brazil and! Peru.** Lastly, enteric fever has been observed in Australia, New Zealand, and Van Diemen's Land, by McGillivray,® Power, ^ and 3Iinigan.» Sect. V. Etiology. ■ A. Predisposing Causes. 1. Sex. — Enteric fever attacks one sex as readily as the other. Of 5,988 cases admitted into the London Fever Hos- pital during twenty-three years (1848-70), 3,001 were males and 2,987 were females ; or the males exceeded the females by 14. Of 2,312 cases collected by Bartlett from several American isources, 1,179 were males and 1,163 females; or the males exceeded the females by 16.^ Of 891 cases admitted into thq 'Glasgow Infirmary from 1857 to 1869, 527 were males and 364 females.^ On the other hand, of 207 cases admitted into the Dundee Eoyal Infirmary during five years (1864-9) ii9 ^^&^'Q females and only 88 males.* The preponderance of one sex in different hospitals is determined by accidental circumstances. Thus of 138 cases observed by Louis in Paris, only 32 were females ; but the excess of males was accounted for by the cir- cumstance that a larger number of males were strangers in Paris and could not be treated at their own homes.J 2. Age. — The predisposition to enteric fever is much influenced hy age, the disease being chiefly met with in youth and adoles- -cence. The mean age of 1,772 cases admitted into the London Fever Hospital during ten years (1848-57) was 21-25; that for males being 21 '45, and for females, 21*06. These averages are more than five years under those of the entire population. (See p. 64.) Table XXXIX. shows the number admitted in each quin- quennial period of life, during twenty-three years (1848-70). (See also Diagram XII.) From this Table it appears that nearly one-half (46-55 per ■cent.) of the cases were between fifteen and twenty-five years ^ HiESCH, 1859, p. 164. <= Stone, iS68. <' HiESCH, 1859, p. 164. ^ McGlLLIVEAY, 1 867. Dublin Quarterly Joiirn. 1843, xxiii. 91. s Hiesch, 1859, p. 165. ^ Baetlett, 1856, p. 109. All but 98 of Bartlett's cases were fatal cases. ' Hospital Beports. J Louis, 1841, ii. 354. 438 ENTERIC OR PYTHOGENIC FEVER. TABLE XXXIX. Ko. of Cases Perceutage Age at eacli period of Males Females Total life Under 5 years 24 34 58 •98 From 5 to 9 years 331 227 558 9'44 „ 10 to 14 „ 629 545 1,174 i8-i6 „ 15 to 19 „ 744 844 1,588 26-86 „ 20 to 24 ,, 545 619 1,164 19-69 ,, 25 to 29 „ 297 303 600 10-15 „ 30 to 34 „ 156 141 297 5-36 ,, 35 to 39 >. 96 105 201 3'40 ,, 40 to 44 ,, 64 60 124 2-09 „ 45 to 49 „ 27 37 64 i-o8 „ 50 to 54 „ 13 23 36 -60 „ 55 to 59 „ 12 8 20 ■33 „ 60 to 64 ,, 12 8 20 ■33 „ 65 to 69 „ 3 2 5 •08 ,, 70 to 74 „ „ 75 to 79 ,. 2 2 •03 Age not specified 46 31 77 1-30 Total, omitting doubtful cases 2,955 2,956 5,911 99-88 of age, and more than one-fourth (28* 5 8 per cent.) were under fifteen.^ Less than one-seventh (i3'3 per cent.) were above thirty, and only i in 71 exceeded fifty. The entire population of England and Wales in 1861 being 12,481,323 persons under thirty years of age, and 7,584,901 above thirty, it follows that persons under thh-ty are more than four times as liable to enteric fever as persons over thirty. The difference in this re- spect from typhus is remarkable. (See p. 64.) The contrast between the ages of the typhus and enteric cases admitted into the London Fever Hospital is also brought out by the following comparison- Per cent, of Per cent, of Typbus cases Enteric cases Under 10 years there were . . 7*88 . 10*42 From 10 to 15 years there were . i2-o6 . i8-i6 „ 15 to 25 „ • 29-39 . 46-55 ,, 25 years and upwards . 50-66 . 24-87 „ 30 " " . 4i*i4 • ^3'3° )» 40 n >» . 24-70 . 4-54 .» 50 »' " . IO-68 . 1-37 ,, 60 ,, ,, . 3-87 . •44 •= The proportion of enteric cases in early life would be still greater, were it not that many children labouring under this disease are treated at dispensaries and at their own homes, as cases of ' Infantile Eemittent Fever,' and that compara- tively few young children are admitted into the Fever Hospital. ieco 1G00 «l ^ , , - , _ ^ =. I f ^ ^ CO CO § ^ ,'^ ^ CD CD g S s 3 s o Jd ^ -S 5 s a ^ Q i£} CO CO § Lo ^ o Ci) ^ ^ ^ _ — . _ ^ ^ = s = o ^^ DutgrcumXlIshows the Ag'es' of 5911 coLses of Ervberw F&.ver, ou±nwbtedy into th^ London Fever Hospital, with ^e mrniber of deaths MM aJb eaxih coge. f Compare wUhLixK^r.H) ETIOLOGY — PREDISPOSING CAUSES. 439 Tlie increase in the number of cases between forty and forty- five years of age, observed in typhus and relapsing fever (see l)p. 65 and 325), did not occur in enteric fever. There was little difference between the ages of males and females. In some years, the mean age of the males was greater ; in others, that of the females ; and during ten years, the mean age of the two sexes was, as above stated, almost equal. Of 1,790 cases under fifteen, the males exceeded the females by 178; of 2,752 cases between fifteen and twenty-five, the females exceeded the males by 174; and of 769 cases over thirty, the males exceeded the females by i ; these results are contrary to what was noted in typhus and relapsing fever. The experience of the London Fever Hospital to some extent bears out the statement of West, that enteric fever is much more common in boys than in girls.' Of 232 cases observed by Barthez and Eilliet"" and Taupin" 166 were boys, and only 66 girls. On the other hand, of 98 cases reported by Friedleben, 46 were boys and 52 girls.** During the ten years, 1872-81, 75,487 deaths from enteric fever were registered in England and Wales. Males, 37,137 ; females. 38,350. Of these 57,685 or 76 per cent, were under the age of 35 ; 17,802, or 24 per cent,, were above the age of 35. 30,157, or nearly 40 per cent., were under the age of 15. Of these 14,646 were males ; 15,513 were females. 6,351, or 8 per cent., were above 55. Of these 3,270 were males ; 3,081 females. Hence it would appear that in early life females are rather more liable than males, in advanced life males than females. The fact that enteric fever is mainly a disease of young per- sons has been confirmed by every observer .p For reasons already stated, cases are more common in infancy and childhood than the returns of the London Fever Hospital might lead one to believe. Of 7,348 cases reported to the French Academy from different parts of France, Gaultier de Claubry ascertained that 2,282, or 31 per cent., had not attained fifteen years of age."! The youngest case observed at the London Fever Hospital during twenty-three years was that of an infant aged six months, whose intestine was exhibited by me to the Pathological Society.'' Many years ago M. Rufz endeavoured to show that the disease • Diseases of Children, 3rd ed. 1854, p. 561. " Barthez and Eilliet, 1853, ii. 714. n Tadpin, 1839. " Brit, and For. Med. Chir. Rev. July 1858, p. 161. p Louis, 1841, ii. 353; Chomel, 1834; Jennee, 1850, xxii. 457; Bartlett, 1856, p. 107 ; Davenne, 1854. 9 Gaultier de Claubry, 1849, xiv. 29. "• Trans, xvi. 125. 440 ENTEEIC OE PYTHOGENIC FEVER. did not occur under four years of age,^ and West states that it is rare under five years.* There are many instances on record, however, of its occurrence in the third and fourth years of Hfe ; " and cases in the first year of hfe have been recorded by Aber- crombie,^ Eilhet,"^ Friedrich,^ Hennig, and Wunderhch.y M. Charcellay, a colleague of Bretonneau in the hospital at Tours, has published two cases of the disease in newly-born children. One died on the eighth, and the other on the fifteenth day after bhth ; in the former, it was inferred both from the symptoms and post-mortem appearances, that the disease must have been contracted in the mother's womb, although the mother had not the fever, either during pregnancy, or after delivery.^ About the same time also, Manzini communicated to the Academie des Sciences the account of a dissection of a seven months' foetus, which died within half an hour after birth, and in which many of Peyer's patches presented appearances similar to those of dothienenteritis ; no mention is made of the mother having the fever.* On the other hand, youth is not necessary for the develop- ment of enteric fever, as Louis was inclined to think.'' Although most observers have noted its rarity above fifty years of age, S3 of 5,911 cases at the London Fever Hospital, or 1-37 per cent., exceeded that age, a proportion which is much larger than at first appears, when it is remembered that only one- seventh of the entire population of England and Wales is con- stituted by persons above fifty, and that many who survive that age have perhaps acquired an immunity from the disease by a previous attack. Twenty-seven cases were noted at the Fever Hospital above sixty, and two above seventy-five ; in one of the latter I found characteristic ' typhoid ulcers ' in the ileum after death. Lombard," Gendron,"^ and Eeeves ® mention 17 cases where the patients' age exceeded fifty ; and Jacquez reports several cases where the age exceeded sixty, and one where it was more than seventy.^ Trousseau records the case of a woman aged 64, in whose body the characteristic abdominal lesions were found after death. ^ These lesions have likewise been found by " EuFz, 1840. ' "West, Dis. of Child. 1S54, p. 561. " EiLLiET and Barthez, 1S40 and 1853 ; Taupin, 1839. '' Aberckombie, 1820. ™ EiLLiET, 1853, ii. 713-4. "^ Feiedrich, 1856. y Brit, and For. Med. Chir. Rev. July 1858, p. 161 ; see also Gazette Med. viii. 717, ix. 781. == Charcellay, 1840. » Manzini, 1841. '' Louis, 1841, ii. 353. ' Lombard et Fauconxet, 1843, p. 591. '' Gendron, 1829. « Beeves, 1859. ' Jacquez, 1845. b Trousseau, 1859. ETIOLOGY PREDISPOSING CAUSES. 441 IVilks in a woman aged 70 ; ^ by Lombard, in a woman aged 72 ; ' by M. D'Arcy, in a woman aged 86,J and by Hamernyk in a patient aged 90.'^ 3. Mode of Prevalence. — Enteric fever differs from typhus -and relapsing fever, in being essentially an endemic disease. It is, in fact, the endemic fever of England, as it is of France and America. The following table shows the number of cases ad- mitted into the London Fever Hospital, and Glasgow Infirmary, during the years that the disease has been distinguished from typhus : — TABLE XL. Years London Fever Hospital Glasgow- Royal Infirmary Years London Fever Hospital Glasgow Royal Infirmary Edinburgh Royal Infirmary 1847 1848 1849 1850 1851 1852 1853 1854 185s 1856 1857 1858 1859 ? 138 137 234 140 212 228 217 149 214 180 176 127 7 ? ? i860 1861 1862 1863 1864 1865 1866 1867 1868 1869 1870 95 161 220 174 253 523 582 380 459 369 595 91 36 79 56 40 89' 68 99 224 131 105 41 55 79 67 140 67 69 120 104 79 69 44 134 45 92 145 163 157 117 87 Total . 5>988 2,002 880 From this Table it is obvious that the number of cases in the London Fever Hospital has varied little from year to year. During the first 17 years of the Table (1848-64) the average annual number was 181 ; or eliminating the year i860, which was exceptional for reasons hereafter mentioned, the average was 186, the largest number 253, and the smallest 137. The mode of prevalence, then, of enteric fever presents a marked contrast to that of typhus, as may be seen in Diagram I., and on comparing Tables I. (p. 52) and XL. Moreover, its prevalence is quite independent of that of typhus. Thus, in 1856, when 1,062 cases of typhus were admitted into the London Fever Hospital, the number of enteric cases did not -exceed 149; but in 1858, when the typhus cases had dwindled down to 15, the enteric cases did not decrease in like manner. *» Path. Soc. Trans, vol. xiii. p. 68. ' Lombard et Fauconnet, 1843, p. 592. J Gaultier de Claubry, 1849, p. 30. '^ Geiesingek, 1864, p. 154. • In this and the subsequent four years the admissions into the City of Glasgow- Fever Hospital are included with those into the Eoyal Infirmary. 442 ENTERIC OR PYTHOGENIC FEVER. neither did they increase to take the place of typhus, as some writers alleged. In fact, the admissions of enteric fever for the year 1858 corresponded exactly to the average of the ten pre- ceding years, the former being 180, and the average 182. Again, the appearance of the last great epidemic of typhus in London was marked by no increase or diminution of enteric fever. Thus the admissions of typhus into the Fever Hospital in the two years 1862-3 heing 1,827 and 1,309, those of enteric fever were only 220 and 174, the average being 187, or almost exactly the same as that of the sixteen years above referred to. But the statistics of the Fever Hospital show a great increase of enteric fever in London during the last six years of the Table (1865-70). The smallest number in these years was 380 and the largest 595, the average for the six years being 484. The increase is perhaps accounted for by the extension of the Fever Hospital buildings (see Preface) and by the unusually high temperature of certain of the years (see p. 449), but it is not a little remarkable that this increased prevalence of enteric fever in the metropolis has been contemporaneous with the completion of the main drainage scheme. It is noteworthy that the increase of enteric fever did not commence until three years after the commencement of the great epidemic of typhus, and that it persisted after the latter had subsided. TABLE XLL Deaths from Enteric Fever registered in the United Kingdom from 1872 to 1881.- Year England Scotland Ireland London Edinburgh. Dublin Liverpool Glasgow Cork 1872 8,741 1,223 1,001 807 59 171 52 206 33 1873 8,793 1,495 1,048 908 75 159 61 235 44 1874 8,861 1,455 910 879 65 173 84 202 22 1875 8,913 1,625 833 817 37 142 69 252 23 1876 7,550 1,448 961 769 59 124 58 196 26 1877 6,879 1,427 974 901 77 155 51 170 47 1878 7,652 1,470 965 1,033 82 190 91 198 33 1879 5,860 1,013 1,037 849 57 233 46 136 28 1880 6,710 1,087 702 54 173 61 279 17 1881 5,528 813 971 59 119 52 175 18 This Table does not, however, give the full number of deaths from enteric fever, as every year a large number of deaths from simple continued fever are recorded, a disease which probably is never fatal ; many of these must be ascribed to enteric fever. In Glasgow enteric fever is also endemic, and in its pre- valence independent of typhus. During nineteen years (185 1- 1869) the annual admissions into the Pioyal Infirmary and Fever Hospital averaged 100, never exceeded 224, and were ETIOLOGY — PREDISPOSING CAUSES. 443 never less than 36, although the annual admissions of typhus varied from 175 to 3,488. Again, in 1858 there were 117 cases of enteric fever to 175 of typhus; whereas in 1847 there were only 127 enteric cases to 2,399 cases of typhus, and 2,333 cases of relapsing fever; and in 1865, 89 enteric cases to 3,488 cases of typhus."" So also in Edinburgh, enteric fever has been as common in years when typhus has been almost unknown, as it has been during some of the greatest epidemics of typhus. In 1862, 79 cases of enteric fever and 14 of typhus were admitted into the Eoyal Infirmary, whereas in 1 866 there were 69 cases of enteric fever and 847 of typhus. As predicted in the first edition of this work (p. 415), the prevalence of enteric fever was in no way affected by the subsequent outbreak of typhus. From all accounts enteric fever appears to have been much more common in Edinburgh during the last few years than it was formerly, although it was certainly not such a rare disease in former years as has been imagined. In 1827 Alison stated that he had frequently seen children presenting all the symptoms and post-mortem appearances of the fever described by French writers." Christison observed the same fever in i829,<> and a few years later several cases came under the care of Craigie p and Home. Home found Peyer's patches ulcerated in 7 of loi dissections of fever.'' On examination of the post- mortem Eegisters of the Eoyal Infirmary, I ascertained that in the years 1833-8 either 2 or 3 cases were dissected annually, 15 cases in all during the six years. Of 132 cases of fever dissected by Dr. John Eeid between 1838 and 1842, ulceration of Peyer's patches was present in 8 ; and only one-fourth of the fatal cases were examined.'' In 1842 ulceration of Peyer's patches was found in 3 out of 29 cases ; and in 85 fatal cases of fever the intestines were not examined.^ Between November i , 1846, and June 1847, 19 cases of fever with ulceration of Peyer's patches were dissected in the Eoyal Infirmary;* and from 1854 to 1 86 1, the number dissected in each year was as follows: — 1854, 5 cases; 1855, 2 cases; 1856, i case; 1857, 8 cases; 1858, i case; 1859, 2 cases; i860, i case; 1861, 6 cases. It is clear from these facts that enteric fever is no new " Since the introduction of its unrivalled water supply, enteric fever appears to have diminished in Glasgow, which in this respect contrasts favourably with London and Edinburgh. » Alison, 1827. " Cheistison, 1858, p. 558. ? Craigie, 1834 and 1837. « Stabk, 1865, p. 310. ■■ Eeid, 1840 and 1842. • Peacock, 1843. ' Bennett, 1847 ; Waters, 1847. 444 ENTERIC OE PYTHOGENIC FEVER. disease in Eclinburgli, but it is no less true that it has been a much more common disease in the ton-n of Edinburgh of late years than it was formerly. From the evidence of John Eeid, Peacock, and Eobertson," it appears that during the five years 1838-42 and the three years preceding 1847, not one case of fever with intestinal lesion was dissected in the infirmary, in which the patient had contracted his illness in the town. But the town of Edinburgh no longer enjoys this immunity. In 1862 we are informed by Dr. W. T. Gairdner that a large pro- portion of the cases were indigenous,' and in 1863 Christison stated that for some years it had been a common disease among the old residenters,'" while the admissions into the Eoyal In- firmary since 1862 (see Table XL.) show that the disease is now endemic in Edinburgh as it is in London. It is to be noted that this increase of enteric fever in Edinburgh followed the introduction of new sanitary arrangements — the substitution for the scavenger and nightmen of drains opening into the interior of the houses, but with a water supply insufficient to prevent the escape of sewer-emanations."" Enteric fever has formed no part of the great fever epidemics which have devastated Britain, although cases are met with during these epidemics, just as we meet with cases of measles and small-pox.y But although essentially an endemic disease it may become epidemic even in localities where for years before it has been unknown. These epidemics, however, are distinguished from epidemics of typhus, in being local and circumscribed. Sometimes they are confined to a single house or village. Many illustrations of such epidemics will be subsequently adduced; others will be found in the works of John Eeid,^ Stewart,^ and Bartlett ; ^ and particularly in the reports on epidemics presented to the French Academy,*^ and in those jjublished by the medical officer of the Privy Council. Owing to the circumscribed cha- racter of its epidemics, enteric fever has often been named from the localities in which it has occurred. Thus we read of the 'Croydon Fever,' the 'Westminster Fever,' the ' Cowbridge Fever,' and the ' Windsor Fever.' 4. Months and Seasons. — Unlike typhus, enteric fever varies greatly in its prevalence according to the months and seasons " KoBERTsoN, 1848. ^ Gairdner, 1862 (No. 2), p. 170. "^ Christison, 1863. ^ See Gairdner, 1862 (No. i), p. 255. y See the accounts of the ejjidemics of 1826 and 1847, at pp. 45 and 50. ' Eeid, 1842. ^ Stewart, 1840 and 185S, p. 275. '' Bartlett, 1856, j^p. 99, 106. ' See Bihliographij , 1833, 1849, and 1S50, and particularly 1849, p. 54. ETIOLOGY — PREDISPOSING CAUSES. 445 of the year. The monthly admissions during thirty-five years into the London Fever Hospital are given in Table XLII. Dia- grams XIII. and XIV. also show the admissions in the quarters and seasons of each year. It is obvious from Table XLII. that by far the largest num- bers have been admitted during the autumn months, October, November, September, and August, in the order here given, and the smallest in April, May, February, and March. In the two months, October and November, 277 per cent, of the entire number were admitted ; but in April and May only 7-3 per cent. Moreover, this great increase of enteric fever in the autumn months was observed in each of the thirty-five years, with one noteworthy exception (i860) hereafter alluded to; and, although the different continued fevers have only been registered at the Fever Hospital since 1847, I find, on referring to the printed reports for at least twenty years before, that ulceration of the bowels was always noted as most common during autumn. The contrast between enteric fever and typhus in this respect will be apparent, on comparing Table XLII. with Table VI. (p. 67), and Diagram XIII. with Diagram III. It is also worth noticing that the increased prevalence of enteric fever in autumn does not subside immediately on the advent of winter. In fact, in the winter months of I)ecember and January the cases have been more numerous than in June and July. The disease, which is at its maximum towards the end of autumn, continues to decrease until April, when it is at its minimum, and then progressively increases through the summer and autumn months. It would seem as if the cause of the disease were only exaggerated or called into action by the iwotracted heat of summer and autumn, and that it required the 'protracted cold of winter and spring to impair its activity or to destroy it. The increased prevalence of enteric fever in autumn is not limited to the Fever Hospital, or to London. Numerous in- quiries have convinced me that the same rule holds gO(pd at the other Metropolitan Hospitals. Of 131 cases treated by the late Dr. Todd in King's College Hospital, during a period of twenty years, I ascertained that 21 were admitted in spring; 25, in summer; 51, in autumn; and 34, in winter.*^ Thirty-five years ago Dr. Burne stated that -^there was no evidence of intestinal disease in the Continued Fevers of London, ' except in * Brit, and For. Med. Chir. Ecv. Oct. i860. 446 ENTEEIC OR PYTHOGENIC FEVER. &3 o •^ '►— 1 g t— 1 C3 1-^ X C^ ^ m . d WW w M NO 1 -5 vO vo •'^00 -^00 N t^ lO O "J^OO N OsOO vO O t^ OsMD "h m roO w w wMwwNwNt-^ N CO a •* Td- tn r>. ro>o Tj- 1^ -^ U-) Tj- m "H rovo moo o i-i oo m t^\o oo WW w w ro 00 00 bo lONvO^O N lOw rornmr^— " O^OO r.0\roi-i r^O " t1-oo 00 oo r^ rooo OsvO wwwN wwM www wMHHWNmcqNw-^w »-4 o 1^ rON " -rl-ONt^O t^r^OM^t^N N "^00 N 0\0n0n<^0 -.0 WW w wrow-Hwwr^ o ro o ro d WW www WW roiNiirOTt-N N >* ON t^ lOOO M t^rOONO >J^r^l^ r^oo vO i-i r)-00 00 vO " m w-j w w w w CSww-^wONNOO 00 On OnnO ro O r^ mvO N OO N N T^00 ^>.Ot-,■^NOO'^"lJ^ wwwwww rOHHW wc^ wt^roMrO'^LO 00 00 •SI- 00 On O "-1 M ro Th ir^vO t-~00 On O >-< N ro t)- ij-i>£> t^oo 0\ O ^ ^ -^Loio^ov^t^i-Oiovovn ir^vo vOvOVOOvOvOvOvOvO f^w oooooooooocooooocooocoooc/Doooooooooooooooooooo J:^ 'S "o H wwwwwwwwwwwwwwwwwwwwwww^ 3pG Z15 iZB 150 IJdS 1864- 1865 186e 18ei 1868 1869 ^870 ^IsTl' hto the Loi'VdMit Fever Hospital W West k C lii n '"'"' '«»» IBM leei tsez ises wet fts ^m DIAGRAM im, shows the. Quccrterly- cidmieswns of Eivterw Fever duriruf tvenlj-fouj' Yeccrs. (Compare with Dixu/ra.m HI ) itUo the London Fe\er Ifospiial 09 570 671 300 zeo 210 184S 134-9 i 18GS 1866 '1861 1868 1869 1870 1871 ynto the Londbony Fever \ P^^^ ^6> noU e.) w_west^c?uth.. DIAGRAM XW shows the. rvumher of ctdmissione of ErUervc Fever vnbo the London- Fev^r Hospital, dMrm^ eccdv Season- of twervtj-fovun TeoLrs . [As to Winter, see pcLge 66, note e) ETIOLOGY— PEEDISPOSING CAUSES. 447 :autumn.' ^ Most of the outbreaks of enteric fever in the j)ro- vincial towns and villages of England, which have been re- corded in the medical journals during the last thirty years, have occurred during autumn ;^ while the * autumnal fever,' observed by Sh" John Pringle and Eutty in Britain and Ireland during the last century, was apparently the same disease.^ In Glasgow, in 1836 and 1837, Dr. Stewart observed that the cases of ' typhoid fever ' admitted into the Infirmary were very nume- rous in the latter part of summer and in autumn, very few in winter and spring.^ During September, October, and Novem- ber 1857, 18 cases were admitted into the Edinburgh Koyal Iniii-mary ; but in the three spring months of the same year, only 6 cases. During the ten years, 1870-79, 3,978 deaths from enteric fever were registered in the eight principal towns in Scotland. Of these 970, or 24*3 per cent., took place during the first quarter of the year ; ■896, or 22*5 per cent., during the second quarter; 710, or 22*8 per ■cent., during the third quarter; 1,202, or 30 per cent., during the fourth quarter. During the same period 3,510 from typhus were registered. Of these 1,138, or 32 per cent., took place during the first quarter of the year ; 911, or 25*9 per cent., during the second quarter ; 652, or i8'5 per cent., during the third quarter ; and 809, or 23 per cent., during the fourth quarter. Similar observations have been made on the Continent. At Oeneva, M. Lombard long ago observed that the disease was always most prevalent in autumn ,J Messrs. Eilliet and Barthez remark : — ' Les nouveaux faits que nous avons recueillis con- ■cordent avec les conclusions auxquelles sont arrives MM. les docteurs Marc d'E spine et Lombard, savoir, que I'automne est de toutes les saisons celle qui predispose le plus a la fievre typhoide. Les trois epidemies qui ont specialement atteint les enfants dans le canton de Geneve ont toutes eu lieu en automne. Apres I'automne vient I'hiver.''' Of 452 cases observed by Piedvache during ten years in the provinces of France, 316 occurred in autumn and winter, and only 54 in spring.^ Of 116 cu'cumscribed epidemics which occurred in different parts of France between 1841 and 1846, 20 commenced during the first quarter of the year, 21 during the second, 39 during the third. <■ Bdexe, 1828, p. 129. 8 See EujiONDSTONE, 1818; Bibliogr. for 1846 ; The Croydon Fever, Bib. 1852; Beadle, 1853; Camps, 1855; Buud, 1856; Murchison, 1859 (No. 3). '' Pkingle, 1752, p. 226; EuTXY, 1770, pp. 196, 202, 320. ' Stewaet, 1840, p. 291. J LoiiB.AED, 1839 and 1843. ^ B.\RTHEZ and Eilliet, 1853, ii. 715. ' Piedvache, 1850, p. 20. 448 ENTEEIC OR PYTHOGENIC FEVER. and 36 during the fourth."^ In the Departement du Doubs, Druher says that the disease is always ' most common in autmiin and winter.'" Of 183 cases at Strasbourg reported by Forget, 60 occurred in autumn, 49 in summer, 38 in spring, and 36 in winter." In Berhn, I have been informed by Dr. Quincke, one of the physicians to the Charite Hospital, that the disease is always most prevalent in autumn, and least prevalent in spring.P In America, Bartlett states that his impression is that enteric fever is most prevalent in autumn. Of 645 cases admitted into- the Lowell Hospital during seven years, 250 were in autumn, and only 104 in spring.^ Wood says that 'it is always most common in autumn and winter ; ' *" while Austin Flint remarks that in New England it exhibits such a manifest predilection for the autumn, that it is there designated ' Autumnal or Fall Fever.' ^ 5. Temperature, Moisture, and Soil. — Not only does enteric fever increase in autumn, but it has been found to be unusually prevalent after summers remarkable for their dryness and high temperature, and to be unusually rare in summers and autumns which are cold and wet. The summer and autumn of i846' were remarkable for their great heat, and the medical journals contain accounts of numerous outbreaks of enteric fever in various parts of the country districts of England,* where the subsequent epidemic of typhus never appeared. Even in France, which was also not visited by typhus, ' typhoid fever '' was unusually prevalent in the autumn of 1846, and was attri- buted by many to the excessive heat." The Eeport of the London Fever Hospital for that year states, that 'in the un- usually hot weather that prevailed in the summer and autumn months, diarrhoea occurred in almost every case of fever,' and that in the fatal cases ' the intestines were extensively diseased.'' It is not surprising, then, that an unusually large number of cases should have been observed in Edinburgh in the autumn and winter of 1 846-7. As I have already shown, this outbreak was independent of the great epidemic of typhus which im- mediately succeeded (see pp. 49 and yy). The summers and autumns of 1865, 1866, 1868, and 1870 were also remarkable for ■" Gaultier de Claubky, 1849, p. 8. ° Druher, 1858. " Forget, 1841, p. 409. p For further evidence of the same nature, see Griesinger, 1S64, p. 149. 1 Bartlett, 1856, p. loi. "■ Treat, on Pract. Med. 4th ed. i. 3S9.. ' Flint, 1852, p. 20. ' See Bibliogrophy for 1846. " De Glaubry, 1849, pp. 1 8, 60. ETIOLOGY — PREDISPOSING CAUSES. 449 their great heat and prolonged drought, and for an unusual and early increase of enteric fever (see Table XLII.). Many instances will be alluded to hereafter of outbreaks of enteric fever oc- curring after prolonged hot and dry weather ; but for the present it suffices to observe, that if a very hot season happens during an epidemic of typhus, both typhus and enteric fever may be unusually prevalent at one time, without necessitating the infer- ence that both spring from a common origin. This was, possibly, the explanation of the slight increase of enteric fever observed towards the end of the typhus epidemic of 1826-8 (see p. 45); at all events, the summer and autumn of 1828 are said to have been remarkably hot. In 1837, Cless collected the records of all the outbreaks of enteric fever which had occurred at Stuttgart from 1783 to that date : all occurred in autumn or at the end of summer, and all had been preceded by unusually hot seasons.'' On the other hand, there have been few years in which the summer and autumn have been more cold and wet in England than in i860, while the remarkable diminution in the prevalence of enteric fever over the whole country in that year, and in London during the wet autumn of 1872, was a subject of general observation. On referring to Table XLII., it will be seen that the admissions into the Fever Hospital for i860 fell to one-half of the average of the previous twelve years, and that this diminution was due to the absence of the ordinary autumnal increase. Mere dryness of the atmosphere, however, is not conducive to an increase of enteric fever. On the contrary, warm damp weather, when drains are most offensive, is often followed by an outbreak of the disease. An increased rainfall, however, sw^eeps away those impurities to which the origin and spread of the disease are in drained towns mainly due ; but in un- drained places it may conduce to an outbreak of the disease, by washing those impurities into water used for drinking purposes, as happened at Festiniog in 1863,"^ and in Dundee in 1864.'' Professor Pettenkofer and M. Buhl of Munich have en- deavoured to show that the prevalence of enteric fever depends solely upon the presence of a certain amount of water in the soil. The poison, to which they believe that the disease is due, multiplies in the soil rather than in the bodies of the sick, the necessary conditions being a porous soil, saturated in its lower "^ Cless, 1837. For other illustrations of the increase of enteric fever in seasons of excessive heat in France, see Db Claubky, 1849, p. iS. * Buchanan, in 6th Rap. of Med. Off. of Privy Council, 1864, p. 787. * Maclagan, T. J. 1867 (2). G G 450 ENTEEIC OK PYTHOGENIC FEVEE. parts with water, and this water rapidly falling after having attained an unusual height. The connection between these conditions and the prevalence of enteric fever in Munich over a long series of years, appears b}^ their researches to be clearly established, and the connexion does not seem, as Buchanan has argued, always to be explained by an increased filtration under the circumstances in question of organic impurities into the surface- wells supplymg water for drinking purposes. Still Prof, Pettenkofer's views as to the origin of enteric fever are, in my opinion, too exclusive, failing to account for the frequent connexion observed in this country between defective house drainage or impure drinking water and enteric fever, quite ir- respective of any variations in the subsoil water ; while at Terling it was sho^n by Dr. Thorne that a great outbreak of enteric fever in 1 867 was coincident with a rise in the subsoil water after drought.^ 6. Tntemjjerance, Fatigue, and Mental Emotions. — There is no evidence that they predispose to enteric fever. In France, drunkards are said to be not more liable to the disease than temperate persons (see pp. 70 and 329). 7. Previous Diseases. — It is doubtful if previous illness in- creases the liability to enteric fever. Most patients are m good health at the time of seizure. It is necessary, however, here to allude to certain relations supposed to subsist between enteric fever on the one hand, and variola, malarious fevers, and phthisis, on the other. Several French writers ^ opposed to vaccination have laboured to show that the practice has effected no reduction, but onh' a ' displacement,' of mortality, and that, although small-pox has been arrested, it has been replaced by enteric fever, which, ac- cordmg to them, is nothing more than an internal variola, the eruption being developed m the intestmes instead of on the skin. It has been even proposed to the French Academy to prevent enteric fever by vaccinating some portion of the mucous membrane. The subject was investigated with the utmost care by the French Academy, and the result was a complete refutation of M. Carnot's doctrine. Of even greater interest is the antagonism supposed to exist between enteric fever and the malarious fevers. The opinion y See on this subject Pettenkofee, 1869 ; various essays by Buhl, Seidel, Pettekkofee, BrxnAT^r, etc. in the first six volumes of the Zcitschrift f. Biologic, 1865-70; BccHAXAN. Med. Tivics and Gaz. March 12, 1870; Pettexkofee, Ibid. June II, 1870; and Thorxe, in loth Pwp. of Med. Off. of Privy Council, p. 51. '■ AN5ELON and Bayakd, 1851 ; Gressot, 1S55 ; Cakxot, 1S56. ETIOLOGY PREDISPOSING CAUSES. 45 I has long been prevalent in America that enteric fever has a tendency to take the place of intermittents and remittents, as these diseases, from the effects of cultivation and other causes, decrease or disappear/ This opinion has been to some extent corroborated by the investigations of M, Boudin,^ who has en- deavoured to demonstrate an antagonism between the diseases in question. According to this writer, localities where the constitution of the inhabitants is modified by malaria are remarkable for the rarity of enteric fever, while localities re- markable for the prevalence of enteric fever are likewise noted for the rarity and mildness of intermittents. Thirdly, he states that the drying up of a marsh or its conversion into a lake diminishes or arrests intermittents, but disposes the system to ii new group of diseases, of which pulmonary phthisis and enteric fever are the most prominent ; and fourthly, he maintains that, by residing in a marshy country, an individual acquires an im- munity from enteric fever, the degree and duration of which are in direct proportion to the length and degree of the resi- dence. M. Boudin mentions some remarkable instances of French regiments, which, after a lengthened exposure to malaria in Algeria, returned to France, where they remained exempt from enteric fever, although many cases were occurring in other regiments quartered in the same barracks. But it is doubtful if any antagonism, such as M. Boudin has endeavoured to esta- blish, really exists between intermittents and enteric fever. The latter is not unknown in countries remarkable for the prevalence of intermittents ; it is not uncommon in India, Burmah, and other malarious countries, where it has probably been often mis- taken for remittent fever. The facts mentioned by American writers and by M. Boudin suggest a similarity, rather than an antagonism, of enteric and malarious fevers, the poisons in both instances being generated under similar circumstances. In con- nection with this subject, a remarkable communication made to the French Academy of Sciences in 1845 by M. An9elon may be mentioned.^ Many years before, enteric fever had been con- stantly endemic in the commune of Guermange, in the duchy of Lorraine, making its appearance every year during the hot season; but for twenty-five years it had entirely disappeared from the northern part of the commune, its disappearance having been simultaneous with the suppression of a stagnant pond in that locality. In the southern part of the commune, however,. Baetlett, 1856, p. 100. " Boudin, 1846. * Ancelox, 1S45. o '2 452 ENTEEIC OR PYTHOGENIC FEYER. there had been epidemics of intermittent fever every third ^''ear (viz. 1829, 1832-5-8, 1 841), alternating with epidemics of enteric fever (1830-3-6-9, 1842), and of furuncular diseases (183 1-4-7, 1840-3). In this part of the commune there was a large lake called the * Indre basse,' which every third year was emptied and cultivated, and afterwards the water was allowed to collect again for two years. The intermittent fevers appeared dur- ing the first year that the pond was full of water. The epidemics of enteric fever coincided with the second year. In the autumn of this year the pond began to dry up, and M, An9elon attributed the fever to the action of heat and moisture upon an immense- quantity of animal and vegetable debris, which during the two years had been collecting upon the banks of the lake. The- houses in the commune were also very badly drained. This is far from being a solitary instance. M. Killiches has recorded an outbreak of enteric fever which occurred in a small town of Bohemia, on the drying up of a lake.'^ Other instances will be found in the reports on Epidemics to the French Academy.® Dr. Woodward/ U.S.A., and other observers describe a form of fever under the name of typho-malarial, which they regard as due to a combination of the two poisons giving rise to a hybrid disease pre- senting intermediate characters— sometimes those of one, sometimes those of the other predominating. Sir Joseph Fayrer says s that there is nothing in Indian experience- to support the theory of antagonism. According to M. Forget, persons labouring under phthisis- are rarely attacked with enteric fever. The former he regards as a preservative against the latter.'' Whether this be so or not, an attack of enteric fever is often followed by tubercular deposit in the lungs ; but such occurrences do not justify the view put forward by Drs. J. Harley' and H. Kennedy-' that the intestinal ulcers of tuberculosis and enteric fever are indistin- guishable. (See Section XII.) Lastly, it is mamtained by Stober, Loschner, and Friedleben,'' that enteric and scarlet fevers bear an inverse ratio, as regards epidemic prevalence, and that when one prevails, only solitary cases of the other are to be met with. My experience is opposed to their observations. I have often noticed the two diseases unusually prevalent at the same time. It was so at Windsor in 1858 ; and the year 1870 was notable for the largest number •1 Killiches, 1837. "^ De Claubey, 1849, p. 54. ' WoomvAKi>, 1S76. » Faykee, 1881. '■ Foeget, 1841, p. 331. ' J. Harley, 1873. •' H. Kennedy, 1873. " Brit, and For. Med. Chir. Rev. July 1858, p. 162. ETIOLOGY PEEDISPOSING CAUSES. 453 •ever known of admissions of both scarlet and enteric fevers into the London Fever Hospital. Moreover, the returns of the Eegistrar-Greneral show that the mortality from scarlet fever is always greatest at the end of autumn, the time at which enteric fever is also most prevalent. Scarlatina appears indeed to pre- dispose to enteric fever. Of 1 2 patients who took enteric fever in the London Fever Hospital during 23 years, 8 were admitted with scarlatina (see p. 462). In several of these cases, there was reason to think that the enteric as well as the scarlet poison had entered the system before the patient's admission into hospital ; but in none has there been more difficulty in recognis- ing the sequence of the two diseases, than when a patient ad- mitted with enteric fever has contracted scarlatina in hospital. I have seen nothing to justify the opinion held by Dr. J. Harley, that scarlatina and enteric fever are different manifestations of the same poison, or that enteric fever is ' an abdominal scarlatina.' ^ 8. Idiosyncrasy.— Many facts seem to show that certain pecu- liarities of constitution favour or avert an attack. 9. Over-croiucling and Deficient Ventilation. — The prevalence of enteric fever is independent of over-crowding and deficient ventilation. The disease prevails without distinction, not only in the most dense, but also in the least populous, districts of large towns, and is of common occurrence in country districts and even in isolated houses. As typhus and relapsing fever prevail only in crowded localities, and enteric fever in all, it follows that in the central and most crowded districts of the metropolis the number of cases of the former far exceeds that of the latter ; but on passing to the suburban districts, the pro- portion of enteric cases gradually increases, while in the country •enteric is almost the sole fever met with. This appears, to some extent, from the residences of the patients brought to the London Fever Hospital, given in Table VH., p. 72, of which the following is an abstract : — Paddington and Belgravia are two of the least populous London districts, and, at the same time, are inhabited by the better classes of the community. Now, of 1 2 cases of fever from Belgravia 10 were enteric, i typhus, and i febricula ; and of .29 cases from Paddington 24 were enteric, 3 typhus, and 2 febricula. That enteric is the prevailing fever in each of these •^districts is also shown by the cases admitted into their local ' J. Habley, 1866, p. 593 ; and Mccl. Chir. Trans. 1S72, Iv. 103. 454 ENTEEIC OR PYTHOGENIC FEVER, TABLE XLIII. Population Districts in each statute acre in 1861 Typhus iiiid Relapsing Enteric Central — Holborn .... 229 1,021 202 City of London . 156 1,222 322 St. George's-in-the-East . 201 1,250 215 Suburban — Paddington 59 3 24 Hackney .... 21 125 145 Beyond London Districts . 9 55 90 hospitals. By the pubHshed reports of St. George's Hospital,™ situated in Belgravia, it appears that of 44 fatal cases of fever dissected during three years, there was ulceration of Peyer's patches in 29, and in 5 only were the intestines healthy. During five years (1853-7), of 117 cases of fever admitted into St. Mary's Hospital from the parish of Paddington, 75 were enteric fever, 38 febricula or of doubtful nature, and only 4 typhus ; in the year 1856 only two cases of typhus were admitted, although in the same year there were admitted into the London Fever Hospital 1,062 cases. The fact that enteric fever is independent of over-crowding^ has been a matter of general observation. For many years, most of the cases admitted into the Glasgow " and Edinburgh ** Infirmaries were brought from the localities in the neighbour- ing country, and not from the crowded parts of the town, to wdiich the cases of typhus were restricted. Bartlett observes that there is no satisfactory evidence that over-crowding pre- disposes to this fever m America ; p and with respect to Paris, Louis remarks : ' Le sejour dans les lieux bas et habites par un trop grand nombre de personnes, pendant la nuit, ne peut pas non plus figurer parmi les causes dont il s'agit.' ^ But though enteric fever is far from being limited to crowded localities, deficient ventilation may favour the action of the poison, by preventing its diffusion and dilution, as happened at Festiniog in 1863.^ 10. Recent llesidence in an Infected Locality. — Petit and Serres," and afterwards Andral,* Louis," and Chomel ^ strongly '" Vide Brit, and For. Med. Chir. Rev. 1855-6. Since 1861 many cases of typhus have been admitted into St. George's from the crowded districts of Chelsea. " Stewart, 1858. » Eeid, 1842. «> Babtlett, 1856, p. no. I Louis, 1841, ii. p. 356. ' See Reference, p. 450. » Petit and Sekkes, 1813, p. 127. ' Ani>i;al, 1823, ed. 1834, i. 484. " Louis, 1841, ii. 357. '' Chomei,, 1834. ETIOLOGY PREDISPOSING CAUSES. 455 insisted on recent residence as a j)redisposing cause of enteric fever. Andral noticed that medical students were most liable to be attacked within a few weeks of their arrival in Paris. Of 129 cases which Louis gives in his work, 73 had not resided in Paris more than ten months, and 102 not more than twenty months. Again, of 92 cases of ' typhoid fever ' under Chomel in the Hotel- Dieu, one-half had resided in Paris only one year, or less. More recently Trousseau has observed that ' foreigners, on coming to reside (in Paris), are soon attacked by it.' The length of resi- dence in London of all the cases of enteric fever admitted into the London Fever Hospital during fourteen years (1848-61), where the circumstance was noted, was as follows : — TABLE XLIV. Less than 3 months . . . 122 or 6-17 per cent. 6 months . . .191 1 year .... 318 2 years .... 432 10 years . . . -in More than 10 years, but not for life 149 For entire life . . . .1,058 9-65 i6'o7 21*84 38-98 7'53 53"49 Total . . 1,978 ,, loo- Upwards of six per cent, of the patients had not resided in London three months before the date of their admission into hospital. This circumstance does not admit of the explanation offered in the case of relapsing fever. It has been already pointed out that the newly-arrived patients did not come from Ireland. Almost all of them came from the provinces of England, and were in good health and comfortable circumstances at the date of their arrival in London, and for some time after. Many of them were servants in private families. Moreover, the above figures do not indicate, to its full extent, the influence of change of residence in predisposing to enteric fever. A large proportion of the patients were first attacked within a few weeks after chang- ing their residence from one part of London to another. Many illustrations of the same fact have come under my notice in l)rivate practice, and I have also met with several instances 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 with diarrhoea, from which the ordinary resi- dents were exempt. These considerations point to the depend- ence of enteric fever on some local cause, to which the system 45 6 ENTERIC OR PYTHOGENIC FEVER. becomes habituated by constant exposure ; and in this respect enteric fever resembles dysentery, ague, and other malarious fevers. Many observations have satisfied me that the immunity of the regular inhabitants is not to be accounted for on the sup- position of a prior attack, as has been suggested by Parkes and Maclagan. The effect of recent exposure to the causes of enteric fever is shown in a striking manner in the case of the English troops serving in India. Under two years' service the proportion of cases was 9-68 per 1,000, above two years' service, i-is.'^ 1 1 . Occupation. — The first edition of this work (p. 68) con- tained a Table showing the occupations of 5,095 patients ad- mitted into the London Fever Hospital, of whom 1,457 were suffering from enteric fever. It is not probable that any of the occupations specified in themselves predisposed to the disease, and for this reason the Table has not been reproduced (see p. 69). It may be mentioned, however, that nearly one-third of the patients were female servants, most of whom had been in comfortable situations, and many of whom had been attacked shortly after changing their residence. Several, entered as ' labourers,' had been engaged in the public sewers before their seizure. Of 64 vagrants, 44 had typhus, 1 2 relapsing fever, and 8 febricula; but none enteric fever. Of 247 hawkers and street musicians, 136 had typhus, 54 relapsing fever, and only 24 enteric fever.. On the other hand, of 45 policemen, 30 had enteric fever, 10 typhus, and 5 febricula; but none relapsing fever. 12. Station in Life, Destitution. — Destitution does not pre- dispose to enteric fever. Indeed it may be doubted if persons in good circumstances are not more liable to it than the poor. While epidemics of typhus and relapsing fever invariably com- mence among the poorest of the population, and are, for the most part, confined to this class, it has been a common observa- tion in almost every outbreak of enteric fever that the rich have not remained exempt, and in many instances the epidemic has commenced among the upper classes. At Nottingham in 1846, Dr. Sibson remarked that ' very many were in good circumstances of those who were attacked: '"^ at Croydon in 1852, we are told that the victims were ' not among the poor, but among the gentry and principal tradesmen of the town : ' ^ at Windsor in 1858, the fever was confined, for the most part, to the upper and " Vide Report of Surgeon-Gcn. Kerr-Inncs, 1877. » yiBsoN, 1846. y See Croydon, Bib. 1852. ETIOLOGY PREDISPOSING CAUSES. 457 middle classes ; the poorest and worst part of the town to a great extent escaped/ In fact, enteric fever is far from being an uncommon disease among the upper classes in England, and €ven the most exalted positions offer no protection from it. Since enteric fever has appeared in Edinburgh it has been encountered ' among people in easy circumstances, and in the best houses of the town.' ^ Similar observations have been make in America by Bartlett,^ and in France by Andral,'^ Louis,'^ Piedvache,® and other observers. Indeed, the evidence on the point is overwhelming. The contrast exhibited by enteric fever to typhus and relapsing fever, in this respect, is borne out by the experience of the London Fever Hospital. The patients admitted into this institution up to 1872 may be divided into three classes, viz. : i. The servants of subscribers, policemen, and persons able to pay for admission. 2. Free patients, not receiving parochial relief. This is a mixed class : some have been destitute, while others have been in easy circumstances up to their ihness. 3. Patients paid for by the parishes, of whom about one-sixth have been inmates of a workhouse. These -classes represent three different grades in worldly comfort, and the foHowing Table shows the proportion of the different fevers in ■each class during twenty-three years (1848-70). TABLE XLV. Class I. Class II. Class III. 1° 1° S a S S >• r° i°l ■^ c3 o| ■ggg ■Si u_, k-H J3 ^"1 -^B °H| ^s . ^i,^ SoSm s^l" S^gH sg^j 1 1 « " 55 -£0 So in a a 5s m 1 ^ ercent fever Class ercent in CI total ^ FM Ph Y-i (U f^ ! Yi P4 97-25 Eelapsing . 18 1-50 •8s 40 4-12 1-89 2,057 778 Typhus 378 31-50 2-o6 395 4072 2-i6 17,495 66- 1 8 95-76 Febricula . III 9-25 4-97 109 11-24 4-88 2,012 7-61 90-14 Enteric 693 5775 11-57 426 43-91 7-II 4,869 18-42 81-31 Total . 1,200 loo-oo 4-19 970 99-99 3-39 26,433 99-99 92-41 In Class I. the proportion of enteric cases is six times that of typhus and about fourteen times that of relapsing fever. In 'Class 11. the proportion of the enteric cases is still predominant, ' MUECHISON, 1859 (No. 3). '' Baetlett, 1856, p. no. '' Louis, 1841, ii. 356. " Christison, 1863. « Andeal, 1823, ed. 1834, i. « PlEDYACHE, 1850, p. 21. 45 S ENTERIC OR PYTHOGENIC FE\'ER. although to a less extent, being more than three times those of typhus and relapsing fever. In Class III. the ratio is reversed,, relapsing fever and typhus being in excess of enteric. The con- trast presented by enteric fever to relapsing fever and typhus- apjDears also from the following comparison : — TABLE XL VI. Per cent. Per cent. of T3'phus of and Relapsing. Enteric. Of the paying patients . 32- 5775 Of the ' free ' patients . 44-84 43*91 Of those sent by parishes • 73-96 18-42 B. Exciting Cause. I. Contagion.^ That enteric fever is in some way communicable from the sick to the healthy is now pretty universally acknowledged^ though the mode in which the transmission takes place, whether as in other mfectious diseases by direct contagion, i.e. by emana- tions from the patient, or his fresh evacuations, or only indirectly from eating, di-inking, or inhaling the emanations from the stools, modified by their having undergone some process of decom- j)osition or fermentation outside the body, is a point about which much difference of opinion still prevails. Many of the highest authorities have doubted or denied the contagiousness of the disease. Andral m 1833 declared that he had never seen it exhibit the slightest contagious character, either m hos]3ital or private practice ; ^ and in the following 3'ear Chomel stated that not more than one in a hundred medical men in France believed it to be contagious.^ In 1840, Dr. Stewart wrote as follows : ' In no case, though questioned with the greatest care, either in Scotland, or in the hospitals of Paris, have I ever found the disease referred to contagion.' ^ Certain French observers, however, have recorded many facts to prove that ' typhoid fever ' is communicable. Lem-et, in 1828, showed that its introduction into Nancy was due to contagion ; J and in the subsequent year Bretonneau communicated to the * Academic de Medecine ' a number of observations, with the object of proving that ' dothienenterie,' as it prevailed in the ' See note, p. 81. ^ Andeal, 1S23, eel. 1834, i. 485. ^ Chomel, 1834. ' Stewaet, 1840, p. 298. J Leuket, 1829. ETIOLOGY — EXCITING CAUSE. 459 country, was eminently contagious.'' These essays were followed in 1834 by the memoir of M. Gendron of Chateau-du-Loir,' who maintained that every case was due to contagion, and that ' typhoid fever ' ought to be ranked amongst the most contagious maladies. Many additional facts tending to prove its contagious nature in country districts were subsequently recorded by various writers.™ These observations excited much discussion, physicians in Paris still maintaining that in that city the disease rarely spread by contagion, whatever might be the case in the provinces. Even Louis in 1841, while fully admitting the facts recorded by Bretonneau, Gendron, and others, stated that in his extensive experience he had only met with three instances in which the disease could be said to have originated from contagion. In 1849, appeared the Prize Essay of M. Piedvache of Dinan : ' Recherches sur la contagion de lafievre tyijlidide.''^ In this essay many facts noted by the author and recorded by previous ob- servers were collected ; the evidence on both sides of the question was honestly weighed, and the conclusion was arrived at that the disease was contagious, but only under certain conditions, while at the same time it was admitted that many facts ' prouvent evidemment que ce phenomene (contagion) n'a pas toujours lieu.' The same view was adopted by Trousseau." In America and in Britain opinions have also been divided on the subject ; but most observers now believe that, although the disease is communicable in a limited degree, it is impossible in many cases to discover any source of contagion. In England, as in France, there are writers who hold extreme views, some believing that there is no conclusive evidence that the disease is in any way contagious, while others, like Dr. W. Budd, maintain that the contagious nature of enteric fever is the ' master truth ' in its history .P The latter view has been endorsed by Sir Thomas Watson in the last edition of his Lectures on Medicine (1871). The question is of such importance, that a consideration of the chief arguments in favour of the contagious nature of the disease will be advantageous. a. When one individual is attacked, many other cases often folloio in succession in the same house or district. Facts of this nature are common in both town and country districts ; but undue stress has been laid" on them by the advocates of ^ Bretonneau, 1S29. ' Gendkon, 1834. "' See Bibliography, 1814 to 1847. ° Piedvache, 1850, p. 72. • Trousseau, 1861. " »■ W. Budd, 1856, 1859, 1861. 4^0 ENTERIC OR PYTHOGENIC FEVER. contagion. A moment's reflection shows that such cases are as readily explicable on the supposition that the disease has a local origin, as upon that of contagion. Although in some instances the cases follow one another, so as to favour the idea that the disease has been communicated by one patient to the other, the circumstances in others are opposed to such a view. Occasionally many persons residing in one house, even as many as twenty or forty, are seized all at once, so as to suggest the suspicion of poisoning, and yet no source of contagion can be traced. On the other hand, the interval between the different cases is sometimes too long to admit of explanation on the theory of contagion. I have met with several instances wdiere single cases of enteric fever have originated in the same house year after year, without any traceable importation of the poison on any occasion. For instance, six cases were admitted from a single house into the London Fever Hospital ; one in June, 1 849 ; one in October, 185 1 ; one in February, 1854; one in November, 1855 ; one in November, 1856 ; and a sixth in July, 1857. Moreover, the order of succession of the cases has often no relation to the degree of exposure to the supposed source of contagion. Piedvache mentions a remarkable instance of enteric fever in a boys' school at Dinan. The boy first attacked was nursed by his fellow-pupils, more than twenty of whom passed the night with him during his illness and used no precaution against the contagion. Not one of the boys thus exposed took the fever ; but the second case occurred nine- teen days after the death of the first in a boy who had no com- munication with the first patient, who had never entered his room, and who slept in a remote part of the building.^ b. Enteric Fever is said to he communicated to the nurses and other attendants on the sick. Many instances might be cited where nurses, who have gone to attend on patients suffering from enteric fever at their own homes, have been attacked shortly after their arrival ; but, on the supposition that the disease may have a local origin, the nurse is exposed to the poison equally with the residents, and, in fact, the recent date of her exposure renders her more liable. I have never known nor heard of a case where the fever has been communicated to the medical attendant not residing in the infected house, and Piedvache makes a similar statement.^ It is, therefore, necessary to search for evidence derived from what occurs when patients are treated in different localities from those in which they contracted the disease. •» Piedvache, 1850. ■■ Ibid. p. 93. ETIOLOGY EXCITING CAUSE. 46 1 Hospital experience lends little support to the doctrine of contagion. One of the chief arguments for the contagious charac- ter of typhus was derived from the liability of hospital attendants to suffer ; but it is universalty admitted to be a very rare occur- rence for the nurses or medical attendants of hospitals to contract enteric fever from the sick under their care. Andral denied that it was ever communicated to the medical attendants in a hospital, or to patients occupying adjoining beds.® During six years, not a single case of contagion occurred in the climque of M. Breton- neau, at Tours.* Louis, in his extensive experience at the hos- pitals of La Pitie and the Hotel-Dieu, met with only three instances where the disease originated in these institutions." During nineteen years, Chomel only knew four cases contracted in the wards of the Hotel-Dieu ; ^ and Piedvache, as the result of his extensive research, declared that in France such cases were quite exceptional.'^ Dr. Wilks informs me that he has never known a nurse in Guy's Hospital contract enteric fever. In 1856 Dr. Peacock remarked that he had never known enteric fever communicated to the nurses or attendants at St. Thomas's Hospital ; '^ while the only instances of enteric fever contracted in all the General Hospitals of London, which Messrs. Bristowe and Holmes could discover in their official inquiry in 1863, were those of two nurses in the Eoyal Free Hospital.^ After five years' experience in the City of Glasgow Fever Hospital, Dr. J. B. Eussell thus writes : ' As an interesting contrast with our experience of typhus, I may say that no case of enteric fever has ever arisen either among the staff, or among the patients beside whom cases of enteric fever are treated.' ^ " Andeai, 1823, ed. 1834, i. 485. ' De Claubey, 1845, p. 844. " Louis, 1841, ii. 374. ' Chomel, 1834. ■" Piedvache, 1850, p. 84. == Peacock, 1856. In 1865 Dr. Peacock i^ublished the cases of two nurses who caught enteric fever in the temporary St. Thomas's Hospital. Both had nursed enteric cases, but Dr. P. doubted if the disease had arisen by infection. The ground on which the temporary hospital was built had no proper system of drain- age, and the nurses slept on the ground floor. He repeated his original statement that he had never known an unequivocal instance of the spread of enteric fever in any hospital by infection. Lancet, Feb. 11, 1865. y Sixth Report of Med. Off. of Privy Council, p. 539. They mention several instances of provincial hospitals in which enteric fever seemed to spread by con- tagion. The chief of these was the Bath Hospital, in which four cases of enteric fever originated in 1862. An account of this outbreak was subsequently published by Dr. Goodridge, one of the physicians to the hospital, who showed that a quan- tity of tow had been thrown into the pan of the water-closet on the floor whei"e the patients contracted the fever, which blocked up the waste-pipe and caused an accumulation of soil. One of the patients who took the fever had been in a sur- gical ward into which cases of enteric fever were not admitted, but all four had been exposed to the efliuvia from fffical fermentation. The defects in the drainage were rectified, and although cases of enteric fever continued to be admitted, nO' fresh cases occurred in the hospital Lancet, Oct. 22, 1864. • Report for 1870. .462 ENTERIC OR PYTHOGENIC FEVER. During twenty-three years (1848-70), 5,988 cases of enteric fever were admitted into the London Fever Hospital, but only 17 residents in the hospital contracted the disease, and most of them had no personal communication with patients sick of enteric fever. Of the 17 cases, 9 were nurses, only 4 of whom were employed in the enteric wards, i was a laundress, i a medical officer, and 6 servants residing in a building detached from all fever wards. Twelve of the 17 cases occurred subsequently to 1864, when various extensions of the hospital buildings led to a serious derangement of the drainage, and on more than one occasion the occurrence of several cases in succession in the hos- pital was found to coincide with the smallest number of patients with the disease in the wards, and with defects of drainage, the removal of which at once arrested any further spread of the disease. During the same period of twenty-three years, 12 patients admitted with other diseases contracted enteric fever in the hospital ; 4 of these patients were admitted with typhus ; and 8 with scarlatina ; 8 (2 typhus, and 6 scarlatina) of the 12 patients were admitted subsequently to 1863. But the most remarkable fact is what follows. Since 1861 it has been the practice to classify the patients in the Fever Hospital in this way. The typhus, relapsing, and scarlatina patients have been kept in distinct wards, whereas the patients suffering from enteric fever have been treated in the same wards with the many patients sent to the hospital, who have not been the subjects of any form of contagious fever. The two classes of patients have remained together, both during the acute stage of their maladies and in convalescence, in most instances for several weeks. The same night-chairs have been used by both classes, and the employment of disinfectants has been exceptional. The result has been this. During nine years 3,555 cases of enteric fever have been treated along with 5,144 patients not suffering from any specific fever ; not one of the latter has contracted enteric fever. The subsequent experience of the London Fever Hospital is in complete accordance with these statements of Dr. Murchison. From 1871 to 1882, 1,795 cases of enteric fever have been admitted and treated in the same wards with 928 cases of other diseases, no special pre- cautions being taken, and not one of these has become infected, though a few cases of enteric fever have originated in other parts of the hospital among patients admitted for scarlet fever. During this time, 7 nurses and a ward servant were infected. Four of these were all attacked about the same time, and it was discovered that the drain of the ward in which they were on duty had become obstructed by the lodgment of a piece of slate in the trap. ETIOLOGY — EXCITING CAUSE. 463 My experience, in fact, has led me to the conclusion that when enteric fever originates in a hospital, as a rule there is something radically defective in the sanitary arrangements,^ and that either the air or drinking water is polluted with decomposing excrement. In rare instances, as in those which follow, the ^attendants alone suffer, but when this happens, it is a fit subject for inquiry whether the poison be not generated in the decom- posing alvine evacuations, instead of emanating directly from the bodies of the sick. 1. In 1858, one of the nurses of King's College Hospital, between 25 and 30 years of age, contracted well-marked enteric fever and died. Immediately before her seizure, she had been engaged in nursing a patient ill of the disease. None of the other nurses nor of the patients in the hospital caught the fever, which, therefore, did not seem to have had a local origin. 2. A similar case is recorded by Gendron. On November 5, 1826, a female, aged 20, was brought to the hospital of Cbateau-du-Loir. She was then in the third week of an attack of ' dothienenteritis,' of which she died on December i. Immediately after her death, her nurse, a female aged 45, was attacked with the fever, no other cases of which occurred in the hospital.^ 3. Some years ago, two young men met in London. A came from the Isle of Wight, where there was no fever ; B came from a village in Cambridge, where enteric fever was prevalent. B was ill at the time of meeting. Both proceeded to Edinburgh, where B had a well-marked attack of enteric fever. A lived in the same house and nursed B, and he also took the fever, although all the other residents in the house escaped. •= 4. At Windsor, in 1858, Emily C was brought home ill of enteric fever to her father's house. She was nursed by her sister Amelia, aged 12, who slept in the same room on a mattress beside her sister's bed. At the end of a fortnight, Amelia was seized with the fever, which ran a severe course and presented all the characteristic symptoms, in- cluding the lenticular spots and diarrhoea. Enteric fever was certainly prevalent in the neighbourhood ; but, though several of the residents in the same house were of the age most liable to it, Amelia C , who alone attended on her sister, was the only one who took the fever.'' [Dr. Collie,^ of the Homerton Fever Hospital, has recently published 19 cases in which he attributes the infection to direct contagion from the fresh stools ; but this is so contrary to the experience of other hospitals that it is impossible not to suspect the existence of some other cause.^ The comparative immunity of the attendants at the » See also Maclagan, 1867. *• Piedvache, 1850, p. 50 ; see also p. 52, ' Communicated by Dr. Buchanan. ^ MuRCHisoN, 1859 (3), p. 311. ' Collie, 1880. ' See MuEPHY, Brit. Med. Journal, 1880, vol. ii. 464 ENTERIC OR PYTHOGENIC FEVER. London Fever Hospital he attributes to their being older than at Homerton.] c. Persons labouring under enteric fever occasionally transport it into localities ivhere it was before unknown, but where it then spreads from them as from a centre. Although many of the cases appealed to in support of this argument have probably been examples of typhus, or of some other fever,^ there are unequi- vocal instances of enteric fever propagated in the manner de- scribed. It is true that such occurrences are exceptional, and that the number of cases ivhere the disease is introduced into a new locality ivithout spreading far exceeds that in ivhich it is propagated.. More than forty instances have come under my notice in private practice where persons have come to a house ill with enteric fever, but in two only of the entire number was there any evidence of the disease spreading, and in one of the instances there were some doubts as to the individual who was supposed to have imported the disease being really ill at the time of arrival.. The fever is occasionally believed to be introduced into a house by a newly-arrived person, when it really has a local origin from which the stranger naturally suffered first (see p. 455). In several instances of this sort, I have ascertained that the stranger- was perfectly well at the time of arrival. In the following illus- trations, however, the disease appeared to spread in a circum- scribed locality, immediately after the arrival of an infected person.'' 1. In 1826, an outbreak of enteric fever occurred in the Military School of La Fleche, in France. It commenced in July, and did not cease until 109 boys were attacked. The school was broken up, and the boys who were not ill were sent to their own homes m distant parts of France ; 29 were taken ill after reaching their homes, and 8 commu- nicated the disease to their families.^ 2. Enteric fever broke out in a family living in an isolated country house on the top of a hill, in France. Three nurses were called in to tend the sick. All three took the fever, and all three communicated it to their own families, residing in a, village at a long distance from the source of infection. J 3. Dr. W. Budd has recorded an outbreak of enteric fever which occurred at North Tawton, Devon, in autumn 1839. During the K For example, at Windsor in 1858, most of the cases popularly reported as provin" the contagious character of enteric fever, proved to be cases of scarlet fever, which was very prevalent at the same time. , , , '■ Others are reported by the writers already referred to (p. 45b), and also by PwEEVES (1859) ; Simon (1S61) ; and Trousseau (1861). ' BrETONNEAU, 1829, p. 70. ' PlEDVACHE, 1S5O, p. 60. ETIOLOGY EXCITING CAUSE. 465 prevalence of the fever, it so happened that three persons left the place after they had become hafected, and all three communicated the disease to one or more of the persons by whoni they were surromided in the new neighbourhoods to which they had removed, although in each of the three new localities there had been no cases of fever previous to their arrival.^ 4. In 1843 the village of North Boston, Co. Erie, New York, con- sisted of 9 families, or 43 persons. On Sept. 21st a stranger from Massachusetts took lodgings in the hotel, having been ill for several days before with fever, of which he died in the hotel on Oct. 19th. Diarrhoea and low delirium were prominent symptoms of his attack. Between Oct. 19th and Dec. 7th, 28 of the 43 inhabitants took enteric fever, of whom 10 died. An autopsy in one case revealed characteristic t}p)hoid ulcers in the ileum. The person first attacked was a son of the innkeeper, and of this family no fewer than 7 took the fever and 3 died. Only 3 of the 9 families escaped ; 2 of the 3 lived at some distance from the tavern. Between the one family living near the tavern which escaped and that of the innkeeper there was a feud, and consequently the former did not draw water from the innkeeper's well, but dug a well of their own. The other 5 families living close to the tavern (and one of those at a distance in which there was no fever) used the tavern water, which was at first believed to have been inten- tionally poisoned. Dr. Flint was of opinion that the fever was not due to the water at all, but to personal intercourse with the sick stranger, but similar occurrences since brought to light make it most probable that the water was at fault.^ 5. In 1858, a servant ill of enteric fever was removed from Windsor to her home at Cippenham, four miles distant. Three weeks after- wards, her father and sister took the disease, although no other cases had occurred at Cippenham. Another girl ill of the fever was removed to Bray, some miles distant. Shortly after, her two sisters took the fever, although no other cases had occurred at Bray previously.™ 6. In October 1864, enteric fever made its appearance at Balletheron, a farm-house at the southern base of the Sidlaw Hills, six miles to the north-east of Dundee. A maid-servant ill with the fever was conveyed thence to her father's house in the Glen of Ogilvie, on the other side of the hills. Within a few weeks, and apparently consequent on the introduction of this one case into a thinly populated and healthy glen, 1 7 other cases sprung up in persons who were in the immediate vicinity of those previously affected." I. Mode of Communication, — Although enteric fever is com- municable, my experience is entirely opposed to the view that it is contagious in the strict sense of the term. Visiting, or ^ BuDD, 1859, p. 29. ' Flint, 1852, p. 377. "^ MuKCHisoN, 1859 (3), p. 311. " Maclagan, 1867 (No. 2). H H 466 ENTERIC OR PYTHOGENIC FEVER. contact with, the sick is neither sufficient nor necessary to produce it, and it is never propagated by a third person." [Although it may not be safe to affirm that enteric fever is incapable of being communicated by direct contagion, it is quite certain that this plays a very small part in the dissemination of the disease, and that wide-spread epidemics are never due to this cause.] As in dysentery and cholera, the alvine dejections appear to constitute the chief, if not the sole, medium of communication. This view, which has been taught at Munich for thirty years by Professor F. von Gietl,? which was first explicitly published by Canstatt in 1 847, "^ and which has been ably advocated by Dr. W. Budd and many authorities in this country, accounts for some of the differences of opinion on the contagiousness of enteric fever, as the disease would cease to be communicable when care is taken at once to remove and destroy the alvine evacuations. But though enteric fever may be propagated by the stools of the sick, it does not follow that the sick give off from their bowels a specific virus like that of small-pox, as has been commonly argued. All evidence is in favour of the view that the fresh evacuations are harmless (see p. 462), and that the poison is developed during their putrefaction ; in other words, that what has been demonstrated in cholera, both clinically and exj^eri- mentally, holds good in the allied diseases, enteric fever and dysentery. The poison developed in the stools is either : a, l^ropagated through the atmosphere ; or, h, finds its w^ay into the drinking water, and so enters the system by the digestive tract. " A contrary opinion has been expressed by some writers. See, for example De la Haepe, 1867. Dr. Clifford AUbutt has recently put on record what seemed a striking proof of communication by contact. A nurse came to her master's house in the early stage of enteric fever, and on the night of her arrival, and on that night only, slept with a little girl of the family, who was seized with a severe attack of enteric fever four days afterwards, no other person in the house being attacked {Brit. Med. Journ. May 7th, 1870). The case was not under Dr. Allbutt's care, but I am indebted to him for the opportunity of obtaining some further par- ticulars respecting it which deserve to be mentioned. The nurse had only left her master's house in Oxford seven days before her return, and two days before she fell ill, and she went to a house in Cheltenham, in which there was no fever ; while nine days after her return to Oxford her master's under-nurse also took the fever. There is no proof, then, that the nurse imported the fever from Chelten- ham, and more probability that its cause was in Oxford, although careful inquiry failed to discover it. p F. VON GiETL, i860, p. 2, and 1865. ■J Spec. Path, und Therap. 2nd ed. vol. ii. ]>. 572. ' Wahrscheinlich sind die Exhalationen des Kranken, seine Excremente, vielleicht die tyi^hosen Aftergebilde im Darme, die Triiger des Contagiums.' Eiecke, in 1S50, recorded several instances of outbreaks of enteric fever traceable to drinking water polluted with sewage (see Eiecke, 1850, p. 44). ETIOLOGY — EXCITING CAUSE. 467 [Admitting that the fresh stools of cases of enteric fever are in- <3apable of communicating the disease, it is important to ascertain if possible how long a period is necessary for the development of their infectious properties. From some observations which I made on this point in the Middlesex Hospital, I am disposed to think that this period ■does not exceed 12 hours, and possibly under favouring conditions of temperature may be shorter.''] W. Taylor ^ and Ballard * have shown that enteric fever is sometimes propagated by means of polluted milk, and several similar instances have been met with by other observers." Many extensive epidemics have since been caused by contaminated milk. One of the most striking was that in Marylebone in 1873, which was traced by Dr. Murchison,^ but in all the poison appears to have been accidentally introduced into the milk either by its being adulterated with contaminated water, or at any rate by contaminated water being used to wash the dairy utensils. As yet no evidence has been adduced that the milk of diseased cows, or of cows fed on sewage farms, is capable of communicating enteric fever. The only exception to con- taminated water having been the cause of milk epidemics appears to have been the outbreak in Du.blin, reported by Dr. Cameron,'^ where the milk was kept in close proximity to a dirty room occupied by the milk seller and his family, who were suffering from enteric fever. Here there was probably direct contamination of the milk by fascal matter. [Another mode by which enteric fever may be communicated is diseased meat. Several outbreaks from this cause have been reported from Switzerland. The most remarkable was one which took place at Kloten, near Zurich, in 1878, and which has been described by Professor Huguenin ^ and Dr. Walder.^ Up- wards of 700 persons were attacked in consequence of eating decomposed veal from a calf, which Huguenin believes to have been affected by enteric fever. He states that enteric fever, with characteristic intestinal lesions, is by no means uncommon among cattle in Switzerland, but in order to communicate the disease it is necessary for the meat to be also decomposed. There was, moreover, evidence that calves became infected from the stools of their owners. Smaller outbreaks due to a similar cause have been observed in other places.] 2. The distance to which tlie poison can he transmitted. — Pied- vache and other writers have maintained that the poison of ' Cayley, 1880. « Taylor,"'i858. * B.u.lard, 1871. " Lancet, 1873, i. 284, 492 ;. and Brit. Med. Journ. 1873, i. 291. '' Lancet, 1873, vol. ii. '^ Camekon, 1879. ^ Huguenin, 1878-79. y Waldek, 1878. A brief account of this epidemic will be found in the Croonian Lectures of the Royal College of Physicians, Cayley, 1S80. H 11 2 468 ENTERIC OE PYTHOGENIC FEVER. enteric fever ceases to take effect at a very short distance from the sick, and that it is always inert when the atmosphere around the sick is constantly changed ; but it is obvious, that if the poison be contained or developed in the stools, it may take effect at a distance from the persons from whom it is derived, through the medium of drains, drinking water, or milk. 3. Fomites. — Bretonneau and Gendron believed that the poison of enteric fever could adhere to the clothes and beddmg of the sick, and that the disease might thus be propagated. Gen- dron, who was an exclusive contagionist, cited several instances,, where he believed that the disease was transmitted by bedding after an interval of many years ; ^ but in these cases, the cause was perhaps localised in the water or sewage of the house, and not in the bedding. At the same time, inasmuch as the stools of enteric patients may putrefy and become poisonous in a drain or in drinking water, there is no reason why similar changes should not take place in the excrement discharged into clothes or bedding, or why these articles should not in this way come to propagate the disease. Thin,'* De la Harpe,^ and other observers have recently recorded illustrations of this mode of propagation, and the following fact has been communicated to me on excellent authority : — In 1859 the wife of a butcher residing in the small village of Warbstowe, 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 Warb- stowe, 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 Warb- stowe previous to her return ; neither were there any cases in the neighbouring villages, either before or after. 4. Period of Incubation. — Few conclusive facts bearing on the period of incubation of enteric fever have been recorded. This is accounted for by the difficulty there often is in deciding when an attack of enteric fever has really commenced ; and by the circumstances that the disease is rarely contracted in hospitals,, and rarel}^ spreads when it has been imported into a healthy locality (p. 464). An appeal for information on this point to- several physicians at the head of large fever hospitals has led to- ' GENDBON, 1834; PlEDVACHE, 185O, p. II9. • Thin, 1865. " De la. Hakpe, 1S67, p. 26. ETIOLOGY — EXCITING CAUSE. 469 negative results ; and in my own practice I have only met with iwo cases throwing any light upon the matter, and in these all that could be said was that the period of incubation was not longer in one case than 21 days, and in the other than 14. The following facts and opinions have been published. Lothholz in 19 cases at Jena found the period of incubation to be between 18 and 28 days.° Seidel, in one case, found it to be at least 12 days."^ Zehnder, from observations made at Zurich, concludes that it is usually between 10 and 20 days, but that when there is a strong predisposition, it may not exceed 24 or 48 hours.*^ De la Harpe infers from 2 1 cases that it varies from 6 days to 11 weeks ! but none of his observations fix the duration precisely.*" Dr. W. Budd states that a large number of cases has led him to the conclusion that it varies from 10 to 14 days.s When the school of La Fleche was broken up on account of an outbreak of enteric fever (see p. 464), of the 29 boys who fell ill with the fever at their own homes, all were seized some time during the second week after their arrival. From Buchanan's observations it would appear that in a large number of cases at Guildford in 1867 the latent period was 11 days.^ Kncevenagel has recorded ^n interesting case, in which it was exactly 8 days.^ Lastly, there is evidence that the period of incubation may be extremely short. Griesinger relates 3 instances in which the attack com- menced on the day following exposure to the infection.^ In the 'Outbreak in a school at Clapham, of which the details will be given presently, 20 out of 22 boys were seized within four days of exposure to the cause (see p. 473). Under such circumstances the disease is usually ushered in severely with vomiting and purging, often attacks at once many persons residing in the same house, and is often fatal, and hence many outbreaks of enteric iever have at first excited suspicions of poisoning. Several in- stances will be referred to presently, where, as in the outbreak some years ago in the royal family of Portugal,^' the symptoms of enteric fever were at first ascribed to criminal or accidental poisoning. From the evidence here collected it would appear that : I . The period of incubation of enteric fever is most com- monly about two weeks ; 2. Instances of a longer duration are more common than in typhus or relapsing fever ; 3. It is often Jess than two weeks, and may not exceed one or two days. It « Lothholz, 1866. "^ Jenaische Zcitsch.f. Med. iv. 480. » Painphlet, 1866. ' De la Hakpe, 1867. ^ Budd, 1856, p. 618. " Tenth Bep. Med. Off. of Privy Council, 1867, p. 4°- ' Kncevenagel, 1869/ J GKiEaiNGEE, 1864, p. I49- *■ See Brit. Med. Joiirn. Jan. 4, 1862. 470 ENTEEIC OR PYTHOGENIC FEYEE. has been suggested that the period of mcubation may be shorter when the poison is imbibed with the ingesta than when it is inhaled ; but in the Clapham case, and in other instances of very short incubation which might be quoted, the poison was ap- parentl}^ inhaled.' [A large number of facts with regard to the incubation period has- since been published. They all confirm the view that the most common period is from ten to fifteen days. I have not found any well authenticated case in which it was certainly less than five days, or more than twenty-two days. The cases above mentioned of Griesiuger's are quite without value, and great doubts have been expressed by high authorities as to the nature of the outbreak at Clapham. Sir Thomas Watson did not regard it as enteric fever. Professor Qumcke,™ of Berne, has published some cases due to drinking contaminated water where the incubation period was very accurately ascertained. In these the shortest period was eight days,, the longest certain period between sixteen and eighteen days. In the Marylebone milk epidemic of 1873 a child was taken ill five days after drinking the infected milk. In the Eagley milk epidemic an adult twenty-two days after.] 5. Stage at wkicli the disease is most communicahle . — There are no data for forming an accurate opinion this point. Accordmg to Gendron and other writers, the disease is most contagious at its advanced stage ; but this conclusion is merely founded on the circumstance that the first patient in a house has occasionally been ill for two or three weeks before the others are- attacked. It would be important to determine at what stage the stools are most virulent. There is no proof that enteric fever can be communicated by the dead body. Putegnat was inclined to attribute his own attack to the autojDsy of a fatal case. It is true that he was seized a few days after the autopsy ; but he had attended both the patient and her mother during their illness.'^ Feron cites the instance of a woman who went a distance of two miles to lay out the body of a little girl who had died of the fever, and who- was herself seized immediately after ; but the circumstance is equally explicable on the supposition of some local cause in the house where the girl had died.° 6. Immunity from second attacks. — It is generally believed that one attack of enteric fever confers an immunity from sub- sequent attacks. P This opinion is founded on observations of a ' For further details of the cases here quoted see Mukciiisox, 1S72. " Q01NCKE, 1874. " Putegnat, 1838, p. 856. " Fkron, 1840, p. 105. " Bketonneau, 1829, p. 58; Gex];eon, 1834; CiioMEL, 1834, p. 333; Louis ETIOLOGY — EXCITING CAUSE. 4/1 twofold nature. First, on questioning patients suffering from the disease, it is rarely ascertained that they have had a previous attack; former attacks of * fever' have usually been of -a different nature. Secondly, several remarkable instances have been recorded, particularly by Gendron and Piedvache, where a second outbreak has occurred in the same house or locality after an interval of many years, and where the fever has attacked almost every person who had not the disease j^reviously, but spared those who had been attacked in the first visitation. At the same. time, well-authenticated instances of persons contracting enteric fever a second time are more common than is generally believed. Several have come under my own notice in which both attacks have occurred subsequent to puberty, and many more in which a patient who had passed through ' infantile remittent fever ' got an attack of enteric fever in adolescence. Trousseau records two examples of a second attack ; one that of a woman in whom there was an interval of four years between Ihe two attacks ; the other, that of a girl who had a severe attack at the age of 12, and a second equally severe a year after- wards.i Piedvache mentions the case of a girl who had an attack in January 1841, at the age of ten, and a second attack in July 1849.'" Three unequivocal examples of a second attack are reported by Michel ; ^ three by Bartlett, after an interval of only one year ; one by Paul, after an interval of three years ; * and four by Dr. W. Budd. 2. Independent Origin. Admitting that enteric fever is, under certain circumstances, communicable, it is, in my opinion, equally true that many cases have an independent origin. Of the patients admitted into the London Fever Hospital, I have rarely been able to trace the disease to contagion. Of 1,576 cases, it was ascertained that 204, or I3'72 per cent., attributed the disease to contagion, but only because other cases had occurred in the same home (see p. 460). Although in large towns it may be difficult to exclude the possibility of contagion, on turning to the history of circumscribed epidemics in country districts, it is found to be often impossible to attribute the first appearance of the disease to contagion. It is not uncommon for the inmates of an isolated 1841, ii. 370; Piedvache, 1850, p. 103; Jenneb, 1849 (i), 38 ; W. Budd, 1S59, p. 56; Baktlett, 1856, p. 106. 1 Clin. Med., Syd. Soc. Transl. iii. 50. "■ Piedvache, 1850, p. 103. ' Michel, 1859, p. 297. ' U Union Med. 1S70, i. 5S7. 472 ENTERIC OR PYTHOGENIC FEVER. country-house to be seized with enteric fever, although no case has occurred within many miles, and there is no evidence of importation of the poison. In fact, if we except Bretonneau, Gendron, and our countryman. Dr. W. Budd, it has been almost universally believed by those who have had much experience of the disease, that a large proportion of the cases of enteric fever are independent of contagion. Even Gendron admitted that, after the most rigid investigation, he was quite unable to account; for the first cases in certain localities, and he added that he had met with several isolated cases of which the cause was unknown to him." Piedvache also states that, in France, it is often im- possible to trace the first cases of a circumscribed epidemic to contagion, and records many instances where it appeared certain that the persons attacked had not directly nor indirectly been exposed to contagion. His conclusions on this point are as follows : ' Je dirai meme qu'il est tres probable, et je crois meme certain, que des fievres typhoides, dans quelques circonstances, se declarent a la fois en nombre assez considerable pour consti- tuer une epidemie independamment de la contagion.' " Dr. Wood, of America, remarks : ' But against the opinion of its ordinary contagiousness is the fact, that it is constantly springing up in isolated cases, without any possible communication.' * ' La transmissibilite,' says Jacquot, * est la regie pour le typhus, I'exception pour la dothienenterie.' -"^ Trousseau, although a decided contagionist, admits that in many instances its origin is spontaneous.^ Lastly, Niemeyer, writing in 1867, observed: ' I must deny that the recent assertions, that abdominal typhus spreads solely by contagion, have been proved, or even rendered very probable, by the facts adduced. "" Until a few years ago, it was not attempted to account for the origin de novo of enteric fever. Chomel remarked : * Les causes de la fievre typhoide sont enveloppees de la plus grande obscurite.' ^ Dr. Stewart observed : ' With regard to the pro- ducing cause of typhoid fever, all is vague and uncertain.''' Piedvache spoke of its etiology as ' enveloped in obscurity ; ' and in March 1858, Dr. Tweedie stated, in his lectures de- livered before the Eoyal College of Physicians, that its causes were ' obscure and unknown.' Air and drinking water polluted with decomposing sewage " Gendeon, 1834, p. 13. ^ Piedvache, 1850, p. 137. " Wood's Pract. of Med. 4th ed. i. p. 389. ^ Jacqitot, 185S, p. 306. ^ Trousseau, 1861, p. 179. ' Text Book of Pract. Med., Ainer.Trcmsl.ii. $72. • Chomel, 1834. »> Stewakt, 1S40, p. 295. ETIOLOGY EXCITING CAUSE. 473 .and other forms of putrefying animal matter had long been re- garded as causes of fever,'' but it had not been shown that the fever thus produced differed from that resulting from other otli of these districts had a complete system of drainage, with water- closets within the houses, and sinks in the basements and kitchens. The drains in these two districts were flushed, partly by a continuous flow of water through them from the Thames, and partly from artificial tanks. But, in consequence of a long-continued drought, the Thames had fallen greatly in its level, while the tanks had, from neglect, been allowed to get dry. The result was, that the sewage accumulated in the sewers, and in consequence of their ventilation being very imperfect, the sewer- exlialations escaped directly into the houses. In the two districts mentioned, thQ fever attacked the rich and poor indiscriminately ; but the cases were most numerous and severe in the low level district,. where all the drains of the town were congregated, ' W. BuDD, 1859, p. 432. ■ See BibliograpUy, 1857. I I 482 ENTERIC OR PYTHOGENIC FEVER. and where tliey had the least incKnation, that is, at the foot of Sheet Street, near the Barracks. The inhabitants in these districts complained of the offensive smells from the drains in their houses, and particularly in the houses where the fever occurred. The district of the town which remained almost exempt from the fever was the worst and poorest, where choleii. had raged with greatest severity in 1849. Although the drains of this custrict also suffered from want of water, the water-closets were outside tlie houses, and there was no direct communication by sinks, or Fig. II. Plan of the Windsor Drainage. At a the private drain from the Castle joins the main drain from the town. otherwise, between the drains and the interior of the houses. With few exceptions, bad smells were not complained of in this district. One woman, however, complained bitterly of the offensive smell from the gully opposite her door ; her daughter had died of fever. No case of fever occurred in Windsor Castle, which, as may be seen from the annexed wood-cut, had a drain of its own, unconnected with the town- drainage. This drain was well ventilated, and was flushed every morning by a special supply of water. A few of the houses in the Eoyal Mews connected with the private sewer of the Castle partici- pated in this exemption ; but in the remainder of the Mews, only ETIOLOGY — EXCITING CAUSE. 483 separated by a roadway from the more favom-ed portion, but comiected with the town-drainage, there were thirty cases and three deaths ; yet all the residents in the Mews derived their drinking water from one source. Lastly, a few cases of fever occurred in the collegiate resi- dences of the Castle, which were also connected with the town- drainage.* In the latter part of 1859, Bedford was the seat of a severe outbreak ■of enteric fever, although before this it had been ' the autumnal habit ■of the town to suffer from it.' On investigation, it was found that the distribution of the fever did not follow the ramification of the sewers, nor did it appear to depend on the escape of cesspool air into the houses : but the fever was traced to faecal matter soaking into the wells from the numerous cesspools of the town. The water from these wells was found to contain a large quantity of decaying animal matter evidently derived from the sources alluded to." At Guildford a sudden outbreak of enteric fever took place in the :autumn of 1867, which was investigated by Dr. Buchanan. At least 500 persons were attacked. The epidemic was restricted with almost absolute precision to the high levels of the town, attacking here the poor and rich alike ; but it spared entirely the low-lying parts of the town, in which alone examples of the disease had been previously observed. The only condition generally coincident with the outbreak was the high service of the town water supply ; and on inquiry it was found that eleven days before the commencement of the outbreak, water polluted with sewage, which had been stored up for sixteen days, had in one day been distributed by this service to the 330 houses in which the fever appeared.^ Facts similar to the foregoing might be multiplied ad infini- tum, but it is now almost universally admitted in this country that enteric fever is traceable to air or drinking water polluted with the products of putrefying sewage. The only opposition to the view of any moment, of late years, has come from the Edinburgh school. Sir Eobert Christison, in his address to the Social Science Association in 1863, stamped with his great .authority the statement that there were insurmountable facts in the way of our accepting the opinion referred to ; ^ although many years before he had taught his pupils to believe that there were proofs of ' the unequivocal origin of continued fever ' in the putrid effluvia from decaying animal matter,^ while in 1846 he had himself traced an outbreak of ' a typhoid fever,' differing * Simon, 1859 ; Muechison, 1859 (3). " Third Rep. Med. Off. Privy Council. ■' Tenth Rep. Med. Off. Privy Council, p, 34. For other examples, see Ward, 1838 ; Croydon epidemic of 1852, Bibliog. 1852 ; Cowbridge epidemic of 1853, Camps, 1855 ; Eouth, 1856, p. 763 ; Mauer, 1862 ; Fever at Munich, Bibliog. 1862 ; Palmer, 1865 ; Reports of Med. Off. Privy Council, passim ; and particularly epidemic at Buglawton, vol. ix. p. 213 ; Stewart, 1867, p. 14. ^ Christison, 1863. "^ OnPoisons, 1829, p. 476. I I 2 484 ENTERIC OR PYTHOGENIC FEVER. from the ' ordinary epidemic typhus of Scotland in the presence- of gastro-intestinal symptoms,' &c., to the effluvia from the filth accumulated in an obstructed sewer. (Vide antea, p. 474.) Pro- fessor Bennett also, in his published lectures, denies that there is any connection between decomposing sewage and the pre- valence of enteric fever.y These authorities, however, stand almost alone. The general opinion of the profession now is that put forth in my Essay on the Etiology of Continued Fevers- in 1858, that enteric fever may be traced to ' the emanations from decaying organic matter, or organic impurities in drinking water.' In the admirable Eeports of the Medical Officer of the Privy Council it will be found that the experiences of many years repeat again and again the general lesson that enteric fever denotes * excremental poisoning ; ' while the President of the Society of Engineers has recently declared that, having examined many hundreds of houses in which enteric fever had occurred, he had in every instance been able to trace the outbreak to some unlooked-for defect in the drainage.^ But there is not the same unanimity of opinion as to how the poison appears in the sewage. Many adopt the view taught at Munich for more than thirty years by Professor F. von Gietl,-'' that the poison, although contained in sewage, is always derived from the excreta of an individual ah-eady suffering from the disease, a drain being merely the vehicle for its propagation, or, in fact, ' a direct continuation of the diseased intestine ' ; while others believe that the poison may be generated in the sewage independently of typhoid excreta. The solution of the question is undoubtedly beset with many difficulties. The former view,, which has been ably advocated in this country by Dr. W. Budd,^ offers the best explanation of the circumstances in those cases where the fever is propagated by the sick; but many, if not most, of the facts adduced in its support are equally explicable on the latter view ; while in others the mode of communication of the fever is not so clearly established as might be desii-ed. It does not, to my mind, necessarily follow, that because the disease may be sometimes communicated by the sick, in every case where it is traceable to bad drainage the poison in the drain has of necessity been derived from a person previously infected with the disease. The independent production of the dysenteric y Pract. of Med. 4th eel. p. 942. Some of Dr. Bennett's arguments appear to me to be beside the question ; others will be adverted to hereafter. ' Letter in The Times, 4th December, 1871. » Gietl, 1S60 and 1865. »" BuL-D, 1856, 1859, 1S61. ETIOLOGY EXCITING CAUSE. 485 poison by the putrefactions of animal substances under certain •conditions has been maintained for centuries, and according to Parkes * there is Httle doubt as to its correctness ' ; ° yet the •evidence of the contagious nature of the dysenteric stool "^ is ■quite as strong, to my mind, as that of the typhoid stool. If, because a disease can be proved to be in a few instances com- municated by the sick, it can never arise in any other way, there is an end of all discussion of the matter ; but this does not .appear to me to be a scientific decision of the question at issue.^ In the remarks which follow I shall endeavour to place the facts «;S fairly as possible ; my readers may judge as to the soundness ■of the argument on which my conclusions are based. I . At the outset it must be conceded that where enteric fever is due to excremental poisoning of air or water, it is often ex- tremely difficult, if not impossible, to exclude from the excre- ment the possible presence of typhoid stools. I am fully alive to the apparently crushing nature of the argument that it is * impossible to prove a negative,' as well as to the facility of using it. It appears to me that the only scientific plan of dealing with such a question is to adopt a process of elimination. 'The two supposed factors are, decomposing sewage and typhoid stool. Taking cases in which there are good reasons for believing that one or other of these factors is excluded, when is enteric iever most likely to occur ? a. In the first place, it is a matter of constant observation that persons are exposed to typhoid stools in their most con- centrated form, but decomposing sewage is excluded, and yet no fever results. Dr. Budd, in common with many writers (pp. 421, 426), regards the intestinal disease as a specific eruption like that of small-pox, and he contends that an ' infinitesimally .small dose ' of the poison derived from this eruption is sufficient to produce the disease.^ Admitting fully the difficulty of proving .a negative, there is no positive evidence that the stools of enteric fever are of so virulent a character as has been contended. ■= On Hygiene, 1864, p. 440. '' See on this point the testimony of Dr. Maclean, Art. ' Dysentery ' in Eey- nolds's System of Medicine, ist eel. vol. i. p. iii. ■^^ Vide antea, p. 8. f Budd, 1859, p. 209. That extremely minute doses of the poison of enteric fever can, as in other contagious fevers, produce the disease, may be regarded as well established. Extensive outbreaks have been repeatedly caused by merely washing the dairy utensils with contaminated water. In other cases, as in the ■outbreak at Caterham and Eedhill, where only a few splashings from the alvine ■discharges of a case of enteric fever were mixed with a very large body of water and caused an extensive outbreak, the contamination must have been almost infinitesimal. See Croonian Lectures, 1S80. 486 ENTEEIC OR PYTHOGENIC FE^-EE. "Well-ascertained facts indeed prove the contrary. First, there is the remarkable exemption from enteric fever, already referred to (p. 461), enjoyed by medical men and the attendants on the sick. Secondly, there is the experience of the London Fever Hospital, of which the details have been ah'eady given (p. 462), but the main fact in which may be here repeated. During nine years 3,555 cases of enteric fever were treated in the same wards with 5,144 patients not suffering fi'om any specific fever. Not one of the latter contracted enteric fever, although it was not an uncommon practice for them to sit over the evacuations of enteric patients, and the use of disinfectants was quite excep- tional. Thiudly, private practice yields similar results. In the last ten years it has been my lot to be consulted in upwards of forty mstances in which j)ersons have contracted enteric fever away from home, and been brought home HI with it. Some of these cases were in London or its suburbs, and others in the country. In only two of the instances did fresh cases of fever appear in the houses into which it had been thus imported, and in neither was there crucial proof that the disease was commu- nicated by the imported case (p. 464). In the outbreak of enteric fever in a nunnery, related at p. 480, of the 37 patients 16 were removed dui'ing their Ulness to then* own houses, but in not one of the 16 houses did the fever spread. Lastly, few can have had much experience in enteric fever without meeting many solitary cases in large families, even where little or no precaution has been taken to prevent its spread. From such evidence the con- clusion appears to me to be inevitable that the fresh stools of enteric fever are not of that venomous character which has been claimed for them, but that, as in cholera, the poison is generated in them during their decomposition out of the body. Moreover, the stools of enteric fever are known to be remarkably prone to decomposition or fermentation. In place of being acid, as healthy faeces always are, they are alkaline ; they also contain abundance of the ordinary products of the decomposition of animal matter, in the form of ammonia and ammoniaco-magnesian phosphate, while then" odour fully bears out the idea of their putrid character. Such a condition must be fatal to the exist- ence of an animal poison, such as that of small-pox. It is alleged that the morbid material deposited in the intestines con- tains the specific poison by which the disease is propagated, just as the contents of the variolous pustule contain the poison of small-pox. But if this be so, the poisonous matter is never passed from the body until it separates as a sloufjli from the ETIOLOGY EXCITING CAUSE. 487 intestine, until, in fact, it is dead and putrid, wliUe the contents of the variolous or vaccine pock will not produce small-pox or cow-pox after they become putrid. It is probable that the stools of enteric fever are more prone than ordinary sewage to the specific fer- mentation by which the poison is produced, and that this explains why the disease is occasionally propagated by the sick. But whether this be so or not, it seems to me far more probable that the poison is always the result of decomijosition, than that it is derived from a specific eruption, like that of small-pox. [Putrefactive decomposition is, however, always accompanied and most probably occasioned by the rapid development of micro- organisms, and as there are strong grounds for regarding the poison of enteric fever to be constituted by one of these organisms, it would seem highly probable that the putrefactive change is one of the conditions necessary for their development from tbe germs contained m the stools of cases of enteric fever.] h. Enteric fever is constantly appearing where decomposing sewage is present, but where every effort fails to trace the pre- sence of typhoid stools. It is difficult to obtain crucial evidence on the point from what is observed in large towns furnished with a complete system of drainage, because with regard to every instance of fever arising from sewage it might be said that ' drains are merely the vehicle for the transmission of typhoid stools,' or that they contain ' the very quintessence of a pre- existing fever.' But even in towns evidence is not wanting that enteric fever often arises from bad drainage, where it seems im- possible to conceive that typhoid stools have been introduced into the drain. For example, in the case of the Peckham Police Station (see p. 475) the cesspool had no communication with the public drains ; in the outbreaks at Westminster (p. 474), Clapham (p. 473), and other places, the source of the fever was traced to the decomposition of sewage in drains which were choked up, and so shut off from the general drainage ; while in the case of the Colchester Union (j). 476) every possibility of im- I)ortation api)ears to me to have been excluded. If drains, in their relation to enteric fever, are to be regarded as merely the vehicle for the transmission of the typhoid stools, in any epidemic it would be right to expect that the fever would be most preva- lent in the houses which communicated most freely with the public drains. Yet the contrary is often observed. Take, for example, the official report to the Privy Council of an outbreak of enteric fever at Forest Hill, in 1 869. ' The prevalence of enteric fever has corresponded very closely with defective sewerage 488 ENTERIC OR PYTHOGENIC FEVER. arrangements. Where houses are connected with the pubUc sewers, there the prevalence of enteric fever has been at a mini- mum, . . . where the houses have cesspools attached to them, or they are connected with sewers which do not form a part of any- proper system of drainage, and which are of radically faulty con- struction and form, in fact elongated cesspools, then enteric fever has been at a maximum.' On turning to what occurs in country- districts, the evidence is still more conclusive. Many instances have come under my notice, like those of the farm-house in Peebles (p. 474) and of Balletheron (p. 478), in which enteric fever has broken out in an isolated country-house, or in a small group of houses, miles away from where any fever has been pre- vailing, and in which every mode of importation or of communi- cation by drains or otherwise seemed impossible.^ The study of enteric fever as it prevails among isolated bodies of soldiers points in the same direction. In a recent official report. Dr. J. L. Bryden, attached to the Sanitary Commission of the Government of India, remarks : ' What I have shown is, that the spontaneous origin of enteric fever is a fact. . . . The question of the spread of typhoid subsequent to its development has nothing to do with that of its spontaneous origin. . . . The doctrine that, without the introduction of typhoid excretory matter in some shape into the systems of these young men, they are safe from the development of the specific fever, does not, however, meet all the facts of the case. My observation tends to teach that, while it may be perfectly true that typhoid is in many instances so propagated, the specific lesion and its attendant fever are capable of development without the application to the system of a poison elaborated elsewhere ; and that the etiology of typhoid is not comprehended within the limits to which, of late years, the tendency has been to seek to confine it.' ^ [Much discussion has lately taken place as to the mode of origin of enteric fever in India and various sub-tropical climates, and great difference of opinion prevails. There is, however, a general consensus that the disease originates de novo. As to the mode of its origin there are two main theories, which may be termed the entogenetic and the ectogenetic. According to the former, without any infection from without the disease may be generated in the system from the effects « Several instances of this nature, in which the circumstances were most carefully investigated, were communicated to the Epidemiological Society, by Dr. Headlam Greenhow, on April 7, 1S62. Dr. G. remarked: 'No discoverable evidence of its having originated in contagion could be traced on the most careful inquiry.' " Eighth Ann. Bep. of San. Com. of Gov. of India for 1S71, p. 226. ETIOLOGY EXCITING CAUSE. 489 of climate, exposure, changed modes of life, or even to the decompo- sition of the ieeces in the intestinal canal (W. E. Porter), and to such causes is attributed the frequency of its occurrence among new arrivals and among troops on a campaign, though when once origiii- ated it becomes communicable. According to the latter view the disease is always due to the entrance of the poison into the system from without, though many observers deny that it can in every case be traced either to contagion or to faecal contamination. Its origin has been ascribed to malarial influences, decomposition of other animal or vegetable matters, &c. Among those who believe that under certain circumstances it may be entogenetic are Dr. Bryden, Dr. Don, Dr. C. A. Gordon, Dr. Grabham, Sir Joseph Fayrer, Dr. Marston, Dr. Martin, &c. On the ■ other hand. Professor Maclean expresses his opinion that the causes of •enteric fever are the same in India as in England, and he gives two striking instances, one in India and one in Zululand, where the out- break was traced to contaminated water.^] To all this it will be replied that small-pox sometimes appears when it is impossible to trace how it has been imported. But there are these differences between the two maladies. The occurrence referred to is very common in enteric fever, but very rare in small-pox ; and in small-pox it is easy to demonstrate the extreme virulence of the poison, while, on the supposition that every outbreak of enteric fever is due to contagion, the poison given off by the sick ought to be much more virulent than it has yet been proved to be. The facts observed and published by Dr. Budd in support of his views are twofold ; some are adduced to show that the dis- ease is communicable ; others, to demonstrate the intimate con- nection between its appearance and bad drainage. Both of these positions I readily concede, and have always contended for. But because in one set of facts the disease was communicated by the sick, the conclusion does not appear to me to be warranted that this has been the case in every instance where enteric fever is traceable to bad drainage. In the fever at North Tawton, which is Dr. Budd's chief illustration of the first position, while the facts leave little doubt that the fever was communicated in some instances by the sick to persons in health, it is not shown that the stools of the infected were the medium of communication .J ' For references see Bibliography. "^ ■> Budd, 1859, p. 695; 1859, p. 29. ' Dr. W. Budd most strongly insists that the essence of Enteric Fever is con- tained in the alvine dejections of the patient, but we cannot adduce any facts recorded by himself that give material support to this view.' Dr. J. Haeley, Art. •'Enteric Fever,' in Eeynolds's Syst. of Med. 1866, i. 623. 490 ENTEEIC OE PYTHOGENIC FEYEE. On tlie other hand, Dr. Budd records three instances to show that enteric fever may be caused by ' a poison which sometimes exists in sewage,' but from two of which he subsequently argues that sewage only causes enteric fever in consequence of its having received from a diseased intestine a specific poison like that of small-pox.'' In all three instances the fever evidently arose from air or water tainted with sewage ; but it is not shown that the sewage in any of the cases had become contaminated with the excreta of a person suffering from enteric fever.' The necessary link in the evidence, viz., the introduction of the poison, is want- ing. In another instance cited by Dr. Budd, where four cases of fever occurred in a retail establishment at Bristol, it was argued that the disease in the last three cases was due to the evacuations of the first case being thrown into the common water-closet. But it was not shown that the poison was imported by the first case, which is spoken of as ' casual,' and on the supposition that the first case was due to some local cause, that cause was suffi- cient to account for all.™ In other instances, such as the Orphan Asylum at Ashley Hill, and the school in the South of England, where the fever appeared in connection with offensive latrines, it is also argued that the cases were due to the children frequenting the latrines into which the dejections of the first patient had been thrown, but it does not appear that the first patient con- tracted the disease elsewhere than in the asylum or school." Even in the account of the North Tawton outbreak, although the date and locality of the first case are mentioned, it is not stated that the patient caught the disease away from the place. The circumstance much dwelt on by Dr. Budd, that extensive ^ ' There are few things in the history of disease so sure as the fact that, under circumstances which are of no uncommon occurrence, the excreta which the sewer receives from the human intestine may become the cause of intestinal fever. The proof on which the inference rests is so clear and jprecise as to leave no room to the severest scepticism to interpose a single doubt.' ' The Abbotsham Place and Richmond Terrace outbreaks further show that these excreta produce this effect, not by a vague or general mode of action — as cold and damp, for instance, may give pleurisy, bronchitis or rheumatism, as the case may be — but by actually furnishing the specific poison which is the physical cause of the fever, as much as the marsh miasm furnishes the poison which gives the ague, or — to take a still stronger illustration — as much as, in the old practice of inocu- lation, the lancet furnished the specific i)oison which gave the small-pox.' — The Lancet, November 5, 1859, p. 458. ' W. Budd, 1859, pp. 432,458; 1861, p. 550. In one of the instances, it is stated, that a few days before the water of a certain well was discovered to be con- taminated with sewage, there was a single case of fever in an adjoining house. But it is not shown that this patient contracted the disease elsewhere than in the house in question, or that diarrhuja had occurred before the patients in the next house began to be ill. It appears to me that Dr. Budd has omitted to place the key-stone in the arch of his argument. "> Budd, 18^6, p. 618 ; 1859, p. 458. " Ibid. 1856 ; 1859. ETIOLOGY — EXCITING CAUSE. 49 1 outbreaks of enteric fever have occasionally been preceded by two or three isolated cases, proves nothing m favour of contagion, in my opinion, except it can be shown that in these first cases the fever was contracted away from the site of the subsequent outbreak." 2. It is a common argument that excremental pollution of air and drinking water may exist for years without causing enteric fever, which only appears after the arrival in the locality of an infected person. The first part of the statement is true,, but admits of another explanation than that usually assigned to it. Excremental pollution may be only one of several factors necessary for the production of the poison, and m the absence of the other factors it may be inert. In point of fact we know that a certain temperature (and perhaps other atmospheric condi- tions) conduces to the prevalence of enteric fever, and it is very possibly essential to the production of the poison. It is generally admitted that autumnal diarrhoea may result from drinking sewage-polluted water ; but the same polluted water may be drunk for a long time with impunity, so long as it has not been subjected to certam atmospheric conditions common in autumn. It is quite true, then, that excremental poisoning may exist for a long time without any fever, but it does not follow that when a sudden outburst of the disease at last takes place, this has always been preceded by the arrival of an infected person. Sometimes the poison may have been imported, but in a large proportion of instances no such importation can be traced ; and when the disease is imported it does not spread, unless there be at the same time defects in drainage or in the water-supply. In some instances a person newly arrived is the first to suffer in virtue of a well-known law of the disease (see p. 455) ; while other out- breaks commence by a large number of persons being attacked simultaneously, without any isolated cases preceding. Many of the instances adduced in support of the argument now referred to have broken down on investigation. One example, which attracted much notice,^ will suffice. In June 1872 enteric fever o An instance of this sort occurred at the Clergy Orphan School at St. John's Wood in 1856. Dr. Aitken in quoting this case in his influential work, Science and Pract. of Med. 2nd ed. i. 408, remarks : ' The first case was imported, and the illness began ten days after arrival.' But on turning to the reference given by Dr. Aitken {Lancet, November 15, 1856) it will be found: i. That the first l^atient was taken ill twelve days after the school reassembled ; 2. That there is no mention of the first case having been imj)orted ; and 3. That the reporter speaks of ' some local cause ' being at work. '• Dr. Ballard's Official Report; Mecl. Times and Gaz. 1873,1. 18; Lancet, 1873, i. 107. 492 ENTERIC OR PYTHOGENIC FEVER. was said to have been imported into the village of Nunney, in Somersetshire, by a man who came there ill from Old Ford, five miles distant. For twenty-eight years there had only been an occasional case of enteric fever at Nunney, although all that time the inhabitants had drunk of a stream polluted with sew- age, the disease only becoming epidemic when what was believed to be a specific ferment entered the stream. It is obvious, how- ever, that there must have been circumstances favourable to the spread of enteric fever at Nunney in June 1872, which had not ■existed when isolated cases had occurred there in 1867, 1870, and February 1872; and when it is added that no other case of enteric fever was observed at Old Ford in the summer of 1872, besides that of the man who was believed to have imported it into Nunney, that this man had visited Nunney three weeks and one week before his illness, and that on the former occasion Tie had attended a meeting of his club in the house where the worst and greatest number of cases of enteric fever subse- quently occurred, 'I it follows that the origin of the epidemic :admits of a very different interpretation from that which was first apparent, and that it is not, as was imagined, a crucial proof of the necessity of a specific ffecal ferment for the produc- tion of enteric fever. [Among the most strildng examples of sewage coutamination of the drinking water only causing enteric fever after the introduction of "the specific poison, are the epidemics at Over Darwen in Lancashire and Lausen in Switzerland. In the former the water supply pipes of the town were leaky, and the soil through which they passed was soaked at one spot by the sewage of a particular house. No harm followed till a young lady suffering fi-om enteric fever was brought to this house from a distant place : within 3 weeks of her arrival the disease broke out and 1,500 persons were attacked. At Lausen the water, which must have been always subject to con- tamination by the sewage of a group of farm-houses, had been drunk with impunity from time immemorial, till some of the inhabitants of these houses were attacked by enteric fever, when an outbreak at once followed.'"] 3. In opposition to the view that the poison of enteric fever can be produced de noco in decomposing sewage, it has been urged that the workers in drains and nightmen are particularly exempt from fever. The facts appealed to in support of this statement have been there recorded by Parent du Chatelet * and 4 Med. Record, March 19, 1S73. >• A brief account of this remarkable epidemic will be found in the Croonian Lectures. Cayley, 1880. " P.uiest du Chatelkt, 1829. ETIOLOGY — EXCITING CAUSE. 495 Dr. Guy,* but on close examination they scarcely justify the inference drawn from them. In an appendix to Du Chatelet's Essay on the Diseases of the Workmen in the Drains of Paris, it is stated that, dm-ing six months, 4 of the 32 workmen who formed the subject of the essay were in hospital for two or three weeks with a 'Jievre biliense,' or a 'Jievre hilieuse et cerebrale.' Although these cases are not dwelt on in the body of the Essay and have been generally overlooked, it is impossible to regard them in any other light than as examples of enteric fever. Again, the result obtained by Dr. Guy was simply this : that whereas of 1 01 labourers and brickmakers 32 had suffered from fever, of 96 nightmen, scavengers, and dustmen, only 8 had suffered. Dr. Guy's observations, however, were made without any refer- ence to the form of fever in either case, and, indeed, at a time when the distinctions between the different continued fevers were little known ; and there is evidence that the excess of fever among the bricklayers' labourers was tyiihus, inasmuch as it was attributed to the men being Irish, and to their habits of over- crowding. Dr. Guy distinctly states that some cases of fever were generated by the effluvia from drains and cesspools. More- over, scavengers and dustmen are not particularly exposed to such effluvia. According to Dr. Peacock's experience, enteric fever is not uncommon among the workers in sewers ;'' and several instances have occurred to me, where workers in obstructed drains have contracted the disease (see also p. 456). The disease would, perhaps, be more common in this class of labourers, were it not that most of them are above the age most liable to enteric fever, that some may be protected by previous attacks, and still more that lengthened exposure to the exciting cause diminishes the risk of infection. Whatever be the cause of enteric fever, it is generally admitted that constant exposure fortifies the system against its action (see p. 456). In the out- break at Clapham, already alluded to, although 20 out of the 22 boys suffered from the opening of a drain, the workmen who went down into the drain escaped. Hence, on the supposition that sewer-emanations can produce enteric fever, it is not so surprising as it might at first seem, that persons most exposed to them suffer less than others whose exposure is casual. It seems, however, to have been forgotten in the discussion, that on the supposition that th« stools of one typhoid patient may give the disease to thousands, and that a drain is but the ' Guy, 1848. " Peacock, 1856(1), 494 ENTERIC OR PYTHOGENIC FEVER. * continuation of a typhoid intestine,' the exemption from enteric fever of the workers in drains is equally extraordinary. It is still more extraordinary when we find that the labourers who ■chiefly contract enteric fever are those employed in drains obstructed by fermenting sewage, where we might naturally suppose that the continuation with the typhoid intestine was interrupted. 4. On the supposition that the poison of enteric fever can be developed from decomposing animal matter, it would be natural to expect that certain conditions would be necessary for its pro- duction. In the first place, the poison is not contained in the •exhalations from every sort of decomposing animal matter, such ■as dead human bodies during exhumations or in a dissecting room, putrid meat,' old bones, putrid blood employed for refining sugar,"^ the horse-slapng yards of Montfaucon,'' or any heap of rubbish, or uncovered dunghill. Secondly, although bad smells often denote the presence of tyxDhoid poison, the latter does not exist in every bad smell, and like the miasma of ague is pro- bably inappreciable by the senses. It is no argument then ■against the production of enteric fever in the manner now advo- cated, that it has not been produced by the odours of flowers, or the intolerable smells of the mangrove-swamps of x^fi-ica.y Thh'dly, it is probably necessary for the production of the poison that the fermenting matter be in a confined space, as m a drain or well, and in a state of stagnation. Free exposure to the atmosphere, or constant dilution in a running stream, may not only render the poison inoperative, but prevent its formation. On this view, it is not surprising that enteric fever did not pre- vail in the filthy closes of Edinburgh before the introduction of drainage, that it is not endemic around the meadows of Craigen- tinny which receive the drainage of Edmburgh, and that no extensive outbreak of it occurred in London in 1858, in con- nection with the unusually filthy and offensive condition of the Thames.^ Fourthly, in most of the instances where enteric ' Gastro-enteritis, but not enteric fever, is excited by eating tainted meat, fish, cheese, and sausages in certain forms of decay. Griesinger, however, seems to think that animal food in a state of decomposition may excite enteric fever (Gkiesixgee, 1864, p. 157). " Chisholm, 1810; Bancroft, 181 i, p. 634; E. Willlajis, 1836. -■^ Du Chatelet, 1832. y Such arguments have been adduced by Professor Bennett {Pract. of Med. 4th ed. p. 942). == The oft-repeated argument, that during 1858 the prevalence of feva- in London ■was much below the average requires a word of explanation. The fact was o'wing to the almost total disappearance of tijphus (see p. 53), which in the two former years had been so prevalent. There was no decrease of enteric fever, as I ascer- ETIOLOGY — EXCITING CAUSE, 495 fever has been traced to fsecal effluvia conveyed through the atmo- sphere, these effluvia have escaped into the interior of houses. A stinking privy outside a house is not so dangerous as a badly appointed water-closet within (see p. 444). Lastly, certain con- ditions of atmosphere are probably essential to the production of the poison, such as a certain degree of heat, or a deficiency of ozone, &c. 5. It has been argued that many cases of fever are indepen- dent of organic impurities ; but this objection has mainly arisen from all forms of continued fever being regarded as one disease. Thirty years ago, a memorable discussion took place between the late Dr. Alison of Edinburgh '^ and the London Poor-Law Com- missioners.^ The London observers showed that fever often arose from putrid emanations, and was independent of destitu- tion ; whereas Dr. Alison brought forward evidence that desti- tution was the chief cause of its propagation, and that putrid emanations had nothing to do with it. Both were right, but their observations were made on different diseases. At the same time, it must be admitted that we cannot succeed in tracing every case of enteric fever to organic impurities. But if the disease can be traced to such causes in a few undoubted instances, it is reasonable to infer that the causes are similar in all cases where it has an independent origin. During the last fifteen years, however, I have met with few examples of enteric fever, which, on investigation, could not be traced to defective drainage, the existence of which was often unknown to the in- habitants of the infected locality. 6. In the discussions which have taken place on the origin of enteric fever, the success of the measures for rooting out the disease have been frequently appealed to in disproof of the *P3^thogenic theory.' It has been contended that the disease may be stamped out by recognising the fact that, when enteric fever is traceable to bad drainage, the disease is due to germs derived from a diseased intestine, and by destroying these germs with chemical reagents, such as chloride of zinc and carbolic acid. But the success of the measures referred to is as much in favour of the pythogenic theory as of that which is opposed to it. In prophylaxis, the upholders of the former theory differ from the holders of the latter simply in this, that they are not satisfied tained by numerous inquiries at the time, and as is shown by the returns of the Fever Hospital (see p. 441). " Alison, 1840 (No. 2) ; also Perky, 1844, p. 84. *> Aenott, 1840; Report of Poor Laiu Com. Bib. 1842. 496 ENTEEIC OR PYTHOGENIC FEVER. with destroying the excreta of the sick, but insist on the necessity of preventing the poHution with sewage of any sort of the air in houses or of drinking water. 7. In connection with this discussion it is not immaterial to observe that there is an analogy on many points between enteric fever and diseases acknowledged to be malarious : a. The preva- lence of both varies with season, temperature, &c. b. Eecent residence predisposes to both. c. Both only prevail under certain known infractions of sanitary laws. d. The quality of the poison varies with the locality. The varieties of small-pox and scarla- tina can be proved to be due not to any difference in the quantity or the quality of the poison, but to the varying constitutions of the recipients. On the other hand, the varieties of malarious remittent fever are due in great measure to the dose of the poison^ or the locality where this has been generated, and the same remark applies to enteric fever. I have often been struck with the similarity in the symptoms of all the cases of enteric fever occurring in the same house. Thus, I have known all the cases in one house very mild, and in another, very severe; urgent diarrhoea or sickness in one house, no diarrhoea nor sickness in TABLE XLVII.« Montlis Diarrhoea ii Fever Cases of Diar- rhoea reported to General Board of Health Deaths from Diarrhoea reported by Registrar- Greneral Total cases Contianed Fever reported to General Board of Health Cases of En- teric Fever only admitted into London Fever Hospital Cases of Ty- phus admitted into London Fever Hospital May June July . . August . September October . November December 633 1,770 13,506-^ 19,557 8,432 2,846* 1,118 767 47 114 609* 915 519 232«- 85 73* 548 704 874* 839 891 1,179* 919 664 I 9 19 26 34 38 33 29 42 18 35 16 14 10 I 2 138 Total . 48,629 2,594 6,618 189 ■= The numbers marked * in the first three columns represent the cases which occurred during five weeks, the others only those for four. This arises from the data being derived from iveekly returns. The last two columns show the numbers admitted from the first day of one month to the first of the subsequent one. The third colmmi, of course, includes typhus cases ; but the fifth shows that this fever was greatly on the decline at the period of greatest prevalence, in- dicated in the third and fourth columns. The fourth column contains only cases of enteric fever. . ETIOLOGY — EXCITING CAUSE. 497 another ; severe cerebral symptoms in one house, no cerebral symp- toms in another. In one instance I have met with three cases of relapse, and in two instances with two cases of perforation, in the same family. It is also interesting to note that the ordinary autumnal increase, or circumscribed epidemics, of enteric fever are usually preceded by a great prevalence of diarrhoea, the diarrhoea reach- ing its acme long before the fever does, and having greatly declined by the time that the latter is most prevalent. This observation has been made in many epidemics of enteric fever, and is illustrated by what occurred in London in 1857, as shown in Table XL VII. p. 496. 8. Lastly, experiments on the lower animals do not as yet warrant any conclusions as to the etiology of enteric fever. Many years ago, Messrs. Gaspard, Magendie,"^ Leuret and Hammond ^ showed that by injecting putrid substances into the veins of animals symptoms very similar to those of enteric fever miight be induced, and that after death the intestines were much congested. The same results were obtained by D'Arcet,^ from injecting into the veins putrid pus. Magendie also made experi- ments on the effects of inhaling the gases emitted by putrefying animal matter. Into the bottom of a cask he introduced putrid substances, and in the upper part he placed an animal, supported on a second grated bottom, so as to expose it freely to the ema- nations from below. In one dog, which died on the tenth day, the intestines were found much inflamed. Although none of these experimenters succeeded in producing the specific lesions of enteric fever, the putrid substances which they employed differed from that which probably produces the poison of this disease, which appears to result chiefly from fgecal fermentation. In 1858 Dr. Barker of Bedford published the results of some interesting experiments, which consisted in making animals inhale cesspool efliuvia.^ The animals were placed in a closed chamber, through which a constant current of cesspool air was kept up. In most of the animals, vomiting and purging were l^roduced, and in one where the experiment was prolonged, the symptoms were not unlike those of enteric fever ; but no men- tion is made of the post-mortem appearances in any ease. Dr. Eichardson, however, states that he succeeded in producing ' patches of ulceration along the alimentary tract ' of a dog, by ^ Magendie, 1823. ° Leuket and Hammond, 1827. ' D'Aecet, 1842. s Bakkek, 1S58. E K 498 ENTEEIC OR PYTHOGENIC FEVER. making it inhale sulphide of ammonium, one of the gases given off by cesspools.'^ On the other hand, some years ago I fed a pig for six weeks on the fresh stools of patients suffering from enteric fever. They were mixed with barley-meal, and given two or three times a day. The animal appeared to suffer no inconvenience, but on the contrary got very fat, and when killed had perfectly healthy intestines.^ But there is no clear proof that any of the lower animals are liable to enteric fever .J The state- ment that the ' cattle-plague ' is pathologically analogous to human enteric fever has been proved to be devoid of foundation ; ^ and the same must be said of the so-called * typhoid or intestinal fever of the pig.' ^ [More recently Dr. Letzerich ^ claims to have communicated enteric fever to rabbits by injecting subcutaneously, and also by giving by the mouth, distilled water containing microbes obtained from the stools of persons suffering from enteric fever. Dr, Tizzoni '^ and Dr. Brautlecht ° have mdependently found that during epidemics of enteric fever the driakuig water contains bacteria, which when injected subcutaneously in rabbits causes death with many of the symptoms and lesions of enteric fever. These observations, however, require further confirmation. The experiment of Bahrdt? gave negative results. Mr. J. B. Sutton See Jennee, 1853, p. 465 ; also Baethez and Eilliet, 1853, ii. 684, 697 ; and H. Kennedy, Lancet, 1863, ii. 725. "i^is '^M SYMPTOMS. 515 ajbdomen, and arms ; more than 200 counted on chest and abdomen alone. Belly tympanitic ; gurgling and tenderness in right iliac fossa ; four stools. Was ordered 4 ounces of wine and acetate of lead (gr. iij.) after each motion. Sept. 19 [i^th day). Pulse 116. Is quieter and a little drowsy ; but intelligence clear, and no delirium. Pupils dilated, and is rather deaf. Sixty fresh spots have appeared on front of chest and abdomen, and they are also very numerous on back, arms, and legs, and even a few on hands, feet, and face. Sept. 21 {i6th day). Pulse 124. Is more prostrate, and has slight tremor of the hands. Intelligence clear ; but had slight delirium in the night. Circumscribed deep-pink flush on both cheeks. Lenticular spots still very numerous. During the last two days, 160 fresh ones have appeared on the chest and abdomen alone, while several of those marked on Sept. 18 are no longer visible. A few of the spots are fully a fifth of an inch in diameter ; they are all elevated and rounded, and disappear completely on pressure. Although mostly isolated, two spots might be seen, here and there, with their edges in contact. The spots were calculated to exceed one thousand ; their appearance on the abdomen is represented in Plate IV. Lips dry and cracked ; tongue red and moist ; six stools. Was ordered 8 ounces of wine, and chalk mixture with catechu. Sept. 23 {iSth day). Pulse 120. More drowsy, and has occasional delirium; pupils rather large. Temp, under tongue io3:|-° Fahr. Ninety fresh spots on chest and abdomen since Sept. 21, and many of those previously marked have disap- peared ; still several on face. Four light, watery stools. Was ordered a mixture every four hours, containing acetate of lead (gr. iij.), and liq, morph. acet. (trtiij.), also a starch and opium enema at night. Sept. 25 {20th day). Pulse 112. Answers when spoken to, but is very drowsy and confused ; pupils rather small. Temp, under tongue io2-^° Fahr. Fifty fresh spots on chest and abdomen. Two stools. More prostrate, and tremors increased. Ordered 8 ounces of brandy. Sept. 26. Twelve fresh spots on chest and abdomen. Tongue red and dry. No stool since yesterday morning. Sept. 28 [zT^rd day). Pulse 114. Is more conscious. Temp, under tongue ioi|° Fahr. Spots much less numerous, and only twelve fresh ones on chest and abdomen in last two days. One stool. Sept. 30 (25^/1 day). Pulse 96. All the symptoms have improved. Temp, under tongue 99^!?° Fahr. Spots less numerous, and only three fresh ones on chest and abdomen. Tongue moist and smooth ; no stool. Yesterday passed 70 fluid-ounces of urine, containing 496 grains of urea, and to-day 43f fluid-ounces, containing 575 grains. Wine was substituted for brandy. Oct. 2. Pulse rose to 108 yesterday, but is to-day 84. Feels and looks much better. No fresh spots, and only six or seven of the old spots remain on front of chest and abdomen. Temp. 99!° Fahr. Oct. 5 {T,oth day). Pulse 80. Temp. 98° Fahr. Tongue clean and moist. One formed stool daily. Only a few traces of spots on back. Convalescent. Oct. 22. Discharged from Hospital, weU. L t 2 5l6 ENTEEIC OK PYTHOGENIC FE"\T:R. 2. Scarlet Rash. In many cases of enteric fever the appear- ance of the lenticular spots is preceded, for two or three days^ by a delicate scarlet rash, all over the body, disappearing on pressure. This is not peculiar to enteric fever, but occurs in other forms of pyrexia. It is best seen in patients with white delicate skins. Jenner mentions an instance, where this rash co-existed with slight sore-throat and the disease was mistaken for scarlatina."^ Several similar cases . have come under my own notice. Occasionally this hyperemia persists throughout the fever ; and in the advanced stages a red or purplish blush of the skin is sometimes observed on the dependent parts of the body. 3. Purpura-sjyots and Vihices I have met with in rare cases,, several of which have recovered. Trousseau records a case in which there were extensive vibices." When petechise occmv they are not developed in the centre of the lenticular spots, but are independent. 4. Taches hleudtres. Spots of a delicate blue tint— the ' taches bleuatres ' of French writers — are occasionally observed on the skin in cases of enteric fever. They are of an irregularly rounded form, and from three to eight lines in diameter. They are not in the least elevated above the skin, nor affected by pressure, even at their first appearance. They have a uniform tint throughout their extent, and they never pass through the successive stages observed in the spots of typhus. Two or three of them are sometimes confluent. They are most com- mon on the abdomen, back, and thighs, and in several in- stances I have seen them distributed along the course of the small subcutaneous veins (see Plate V.). The cases where I have met with these spots have usually been mild ; and Trousseau makes a similar observation.^ They occur in other diseases than enteric fever. 5. Sudamina are alluded to by most writers. Louis observed them in 104 out of 141 adults; and Taupin, in 104 of 121 children. They appear to be less common in England. Pea- cock met with them in only 22 of 52 cases ; and Jenner, in only 7 of 23 fatal cases. I have noted them in about one-third of my cases. Their most common situation is on the front of the chest or abdomen. They usually appear in the third or fourth week of the disease, along with perspiration. From the " Jenner, 1850, xxii. p. 277 ; also Baumler, 1866. " Trousseau, 1861, p. 152.. « See Trousseau, 1861, p. 159 ; Forget, 1841, p. 226 ; Jenner, 1850. xxiii. 313.. SYMPTOMS. 517 frequency with which Louis found sudamina, he was inclined to regard them as a specific character in ' typhoid fever,' p but they are probably equally common in all febrile diseases attended with perspiration. 6. Desquamation of the cuticle, on the cessation of the fever, is chiefly observed in cases where sudamina have been present ; but in many other cases, the skin during convalescence is rough from the separation of the cuticle in minute branny scales. The hair often falls out, and the nails may present markings similar to those which follow an attack of typhus (see p. 136) -and other acute diseases.*! 7. The Temperature. (Cases XLI., XLII., LIII., and Dia- grams XV.-XVIII.) Since the appearance of the first edition ■of this work, I have taken the temperature three times daily in many hundreds of cases of enteric fever. My observations agree in the main with those of Thierfelder, Wunderlich, and other writers. As a rule, from which there are few exceptions, the pyrexia lasts for at least three weeks. It is of a remittent type, or is ■characterized by morning remissions and evening exacerbations, which sometimes are observed throughout the malady, but are always present at the commencement, and are still more marked at the close in cases which recover.'' The rise of temperatm*e at the onset is in a gTadual zig-zag fashion, the temperatures ■ each morning and evening being each day about a degree (Fahr.) higher than those of the day preceding, but there bein always a temporary arrest or remission of about 2° in the morning (Diag. XV.). Each day the temperature begins to rise about noon, and attains its maximum between 7 and 12 P.M. ; and about midnight it begins again to fall, the greatest remission being usually between 6 and 8 a.m. Enteric fever would be excluded fi-om the diagnosis by a temperature ap- proaching to normal on any evening durmg the first week, .and on the other hand by a temperature of 104° on the first day or second morning of illness. The maximum evening temperature is usually reached between the fourth and sixth day, but sometimes not until the eighth day or later, and is usually about 104° or 105°, or it may be even 106°, but the diagnosis of enteric fever must not be excluded, as Wunderlich teaches, if it does not reach 103°. After attaining its maximum, p Louis, 1841, ii. no. « See Lmwet, 1870, i. 3. ' For an attempt to explain these variations in the degree of j^yrexia, see H. Imjiekmann, i86q. 5l8 ENTERIC OR PYTHOGENIC FEVER. there is little change in the daily variations, except that perhaps the maximum may be scarcely so high, as long as deposit is taking place in the intestinal glands, or until about the twelfth day of the disease. At this time, which corresponds to the com- mencement of ulceration or absorption of the enlarged glands,, the course taken by the temperature varies with the severity and duration of the case. In mild cases at this time the morning remission becomes more decided, and the daily ascent begins later. At first there may be little difference in the evening rise, so that this may be 4° or 5° or even 9° (E. E. Thompson) in excess of the morning temperature; but soon the evening exacerbation also diminishes, and by the end of from six to twelve days, the evening temperature may be normal, which is the only certain proof of the fever having ended. During this lengthened de- fervescence the fever may be truly intermittent, the morning temperature being normal with a rise of several degrees towards evening. In eases which run a severe and protracted course the morn- ing remissions become less decided about the twelfth day, and both the morning and the evening temperatures may remain stationary, or become increased, and thus the fever may con- tinue without any considerable remissions until some time during the fourth week, when defervescence takes place as in the milder form, although sometimes after decided but irregular remissions, which may extend into the evening, the temperature again rises owing to some complication or a recrudescence of the fever. In these severe cases the fever at any stage is apt to ■ take an irregular course from the occurrence of complications. Before death the temperature may rise to 108°, or even to 108-95° (Lade) or 110-3° (Wunderlich) ; ^'^^ when death takes place by collapse, the temperature may sink previously to the normal standard or even below it. Cases intermediate between the mild and severe forms are not uncommon. A case of enteric fever must always be regarded as severe when the temperature rises, and the remissions become shorter and less decided, in the latter half of the second week ; when the morning temperature rises to 104°, or is persistently 103°; or when the evening temperature exceeds 105°. Eecovery is rare after a morning temperature of 105°, or a temperature at any time of 107°, but Wunderlich mentions a case where re- covery took place after a temperature of 107*825° had been Ui ! i 1 1 i ' i ' !'!■■ ' i j : M : JN 04 ; I ' ' 1 ' I ■ i • 1 ij U- ^1 Ml :^ 1 ' 1 1 ■ '*iM : ^ ; i j 1 \ ! I 1 ' ' 1 M i ' 1 N i_l ^-t—H^ •; 1 1 ! 1 1 '^ 1 i 1 ' ' ■ ■■ ' -Ft+X '^ Mil i 1 1 ' ' !" 1 ! 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MM 1 i ' Mil 1 ?d co N»i ■ l-i i ' M ■i 1 ■ i ' I 1 j 1 1 -i— 1 1 i i 1 Ua^ ,"M ; j 111 i i M i 1 ! \ Mi 1 ' i ■■ 2 LO ! M I ♦^ M\\ i 1 i 1 1 1 1 . i i < J- -I -i i ! 1 1 1 1 ' 1 I 1 1 ; -Mm ! ! i ! 'ii 1 III a: o < ;. ■a >. ^ ' ; i ; '■ M '! ;co ! M '<>^ M M;= 1 : Mo ! M lc5 '■ Moo 1 1 i li> M M40 M ' ji6 1 ? M ' ;0 : Ml iO i ' M2 1 M !o : M l-:^ : i iCi : ■ , icJi M !m. M McJ) ; ■■i M M ! j : M 1 = 1 M"j i M M . i - M m i j" M ! i ; MJN M ^-Nm m^' !Im 'M\ I:!^ ^'iriiNi^; SYMPTOMS. 519 reached during a rigor in the course of the disease/ A sudden and irregular rise' of temperature, and especially one which re- duces the morning fall more than it raises the evening rise, denotes some local complication ; but profuse diarrhoea, epistaxis, or intestinal haemorrhage will cause the temperature to fall. (Diagram XVI.) A sudden rise of the pulse with a fall of temperature after the fourteenth day points to intestinal haemor- rhage, even though no blood may yet have been passed from the bowel. During convalescence, the temperature is often below the normal standard, especially in the morning, but short though often considerable rises may be induced by slight causes, such as the first indulgence in animal food, the visit of friends, or any emotional excitement. A persistent rise can only result from some complication or a relapse.* [Cases and even epidemics of Enteric Fever have been observed in which the temperature throughout has not risen above the normal point, and has often been sub-normal, though the disease has been of a severe type with well-marked intestinal lesions. This abnormal range of temperature seems to have always been due to the patients havmg previously been exposed to great hardships and insufficient food. An epidemic of this kind occurred among the German troops besieging Paris in 1870. Described by Dr. Struve." Another epi- demic has been described by Dr. Frantzel.^] 8. Moisture. The skin is dry, as well as warm ; but in most cases the dryness alternates with clamminess, or actual perspir- ation ; some years ago I noted considerable perspiration in 1 9 of 84 cases, and since then I have met with several instances in which there have been frequent and profuse perspirations with only temporary abatement of the fever. Perspiration usually occurs during the night, the skin in the daytime being dry. 9. Odour. There is rarely any peculiar odour given off by the skin in enteric fever (see p. 138). An experienced nurse at the Fever Hospital once informed me that she could always distinguish the typhus from the enteric cases, by the peculiar odour given off by the former, which was absent in the latter. ^ According to Trousseau, ' a temperature of 1067° or 107-6° Fahr.' indicates inevitable death. 'Consult Thieefelder, 1855; Wundeklich, 1857 and 1871 ; Lade, 1866; Baumlee, 1866; CoMPTON, 1866 ; E. E. Thompson, 1867; Millee, 1868; T. J. Maclagan, 1869 ; and Trousseau, Clin. Med. Eng. Trans. 1869, vol. iii. p. 338. " Struve, 1 87 1. ^ Frantzel, 1880. 520 ENTEEIC OE PYTHOGENIC FEYEE. c. SymjJtoms referable to the Circulating System. I. The Pulse is accelerated. Out of loo cases, I ascertained 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 no; in 32 cases, it exceeded 120; in 25 cases, it exceeded 130; in 10 cases, it was above 140; and in 2, above 150. But the great peculiarity of the pulse of enteric fever is that its frequency varies greatly on different days and at different hom's of the same day. These variations correspond in great measure, although not entirely, with the variations of tem- IDerature, the pulse rising in the evenmg and falling in the morning. There may be a difference of 10, 20, or even 30 beats between these two periods of the day. The differences are most marked in mild cases, and in the earlier stages of more severe forms of the disease. These variations in the pulse and temperature impart to many cases of enteric fever a distinctly remittent character, and the resemblance to remit- tent fever may be further increased by the remission being attended by perspiration, more or less profuse. With the commencement of convalescence, the pulse falls slowly; there is rarely any sudden reduction. At first, the morning fall may l)e more decided, but it is especially at this time that there is a want of correspondence between the temperature and the pulse. Irrespectively of any complications, and apparently from mere weakness or nervous nritability, the pulse often keeps up, or even increases in frequency, while the tempera- ture is falling, and it often happens that the pulse is quicker in convalescence than it has been during the fever, although sometimes in convalescence it is abnormally slow (44), as in typhus (p. 139). At the same time, it is remarkable how low the pulse sometimes falls, even while the fever continues, as shown by the temperature and the eruption of fresh spots. In 6 out of 100 cases I found it fall to 60 ; in 2 other cases, to 56; and in a 9th case, to 52. In another case it fell to 37, and never throughout the fever exceeded 56, but it rose with convales- cence to 66. Another fact, not so generally known as it ought to be, is that enteric fever may run its entire course with a pulse little, if at all, above the normal standard of frequency (60-80), the temperature, however, reaching 102° or 104°. I have met with not a few such cases, and Griesinger refers to others. SYMPTOMS. 521 As a rule, those cases are most severe in which the pulse is «quickest, and the prognosis is usually bad when, in an adult, the pulse persistently exceeds 120. Of 30 cases where I found the pulse never exceeded no, not one died; whereas, of 70 <5ases where it was above no, 21, or 30 per cent, died; of 32 cases where it was above 120, 15, or 47 per cent, died; of 25 cases where it was above 130, 13, or 52 per cent., died ; and of 10 cases where it was above 140, 6 died. Two of the patients who recovered after the pulse had exceeded 140 were under ten years of age. Still, I have known cases prove fatal where the pulse never reached 100 ; and in 8 of Louis's fatal cases the pulse never exceeded 90.^ During the first week or ten days of the disease, the pulse often exhibits some resistance ; but after this, or sometimes -earlier, it is soft and compressible ; and in the advanced stage it may be small, feeble, undulating, irregular, intermittent, or imperceptible (see p. 139). Louis noted the pulse as irregular or intermittent in 7 out of 41 fatal cases, and in 6 out of 57 severe cases which recovered. 2. Action of the Heart. The impairment, or complete ab- sence of the impulse and first sound of the heart noted in typhus may also occur in severe cases of enteric fever. For further details, the reader is referred to p. 141. d. Morbid Phenomena of the Resjnratory System. I. The respiratory movements in the advanced stages are usually quickened, independently of pulmonary complications. Of 60 cases in which they were counted daily, I found that they exceeded 20 in the minute in 50; 30 in 38; and 40 in 22 ; but in most of the cases where they exceeded 40, and in some others also, the lungs were diseased. The respirations vary with the pulse, but in those cases where the pulse is remarkably slow, there may be no corresponding diminution in the rate of respiration. Thus, in one case the pulse was 64 and the respirations 28; in another, the pulse was 58 ^nd the respirations 26 ; and in a third case, the pulse was 42 and the respirations 48, although no pulmonary lesion could be discovered. Occasionally^ the breathing is irregular, noisy, or 'nervous,' as described under the head of typhus (p. 142). Louis, 1841, ii. 347. 522 ENTEKIC OR PYTHOGENIC FEVEE. 2. The expired air has not yet been sufficiently examined ; but in severe cases, during the typhoid stage, the breath is very offensive, as in typhus. In several cases it has been found to contain ammonia. '^ e. Morbid Phenomena "presented by the Digestive Organs. 1. The Tongue, at iirst, is moist and covered with a thin white fur, while its tip and margin are unusually red. It may remain in this state throughout the attack; or, about the middle or end of the second week, it may become dry and brownish over a triangular space at the tip or along the centre, and afterwards it may be covered with a thick, brownish crust, or it may become clean, red, dry, glazed, and fissured. Cases may prove fatal where the tongue has never been brown. Of 45 in 100 cases, where I noted the tongue as dry and brown, 16 died; but of the remainder, 5 were fatal, in which the tongue had never been dry. The tongue also was moist throughout in 16 of 40 fatal cases recorded by Louis, and in 6 of 20 fatal cases noted by Jenner.y A peculiarity of the tongue is its unusual redness, which may be confined to the tip and edges, or extend over the entire surface. I have noted this redness in 69 out of 100 cases. In 16 of the 69 cases, 5 of which were fatal, the entire tongue was red, and its surface clean, smooth, and glazed. Jenner noted this glazed appearance in 5 out of 20 fatal cases. Occa- sionally, I have seen the tongue of a bright scarlet hue, with enlarged papillae, as in scarlatina. Another character of the tongue is the existence of trans- verse fissures, often deep and painful. They were noted in 35 of my 100 cases, and in 4 of 20 fatal eases observed by Jenner. Louis mentions cases where they proceeded to extensive ulcera- tion, with great thickening of the tongue. Inability to protrude the tongue is much rarer, even in fatal cases, than in typhus. 2. Lips and Teeth. The lips are usually parched, and in severe cases may crack and bleed, a condition which in children is often aggravated by picking. When the typhoid stage is developed, sordes collect on the teeth. In rare cases, hsemor- rhage from the gums occurs. '^ Louis, 1S41, ii. p. 145 ; and Parkes, 187 i, p. 400. y Louis, 1841, i. 474 ; Jenner, 1849 (2). SYMPTOMS. 525 3. The Ajjpetite is usually lost, but in mild cases it may continue throughout the disease. I have noted it as present in II out of 100 cases. 4. Thirst is usually complained of in the early stages. In 39 out of 100 cases, I have noted it as excessive. 5. Dysphagia (see Pharyngitis, under Complications). 6. Nausea and retching are common symptoms, especially at the commencement of the illness, which is in consequence often regarded as a simple ' bilious attack.' In 36 out of 100 cases I have noted vomiting. In 12 out of 63 of the cases, it was one of the earliest symptoms ; * in the others it came on after the first week. In most of the cases, the vomiting was only occasional ; but in 8 it was protracted and distressing. It was usually associated with some pain and tenderness at the epigas- trium. Louis observed vomiting in 36 out of 108 cases, and epigastric pain or tenderness in 59 out of no cases.'"" Vomit- ing, at the commencement of the disease, I am inclined to regard as a favourable symptom, but an opposite opinion has been ex- pressed by Peacock.^ In several cases, where it was very urgent, I have known the disease afterwards run a mild course. But when vomiting comes on after the second week, it is often the first symptom of peritonitis. The vomited matter usually consists of a greenish bilious, fluid. Chomel mentions one case where it contained blood ; ^ and in one instance I have known fsecal vomiting persist for 36 hours before death, which was due to perforation of the bowel. 7. Meteorism is observed in most cases. Out of 100 cases,, I found that the abdomen was unusually resonant or distended at some period of the fever in 79, and in 17 the distension was. great ; but in 21 the abdomen remained flat throughout. Louis noted meteorism in 89 out of 1 34 cases.*^ In one fatal case he observed it as early as the third day ; but as a rule, it does not supervene until after the first week. It is most developed in grave cases. Thus, in 21 fatal cases, I noted it in 20; while Jenner observed it in 18 out of 19 fatal cases. Of 17 cases in which I have noticed extreme tympanites, death occurred in 7 ; while of 62 in which it was moderate or slight, only 14 diedj and of 2 1 where it was absent, none died. Louis noticed greart * In 37 of the 100 cases, it was not noted whether there had been any vomiting before admission. • Louis, 1841, i. 459. " Lancet, 1865, i. 117. ° Chomel, 1834, Case x. ^ Louis, 1841, i. 452. 524 ENTERIC OR PYTHOGENIC FEVER. meteorism in one-half of his fatal cases, but only in 7 of 88 cases which recovered. The distension is of a peculiar form, the convexity being from side to side, in place of from above down- wards, owing to the flatus being chiefly contained in the colon. Unlike the meteorism of typhus (p. 147), that of enteric fever is almost invariably associated with pain and tenderness of the abdomen and diarrhoea. 8. A sensation of gurgling is felt in many cases, when pres- sure is made rather abruptly in the right iliac region. Accord- ing to Chomel, it is much more common in enteric fever than in ■ordinary diarrhoea. Some years ago I noted it in 3 1 out of 44 •cases ; but subsequent experience has satisfied me that it is absent in a larger proportion of cases than is indicated by these figures. 9. Abdominal Pain and Tenderness are common, but not necessary, symptoms. Patients often complain of pain m the abdomen ; and still more h-equently tenderness is elicited, when pressure is made in the right Uiac region. I found tenderness at this part in yi of 81 cases; 16 of the 71 died, but none of the remaining 10 : of 5 patients, who complained of severe pam at the commencement of the disease, 3 died. Louis noted abdominal pain in 106 out of 127 cases; of 39 fatal cases, it was present in all, and in 16 on the first day; whereas of 31 mild cases, it was absent in 10, and in only 4 existed on the first day." Jenner noted abdominal pam in 15 out of 20 fatal Barthez and Eilliet, 1853, ii. 682. <= West, 1848, ed. 1S54, p. 561. '1 Louis, 1841, ii. 87. " Jennek, 1849 (2). ' Baktlett, 1S56, p. 53. s Loois, 1841, ii. 88. ^ Jennek, 1849 (2). ■ Gaikdnee, 1862 (2), 148. SYMPTOMS. 543 already described (see p. 538). In cases, however, where there is great stupor and complete unconsciousness, the pupils are often contracted, and I have then often known them to be as contracted as in any case of typhus (see p. 177). The difference between typhus and enteric fever as regards the size of the pupil is in keeping with the differences in vascularity; a small pupil is associated with hypersemia, and a dilated pupil with anaemia, of the eye. Some patients complain of haziness of vision, increased by sitting up. In very rare cases, strabismus is observed; and in at least 6 eases I have known inequality of the pupils supervene during the attack. I have notes of two such cases in which there was a post-mortem examination ; in both there were the intestinal lesions of enteric fever, and in neither could any tubercle or other lesion within the cranium be found to account for the state of the pupils. 2. Organs of Hearing. Einging and buzzing sounds in the ears are often complained of in the early stage of the disease. Louis noted them in 36 out of 99 cases, and Barth in 85 out of 129 cases.J According to Louis, they are more severe and last longer in the severe cases than in the mild. Deafness of one or both ears is a common symptom. I noted it in 20 out of 46 cases; Louis observed it in 58 of 99 cases; Barth, in 36 of 129 cases; and Jenner, in 6 of 23 fatal cases. It is rarely observed before the end of the second week. As Louis observes, ' La plus extreme surdite n'ajoute rien a la gravite du pronostic' Trousseau draws a distinction between deafness of one, or of both ears ; deafness of one ear he thinks unfavourable, as it is apt to arise from suppuration of the ear, which may excite meningitis ; on the other hand, he asserts that he has scarcely ever known a patient die after having deafness of both ears, which he attributes to catarrh of the Eustachian tubes.^ My experience does not lead me to regard deafness in quite so favourable a light, and probably the remarks made at p. 177 are equally applicable here. 3. Cutaneous Sensibility. Hypersesthesia of the integuments has occurred in about 5 per cent, of the patients under my care.^ It is most common in children and females, and is not a formid- able symptom. It may occur in the first week of the disease or not until convalescence. It is chiefly observed in the abdomen J Louis, 1841, ii. 93. ^ Trousseau, 1861, p. 170. ' See also Fkitz, 1864, p. 27. 544 ENTERIC OR PYTHOGENIC FEVER. and lower extremities, and it always follows an ascending course, . its upper margin being tolerably well defined and the whole body below this being affected. The slightest touch over the affected part makes the patient cry out, and there is also in some cases tenderness over the spines of the cervical or dorsal vertebrse. The abdominal tenderness from this cause must not be confounded with that due to peritonitis. On the other hand, Eilliet and Barthez speak of anaesthesia as an occasional grave symptom in children. 4. Epistaxis is a common symptom, but appears to be more frequent in Paris than elsewhere. Thus, while Louis and Barth found it in 91 of 156 cases,™ Dr. Flint noticed it in only 21 of 73 cases in America ;° Jenner in 5 of 15 fatal cases ; and it occurred in only 13 of 58 cases noted by myself. As to children, Eilliet and Barthez speak of epistaxis as occurring in one-fifth of their 107 cases," and Taupin observed it in only 3 of 121 cases.P The haemorrhage may take place at any period of the fever, and may recur repeatedly. The quantity of blood lost may vary from a few drops to several pounds. All observers agree in stating that the bleeding is never followed by any relief to the symptoms ; while, on the other hand, it may be so profuse as to be the immediate cause of death. Several examples of death from epistaxis have come under my notice. Case L. Enteric Fever. Death on loth day from Epistaxis. Autopsy : Enlargement of Spleen and Mesenteric Glands. Com- mencing Ulceration of Peyer's Patches. M.a,xj F , aged 20, a servant in a gentleman's family, adm. into L. F. Hosp. on JtUy 29, 1857. Was taken ill on 22nd at Eamsgate, where she had been on a visit for three weeks. Her symptoms before admission had been cold shivers, headache, pains m limbs, urgent diarrhoea, and prostration. July 30 {Sth day). Pulse 120. Slept well; is free from pain and intelHgence clear, Sldn hot and dry; circumscribed flush on both cheeks ; one or two lenticular spots ; tongue furred and red at edges ; abdomen tympanitic ; gurgling, but no tenderness, in right iliac fossa ; three watery stools. Was ordered beef-tea and milk, a starch and opium enema, and a mixture containing acetate of lead (gr. iij.) and liq. morph. acet. (ntv.) after each motion. Aug. i {10th day). No worse until 9 p.m., when she began to bleed from nose very profusely. When seen about an hour after, pulse was ■" Louis, 1841, ii. 84. " Flint, 1852. ° Babthez and Eilliet, 1853, ii. 685. p Taupin, 1839. SYMPTOMS. 545 almost imperceptible, skin cold, and features pinched. Four stools, but no blood in any of tliem. Cold was applied to forehead, and lo grains of gallic acid, with 20 minims of sulphuric acid, were ordered every hour. Bleeding, however, continued, and patient died at 11 "40 P.M., before plugging could be resorted to. Autopsy, 31 hours after death. — Cadaveric rigidity well-marked, All internal organs very pale and anaemic ; old adlresions over left lung. Liver 34 ounces, very pale. A little pale, thin bile in gall- bladder. Spleen 9 ounces ; very soft. Mesenteric glands much enlarged, one or two almost as large as walnuts ; surface on section much injected. Stomach and upper part of small intestines contained several ounces of partly coagulated dark blood, but mucous membrane of this portion of digestive canal was healthy. No blood in lower portion of bowel. About a yard above caecum, Peyer's patches began to be diseased. The number and extent of diseased patches increased towards caecum ; many of patches were elevated fully one-eighth of an inch above surface, and contained a cheesy, yellow deposit ; mucous membrane over most of them was intact, but on one or two, close to ileo-colic valve, there was slight ulceration ; membrane between patches was intensely injected. Solitary glands in csecum, ascending colon, and lower part of ileum likewise elevated, and contained a cheesy deposit. i. Emaciation. In cases of enteric fever protracted to three or four weeks there is usually great, and often extreme, emaciation. The difference from typhus in this respect is very remarkable. (See p. 248.) Sect. VII. Stages and Duration. — Eelapses. a. Stages. Although any sub-division of enteric fever into distinct stages must be artificial, it may be well to consider the disease under the following stages: i, the stage of incubation; 2, the stage of invasion; 3, the stage of glandular enlargement; 4, the stage of ulceration or sloughing; 5, the stage of lysis; and 6, convalescence. 1. The stage of Incubation is considered at p. 468. 2. The stage of Invasion lasts for one or more days, and extends from the first feeling of illness until the development of decided febrile symptoms. The invasion is often so gradual, that neither the patient nor his friends can state the precise day on which the illness commenced. This has been the case with more than one-half of the patients under my care. Jenner N N 54^ ENTERIC OR PYTHOGENIC FEVER. could only ascertain the day of commencement in 7 of 1 5 fatal cases.'i Louis and Chomel '' speak of the invasion as being in most cases sudden : but the experience of Forget, as well as of Bartlett and other American writers, confirms that of Jenner and myself. At all events, the contrast which enteric fever presents in this respect to typhus and relapsing fever is remarkable. (See pp. 179 and 344.) Of 63 cases, where I noted the mode of commencement some years ago, pains in the head and limbs, commonly aching, but sometimes neuralgic, were among the earliest symptoms in 56, and most of these patients also suffered from irregular chills, languor and giddiness ; in only 3 cases did the disease com- mence with anything approachmg to rigors, but in several in- stances not included in this analysis I have observed decided rigors, and, in fact, all the phenomena of ague, durmg the first few days. In 1 2 cases there was great nausea and vomiting ; in 5, considerable pain in the abdomen; and in 26, or 41 per cent., diarrhoea. In several of these last cases, the patients had been suffering for a week or two from ordinary autumnal diarrhoea before any symptom of fever appeared. Yery often the patient is at first thought to be suffering merely from an ordinary bilious attack. Boils and abscesses have been sometimes noted among the earliest symptoms. But the one symptom which is never absent from the first is an elevation of temperature. 3. The stage of Glandular Enlargement extends from the com- mencement of fever until about the twelfth or fourteenth day. Some of the intestinal glands probably continue to enlarge after ulceration has commenced in others. Strictly speaking, this stage includes the stage of invasion. It is characterized by a fever of a remittent type (the evening exacerbation reaching its acme about the fourth or sixth day), vertigo, headache, and general pains, disturbed sleep, daily increasing prostration, copious ex- cretion of urea, furred tongue with red edges and tip, diarrhcea, occasional vomiting and epistaxis, and the appearance of the eruption. Sometimes there are no abdominal sj^mptoms, and in rare cases there may be acute delirium, or bronchitis with great pulmonary engorgement, which may terminate fatally. Death, however, rarely occurs during this stage, and very often the patient continues to go about. 4. The stage of Ulceration or Sloughing extends from about the twelfth or fourteenth day to some time between the twenty-first 1 JtNNiiK, 1849 (2). -• Louis, 1841, i. 419; Ciiosiel, 1834. STAGES AND DL'EATION. 547 ■and twenty-eighth day. This stage is characterized by a per- sistence of fever with less decided remissions ; successive crops of eruption ; tongue more or less dry and often red, glazed, and fissured ; distended abdomen ; diarrhoea, often with mem- branous flakes or blood in the stools; retention of urea; de- lirium, and other phenomena of the typhoid state. The dm-ation of this stage is variable. It may be protracted by pulmonary, abdominal, and other complications ; but independently of any such cause it may be carried on to the end of the fourth, or even into the fifth, week, and for a time there may be what Wunderlich has designated the amphibolic stage — a period of uncertainty, or of changing fortunes. After decided remissions or even a con- dition approaching to coUapse, there may be one or more recru- descences of fever lasting for several days. These must be distinguished from true relapses which supervene after a decided intermission of pyrexia and apparent convalescence : at all events, when death occmrs after recrudescences we do not as a rule find evidence of recent disease in the intestinal glands, as in fatal cases of relapse. 5 . Stage of Lysis. The termination of enteric fever, like its commencement, is gradual, and is not marked by any critical evacuation. Kesolution takes place by lysis, and not by crisis. At first the morning remissions become more decided, and then the evening remissions less severe. Simultaneously with these changes, the tongue becomes cleaner and moister ; the cerebral symptoms abate; and fresh lenticular spots cease to apj)ear. When the intestinal lesion does not go on to ulceration, the stage of lysis may commence as early as the end of the second week of the disease ; and then during the third week the pyrexia may be essentially of an intermittent type, the pulse and tem- perature being normal in the morning, but the latter rising two or more degrees towards evening. More commonly lysis does not begin until some time during the fourth week, and then it may last from two or three days to a week, and is liable to be interrupted by complications. 6. Convalescence can only be said to be fah-ly established when the temperature is normal on two successive evenings. It is also liable to be interrupted by relapses, peritonitis, the development of tubercle, and other dangerous sequelae; and irrespectively of such mishaps, "it is always slow in cases which have run the ordinary course of three or four weeks, and where consequently there has been considerable emaciation. Although the temperature keeps low, the pulse may be quicker than N if 2 548 ENTERIC OR PYTHOGENIC FEVER. during the fever, and the patient is slow in regaining his appetite- and strength. In all these respects enteric fever contrasts strongly with typhus. b. Duration. The ordinary duration of enteric fever is from three to four weeks. Of 200 eases which recovered, and in which I was ahle to fix the commencement with tolerable certainty, the duration was : 10 to 14 days in 7 cases ; 15 to 21 days in 49; 22 to 28 days in iii ; and 29 to 35 days in 33, Thus, in all but 7 cases the duration exceeded two weeks ; in nearly three-fourths of the total number it exceeded three weeks ; and in one-sixth it was more than four weeks.^ The mean duration of the 200- cases was 24-3 days ; and the mean duration of 1 12 other cases, which were fatal, was 27-67 days. The mean stay in hospital of 500 cases which recovered was 31*24 days, and of 100 fatal cases, 16*52 days; while the average duration of illness before admission of the 600 cases was 10*78 days. Of Hoffmann's 250 fatal cases I have ascertained the mean duration of 2 1 5 cases to be 28*9 days.* It is obvious that enteric fever, apart from com- plications and the chances of a relapse, is a much more j)rotracted disease than typhus. (See p. 185.) My observations lend no support to the doctrine of critical days, as applied to enteric fever, although I have often noticed that it terminated about the 21st or 28th day. When the fever is protracted beyond the middle of the fourth week, it is in most instances kept up by some complication or by non-cicatrization of the ulcers in the bowel. Under these cii*- cumstances the fever is often marked by extreme prostration and emaciation and a tendency to bed-sores. Sir W. Jenner has ex- pressed the opinion that, except in cases of relapse, fresh spots never appear after the thirtieth day, and that febrile symptoms after that date are always due to some incidental complication. I have met, however, with several instances in which fresh spots appeared daily as late as the thirty-fifth day ; and in one remark- able case, where the general symptoms were mild, fresh spots were noted almost daily from the fourteenth to the sixtieth day " Cases are not included in this calculation, in which there was a relapse, or in which the fever was prolonged by complications, after spots had ceased to appear on skin. In most instances the cessation of fever was determined by the ther- mometer. ' Hoffmann, 1869. In some of the cases the precise duration was not deter- mined, and I have excluded others where death was due to pulmonary phthisis followint^ enteric fever. STAGES AND DUEATION. 549 (Case LI.). Griesinger has also observed that in uncomplicated 'Cases the fever does not invariably terminate at the end of the fourth week.^ On the other hand, enteric fever may terminate in death or in recovery at a comparatively early date. Most of the febrile attacks known in this country as ' simple continued fever,' or 'febricula,' are abortive attacks of enteric fever, terminating between the tenth and twentieth days (Cases LII. and LIII.). In these cases the inflammatory products deposited in the intestinal glands are probably absorbed, and ulceration never takes place. (See Varieties of Enteric Fever.) Again, although death in en- teric fever rarely occurs before the fourteenth day (in 29 of 250 cases, Hoffmann), in rare cases it may occur much earlier. In several instances I have known, it takes place about the twelfth day ; in Cases LV. and XLIV. the patients died on the seventh and on the sixth days. Bretonneau,^ Forget,'' Jenner,"^ Bristowe,^ and Trousseau,'^ each record a case fatal on the fifth day; while Hoffmann,'' and Trousseau each give the details of a case fatal in less than four days. Lastly, cases have been already referred to terminating fatally on the second (Case LIV.), or even on the first day (p. 473). The symptoms in these rapid cases are usually severe headache and acute delirium, with profuse diarrhcea or great engorgement of the lungs. Case LI. Enteric Fever remarkable for Long Duration. William S , aged 20, adm. into L. F. Hosp. Jidy 9, 1858. His illness had commenced on June 27 with diarrhoea, cold shivers, -and pains in limbs. Mly 10 {14th day). Pulse 96. Some quiet delirium in night. Circumscribed flush on cheeks, and about twenty lenticular rose spots on chest and abdomen. Tongue moist and furred ; abdomen tympan- itic and tender ; four light watery stools. Fresh spots were noted almost daily from this date till Aug. 25, and on no day were they entirely absent. Pulse varied from 96 to 132. Tongue, for a few days, was dry and brown ; but after July 26, it was moist, red, and fissured. Bowels were all along relaxed ; scarcely a day passed that patient did not void from two to six light watery stools. On Atig. 9, there was considerable epistaxis. Intelligence was always good, and after July 20 the delirium at night ceased. Pupils were mostly dilated, and from Aug. 9 to 20th, there was con- -siderable deafness. Appetite began to return on Aug. 3, and on « Gkiesingee, 1864, p. 244. " Bretonneau, 1829, p. 70. ^ FOEGET, 184I, p. 119. "^ JeNNER, 1853, p. 260. y Lancet, A-pril 28, i860, p. 422. == Trousseau, 1861, p. 168. '^ HOEEMANN, i860, p. 38. 550 ENTERIC OR PYTHOGENIC FEVER. Aug. 14 patient was very hungry, altliougli pulse was 120; twenty lenticular spots were counted on body, and there were four light - watery stools. The patient ultimately recovered, and was discharged on Sept. 10. The temperature was, unfortunately, not taken. Case LII. Enteric Fever, ahorting on loth day. Charles G , aged 4, adm. into Middlesex Hosp. Oct. 22, 1869. Several other patients from the same house were in the hospital at the same time with enteric fever. C. G. had first complained on the afternoon of the 18th of pain in the head and stomach, thirst, and loss of appetite. On the morning of the 21st he had vomited, and at 4 a.m. of the 22nd diarrhoea set in rather severely — 4 loose motions within a few hours. After admission, tongue moist with white fur and red at tip and edges. Considerable heat of skin, but no spots. He was ordered a draught every two hours containing 15 minims of dilute hydrochloric acid, 2 minims of laudanum and syrup, with milk and beef tea. The diarrhoea was at once checked, and by the 27^/1 [loth day) the fever had entirely ceased and the patient was quite con- valescent. On Nov. 9 he was discharged from the hospital well. The morning and evening temperatures are shown in the following table : — TABLE L. Day of Fever Morning Evening P. T. P. T. 5 6 7 8 9 10 II 12 125 117 117 109 112 104 100 100-5 100-4 99-8 99-2 98-5 98-4 98-5 128 120 112 IIO 104 86 102-7 I02-2 102-6 IOO-8 100-8 98-6 98-6 98- The temperature was taken morning and evening for another week, but continued normal. Case LIII. Enteric Fever, ahorting on i6tli day. confined. Boivels The following case I saw in consultation with Dr. E. D. Harling.. The patient was also seen on two occasions by Sir W. Jenner, who confirmed the diagnosis, Mr. D. W , aged 23, sickened with pyrexia on March 13, 1872. His symptoms during the first week were considerable fever with morning remissions, the highest temperature being reached on the evening of the 4th day (104*5° F.), great prostration, considerable headache and sleeplessness, thirst, loss of appetite, coated tongue with CO 04 ! 1 I 1 ■ t i f i ! ! . 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On the "jtJi day characteristic rose spots appeared, and they continued to come out in successive crops till the 15^/^ day. The bowels were kept open by small doses of castor oil. On the morning of the ibtli day, the patient, who had perspired freely m the night, felt much better, and the pulse, which had never exceeded 86, fell to 56 ; and on the I'jth day the evening temperature became normal. On the i6th day the patient felt quite well and was desirous to get up. The pulse and temperature from the 2nd day of the disease are shown in the following table. (See also Diag. XVII.) TABLE LI. Days 9 A.JI. 2 to 4 P.M. 9 P.M. Days 9 A.M. 2 to 4 P.M. 9 P.M. P. T. P. T. P. T. P. T. P. T. P. T. 2 3 4 5 6 7 8 9 10 II 12 13 14 80 82 84 84 78 78 72 72 70 72 72 72 102 102 104 103 lOI lOI 100 102 100 100 100 98 5 5 9 9 8 6 2 2 5 8 80 80 84 80 72 72 72 78 72 70 72 64 102" 104-5 103-8 103-5 103-8 103-4 103- 103- 103 '5 103-5 102-5 lOI* 84 82 84 86 76 76 76 74 76 74 70 70 68 103- 103- 104-5 104- 102- 102-5 102-8 IOI-5 lOl" loi- 100- 100-6 loo- IS 16 17 18 19 20 21 22 23 24 25 26 56 60 68 52 64 60 64 64 64 72 72 99 97 98 98 97 99 98 97 97 97 98 97 8 I 2 2 5 2 8 2 2 2 66 60 68 72 64 72 101-3 99-6 99-6 lOO'l 97-8 98-2 70 62 66 64 68 99 '4 97 "S 99-8 97*5 Case LIV. Enteric Fever, fatal on 2nd day. In June 1861, a girl, aged 9, was admitted into the Middlesex Hospital. Her father had been sujffering for two or three weeks from enteric fever, but the girl had been quite well the day before admission, when she had been suddenly seized with vomiting and febrile symp- toms, followed by severe purging, intense headache and acute delirium, which symptoms continued until death, 47 hours from the time of her seizure. Autopsy. The solitary glands in the lower two yards of the ileum and in the colon were enlarged to the size of a hemp-seed or split pea, and contained a yellowish-white morbid material. Peyer's patches were similarly affected, but there was no ulceration. The mesenteric glands were as large as hazel-nuts, and congested. A figure of the lower end of the ileum will be found under the head of ' Ajiiatomical Lesions.' (See also p. 473.) Case LV. Enteric Fever, fatal at eiid of seven days. Commenc^ig Ulceration. For the particulars of the following case I am indebted to Mr. J. N. Eadcliffe. Thomas Pt , aged 40, a weaver, died suddenly in 1848 from 552 ENTERIC OR PYTHOGENIC FEVER. long-standing valvular disease of the heart, having suffered for exactly seven days before death from pyrexia, the symptoms of which were slight shivermgs, hot dry skui, great lassitude, headache, tongue coated and very red at the tip and edges ; no diarrhoea. The s}Tnptoms were not sufficiently severe to prevent him worldng up to the day of his death. His wife had, shortly before, recovered from a severe attack of enteric fever. Autopsy. Mitral valve extensively diseased, with much calcareous deposit. In lower third of ileum and first nine inches of colon, Peyerian and sohtary glands were much enlarged and prominent, and there was a distmct ulcer in a patch upon the upper margin of the ileo- colic valve. Mesenteric glands much enlarged. c. Pielapsesy By a relapse of enteric fever is understood a second evolution of the specific febrile process, after convalescence from the first attack is fairly established. Eelapses must not be confounded with the recrudescences, which are common during the stage of ulceration. (See p. 547.) It is possible, however, that a true relapse may occasionally overlap the primary attack without any apyretic interval, and that this may be the explanation of certain cases of enteric fever which are unusually protracted ; but ;post- mortem examinations of such cases are still wanting. During seven years (1862-8), relapses were observed in 80 of 2,591 cases in the London Fever Hospital, or in 3 per cent. ; Griesinger noted them in 6 per cent, of 463 cases at Zurich ; Human in 8 per cent, of 548 cases at Leipzig; and Maclagan, in 13 (10 per cent.) of 128 cases at Dmidee. After a convalescence from the first attack of ten or twelve days, the temperature again rises, and the patient is attacked with rigors or chilliness, followed by the ordinary symptoms of the first attack, viz. headache, pains in the limbs, loss of appetite, furred tongue, nausea, and often retching, diarrhoea, enlargement of the spleen, and a fresh eruption of rose spots. The fever reaches its maximum between the fourth and sixth day. The eruption usuallj^ appears earlier than in the first attack. Of 38 cases I found that it appeared on the thii'd day in 7; on the fourth, in 8 ; on the fifth, in 7 ; on the sixth, in 2 ; on the seventh, in 12; and at a later date, in 2. It is on the presence of the eruption, and on the absence of any local inflammation to accomit '' Eelapses in enteric fever were first described by Scliultzin 1830 (see Ebsteix, 1S69), and since then they have been studied by many observers, and more par- ticularly by A. P. Stewart (1840), Hamernjk (1846), Thierf elder (1855), Michel (1859), Griesinger (1864), Lad6 (1S66), Ebstein (1S69), Wunderlich (i 871), and Maclagan (1871). (See Bibliorjraphy.) STAGES AND DURATION. 553 for the pyrexia, that the diagnosis of a true relapse must be hased. Stewart, Trousseau, Wunderlich, and Maclagan have recorded rare instances in which there was a second relapse, or a third -attack ; two also have occurred in my own practice. (See Diag. XVIII.) The duration of the second attack is usually, but not neces- sarily, shorter than that of the first. Of 24 cases collected from various somxes by Michel, the mean duration of the first attack was 27 days ; of the intermission, 1 1 days (shortest 2 and longest 31 days ; and of the relapse, 16 days, longest 30). In 53 cases which have come under my own observation, the duration has been as follows : — TABLE LII. Shoioing duration in days of sz cases of Enteric Fever followed hy a Belapse. * Denotes fatal cases. Males Females Age First Attack Inter- mission Relapse Total Dura- tion Age First Attack Inter- mission Relapse Total Dura- tion 35 18 27 15 21 13 5 18 18 24* 27 II 24 25 32 14 14 24 18 16 24 16 16 40* 15 15 44 25 25 12 16 28 24 24 24 24 22 26 24 32 28 21 23 24 30 32 21 28 26 24 21 24 30 28 28 25 34 37 30 39 3 6 10 9 7 10 14 9 12 10 7 14 9 12 9 9 14 10 14 18 8 8 12 14 15 19 15 10 10 II 18 10 10 II 14 12 10 13 13 7 14 14 18 14 12 10 16 14 13 12 26 24 14 15 14 14 10 14 21 13 37 44 44 44 45 46 46 48 49 49 49 49 50 50 51 51 51 52 53 54 55 56 56 57 57 5& 59 61 61 63 9 5* 18 9 30 39 25 12 22 21 15 IS 19 17 16 19 20 16* 16 43* 27 Average 14 21 22 24 16 25 26 24 21 14 26 26 24 28 30 38 30 36 46 27 41 10 10 7 8 10 8 10 12 15 9 14 10 14 9 12 12 16 16 12 8 25 12 9 12 12 20 14 12 14 14 28 II 16 16 19 18 14 18 13 13 39 21 36 40 41 44 46 47 48 50 50 51 51 52 54 56 60 64 64 65 71 74 87 27- 1176 16-4 54-8 Average \ of Males and Females j 26-58 11-27 15- 52-86 M. 23* F. 22* ? ? ? 14 28 ? 80? Average 26-5 10-9 14 51-5 554 ENTERIC OR PYTHOGENIC FEVER» [Dr. Goltdammer '^ reports a case in wliich a severe attack, followed by relapse, recurred lo weeks after recovery from a primary attack. Tliis may, however, possibly have been an instance of an independent second attack and not a relapse.] As a rule the relapse is milder than the primary attack, and the patient recovers, but there are many exceptions. In several instances I have known the first attack mild and abortive, but the relapse severe and protracted, and in one-thii-d of my cases the symptoms were more severe in the relapse than in the first attack. Moreover, of my 5 3 cases 7 were fatal ; in 2 of the eases death was due to perforation ; in 2 to peritonitis, induced by in- farctions in the spleen, and in i to abortion. Of 21 cases observed by Maclagan ( 1 3) and Baumler (8)*^ all recovered ; but of Ebstein's 13 cases, 3 died. Post-mortem examination of fatal cases discloses the recent intestinal disease of the relapse, coexisting with the cicatrizing ulcers of the first attack; but, as those glands only become inflamed wdiich have formerly escaped, the lesions of the relapse are usually less extensive than those of the first attack, and for the same reason they are often farther distant from the ileo- colic valve or in the colon. Fresh enlargement of the mesenteric glands and of the spleen is also found. Trousseau denied that any fresh disease of the bow^el occurs in these cases, and regarding, the intestinal lesion as the specific eruption of the fever, he maintained that these were not true relapses.^ But in this opinion Trousseau stood alone. The observations of Stewart, Hamernjk, Griesinger, Thierfelder, WunderHch, Peacock,^ H. Weber,^" Habershon,^ Ebstein, &c., agree with my own as above detailed. It is difficult to give a satisfactory explanation of these relapses. In my experience they have been more common in males than in females, the proportion having been as 3 to 2, but Griesinger found them more common in females. Age has no influence in their production ; the youngest of my patients was 5 years, and the oldest 44. Barthez and Pdlliet noted relapses in 3 of 1 1 1 children.^ They are often attributed to errors in diet, but I have never been able to trace them to such a cause, and it is a priori improbable that any error in diet should bring back the intestinal disease and the cutaneous eruption. They vary in frequency at « GOLTDAMMEB, l?>^^ . " BaUJELEE, i866. "= Tkousseau, 1861, p. 158. ' Quoique I'appareil symjDtomatique soit trfes com- plet, quoiquer^ruption cutauee se reprocluise, la l&ioii caracteristique cle rintestin ne se renouvelle pas.' ' Trans. Patli. Soc. ix. 209. ^ lb. xii. 96. '' Med. Times and Gas. February 9, 1867. ' Bakihez and IIilliet, 1853, ii. 691. STAGES AND DURATION. 555 different times and in different epidemics ; and, although they are comi^aratively rare, I have known them occur in three members of one family. Griesinger has suggested that they may possibly be due to a fresh contagium from other patients with enteric fever in the same ward, but this view is negatived by the circum- stance that relapses occur in solitary cases treated in private dwellings ; whUe the fact of their also occurring in patients removed for treatment to hospitals prevents our ascribing them to a fresh poisoning from the original source. More than a quarter of a century ago Hamernjk maintained that the relapses were to be accounted for by a re-absorption of the 'typhous material ' thrown off by the patient's own bowel, and this view has been recently very ably advocated by Dr. T. J. Maclagan, who believes that healthy glands become inoculated by the sloughs thrown off from those first affected. Keeping in mind the cause why the glands seem to become inflamed in the first attack, there is much in this view to commend it ; but, if this be the correct interpretation of relapses, it furnishes another argument against the specificity of the poison of enteric fever, for in that case the fact of an individual having passed through an attack of the disease even immediately before does not protect him from a fresh infection. (See p. 470.) Moreover, it is to be observed, that it is only the dead and putrid material thrown off from the intestinal glands which can be hurtful, for no bad result ensues in abortive cases, when the inflammatory products in these glands are absorbed without sloughing, while in every case of enteric fever the inflammatory products in the mesenteric glands, which are identical with those in the intestinal, are absorbed without any appreciable harm to the patient. In accordance with his view, Maclagan further maintains that relapses are only met with when there has been constipation during convalescence. Unfortunately, the condition of the bowels in the first convales- cence was not noted in most of my cases, but in several thep was certainly diarrhoea, and it does not appear that relapses have been prevented by counteracting the constipation with aperients. It is remarkable that at the London Fever Hospital, where constipation was rarely (perhaps too rarely) meddled with, they were, as already shown, much rarer than in the experience ,of Maclagan, in several of whose relapsing cases also, castor oil was administered dm-ing the interval between the paroxysms.^ J It may be added that in two of my fatal cases the fresh lesions were higher ui) in the ileum than those of the first attack, although a contrary arrangement might be inferred from a jjerusal of Maclagan's essay. My experience is also 556 ENTERIC OR PYTHOGENIC FEVER. [According to Dr. Irvine,^ relapses are mucli more frequent tlian is usually supposed, and are liable to be overlooked if the temperature be not taken. He considers that they are frequently intercurrent, i.e. that they occur without any apyretic interval, and are often repeated, and a second, third, or even a fourth recurrence often takes place. Where the interval between the primary attack and the rela^ase is very great, he believes that intermediate relapses have occurred, but have been overlooked. According to him the fever of relapse usually reaches its height on the 5 th evening, and a critical fall of temperature takes place on the 8th or gth. day, though in a primary relapse the whole attack lasts 2 1 days. According to Liebermeister,i Immerman,*^ and many other ob- servers, relapses are more frequent when the cold bathing treatment is employed.] Sect. VIII. Complications and Sequelae. Many of the complications and sequelge of enteric fever are the same as those already described under the head of typhus ; others are peculiar to enteric fever. The latter only require a detailed consideration. a. Diseases of the Respiratory Organs. (Seep. 190.) I . Bronchitis is not uncommon, although rarer than in typhus. Some years ago I noted it in 21 out of 100 cases. It may be one of the earliest phenomena of the disease, and in a large pro- portion of the cases which terminate fatally within the first ten err fourteen days death is due to bronchitis and hypostatic en- gorgement of the lungs. (Case LVI.) More commonly both these conditions supervene in the fourth week, and then also they may lead to a fatal result, or may keep up the fever and retard convalescence for many weeks. The bronchitis is sometimes aggravated by spasmodic attacks of cough and dyspnoea in which death may appear imminent, but from which the patient often recovers. Case LVI. Enteric Fever fatal on iT,th day from Congestion of Lungs. Marian B , aged 28, was a ' sister ' in the Middlesex Hosp. She had been very prone to acute specific diseases. When 21, she had typhus; when 25, though vaccinated, she had contracted small-pox, opposed to that of Maclagan, who states that in none of his 13 cases was there severe diarrhoea during the first attack ; for this occurred in fully one-third of '^y 53 cases. It may be also worth mentioning that relapses occurred in 2 out of 9 of my patients who had been treated with carbolic acid. '' IllVlNE, 1882. ' LlEBEKMEIBXliE, 1875. '" IjIMEEJUN, 1878. COMPLICATIONS AND SEQUELAE. 55/ and in the following year she had a severe attack of scarlet fever. On Sept. 17, 1870, her fatal illness commenced with chillmess and thirst, and on Sept. 19 she took to bed, complaining of very severe head- ache, frequent and violent retching, and high fever. There was intense thirst, but no tenderness or distension of abdomen, and the bowels were constipated. On Sept. 23 {'jth day), when I first saw her, the same symptoms persisted. Pain in head intense, and described as ' bursting,' with occasional flashes of light before eyes ; no sleep for several nights ; mind clear ; frequent vomiting ; tongue thickly coated and white; bowels confined; pulse 120; temp. 103-4°; no eruption. On evening of Sept. 25 (9^/t day), patient became much worse ; pulse 120 ; temp. 103-4°; respirations 44 ; signs of hypostatic engorge- ment of both lungs ; wild, anxious look, with delirium, subsultus, and tremors. On lotli day, pulse 112; resp. 60, and irregular; temp. 104-8° ; tongue dry ; bowels confined ; no albumen in urine ; headache and vomiting less urgent, but occasional delirium ; a few petechial spots, but none characteristic of any form of fever. On nth day, carphology; pulse 135; resp. 65; temp, 104-8°. On i2tli day, for first time, slight diarrhoea ; three ochrey stools. On 13^/2, day, face and lips livid ; moist rales all over lungs, but no power to cough ; albumen {-^ in volume) in urine ; temp. 103-2° ; tongue dry ; no diarrhoea ; very heavy and prostrate, but apparently conscious. Died at 7.30 P.M. The treatment consisted in brandy, ether, and ammonia, with sinapisms to chest ; then in small doses of turpentine with dry cupping ; and, last of all, 8 oz. of blood were taken from the chest by cupping, with apparently temporary relief to the breathing. Autopsy. Intestme only examined. Characteristic lesions of enteric fever in lower three feet of ileum ; the agminated and solitary glands much enlarged and elevated, but no ulceration. 2. Pneumonia is more common than in typhus. I noted it in 13 out of 100 cases, and Flint in 12 of 73 cases." (Case XLV.) It may be lobar or lobular ; more commonly it is lobular, and then it may terminate in small abscesses, or very rarely in gangrene. Pneumonia rarely supervenes before the third or fourth week ; in rare cases it occurs early in the attack, and may be mistaken for the primary disease. 3. Pleurisy is also more common than in typhus, and occa- sionally it terminates in empyema, or in an interlobar pleural abscess. I have notes of two cases of empyema ; in one, the pus burst into the lung and the patient recovered; in the other, paracentesis and the drainage tube were resorted to, and the patient at first did well, but died nearly a year afterwards of phthisis. Peacock records the case of a patient who, when convalescent from enteric fever, suddenly expectorated a large " Babtlett, 1856, p. 47. 558 ENTERIC OR PYTHOGENIC FEVER. quantity of pus which was supposed to come from a circumscribed pleural abscess, and eventuahy recovered." 4. Tubercular Deposit in the lungs and elsewhere is a more •common sequel of enteric fever than of typhus, as might have been expected from its longer duration and the greater emaciation which it entails. Louis records four fatal cases of enteric fever, in which the lungs were found studded with recent tubercles ; and Bartlett observes that consumption is a common sequel of enteric fever in America.^' Tubercle ought always to be feared when hectic fever and bronchitis persist after the end of the fourth week. (See pp. 192 and 452.) 5. Laryngitis is occasionally a very serious complication of enteric fever. It may assume different forms. Ulceration of the mucous membrane of the larynx or trachea constitutes the laryn- gitis or ijericliondritis typliosa of Eokitansky and other German pathologists. According to Trousseau "^ it is most apt to occur in cases where there is unusual prostration, where the disease has been very protracted, and where the diet has been too rigorous. In Germany it appears to be very common ; Grie- singer, for example, found ulceration of the larynx in 3 1 out of 118 autopsies.'' In this country it is comaparatively rare, but I have sometimes found it in the dead body when there had been no symptoms referable to the larynx during life. But, when present, it is always liable to excite acute cedema of the glottis, necessitating tracheotomy, or causing death by asphyxia, or to induce necrosis and exfoliation of the cartilages, abscesses in the neck, and permanent disease of the larynx.^ Acute csdema of the glottis may supervene in the advanced stages of enteric fever independently of ulceration of the larynx. I have also known it to occur in conjunction with erysipelas of the head and face, and two cases of this sort are recorded by Jenner. Several ex- amples of enteric fever complicated with diphtheria have come under my notice ; Louis records three, and Forget two cases ; while Eilliet and Barthez mention six cases in children. In connection with these different forms of laryngitis, collections of matter sometimes form in the submucous tissue. " Med. Times and Gaz. April 26, 1862. v Bartlett, 1856, p. 120. 1 Trousseau, 1861. ■■ Griesingek, 1864, p. 211. ■* For further information on this subject, see Trousseau, 1861, and Pachmayr, Verhandl. dor Ploys. Med. Gcscllschafi in Wilrzburg, 1868, Bd. i. COMPLICATIONS AND SEQUELAE. 559 Case LVII. Enteric Fever. Necrosis of Cartilages of Larpix. Extravasation in Becti Mtiscles. Eichard C , aged 22, adm. into L. F. H. March 26, 1869, in third week of a severe attack of enteric fever. Pulse 120-140 ; typical rose spots ; tongue dry, red, and cracked ; diarrlioea. On Ajjril 7 (about 30^/i day), difficulty in swallowing. April 9. Troublesome cough. A23ril 10. Cough and breathing distinctly laryngeal, voice husky, and air entered lungs imperfectly from some obstruction in windpipe. Pulse 140. ^jjnZ ir. Breathing no better, and makes a loud hissing noise. No lividity of face. Swallowing dinner (liquids) fairly at i p.m., and conversed with friends, but died suddenly at 5 P-M. Autopsy. Extensive typhoid ulcers in lower end of ileum, cica- trizing. Below right vocal cord was a sloughy ulcer, half an inch long, opening into an abscess around cricoid cartilage, which was quite bare. In lower part of each rectus abdominis muscle was a cavity as large as a hen's egg, one contaming pure blood, and the other a reddish purulent-looking matter, evidently altered blood. 6. General Emphysema and Pneumothorax. Chomel and other writers alluded to several instances in which extensive emphy- sema of the subcutaneous areolar tissue was observed during life,* and this complication was likewise observed by the army- surgeons in the Crimea ; but its origin was first satisfactorily explained in 1857, in a communication made to the Pathological Society by Dr. Wilks. A boy, aged 12, became emphysematous on the twelfth day of an attack of enteric fever, the emphysema commencing in the neck, spreading to the face, arms, and chest, and greatly impeding deglutition. Death occurred on the twenty- second day, when it was found that the air had escaped through a sloughing ulcer of the larynx, situated at the posterior junction of the vocal cords." Sometimes, as in typhus, emphysema is caused by the ulceration of a small bronchial abscess or gangre- nous cavity in the lung. Gairdner has known pneumothorax induced in this way in at least 4 instances of enteric fever ;^ and one case where this happened has been recorded by Beck."^ [A case was reported by me to the Clinical Society, and will be found in vol. xvi. of the Transactions.] Chomel, 1834. " Trans. Path. Soc. ix. 34. ■' W. T. Gairdner, 1865. ^ Verliandl. cler Phys. Med. G-esellsch. in Wurzburg, 1868, p. 2 560 ENTEEIC OE PYTHOGENIC FE^^E. h. Diseases of the Organs of Circulation. (See p. 193.) 1. Hemorrhages. Epistaxis and intestinal hsemorrhage are- not uncommon (see pp. 526, 544), but sometimes bleeding takes- place from the gums, kidneys, bladder, and other mucous surfaces, constitutmg what has been called ' hsemorrhagic putrid fever.' 2. Pycemia. I have met with many instances in which during convalescence abscesses have formed beneath the skin in different parts of the body, and similar cases have been pubhshed by Louis,^ Forget,y and Peacock.^ Many such cases recover. In rarer instances pus is deposited in the joints or in some of the internal organs, and then the case usually terminates fatally^ (See p. 1 94-) 3. Venous Thrombosis hsis, been fully described under the head of Typhus. (See p. 195.) It is a more common sequel of en- teric fever, although a contrary opinion has been expressed by Stewart^ and Begbie.^ Obstruction of the femoral vein has occurred in fully one per cent, of the cases under my care. Of 17 cases it was restricted to the left leg in 14, to the right m i, and both limbs were implicated in 2. Three of the 17 patients died ; in one death was due to intestinal hsemorrhage and effusion in the pleura ; in a second case it was caused by bed-sores and sloughing of the nates ; while the thhd patient had also jaundice, albuminmia, and a very feeble heart, and died six months after the commencement of the fever. Maclagan noted swelling of one leg once in over 200 cases. ^ 4. A rterial Throm hosis. Spontaneous gangrene is less common than in typhus. (See p. 1 99.) In rare instances, however, I have- met with gangrene of the feet, of the ears, of the penis, of the labia and vagina, of the corneEe, and even of the anterior wall of the abdomen. Many other instances of the same sort will be found in- the memoir of Patry,"^ in Trousseau's Clinical Lectures, and in the references given below.*" Patry records one remarkable case in which sphacelus, commencing in the left ear, but extending to the forehead, eyelids, and cheek, resulted from obstruction of the external carotid artery. 5. Diseases of the Heart. The valves of the heart rarely be- come diseased in enteric fever, but degeneration of the muscular ^ Locis, 1841, Case 15. > Forget, 1S41, Cases 45 and 46. ' Med. Times aiid Gaz. April 26, 1S62. » Stewart, 1857. " Begbie, 1872. ' Ibid. "^ Patry, 1863. <■■ Gaz. Hebdomad. 1867, p. 651 ; Med. Times and Gaz. iS67,ii. 521 ; VerhaiulL der Phys. Med. Gesellsclmft in Wilrzburg, 1S6S, i. iS. COMPLICATIONS AND SEQUELS. 56 1 walls occasionally leads to the same results as in typhus. (See p. 200, and Anatomical Lesions.) [Pericarditis is occasionally met with ; it is usually latent, and can only be detected by the physical signs. It has recently been made the subject of a thesis by Dr. Petitfour.*] c. Diseases of the Nervous System. (See p. 203.) I. Meningitis. As in typhus, the cerebral symptoms of enteric fever are independent of inflammation, but true meningitis does occasionally result from pyaemia, disease of the internal ear (Case LIX.), or tubercle, and in very rare instances it occurs independently of such causes. Eeferences to several cases are given by Griesinger,^ and Trousseau has recorded an interesting; case of enteric fever complicated with tubercular meningitis.^ Case LVIII. Enteric Fever, coviplicatecl by acute Meningitis. William P , aged 25, a porter, was admitted into the London Fever Hospital Oct. 10, 1879. He was stated to have been ill for a fortnight. The attack began with headache and vomiting, afterwards he had pain in the belly, and diarrhoea, and for more than a week he had been delirious. Before his admission he had passed blood in his motions. Patient on admission was in a state of furious maniacal delirium ; pulse 146 ; temp. 103-4° ; tongue dry, brown, and coated ; sordes on teeth ; belly distended ; spleen enlarged ; many rose spots on trunk. Patient was bathed and an ice bag applied to his head, but without relieving his symptoms. He ultimately passed into a state of stupor, and died 30 hours after admission. There were no convulsions, nor was any paralysis observed. On post-mortem examination numerous ulcers were found in the lower part of the ileum occupying Peyer's patches ; some had brown sloughs still adhering to them ; there were also ulcers in the large intestine. There was great hyperaemia of the pia mater, and' both the upper and under surface of the cerebrum were partly covered with a soft recent lymph. No tubercles were present. On the left side were signs of recent pleurisy. Case LIX. Enteric Fever followed by Disease of the Temporal Bone and attacks of Meningitis. Amiie W , aged 16, adm. into Middlesex Hosp. Jan. 14, 1867, on fourth day of an attack of enteric fever. During the attack there were characteristic rose spots and considerable diarrhoea, the tongue was dry, red, and smooth, and the range of temperature was that of \ Petitfouh, 1878. e Gbiesingee, 1864, p. 224. >> Union MM. 6 Aout, 1859, O 562 ENTERIC OR PYTHOGENIC FEVER. enteric fever. In tlie early stage the lieadaclae was unusually severe, and subsequently there was much dehrium and stupor, with tremors and subsultus, congestion of the lungs, and albuminuria. Conva- lescence commenced on the 2Sth day, the temperature throughout that day being normal. During convalescence the mind remained feeble. On the 2,4th day there was a return of pyrexia, which lasted only for a day, but was followed by pain and deafness of the left ear, these symptoms ceasing on the appearance of a purulent discharge from the ear on the ^gth day. On the 4Sth day she was able to get up, and on the T^th day [March 28) she went to the Convalescent Hospital, the discharge from the ear persisting. As soon as she arrived at Walton, she began to complain of pain m the left side of the head, which on Ai^ril 7 became very severe, and was accompanied by pyrexia, acuteness of hearing, and vomiting. On April 11 she was re-admitted mto Middlesex Hospital with these symptoms, which sub- sided on April 13 on a copious discharge of fetid pus from the ear. On April 24 she had a rigor, followed by a return of the headache and vomiting, although the discharge from the ear continued profuse, and on May i considerable swelling was noticed over the left mastoid process. An incision made over this came down upon bare bone. On June II she again left the hospital, the discharge from the left ear persisting, and the wound behind the ear unhealed and communicatmg "with bare bone. A fortnight afterwards the cerebral symptoms returned, and several small pieces of bone came away from the sinus behind the ear. She was again in the hospital from July 10 to 30^/2-, and during the follomng autumn and winter she had repeated attacks of headache and vomiting. On March 7, 1868, she was admitted a fourth time into the hospital with the same symptoms as before, accompanied by t's^dtchings of the extremities and unconsciousness. She left the hospital on March 29, and for nearly a year conthiued well, but in Feb. 1869 she had another attack of headache and vomiting. She was last seen on June i, 1869, in good health, and with no dis- charge from the ear, but completely deaf on the left side. The attacks were usually preceded by a cessation of the discharge from the ear, and the cerebral symptoms subsided when this was re-estabhshed. The treatment which always relieved the attacks consisted m leeches, blisters, and setons behind the ear, poultices over the ear, and mjecting it frequently with warm water, together with purgatives and iodide of potassium. 2. Mental Imbecility and Mania. After severe and protracted cases, more or less fatuity is occasionally observed during con- valescence. The patient exhibits a childishness of manner and want of memory, and is the subject of delusions. One little girl under my care believed the nurse to be her aunt, and some of the other patients her sisters ; another thought that he had inherited a fortune, with which he intended to enrich the hos- COMPLICATIONS AND SEQUELJE. 563 pital; while a third became very excited every evening, and wished to be removed to an asylum. Bartlett quotes the case of a young man, who had previously borne a good character, but who, after recovery from a grave attack of enteric fever, exhibited a strong propensity to steal.^ In several instances I have known a patient, after convalescence was fairly established, suddenly attacked with violent maniacal delirium without any elevation of temperature. Similar cases have been observed by Griesinger,J H. Weber,^ Handiield Jones,^ Ogle,™ &c. These symptoms de- pend, not upon inflammation, but upon an ansemic or atrophied state of the brain. Mania as a rule soon subsides under appro- priate treatment, but the other forms of mental derangement may last for months, although I know of no case where they have been permanent. (See p. 204.) 3. General Convulsions. (See p. 541.) 4. Paralysis is an occasional sequel of enteric fever. It may not supervene till many weeks after the commencement of con- valescence, and it is usually temporary, recovery taking place within a few weeks or months. According to Nothnagel," who has made it the subject of a special memoir, the most common form is paraplegia, but it may also take the form of hemiplegia, strabismus, paralysis of the portio dura, motor paralysis of individual spinal nerves such as the ulnar or peroneal, or local anaesthesia. West mentions the case of a child who had convul- sions followed by hemiplegia, and recovered." Several cases of temporary aphasia after enteric fever in children have been recorded by Weisse and Friedrich,P and a case of temporary paraplegia has been observed by Mr. B. Bell.i Now and then these attacks of paralysis, particularly in the legs, terminate in atrophy of certain of the muscles, and I have met with several instances where permanent distortion has resulted.^ One of my patients, a girl, aged 18, had all the signs of paralysis of the right third nerve in a marked degree throughout an attack of enteric fever ; this had first occurred fourteen years before, after an attack of measles, but for many years had almost disappeared until the seizure with enteric fever, on convalescence from which only slight ptosis remained. The cause of the post-febrile ' Bartlett, 1856, p. 51. J Mental Path, and Therap. Syd. Soc. Transl. p. 181. ^ Med. Chir. Trails, xlviii. 148. ' Brit. Med. Journ. 1867, i. 27. " Ibid. i. 385. " NOTHNAGEL, 1872. " WeST, 1848, 5th ed. 1S65, p. 744. p Gaz. Hebdom. 1865, 140, 591. « Edin. Med. Journ. May 1870. "■ See also H. Jones, Med. Times and Gaz. 1866, i. 390. o o 2 564 ENTERIC OR PYTHOGENIC FEVER. paralysis is obscure, but is believed by Nothnagel to be similar to that of diphtheritic paralysis, which, according to Oertel and Buhl, is due to cell-proliferation in the sheaths of the nerves and between the fasciculi. (See p. 205.) [Besides these after paralyses sudden hemiplegia, probably due to embolism, sometimes occurs during enteric fever. A ease of right hemiplegia and aphasia was reported by me in the ' Medical Times and Gazette,' March 23, 1878. The consecutive paralyses have recently been made the subject of a thesis by Dr. Paulin.^] 5. Neuralgia and Hyperczsthesia in different parts of the body are much rarer sequels of enteric than of relapsing fever, but cases in which they have been observed have been recorded by Nothnagel * and other writers. 6. Muscular Tremors and Chorea are also, according to Noth- nagel, occasional sequels of enteric fever. d. Diseases of the Organs of Special Sense. (See p. 207.) 1. Otorrhoea is not an uncommon complication or sequela, particularly in children." I have seen many examples. Suppu- ration of the internal ear occasionally terminates in menmgitis ; examples are recorded by Louis ^ and Peacock.'" (See also Case LIX.) 2. Deafness, independently of otorrhcea, is an occasional sequel. (See p. 543.) 3. Amaurosis, usually incomplete, occasionally occurs during convalescence. Examples of amaurosis and amblyopia are re- ferred to by Nothnagel,^ and Gillespie mentions a case in which there was total blindness for six weeks. ^ 4. Sloughing of Cornecs. (See p. 560.) e. Diseases of Organs of Digestion. (See p. 207.) I. Pharyngitis. Dysphagia may result from dryness of the throat, in severe cases from muscular paralysis, and sometimes in children it is a purely nervous affection, attempts to swallow inducing a spasmodic cough resulting in the rejection of fluids by the nose.^ But sometimes it is due to an inflammatory affec- Paulin, 1879. ' Nothnagel, 1872. " Eilliet and Baethez, 1S53. Louis, 1841, ii. 92. " Peacock, 1856 (No. i). "^ Nothnagel, 1872. y Gillespie, 1870. ' Taupin, 1839. COMPLICATIONS AND SEQUELiE. 565 tion of the pharynx, which in several of my cases has been diph- theritic. Louis noted dysphagia in lo out of 46 fatal cases, and in 1 3 of 5 5 cases which recovered. In the latter, the fauces were much injected ; in the former, recent disease, such as ulceration or diphtheritic exudation, was found in the pharynx or oesophagus after death. 2. Vomiting. Constant vomiting of food occasionally occurs during convalescence. Trousseau says that this is often nervous, and is best treated by giving solid food.^ 3. Diarrhoea. The intestinal ulcers, instead of cicatrising, sometimes become ' atonic,' and may give rise to exhausting diarrhoea after the fever has ceased. 4. Dysentery. In several instances I have known the symp- toms and lesions of dysentery to coexist with those of enteric fever. The diagnosis in some of these cases during life was extremely difficult. Similar observations have been made by Forget,*' Lyons,° and Gairdner.*^ 5. Jaundice. I have met with jaundice in three cases of enteric fever, all of which were fatal, although in two the jaundice had disap2)eared before death. In two of the cases there was an autopsy, and m both the liver was small, and its secreting cells loaded with oil. Two cases are recorded by Louis,^ two by Frerichs,^ and one by Jenner,^ which occm-red on the West Coast of Africa. All of these cases were fatal, but Dr. Eobert Barnes has given me the particulars of a case which terminated favour- ably. In most cases the jaundice does not appear until late in the disease ; but in one case reported by Frerichs it appeared as early as the fifth day, and death occurred on the 8th day, before ulceration had commenced in the intestines. Of 600 patients with enteric fever, Griesinger observed jaundice in 10, of whom several recovered.^ The pathology of the jaundice varies in different cases, as in typhus (p. 210). 6. Peritonitis is the complication of enteric fever most to be dreaded. It may result from various causes. a. The most common cause is perforation of the bowel, to be presently considered. b. Inflammation may be propagated by continuity from the mucous to the peritoneal coat of the bowel, without any perfo- ration. I have notes of four cases in which no other cause could ^ Trousseau, 1861. *• Forget, 1841, p. 351. " Lyons, 1861, p. 252. '' Ed. Med. Journ. August 1862. « Louis, 1841, Obs. 17 and 26. ' Dis. of Liver, Syd. Soc. Transl. i. 172, 215. S JeNNEE, 1853, p. 312. ^ OlilESINGEB, I864, p. 2O3. 566 ENTEEIC OR PYTHOGBNIC FEVER. be found for the peritonitis which was the cause of death. The patients were aged 13, 21, 36, and 50, and death occurred on the 56th, 22nd, 1 6th, and 35th day of the fever. (Case LX.) In this way peritonitis has been known to occur before ulcera- tion has commenced, and even during the first week of the disease. c. Peritonitis may be excited by softened infarctions in the spleen. This happened in two patients under my care ; both were men, one aged 23, and the other 40, and both died during a relapse of the fever. Two similar cases have been recorded by W. Kobertson,^ one by Jenner,J and two by C. E. Hoffmann.'^ d. A fourth cause of peritonitis is the bursting into the peri- toneum of a softened mesenteric gland. Jenner records a case of this sort, in which recovery from the peritonitis took place under large doses of opium, the patient dying subsequently of erysipelas of the face.^ e. An abscess in the wall of the urinary bladder,"* or in the ovary,** or the bursting inwards of a pseudo-abscess in the sheath of the rectus-muscle," has been known to be the cause of fatal peritonitis in enteric fever. /. Lastly, fatal peritonitis may result from ulceration of the gall-bladder, proceeding to perforation. Some years ago, a youth, aged 19, in the London Fever Hospital, was seized with symp- toms of peritonitis on the i Sth day of enteric fever, and died within twenty- six hours ; the cause of the peritonitis was a per- forating ulcer of the gall-bladder, which had allowed bile to escape into the peritoneum. Barthez and Killiet record a similar occurrence in a girl aged 1 2 ; p and three other cases have been recorded by Hamernjk,i Archambault,*" and Thierfelder.'" In Thierfelder's case the cystic duct was obliterated. G. Budd also relates the case of a female, aged 18, who died of peritonitis on the 36th day of enteric fever ; here the peritonitis was excited by suppurative inflammation of the mucous membrane of the gall-bladder, but there was no perforation ; the gall-bladder contained fourteen gall-stones, one of which completely blocked the cystic duct.* (See Gall-Bladder, under Anatomical Lesions.) ' W. EoBEETSON, 1848. J Jenner, 1853, p. 312. ^ Hoffmann, 1869, p. 203. ' Jennee, 1850, xxii. 405. "" Geiesinger, 1864, p. 199. " Hoffmann, 1869, p. 302. Zenker, 1864, p. 96. p Barthez and Eilliet, 1853, ii. 5, 701. •i Hamernjk, 1846, p. 58. "■ MoEiN, 1869, p. 75. " Dis. of Liver, 3rcl ed. 1857, p. 195. COMPLICATIONS AND SEQUELS. 567 It is usually impossible during life to distinguish between these different causes of peritonitis ; but in the great majority of cases the cause is perforation of the bowel. Case LX. Enteric Fever, fatal on 22nd day from Peritonitis. Sloughing of all coats of Intestine, hut no Perforation. Elizabeth L , aged 21, adm. into L. F. H. July 18, 1864, having been ill eight days. Her symptoms were general fever, diar- rhoea, a copious eruption of lenticular rose spots, and great nervous prostration. On July 27, or iW% day, she became much worse. Great increase of prostration, and abdomen much distended ; vomiting, but no pain or tenderness of abdomen. Pulse 120. Turpentine stupes were applied to abdomen, and opium administered in large and repeated doses, with stimulants. On July 28, pulse 140 ; patient had occasional vomiting, and was delirious, and evidently worse. She continued to sink, and died on Aug. i. Autopsy. Intestines much injected, and coated with recent lymph. Extensive ulceration of lower end of ileum ; most of sloughs still adlierent. Bases of ulcers, from which sloughs had separated, formed by the denuded transverse muscular fibres. In five or six of Peyer's patches at lower end of bowel the sloughs had extended through the peritoneal coat, but were adherent at their margins, so that contents of bowel had not escaped. 7. Perforation of the Boivel, with escape of the intestinal contents into the peritoneum, is the most important and dan- gerous complication of enteric fever. It occurs in the course of no other aciUe disease, except in comparatively rare cases of dysentery and tuberculosis. Intestinal perforation is a more common termination of enteric fever than is generally believed, and is apparently more common in England than on the Continent. It occurred in 48 out of 1,580 cases under my care (or in 3*04 per cent.), in 14 out of 600 cases (or 2*3 per cent.) observed by Griesinger,^ and in 2 of 73 cases (2*74 per cent.) observed by Flint" in America. The frequency with which perforation has been found in autopsies of enteric fever by myself and other observers will appear from the following figures : — - * Geiesingee, 1864. ■" " Baetlett, 1856, 13. 60, 568 ENTEEIC OE PYTHOGENIC FEVEE. English Observers. Autopsies Perforations Per Cent. Murcliison, 60 in 325, or i8'46 per cent. ;] Bristowe,^ 15 in 52; Jenner,^ 3 in 23 ; r 412 80 i9'4i Waters,'' 2 in 12. j French Observers. Louis,y 8 in 55 ; Bretonneaii,^ 8 in 80 ;'| Chomel,* 2 in 42; Montault,^ 5 in 49;;- .270 25 9*25 Forget, ° 2 in 44. j German Observers.^ Griesinger,® 14 in 118; collected byGrie-\ singer, 42 in 467 ; Hoffmann, ^ 20 in 250;! ^ __^ Lebert, 7 in 100 ; Schnueder, Frey, andf ' ^^ " '^ Harmius,g 8 in 104. > Total . . 1,721 196 11*38 From the above results it may be inferred, that in England, of every 33 persons attacked with enteric fever, one dies of i^er- foration, and that perforation is fomid in nearly one-fifth of the fatal cases. Perforation is much more common in males than in females. Of 45 cases which occurred in my practice at the Fever Hospital during the years 1862-9, 32 were males and 13 females. Adding to these 24 cases mentioned in the first edition of this work, and 4 cases which came under my care in the Middlesex Hospital, the total is 73 cases — males 51, and females 22. Yet the number of patients in either sex was almost identical, and the total female mortality was in excess of the male. The greater liability of males to perforation has been confirmed by Griesinger and other observers. The ages of my 73 patients in whom perforation occurred were as follows. Under 10 years, in 6; from 10 to 14, in 8; from 15 to 19, in 18 ; from 20 to 24, in 2j ; from 25 to 29, in 6 ; from 30 to 34, in 5 ; from 35 to 39, in 5 ; from 40 to 44, in 2 ; and from 45 to 49, in 2. From this, it appears that age does not much influence the liability to the accident. Perforation is generally stated to be rare in children. Messrs. Barthez, Eilliet, '' Bkistowe, i860. ■" Jexxer, 1S49 (2). ^ Wateks, 1847. y Louis, 1841, ii. 325. ' Bketonxeau, 1829. * Chohel, 1S34. •> MONTAULT, 1838, p. 220. « FOEGET, 184I, p. 33O. " During ten years (i 840-49), Heschl found perforation in only 56 of 1,271 autoiDsies, or in less than 5 per cent. It may be doubted, however, if he did not include cases of typhus, for the same observer in 1S52-53 found perforation in no fewer than 11 of 72 autopsies of ' typhus' (see Heschl, 1853). " Griesingeb, 1864, p. 197. ' Hoffmann, 1869, p. 129. « Moiun, 1869. COMPLICATIONS AND SEQUELS. 569 and Taupin^ met with it in only 3 of 232 children under treat- ment ; still, of fatal cases, as large a proportion seems to be due to perforation in children as in adults. One patient under my care died of perforation at the age of 5. Doubts have been ex- pressed as to whether perforation ever occm's in persons over 40 ; and Hoffmann dissected 38 such cases without encountering perforation once ; but 4 of my patients were between 40 and 50. Among the circumstances which favour the occurrence of perforation may be mentioned indigestible food, distension of the ulcerated bowel with gas or fseces, vomiting, and movements on the part of the patient. Morin relates an instructive case in which perforation resulted fr.om the administration of an enema : many mstances might be quoted where it has been produced by the injudicious administration of a purgative, and one of Thier- felder's patients was seized with peritonitis the moment she sat up in bed to take some soup. Perforation is most likely to happen during the third, fourth, or fifth week of the disease. In 58 of my cases the date of its occurrence was determined as follows : — During second week, 4 cases; dm-ing third, 13; during fourth, 16; during fifth, 13; during sixth, 8 ; during eighth, i ; during ninth, i ; and during tenth, I. Peacock mentions a case where it happened on the eighth day ; ^ in one case at the Fever Hospital it occurred on the ninth day; in a case related by Goodridge, on the eleventh ;J and in one of Louis's cases on the twelfth day. On the other hand, in two of my cases perforation did not occm' until about the 66th day, while in 3 cases referred to by Morin, the date of its occm-rence is said to have been the 72nd, 7.6th, and iioth day."^ The liability to perforation, long after convalescence has fairly commenced, is a point which cannot be too strongly insisted upon. Some years ago a man came under my ©are suffering from acute peritonitis, with which he had been seized while at work as a labourer, and which proved fatal in a few hours. On examining his body, cicatrising typhoid ulcers were found in the ileum, but one had advanced to perforation. About six weeks before, the man had been seized with a mild attack of enteric fever, but he had been quite convalescent for a fortnight. In several other instances I have known perforation occur after the patient had got up, and v/as apparently doing well. (Cases '' Bakthez and Eilliet, 1853, ii. 701. ' Peacock, 1856 (No. i). ^ Lancet, March 11, 1865. In referenoe to these cases the difficulty of fixing the date of attack must be remembered. I' MoEiN, 1869, p. 47. 570 ENTERIC OR PYTHOGENIC FEVER. LXIV. and LXY.) Tweedie also observes that he has known it happen when convalescence was supposed to be progressing so surely and satisfactorily, that the patient had been allowed to leave the house, and the stools had been formed and perfectly healthy in appearance.^ In a large proportion of cases of perforation, the previous symptoms are severe, and diarrhcea, as might be expected, is a prominent symptom. This was the case in 60 out of 69 of my patients ; in 11 of the 60, the s}Tnptoms of peritonitis were preceded by considerable intestinal haemorrhage, and in many there was an unusual amount of abdominal pain. On the other hand, it is a fact which cannot be too strongly insisted on that perforation may occur in cases of the mildest description, and in which the bowels have been throughout confined. In 9 of my 69 cases there had been constipation up to the occurrence of per- foration, and in 5 of the 9 cases the general symptoms had been very mild. (Cases LXIII., LXV.) I have known a man walk more than a mile to the London Fever Hospital at the end of the third week of the fever, and die of perforation within thu'ty hours of admission. Another of my patients was seized with perfora- tion while digging. (Case LXIY.) Louis relates the case of a man who walked daily in the hospital garden up to the 23rd day, when perforation occurred, which was followed by death in 36 hours.™ Two similar cases occurred in Guy's Hospital some years ago.'' Most writers agree in stating that perforation is chiefly met with in these latent cases, and this opinion, founded mainly on the experience of Louis and Chomel, who found the disease latent prior to perforation in 10 out of 12 cases," was expressed in the first edition of this work. The data now pub- lished show that this opinion is erroneous. The occurrence of perforation is denoted by the sudden super- vention of collapse, with or without rigors, but with acute pain and tenderness of the abdomen, which at the same time is tense and tympanitic. Vomiting is common, and often precedes the other symptoms for several days, and is then often accompanied by an increase of diarrhoea,? with or without intestinal hiemor- rhage. The decubitus is dorsal, with the legs drawn up ; the temperature rises ; ^ the pulse is rapid, thready, or imperceptible ; 1 Tweedie, 1862, p. 75, "> Locis, 1841, ii. 223. ° H.tBEESHON, in Trans. Med. Soc. of Lond. 1862, ii. 120. ° Chomel, 1834. p After perforation has occurred, the diarrhcea does not ahvays cease, as has been stated. « When the collapse is very sudden and profound, there may be a considerable fall of temiDcrature ; but the rule is that the temperature rises. COMPLICATIONS AND SEQUELS. 5/1 the breathing is thoracic ; the countenance pale, pinched, and expressive of suffering; and there is great thirst, and often suppression of urine. Soon the prostration becomes extreme, the extremities cold, and the face covered with large drops of perspiration ; and the patient gradually sinks, the mind remain- ing clear to the last. With such symptoms, the diagnosis of peritonitis can never be a matter of doubt. But occasionally, the symptoms are more obscure, and probably many patients die of peritonitis, where its existence has not been suspected. (Cases LXI. and LXVII.) In fully one-fourth of my cases of perfora- tion there was neither pain nor rigors, and the chief indications of its occurrence consisted in a sudden increase of prostration, a rise in the pulse and temperature, and a distended, motionless state of the abdomen. The advent of perforation may likewise be latent, in consequence of the patient being delirious or un- conscious ; the prostration being accounted for by the severity of the fever, and the ordinary symptoms of peritonitis being absent. Jenner reports a case where the only symptoms were vomiting and coldness of the extremities, coming on eight hours before death ;"" and in 3 out of Louis's 8 cases, the symptoms were obscure. The occurrence of perforation is sometimes followed by death within a few hours, and life is rarely prolonged beyond two days. Of 65 cases in which I have noted the circumstance, only 9 sur- vived the commencement of peritoneal symptoms more than 4 days ; 47 died within 48 hours ; 30 within 24 hours ; and 14 in less than 12 hours ; ^ one of my patients, however, lived 12 days, another 15 days, and a third 21 days. (Cases LXYIII. and LXIX.) In one of Bristowe's cases there was an interval of up- wards of a fortnight between the first symptoms of perforation and the fatal result. Most observers, including Louis, Chomel, Eokitansky, and Jenner,* have expressed the opinion that perforation in enteric fever is invariably fatal. Still, it is satisfactory to know that rare cases are met with, where recovery ensues after all the symptoms of peritonitis from perforation. Tweedie states that he has witnessed the recovery of two cases, in which the distinctive signs of perforation had been unequivocal, and a similar case occurred in the practice of the late Dr. Todd. Other cases of ' Jennee, 1850, xxii. 298. ' According to Griesinger, death rarely occurs within the first 24 hours, but usually from the 2nd to the 4th day, and in many cases not till the 7th or even ibth day. ' Jennee, 1S53, p. 2S6. 57^ ENTEEIC OR PYTHOGENIC FEVER. recovery have been recorded by E. L. Fox," Ballard/ Joseph Bell,"^ Bristowe,'' Griesmger,y Buhl, Thierfelder,^ and Morin.^ Six cases have come under my own observation of which a brief summary is appended. (Cases LXX. to LXXV.) Cases in which recovery has been thought to follow perforation, are, of course, open to the objection that the peritonitis may have resulted from some of the causes, other than perforation, already referred to. At the same time, on pathological grounds, there appears to be no reason why recovery should not occasionally take place. On several occasions I have found a minute perforation with its edges glued to the abdominal parietes, or to an adjoining coil of bowel, in such a way that little or no escape of the intestinal contents had taken place, and where, in fact, a process of cure appeared to be commencing, which, it is legitimate to infer, might in other cases be completed. Facts are not wanting to confirm this inference. Buhl, for example, relates the case of a patient who got symptoms of perforation on the 25th day of enteric fever, and was recovering, but died twenty days afterwards of profuse hemorrhage ; a perforation was found completely closed by adhesions to the mesentery.'' But even when the opening is large enough to permit a leakage of some of the intestinal con- tents, the peritonitis may be limited by adhesions, so that a cir- cumscribed peritoneal abscess results, and then a long period may intervene between the occurrence of perforation and the fatal event, which may be due to septicaemia ; or recovery is not im- possible. In three instances I have known a patient recover after such an accident, the abscess in two of the cases discharging it- self by the bowel (Cases LXXIII. and LXXIV.), and in the third opening externally (Case LXXV.). Oases similar to the last have been observed by E. L. Fox,^ Thierfelder,*^ and Jenner ; ® and Bris- towe has recorded the case of a girl who had a circumscribed suppurative peritonitis resulting from perforation of the bowel in enteric fever, from which she recovered after paracentesis.^ In another patient, under the care of Griesinger, perforation occurred at the end of the 6th week of enteric fever ; from this she was evidently recovering ; but nine days after, she turned from her back on her side, and at once the symptoms of acute peritonitis returned, and ended in death within seventeen hours. A small " Brit. Med. Journ. June 8, 1861 ^ Bell, i860, viii. 388. y Gbiesinger, 1864. ■'' MoRiN, 1869. ° Brit. Med. Journ. 1861, i. 602. ° Lancet, 1869, i. 9. " Lancet, i860, i. 422. ^ Beistowe, i860, p. 115. ' Thierfelder, 1855. i* Cited by Moein, 1869, p. 70. '• Thierfelder, 1855. ' Bristowe, i860, p. 115. COMPLICATIONS AND SEQUELS. 573 abscess was found in connection with a perforated bowel, con- taining fgecal matter and circumscribed by adhesions, some of which had been torn by the girl changing her position.^ Buhl speaks of a similar case, where recovery was maintained for five weeks before the fatal catastrophe.^ From the above evidence, it follows that recovery does, in rare cases, follow perforation of the bowel in enteric fever. Case LXI. Enteric Fever. Acute Delirium. Profiise Intestinal HcBMorrhage, and Death on igth day. No Symptom of Peritonitis. Autopsy : — Ulceration of Intestines ; Perforation ; Peritonitis. James L , aged 19, adm. into L. F. Hosp. on Aug. 19, 1858, having been ill eight days. Bowels had been much relaxed, and for two days he had been very delirious. Aug. 20 [10th day). Pulse 120, full, but compressible. Slight headache ; rather confused. Was very delirious in night, and at- tempted to leave bed. Several rose spots on chest and abdomen. Tongue moist and furred, red at edges ; intense thirst ; great tym- panites and tenderness in right iliac fossa ; two light watery stools. Aug. 21 [nth day). Pulse 132. Is more prostrate, and was again very restless and delirious in night. Skin hot and dry ; temperature in axilla 104° Fahr. Lenticular spots more numerous ; tongue dry along centre, red at edges ; abdominal tenderness increased ; five watery motions. Was ordered turpentine stupe to abdomen ; acetate of lead (gr. iij.) every four hours ; starch and laudanum enema at night, and four ounces of brandy. Aug. 24 [i^th day). Pulse 144, weak. Is now unable to get out of bed, but still tries to do so when he is delirious at night. Is confused, but understands what is said to him ; pupils natural ; circumscribed flush on both cheeks ; numerous rose spots ; fresh ones appear daily. Tongue red and moist ; great tympanitis; two watery stools. Since Aug. 22, patient has been taking ammonia and chloric ether, instead of the lead, and he has had a morphia draught at night. To-day, brandy was increased to 8 ounces. Aug. 26 {16th day). Pulse 136. Scarcely knows friends ; moans and sighs very much ; but always calls for bed-pan when he requires it. Spots continue ; skin is moist, and has perspired every night since admission, after which he has been very faint. Two stools, Aug. 27 [i^th day). Had no motion since yesterday till this after- noon, when he passed a large quantity of fetid, liquid, red blood. No vomiting, and tenderness of abdomen seems less than before ; but patient is scarcely conscious. Was ordered a starch enema with 20 drops of laudanum, and a draught with 15 minims of turpentine every three hours. Aug. 28 [iSth day). No motion for some hours after enema, but since then he has ha"d five, of pure blood. Tongue dry and brown; sordes on teeth; slight tenderness of abdomen. Pulse 136, e Griesingek, 1864, p. 198, '' Cited by Moein, 1S69, P- 7^- 574 ENTERIC OR PYTHOGENIC FEVER. small and weak ; very noisy in night, and scarcely knows father ; but got up to stool himself, when nurse was not present. Aiig. 29 (igth day). Died at 7^ a.m. Was very restless and delirious until half an hour before his death. Passed one bloody motion in bed, in night. Autopsy, 35 hours after death. Heart 10 ounces ; permanent fora- men ovale ; small white coagulum in right ventricle. Abdominal cavity contained about half a pint of dirty yellow faecal fluid. The peritoneal surface of small intestines very vascular, and coated with loosely adherent flakes of lymph. Twelve inches above ileo-colic valve was a semilunar perforation, measuring 2 lines in long diameter, and formed in this way : — An oval patch of peritoneum, measuring 4^ lines by 2 lines, had sloughed, its smooth pale yellow surface contrastmg strongly ^^^^^. Fig. 12 Perforation of ileum, seen from peritoneal surface, a. Enlarged me?enterir; gland. 6. Dead portion of peritoneum, surrounded by increased vascularity : at its lower end is the perfora- tion, c. Plakes of lymph. The preparation is in ttie museum of iliddlesex Hospital. with the surrounding bright red membrane roughened by deposit of lymph. This slough still adhered by its edges, except at one ex- tremity, where it was detached, forming the semilunar perforation (see fig. 12). The little opening was plugged by a fragment of slough from interior of bowel. On slitting open intestine, lower four inches of ileum were found to be one mass of ulceration, which terminated abruptly at valve. This ulcerated surface was covered with loosely attached yellowish sloughs, and with masses of coagulated blood. Six of Peyer's patches and many of solitary glands above this were ulce- COMPLICATIONS AND SEQUELS. 575 rated, yellowish slouglis being still loosely attached to most of ulcers. In one of Peyer's patches was the perforation already described. Some of soHtary glands were enlarged from morbid deposit, up to size of a split-pea, but were not ulcerated. Many of solitary glands in caecum and ascending colon were either ulcerated or contained morbid deposit. Large intestine contained a few ounces of blood. Mesenteric glands were much enlarged, some near c^cum being as large as a pigeon's egg. Liver 60 ounces, anaemic, but healthy ; 12 drachms of very pale watery bile in gall-bladder. Spleen, 9 ounces, dark, and rather firm. Kidneys large, and very congested ; right, 6i ounces ; left, 5 ounces. Case LXII. Enteric Fever of moderate Severity. After temjjorary Improvement, Peritonitis and Stercoraceous Vomiting on 2^rd day, and Death within 36 hours. Auto^osy : — Ulceration of Intestines. Perforation and Peritonitis. Thomas P , aged 21, was adm. into L. F, Hosp. Sept. 15, 1858. He began to complain of giddiness, headache, and pains in limbs on Sept. i, and almost from first, bowels had been much re- laxed. Sept. 15. Pulse 108. No headache. Litelligence clear ; pupils dilated. Several rose spots on chest and abdomen. Temperature under tongue 104° Fahr. Tongue red ; abdomen tympanitic ; bowels still relaxed. Was ordered acetate of lead (gr. iij.) after each motion of bowels. Sept. 16 {16th day). Pulse 92. More prostrate, but can get up without assistance ; restless at night, and mutters in sleep ; but intelligence is clear, when awake. Tongue dry and brown along centre ; 4 light watery stools. Ordered 6 ounces of wine. For next four days patient continued much in same state, except that on Sept. 1 1 he became a little drowsy. His intelligence always seemed clear when he was spoken to ; pupils were always dilated ; fresh spots continued to appear daily in large numbers ; bowels were moved two or three times daily, and pulse never exceeded 96. Sep)t. 20. Pulse 120, but patient feels much better. Three motions. Sept. 21 (215^ day). Pulse 88. Litelligence clear, but is more drowsy. Temp, under tongue only 102° Fahr. ; 105 rose spots counted on front of chest and abdomen. Lips parched ; tongue dry, red, smooth, and deeply fissured ; less tympanites, and scarcely any tenderness of ab- domen ; three stools. Appearance much improved. Sept. 23 (2 3r^ day). Pulse 120, and weaker, and does not feel quite so well. Slept well, but is a little confused; pupils dilated; 21 fresh spots on front of chest and abdomen, and many of old ones gone. Only two stools, which are of more consistence. Ordered 6 ounces of brandy. At 6 P.M. urgent diarrhoea came onj and in night he was seized with acute pain in abdomen, followed by vomiting. Sept. 24. Pulse 108, very weak ; features pinched ; very prostrate, but is perfectly conscious. One stool since midnight, passed in bed. The vomited matters exactly resemble the faeces, both in smell and colour ; abdomen tense, and 576 ENTERIC OR PYTHOGENIC FEVER. very tender ; spots numerous. A starch and laudanum enema was administered, and a grain of opium was ordered every second hour. Diarrhoea and vomiting continued, and at 8 a.m. of 2C,th, patient died, his mind remaining clear to last. Autopsy, 8 hours after death. Cadaveric rigidity marked. None of lenticular spots visible, although their situation was indicated by circles of ink. Both lungs healthy ; right, i6 oz. ; left, i6^ oz. Abdomen contained about a pmt and a half of opaque yellowish fluid, containing flakes of lymph, but apparently not faecal. The whole of intestines were glued together by recent lymph, which also coated surface of liver and under-surface of diaphragm. Peritoneal surface of intestines intensely injected, especially over lower six feet of ileum. The portions corresponding to Peyer's patches were particularly bright, and here also lymph was more adherent than elsewhere. An ulcer was found in almost every one of Peyer's patches in the lower four feet of ileum. The sloughs had separated from all of them, and in several the floor was formed by transverse muscular fibres, or by peritoneum ; in one, 5^ inches above valve, was a small circular perforation, barely large enough to admit a stocking wire. The peritoneal edges of this perfora- tion were glued by lymph to a neighbouring coil of bowel, so that contents of bowel had been prevented escaping in any quantity. None of solitary glands in large intestine, and but few in ileum, showed any trace of disease. Mesenteric glands enlarged ; but none larger than a hazel-nut. Spleen 14 ounces, dark and rather soft. Liver 73 ounces, fatty ; one ounce of pea-green bile in gall-bladder. Kidneys enlarged ; each 6 ornices ; hyper^mic. Case LXIII. Enteric Fever running a mild course up to occurrence of fatal Peritonitis about 16th day. Thomas K , aged 17, admitted into Middlesex Hospital, under my care Oct. 14, 1870, and died within 24 hours. He had all the symptoms of acute peritonitis, viz., features pinched, cold clammy sweat, pulse 140, respiration 56 and thoracic ; abdomen distended, tender and motionless, and legs drawn up ; frequent vomiting, and scanty urine. The boy's mother stated that he had followed his work till Oct. 7, although for ten days before he had complained of being ' out of sorts.' He had no diarrhoea, and so little was it thought that he was seriously ill, that he continued going about until afternoon of day preceding admission, when he was obliged to go to bed on account of a sudden Seizure of acute pain in abdomen. Autopsy. Numerous ' typhoid ulcers ' m ileum, many of sloughs still attached. One Peyer's patch, 12 inches above valve, had sloughed out bodily, leaving an opening in the gut through which the finger could be passed. Contents of bowel had escaped into peritoneum, and there were all the signs of extensive recent peritonitis. COMPLICATIONS AND SEQUELS. 5// Case LXIV. Latent Enteric Fever. Perforation of Boivel after apparent Convalescence, about ^oth day. John B , aged 43, adm. into L. F. H. Oct. 20, 1865, with all the symptoms of acute peritonitis. He stated that, four days before, while at work as a labourer, he had been suddenly seized with acute pain in the abdomen, and that since then his bowels had not acted. He was extremely prostrate; extremities cold; pulse 120, counted with difficulty ; respirations, 48, thoracic ; lower part of abdomen much distended, tympanitic and tender ; and here, on tapping, there was a distinct thrill, as from a thin film of fluid. No eruption ; urine con- tained albumen. A few hours after admission an attack of urgent vomiting set in, which terminated in death. Autopsy. Extensive recent peritonitis ; nearly a pint of purulent fluid confined to lower part of abdominal cavity by adliesions of great omentum. Numerous typhoid ulcers, mostly cicatrising, in ileum, in one of which, three inches above the valve, was a perforation two lines in diameter. After patient's death it was ascertained that he had been ill with ' fever ' for three or four weeks, but that four days before admission he had been told by his medical attendant that he was well enough to return to work, and that he had been working for several hours before he was seized with the acute pain above referred to. Case LXV. Enteric Fever. Death from Perforation and Peritonitis on 42nd day after apparent Convalescence. The occurrence of Per- foration preceded hy Constipation. Solid fcBces in perforated Bowel. William S , aged 14, adm. into L, F. H. on July 4, 1864 ; ill ten days, and in bed four days. His symptoms were fever, diarrhoea, dry brown tongue, sordes, rose spots, delirium and subsultus. On July 21 (27^/1 day) he appeared convalescent, and from this date he continued to gain strength, and was able to walk about ; but on Aug. 2 {2,gth day) he had pain in stomach relieved by pressure, and on following day pulse rose to 124, belly became very distended and tender, features were pinched, breathing thoracic, and there was general collapse. It is worthy of notice that bowels had been consti- pated for several days, and that on this {40th) day a solid motion was passed. On Aug. 4 pulse was 132, and there was retching. On fol- lowing morning he died. Autopsy. Peritoneum contained several pints of opaque ochrey fluid. Intestines glued together by recent lymph, and the peritonitis extended over upper surface of the liver. In ileum, immediately above valve, extensive ulcers, almost cicatrised ; but 2^ feet above valve was an ulcer, in centre of which was a circular perforation one line and a-half in diameter. The surrounding peritoneum was plastered with recent lymph. Solid faeces were found in ileum. Mesenteric glands scarcely enlarged. Spleen weighed only 4 ounces, and seemed healthy. P P 578 ENTEEIC OR PYTHOGENIC FEVER. Case LXVI. Enteric Fever of about 5 weeks' duration. Sloughing through entire coats of Boivel. No Peritonitis. Thomas W , aged 32, adm. into L. F. H. Aug. 27, 1864, having been ill for about a month. His symptoms were quick, feeble pulse, successive crops of lenticular spots, dry tongue, diarrhoea, low delirium, and rapidly increasing prostration mitil death, on SejJt. 7. Autopsy. Body extremely emaciated. No trace of peritonitis. Numerous ulcers in ileum, for about three feet above valve. Most of ulcers were clean, with no adherent sloughs, and with margins formed by loose fringes of mucous membrane, and bases exhibiting denuded transverse muscular fibres. About 2^ feet above valve bases of ulcers had sloughed through to peritoneal surface. The sloughs came away in washing bowel, leaving two large oval holes, about size of a vege- table-marrow seed. The absence of any peritonitis showed that no detachment had taken place during life. Case LXVII. Enteric Fever. Profuse intestinal Hemorrhage. Perforation of Appendix vermiformis ahout 22>th day. Mary Ann B , aged 13, adm. intoL. F. H. Sept. 11, 1865. She was confused, and could not say how long she had been ill. Skm hot ; several typical rose spots on abdomen ; pulse 120, small and feeble; tongue moist and brown in centre ; bowels loose ; abdomen tender and tympanitic. Until Sept. 16 fresh spots were noted daily, but from that date they faded. For five days after Sep)t. 14 she obstinately refused to take drinks, and was supported by injections of beef-tea and brandy. The tongue became dry and rough ; the pulse ranged from 120 to 144 ; cough set in on Sept. 16, and moist rales were heard over the lungs ; the abdomen contmued tense and tender, and the diarrhoea persisted. The motions were ochrey and free from blood, but in the night of Sept. 23 there were four very copious motions consisting almost entirely of pure blood. The haemorrhage was checked by large doses of gallic acid and opium ; but although for four days previously her general condition had improved, and hopes had been held of her recovery, she rapidly sank after the bleeding, and died on Sept. 25. Autopsy. Patches of recent lymph over surfaces of intestines, especially in vicinity of caecum. Inside vermiform appendix were four ulcers, in one of which, about three-quarters of an inch from the distal end, were two small perforations ; the contents of the bowel had not escaped into the peritoneal cavity. Extensive ulcers in the ileum, and a few in the c^cum near the valve ; the sloughs had separated from most of the ulcers, which were beginning to heal. The source of haemorrhage was not determined. Eecent pneumonic consolidation in lower lobe of both Imigs. COMPLICATIONS AND SEQUELS. 579 Case LXVIII. Enteric Fever, fatal ahout ;^oth day. Symptoms of Peritonitis a fortnight before death. Three Perforations in large intestine. John S , aged 19, adm. into L. F, H. on Aug. 23, 1865. He had been ill for 14 days at least, and on admission had all the symp- toms of severe enteric fever with peritonitis. Skin hot and moist ; numerous rose spots over trunk. Pulse 120, small and feeble. Tongue dry, cracked, and covered with sordes. Abdomen enormously dis- tended, tympanitic, and tender ; motions frequent and watery. Breath- ing entirely thoracic. Bed-sore over sacrum. The rose spots were not seen after Aug. 25. The greatly distended and tympanitic state of abdomen continued throughout ; and on 2,1st an uneven nodulated appearance was noticed which continued till his death, and seemed as if intestines adhered to abdominal parietes. In spite of all treatment, diarrhoea continued profuse ; but no blood was passed, except small quantities in motions oi Aug. 29 and Sept. 2 and 3. Mind was heavy and confused from first ; but he was always ready to take drinks, and could answer questions till day he died. Pulse varied from 100 to 140, but was usually about 120, and always very small and feeble. The bed-sore extended and caused much pain. After Sept. i evacuations were passed involuntarily. He died on Sept. 7. Atitopsy. Whole surface of peritoneum coated with a thin layer of lymph. Numerous small ulcers in large intestine, three of which had proceeded to perforation, one about 3^ inches from ileo- colic valve, and two in sigmoid flexure. The contents of bowel had not escaped in any quantity into peritoneal cavity. Extensive atonic ulcers in ileum ; their margins formed by loose fringes of mucous membrane ; but in none was there any perforation. Lobular pneumonia of both lungs. Case LXIX. Enteric Fever. Convalescence. Belapse. Perforation of Colon on 73r(i day. Adhesion of perforated Bowel to Gall-bladder. Death on g^th day. Samuel W , aged 48, was taken ill about Feb. 5, 1872, and on Feb. 13 adm. into L. F. H., where he remained till March 5, when he was discharged convalescent. Among the symptoms noted in the Fever Hospital were a dry red tongue, distended abdomen, diarrhoea, delirium, and rose spots. On March 23 {^Sth day) he was again seized with pyrexia and diarrhoea, and on April 3 (59^/1 day) he was admitted into St. Thomas's Hospital under my care. He was then very prostrate and emaciated ; tongue dry and brown ; much delirium ; obstinate diarrhoea, and tenderness over caecum. After a few days the fever subsided and the general symptoms improved ; but there was no marked convalescence, and on April 18 (74^/1 day) he was suddenly seized with acute pain at the epigastrium, rapid thoracic breathing, and collapse. He had frequent recurrences of these attacks, the hepatic region became very tender, and the patient lapsed again into a low typhoid condition, 580 ENTEKIC OR PYTHOGENIC FEVEE. but had no rigors or night sweats. He died on May 8 (94^/1 day), and for several days before death the extremities were cold and h%TLd, and the temperature subnormal (94° Fahr.). Autopsy. Numerous ' typhoid ulcers ' for the most part cicatrised in lower part of ileum. Eecent perihepatitis over upper surface of liver. Hepatic flexure of colon adherent to fundus of gall-bladder, an abscess of about the size of a cherry intervening ; the corresponding mucous surface of the gall-bladder intact, but that of the colon ulce- rated, and had apparently been at one time the seat of a perforation communicating with the abscess. Case LXX. Enteric Fever. Acute Peritonitis 011 ;^ist day. Becovery. In 1858 a girl, aged 15, was under my care m the Fever Hosp., suffering from enteric fever. On the 31st day of her illness she was suddenly seized with -acute pain and distension of the abdomen, thoracic breathing, urgent vomiting and collapse. One gram of opium was ordered every second hour, and ten grains were taken during the first 36 hours. The patient made a tedious recovery, and was discharged from the Fever Hospital 55 days after the commencement of the peritonitis. Case LXXI. Enteric Fever. Acute Peritonitis on 7,gth day. Becovery. On Sejyt. 27, 1867, Isabella E was admitted into the Fever Hosp. on the 15th day of an attack of enteric fever. On the 39th day, when apparently convalescing, and after having eaten fish for a week, she was suddenly seized with acute pain in abdomen, which became greatly distended, motionless, and very tender; pulse 132; frequent vomiting. She was treated with opium, and at first took a gi'ain every two hours. The symptoms of peritonitis did not subside for a fortnight, but the patient recovered, and left the hospital on Jan. 7, Case LXXII. Enteric Fever. Acute Peritonitis on T,c^th day. Becovery. Ann P , aged 29, came under my care at the Middlesex Hos- pital on Nov. 25, 1870, about the 14th day of a very severe attack of enteric fever. About the 35th day symptoms of peritonitis came on ; pulse 156, legs drawn up, great distension and exquisite tenderness of abdomen, thoracic breathing, occasional retching, temperature 105 '4° Fahr. These symptoms began to improve. The patient left the liospital on Feb. 13, 187 1. The treatment in this case also consisted in grain doses of opium every 3 or 4 hours. COMPLICATIONS AND SEQUELS. , 58 1 Case LXXIII, Enteric Fever. Acute Peritonitis on iSth day. Peritoneal Abscess opening into hoioel. Eose T , aged 25, was admitted into the Fever Hosp. Nov. 10, 1865, suffering from enteric fever. On the i8th day of her ilhiess she was seized with acute pain in abdomen, which was greatly distended, tense, tender, and motionless, and with these symptoms there was ex- treme prostration. Opium was prescribed. On the 29th day a painful swelling appeared in the right iliac region. This increased in size till the 47th day, when fresh, though less severe, peritoneal symptoms came on, and lasted off and on till the 73rd day, when the patient passed a large quantity of x^i-i^s and blood per anum, and the swellmg disappeared. The patient recovered and was able to leave the hospital at the end of January 1866. Case LXXIV< Enteric Fever.- Acute Peritonitis. Peritoneal Abscess opening into hoioel. Mary S , aged 32, was admitted into the Middlesex Hosp, under the care of Dr. H. Thompson, on Oct. 14, 1861, suffering from enteric fever, in the course of which she was seized with symptoms of acute peritonitis, followed by the formation of a large abscess in the lower part of the abdomen. After several months a large quantity of pus was discharged per anum, and the patient slowly recovered, but alto- gether she was confined to bed for nine months. Case LXXV. Enteric Fever, Peritonitis in fourth week. Circumscribed Peritoneal Abscess opening externally. Patrick G , aged 11, was admitted into the Fever Hosp. on Nov. 18, 1867, having been ill for about three weeks with a severe attack of enteric fever. On Nov. 23 he was seized with acute pain in abdomen, which was greatly distended and tender ; vomiting ; thoracic breathing ; pulse 132, and thready. Opium was given freely, and after four days the urgency of the symptoms subsided, and the patient began to improve. About the end of December the patient called attention to a painful swelling above the crest of the left ileu.m,^ which continued to enlarge until he was removed by his friends on April 26, 1868, when the swelling had all the characters of a large abscess. On Jan. 11, 1870, was again brought to the hospital, suffering from typhus, from which he also recovered. He had then a fistulous opening discharging thin pus in the left lumbar region, and the cicatrix of another open- ing in front of the anterior spine of the left ileum. The abscess had not opened until six months after his leaving the hospital in 1868 ; the first opening had been the anterior one, and the discharge of pus had been enormous. ' In Thierfelder's case also tlie abscess was on the left side. 582 ENTERIC OE PYTHOGENIC FEVER. /. Diseases of the Urinary Organs. (See p. 212.) 1. Disease of the Kidneys is always a very serious compli- cation of enteric fever. (See pp. 212, 533, and Anatomical Lesions.) 2. Hcematuria. (See p. 534.) 3. Catarrh of the Bladder may be troublesome in convales- cence, in cases where retention has been neglected, during the fever. g. Complications referable to Organs of Generation. (See p. 212.) 1. The Catamenia often occur during the febrile attack, and are sometimes profuse. 2. Pregnancy. According to EokitanskyJ and Niemeyer,^ pregnancy confers almost entire immunity from enteric fever ; but the correctness of this opinion has been denied by Forget, Jenner,* Griesinger,™ &c., and I have met with many instances of pregnant females attacked by the disease. Pregnancy is a less formidable complication than is commonly imagined, or than it was stated to be in the first edition of this work, nor does abortion or miscarriage necessarily take place. I have notes of 14 cases : 10 recovered; 2 of the 10 carried the child (at the fourth and eighth month) throughout the attack ; in 8 of the 10 abortion or miscarriage took place between the fourth and eighth month, and I woman in her eighth month was delivered of a living child : 4 of the patients died ; all 4 miscarried, 3 in the seventh month, and in the fourth the duration of pregnancy was not noted : abortion or miscarriage occurred in the second week of the fever in 2 cases ; in the third, in i ; in the fourth, in 6 ; in the fifth, in 2 ; and in a relapse, in i. h. Diseases of the Supporting Tissues, Integuments, Bones, dc. (Seep. 213.) I . Erysipelas, mostly of the face, was noted by Louis in 9 of 1 34 cases ; by Chomel in 4 of 42 fatal cases ; and by Jenner in 7 of 23 fatal cases; but it did not occur in i per cent, of my cases. It usually appears in an advanced stage of the disease, is sometimes associated with otorrhcea, and is often fatal ; 6 of J Path. Anat. Syd. Soc. Transl. ii. 82. ^ Text Book of Pract. Med. Amer. Transl. ii. 574. ' Jennee, 1850, xxii. 439. '" Gkiesinger, 1864, p. 229, COMPLICATIONS AND SEQUELS. 583 Louis's 9 cases died, and 4 of 9 cases observed by myself. (See p. 213.) 2. Anasarca. Local oedema may result from venous throm- bosis (see p. 560) ; and oedema of both lower extremities from weakness of circulation is occasionally observed during convales- cence from protracted attacks. Leudet has published an account of seven remarkable instances of enteric fever, observed at Eouen, in which the inferior extremities and the entire body became very oedematous in the second or third week of the fever, or during convalescence. All but one, who died of peritonitis, recovered ; none had albuminous m'ine. The swelling was unattended by pain, but was ushered in by severe bronchitis and profuse sweating. After lasting for two or three weeks it disappeared, and it gave rise to no inconvenience, except that it retarded convalescence. The cause of the dropsy was believed to be the adynamic constitution of the persons attacked." Similar cases were observed at Tubingen by Griesinger in persons who had been very destitute prior to their attack of fever.° Barthez and Eilliet also speak of general or partial anasarca as a not uncommon sequela of enteric fever in children ; it occurred in 7 out of II I cases which they analysed. In 2 other of their cases, extreme general anasarca came on as early as the fifth day of the fever and lasted eight or ten days ; there was no albumen in the urine, and after the disappearance of the oedema the fever ran its usual course ; both children recovered.P 3. Gangrene from Pressure. It has been a common observa- tion that bed-sores are more common in enteric fever than in typhus, and the fact is readily accounted for by the greater emaciation in the former malady, and its longer duration. I have seen them not only over the sacrum and trochanters, but at the elbows, heels, and occiiDut. 4. Spontaneous Gangrene. (See p. 560.) 5. Noma or Cancrum Oris is a rare complication of enteric fever, and only occurs in children. I have met with it only once, and it occurred in only i of 600 cases observed by Griesinger.'' Two cases are mentioned by West ; ^ and of 98 cases of gangrene of the mouth observed by Tourdes, 7 followed on enteric fever. ^ It is usually fatal. (See p. 214.) 6. Ulceration from Blisters. Louis pointed out that blisters = Leudet, 1858. ° Gkiesinger, 1864. p Babthez and Eilliet, 1853, ii. 707. See also Troukseau, 1861, p. 192. 4 Griesingeb, 1864, p. 232. "■ West, 1848, eel. 1854, p. 561. ' Babthez and Eilliet, 1853, ii. 704. 584 ENTERIC OR PYTHOGENIC FEVER. in enteric fever were slow in healing, and apt to degenerate into unhealthy sores,* and his experience has been confirmed by subsequent observers. 7. Necrosis is a more common sequel of enteric fever than of typhus (see p. 216). In two instances I have met with necrosis of the tibia, in two with extensive necrosis of the lower jaw during convalescence, and in one with necrosis of the temporal bone. (Case LIX.) All of the patients were young children excepting one, a girl aged 16. In the Pathological Transactions," the case of a child is reported, in whom necrosis of the upper third of the femur followed an attack of enteric fever. 8. Periostitis is an occasional sequela of enteric fever to which Sir James Paget ^ has called attention. It is most commonly seen on the tibia, but may affect other bones, as the femur, ulna, ribs, temporal bone. 9. Accidental Eruptions. Herpes is occasionally observed on the lips. In three instances, of which two were fatal, I have seen large hullce on various parts of the body. (See p. 217.) 10. Buboes. Collections of pus in different parts of the body are not unfrequent after severe attacks of enteric fever ; but the hard inflammatory swellings in the region of the parotid and elsewhere, so common in typhus (see p. 216), are comparatively rare. I have met with 6 cases of parotid bubo, while Louis,'' Chomel,'' and Gairdner y each report one case. Chomel regarded these swellings as critical and auspicious ; but Trousseau ^ scarcely ever knew a case recover in which they appeared. Five of my 6 cases died. (For pseudo-abscesses in muscles, see Ana- tomical Lesions.) i. Marasmus. It occasionally happens that after a severe attack of enteric fever, the patient remains very weak and angemic, and continues to emaciate without any obvious cause. He has a repugnance to food ; or he may eat well, but the food is not assimilated, and slight errors in diet will often cause flatulence, and rumbling noises in the abdomen, or sometimes diarrhoea. Yet the tem- perature is normal, or even too low, and no local disease can be recognized, I have known several cases prove fatal in this way months after the cessation of the fever, where no lesion could be discovered after death, except an unusually smooth appearance ' Louis, 1841, ii. 124, 483. " Path. Trans, xx. 290. ' Paget, 1877. " Louis, 1841, ii. 97, 371. * Chouel, 1834. y Gaikdnek, 1S62 (2), 141. '■ Trousseau, 1861, p. 170. COJIPLICATIONS AND SEQUELS. 585 of the mucous membrane of the ileum, and a shrivelled condition of the mesenteric glands. Similar observations have been made by Eokitansky ^ in fatal cases, but according to Griesinger ^ the mesenteric glands are not invariably atrophied. Occasionally, as Dr. Allbutt *= has shown, the patient survives in this state of marasmus for years, all treatment failing to do good. k. Sudden Death. [Among the accidents liable to occur in typhoid fever is sudden death, sometimes during the height of the attack, but much more frequently at the commencement of convalescence at the end of the third or in the fourth week. In many cases it is due to softening of the heart, or thrombosis or embolism of the pulmonary artery, but very often no such cause can be detected, and various explanations have been offered— reflex spasm, Dieu- lafoy ; ^ ischaemia of the brain, Tambereau,® Liberman ; ^ pneu- matosis of the blood, Sohier.s In some cases mental emotion or muscular exertion seems to have caused the fatal event, which is occasionally preceded by convulsions. On the whole, it seems to be more common in the milder attacks than in the more severe ones. In his thesis on this subject Dr. Eabere^ has collected 64 cases. The knowledge that this accident is liable to occur, even after mild cases, should render caution necessary in allowing convalescent patients to exert themselves mentally or bodily.^ Case LXXVI. Enteric Fever of moderate severity. Sudden death 07i the ijth day. Emily S , aged 28, admitted into the L. F. H. on Aug. 26, 1883, on the loth day of her illness, which was caused by contaminated milk, there being at this time an extensive epidemic traced to this cause in her district — Camden Town. Patient well nourished, somewhat pale ; pulse very compressible. There was no very great prostration ; skin hot and perspiring ; tongue dry ; heart sounds normal ; abdomen moderately distended ; many rose spots ; no diarrhoea ; retention of urine; temp. 104°; ordered brandy ^vj. daily. A bath at 70° was given, after which the temp, fell to 98°. The next day, the abdomen being much distended, ice compresses were applied. The temperature did not rise above 162°. Aug. 28. Highest temperature 102-4°; patient's ^ Path. Anat. Syd. Soc. Traiisl. ii. 81. See also Huss, 1855, p. 221. '^ Geiesingek, 1864, p. 243. -^ = Allbutt, 1871. ■* DiEULAEOY, 1877. " TaMBEREAU, 1S77. f LiBEEJLiN, 1877. e SOHIEE, 1880. ^ EaBERE, 1878. ' See also a case reported by Dr. Morrell [Practitioner, 1875, id. 345), which is ascribed, but I think eri'oneously, to the effect of digitalis. 586 ENTERIC OE PYTHOGENIC FEVER. general condition much the same. Aug. 29. To-day temperature rose to 105-8° ; three baths had to be administered in the 24 hours. Atig. 30. Temp, rose to 104°, one bath was given ; patient has re- covered tone of bladder. Atcg. ^i. Highest temp. 101-4°. Sept. i. Highest temp. 102° ; patient going on well ; no bad symptoms of any kind. Se2}t. 2. Temp. 101-4°; patient appeared to be improving, but at 11.30 A,M., while lying quiet in bed, suddenly turned very pale, her respiration became sighing, and she died in five minutes. On post-mortem examination, when the right auricle was opened, a firm somewhat cylindrical clot escaped about the size of a leech. It had evidently extended into the pulmonary artery, as near its extremity it showed markings of the semilunar valves. I do not suppose it had anything to do with the sudden death. The heart otherwise was normal. There were numerous typhoid ulcers in the small intestine. In this case no drugs had been administered, except one dose of 20 minims of laudanum to procure sleep, Case LXXVII. Mild Enteric Fever. Sudden death on 2T,rd day. Ellen W , aged 35, admitted into the L. F. H. Sept. 3, 1883, on the 13th day of her illness. Cause of illness the same as in the previous case. Patient was a fat flabby woman, suffering from general malaise and febrile languor, but no marked symptoms ; pulse, 104 ; heart sounds normal ; no great degree of prostration ; many rose spots ; temp. 102°; in the evening it rose to io2'6°. During the first six days patient progressed favourably. The temperature after the first even- ing never reached 102°. There was moderate diarrhoea. Sep)t. 9. Patient complains of severe pain m the calf of the right leg, and the following day some hardness could be felt in the popliteal space. On Se2}t. 12 this had almost entirely disappeared. Since Sept. 4 the morning temperature had been normal or sub-normal. Se2Jt. 13. In the morning seemed going on well, and expressed a wish for food. In the afternoon at 4.50 she suddenly cried out that she was in great pain and fell back dead. This case had not been bathed, and no drugs had been administered. On post-mortem examination the heart was found to be flabby. There was a firm laminated clot in the right ventricle extending into the pulmonary artery. Left ventricle empty. On microscopical ex- amination there was found very slight granular infiltration of the muscular fibres of the heart.] I. Other Specific Diseases. (See p. 225.) I . Scarlatina. In the London Fever Hospital, when it was the practice to treat all forms of fever in the same wards, it was not uncommon for a patient suffering from enteric fever to contract scarlet fever, and I have notes of 8 cases in which the eruptions of the two diseases co-existed. Similar cases have been COMPLICATIONS AND SEQUELS. 587 recorded by Forget,J Taupin,^ and Peacock.^ The cases of scarlet merging into enteric fever already referred to (p. 453) have also been cases where both poisons have acted on the system simul- taneously, or in succession. The two following cases are taken from my memoir on the Co-existence of Specific Morbid Poisons."^ Case LXXVIII. Co-existence of Scarlatina and Enteric Fever. A policeman, aged 23, was admitted into L, F. Hosp. Nov. 9, 1857, having been ill two or three weeks. On admission he had all the symptoms of enteric fever, including a red, glazed, and fissm'ed tongue, tympanites, profuse watery diarrhoea, and very numerous lenticular spots. Fresh spots continued to appear, and eight days after admis- sion they were still very numerous, and the diarrhoea persisted. There was now, in addition, a punctated scarlet rash, identical with that of scarlet fever, a strawberry-red tongue with large papillae, sore throat, and redness of the fauces. Two days later, lenticular spots still very numerous, and scarlet rash persisted. Two days after this, scarlet rash was fading, but lenticular spots continued out for a few days longer. A week after disappearance of scarlet rash there was copious desquamation. The patient made a good recovery. Case LXXIX. Co-existence of Scarlatina and Enteric Fever. A boy, aged 14, was admitted into L. F. Hosp. Aug. 25, 1858, from a house in which there had been other cases of enteric fever. He had all the ordinary symptoms in a mild form, Lenticular spots appeared on 13th day of fever, and continued coming out in successive crops. On 22nd day there were still several spots, and also a punctated bright scarlet rash having all the characters of that of scarlet fever. The tongue, which before had been almost clean, became covered with a thick white fur, through which could be seen large red papillse ; throat sore ; tonsils enlarged and red, and coated with a white membranous exudation. On same day pulse was found to have risen from 72 to 132, and temperature under tongue from 99° to 104° Fahr. Both eruptions continued distinct for four days and then disappeared. On 25th day tonsils were so large as almost to meet, and tongue was clean, red, and of a strawberry aspect. On 27th day, desquamation com- menced. Convalescence was delayed by glandular swellmgs in neck, one of which terminated in abscess. After this boy's admission, a patient with scarlet fever lay in the adjoining bed, and there were many cases in the same ward. 2. Measles. Barthez and Piilliet," Taupin," Jenner,P and i FOEGET, I84I, p. 146. ^ TaUPIN, 1839, p. 245. ' PeACOCK, 1862, p. 138. "■ MuRCHisoN, 1859, No. 4, p. 194. ■' Bakthez and Killiet, 1853, ii. 706. " Taupin, 1839, p. 245. p Lancet, 1866, i. 619. 588 ENTEEIC OR PYTHOGENIC FEVER, Kesteven'i have observed cases in which enteric fever and measles have coexisted. 3. Variola and Vaccinia. In the following remarkable case enteric fever was complicated with both Variola and Vaccinia. Case LXXX. Coexistence of Enteric Fever, Vaccinia and Variola. Jane H , aged 22, on Nov. 25, 1863-, was seized with pyrexia, great pain in the back, and vertigo. On the 2'jth she had rigors and diarrhoea set in, and for nearly a fortnight she had four or five stools a day. On the 2^th she went to a Metropolitan Hospital, where she was told that she had small-pox, and sent to the Small-Pox Hospital. On Nov. 30 she was told by the physician of the S.-P. Hospital that she had not small-pox, but she remained in a small-pox ward until Dec. 2, when she was discharged, being previously re-vaccinated in three points in the left arm. On the evening of Dec. 5 she had another rigor, followed by lumbar pain more severe than before, and on the ^th by vomiting, on which day she was admitted into the Middlesex Hospital under Dr. A. P. Stewart. Here she presented all the symp- toms of enteric fever ; tongue red and dry ; abdomen distended ; ten- derness over caecum ; diarrhoea, which continued more or less for ten days; and rose-spOts appearing m successive crops until Dec. 16. Secondly, on Dec. 8 variolous papules appeared on face, so that the attack of smalhpox probably commenced with the rigor on Dec. 5, and the latent period could not have exceeded seven days. Only about a dozen papules ran the entire course, but the pustules were typical ; there were very few on the body. Thirdly, the patient on admission had three characteristic vaccine-vesicles on the left arm, which on Dec. 9 (%th day) were surrounded by a distinct, though small, areola. She had been vaccinated in infancy, and had two marks on left arm. On Dec. 15 and 16 there was an increase of pyrexia, with restlessness and delirium, much albumen in urine, and a bubo over left parotid. This suppurated, and was opened on Dec. 20, and after this patient recovered. 4. Pertussis. Gillespie "" mentions the case of a child who contracted hooping cough while suffering from enteric fever. 5 . Diphtheria. Cases have been already referred to in which enteric fever was complicated with dij)htheritic inflammation of the fauces and larynx (p. 558).- In Case LXXXI. there were also albuminuria and paralysis of the pharynx. Case LXXXI. Enteric Fever. Diphtheria. Alhiiminuria. Paralysis of Pharynx, Edward M , aged 22, admitted into L. F. IJ.- Sept. 24, 1864, having been ill a fortnight with fever and diarrhoea. After admission, ■J Lancet, 1S66, i. 619. ■■ Gillespie, 1S70. COMPLICATIONS AND SEQUELS. 589 pulse 1 08 ; violent pugnacious delirium ; tongue dry and red ; much diarrhoea ; rose-spots. No fresh spots appeared after Oct. 4, but the tongue continued dry and the bowels loose, and there was a thin purulent discharge from one ear. On Oct 14 {2,5th day) it was found that the patient had difficulty in swallomng, apparently owing to paralysis of pharynx. "When an attempt was made to swallow fluids a great part was rejected by the nostrils. The dysphagia increased and the breathing became rapid and embarrassed, and the countenance dusky. Injections of beef-tea and brandy were administered by the rectum, but the patient died at 10 p.m. on Oct. 15. Autopsy. Numerous small ulcers at lower end of ileum, most of them cicatrising. Spleen 10 oz., soft. Both kidneys large, smooth, and congested ; cortices hypertrophied and opaque ; weight of both together 17 oz. ; urine in bladder contained a good deal of albumen. Epiglottis and upper third of larynx swollen and red, and the mucous membrane covered with a continuous thin false membrane, becoming broken up into shreds at its lower margin ; no ulceration. Both lungs congested, with a few scattered patches of lobular pneumonia. 6. Typhus. Some years ago I published the reports of three cases, in which the patients appeared to suffer simultaneously from both typhus and enteric fever, in consequence of exposure to the XDoisons of both diseases.^ In the two following instances, patients contracted typhus in the London Fever Hospital, while still suffering from enteric fever, for which they had been admitted : — Case LXXXII. Coexistence of Typhus and Enteric Fever. George B , aged 14, adm. into L, F. Hosp. June 3, 1862. He had been ill for ten days, and on admission he presented all the ordi- nary symptoms of enteric fever. Pulse 108. Tongue moist and fissured ; belly distended and tender over caecum ; two watery stools. Several well-marked lenticular rose spots. Two of this boy's sisters had been admitted about a fortnight before with the same fever, which had run the usual course. Both had lenticular rose-spots, and one died of intestinal haemorrhage. The boy was placed in a ward in which were many patients suffering from typhus. On June 12 fresh lenticular spots were noted as appearing; skin warm and dry ; tongue moist and fissured ; belly tender ; bowels still relaxed. Pulse 80. Intelligence clear. Slight headache. June 17 [about 22nd day). Tongue red and dry in centre ; belly tender and tympanitic ; one stool. Lenticular spots still distinct, and trimk covered with a dusky mottling like that of typhus. Pulse 90. Head- ache much increased. June 18. The mottling has developed into an immistakable typhus-rash, in midst of which can be singled out a few MuKCHisoN, 1859 (4), p. 197. 590 ENTEKIC OR PYTHOGENIC FEVER. pink, circular, elevated, lenticular rose-spots of enteric fever, whicli had previously been encircled with ink. June 19. Pulse 90. No motion for two days. Expression stupid, and is a little confused when spoken to. Ju7ie 20. The mottling has faded a little, but is still distinct. Several fresh lenticular spots. To-day the patient was visited by Dr. A. P. Stewart, who was satisfied as to existence of both eruptions. Bowels still confined. Jufie 21. One fresh lenticular spot ; mottling remains. No fresh lenticular spots appeared after this date, but the mottling was still visible on Jwie 26. The patient v*^as dis- charged well on July 8. Case LXXXIII. Coexistence of Typhus and Enteric Fever. Henry W , aged 25, adm. into L. F. Hosp. Jan. 10, 1853, having been taken ill on the 6tli. He was brought from Croydon, ten miles distant from London, where enteric fever (but not typhus) had been very prevalent for some months. Another patient suffering from enteric fever was admitted at the same time from the same house. There were several cases of typhus in the wards in which these patients lay. The chief symptoms in Henry W were giddiness, headache, vomiting, flushing of face, disturbed sleep, loss of appetite, thirst, a variable pulse, and lenticular rose-spots. Several of these spots were noted as late as Feb. 2 {zMh clay). On Jan. 30 (25^/1 day) patient complained of irregular chills, alternating with flushing. The head- ache returned ; and the tongue, which a few days before had been clean and moist, became coated. The pulse, which for several days had never exceeded 72, rose to 86. For the next few days patient com- plained greatly of headache, pains in the limbs, thirst, and diarrhoea. On Feb. 4 pulse was 120, and body was covered with a well-marked typhus-eruption consisting of spots and mottling. The bowels were moved ten times. The rash continued very copious for ten days, and all this time the bowels were much relaxed. On Feb. 5 there was copious epistaxis. There was occasional delirium, and for five days pulse remained at 132, without any variation. Between the ^oth and 4isi days, or about the 14th day of the attack of typhus, pulse fell from 120 to 72, and from this date the patient convalesced rapidly. In the following case, the patient appeared to have been exposed to the poisons of both typhus and enteric fever before admission into the hospital. Case LXXXIV. Supposed co-existence of Typhus and Enteric Fever. Norah H , aged 16, adm. into L. F. Hosp. in Dec. 1857, on the eighth day of an attack of fever. Her body was covered with a well-marked typhus -eruption, composed of spots and mottling, and she presented all the ordinary symptoms of typhus, viz., a dry brown tongue, confined bowels, heavy confused expression, small pupils, and COMPLICATIONS AND SEQUELJE. 59 1 low wandering delirium. On the nth day the typhus-eruption faded, and was succeeded by lenticular rose- spots, which came out in successive crops for more than a week, and were accompanied by diarrhoea, abdominal tenderness, red tongue, and dilated pupils. A fortnight before this girl's admission she had slept away from home, in the same bed with another girl who had ' fever.' The father and brother of this second girl were admitted into the Fever Hospital with well-marked typhus. On the other hand, it was ascertained that in the house where Norah H lived, the drainage was very bad, and that the water-closet had been greatly neglected, so as to become most offensive. Since the publication of these cases, several equally conclusive have been noted by other observers. One has been observed by Peacock,* in which the rash of typhus appeared on the 23rd day of enteric fever ; three by T. J. Maclagan ; " one by Dr. M. Ward ; ^ and one by J. W. Miller.^ Sect. IX. Vaeieties of Enteric Fevee. No acute disease presents itself under a greater variety of forms than enteric fever. As in many other diseases of the same class, the poison of enteric fever produces symptoms of a twofold nature, viz.: i, general pyrexia, with derangement of all the bodily functions ; 2, local disease in one particular part of the body, which in this case is the ileum. In some cases, the fever and general symptoms preponderate ; in others, those of the local disease ; in a third class, both are prominently developed ; in a fourth, both occur in the mildest forms, or there may be no symptoms of the local lesion ; while in a fifth, the primary disease is obscured by complications. These differences are partly accounted for by constitutional peculiarities in the patient, and partly by differences in the intensity, or perhaps quality, of the poison (p. 496). "^ Many varieties of enteric fever have been described by syste- matic writers. Among these may be mentioned : the adynamic or low nervous fever, of which the prominent characters are pro- tracted pyrexia and great prostration ; the ataxic form, sometimes called ' Brain Fever,' in which delirium and the typhoid state are well developed ; the abdominal form, in which abdominal symptoms predominate ; the thoracic form, in which thoracic * Peacock, 1862, p. 138. " Maclagan, 1S67 (2). ^ Med. Press and Circ. Feb. 13, 1867. " MiLLEE, 1S68 ; see also Kennedy, 1866. " See Muechison, 1870. 592 ENTERIC OR PYTHOGENIC FEVER. complications are prominent ; and the hcemorrhagic form, charac- terized by hsemorrhages from mucous surfaces, and into the skin (see pp. 516, 560). To these may be added the ague-like form, in which the disease commences Hke an attack of ague (see p. 546). This form is chiefly seen in persons who have been exposed to the malaria of ague, and in whom the poisons of the two diseases may be supposed to co-exist. But the varieties which call for especial notice are the following : — I . The abortive form is that in which the fever does not run its regular course, the intestinal lesions undergoing resolution, instead of advancing to ulceration. The disease commences like an ordinary attack of enteric fever, and at first there may be considerable pyrexia, the evening temperature about the fourth or fifth day rising to 104° or 105°. (See p. 549, and Case LIII.) There is often considerable headache and restlessness ; the tongue is coated and red at the edges ; vomiting is not uncommon ; sometimes there is diarrhoea, but more commonly constipation ; epistaxis occurs in some cases ; and very often, but not always, a few lenticular spots appear about the seventh day. The pulse, as a rule, is not much accelerated (70-90), and sometimes the temperature is the only evidence of the existence of fever. About the eighth or tenth day, the morning remissions become very decided and all the symptoms improve, and by the middle or end of the second week, the morning temperature may be normal, that of the evening continuing to rise several degrees for three or four days, or even a week, the type of the fever being now distinctly intermittent. But occasionally the fever terminates at the end of a week, and Griesinger and Baumler have observed cases in which its duration did not exceed five days. In my experience, the pyrexia, even in these short cases, terminates gradually by lysis (see p. 547), but according to Griesmger and Baumler it may terminate abruptly with copious perspiration. These abortive cases correspond to the forme muqueuse or mucous fever of French writers, and in this country they are commonly designated Febricula. The proofs that they are really cases of enteric fever are, that in some of the cases there are character- istic rose-spots, and that they are often found to occur in the same house as typical cases of this disease. 2. The insidious or latent form is another important variety of enteric fever. It was well described by Dr. Hewett ^ of London in 1826 ; and it has been prominently noticed by Louis, Chomel, J' Hewett, 1826. VAKIETIES. 593 and many other writers. In this form all the sj^mptoms are mild ; there may be little or no acceleration of the pulse ; pro- stration and increase of temperature may be the only signs of pyrexia, and yet the fever has its usual duration of three or four weeks, and the intestinal lesion takes its ordinary course. In some cases, the chief symptoms are irregular chills, alternating with heat and flushing, slight headache, loss of appetite, lassitude, and disturbed sleep ; diarrhoea may be absent, or there may be constipation. In other cases, the patient complains chiefly of bronchial catarrh, and is thought to have merely * taken a cold.' In a third class, the chief symptoms are nausea, vomiting, and a red tongue, and the illness is regarded as a ' bilious attack,' or ' gastric fever.' In any of these ways the patient may pass through the entire attack and make a good recovery, and then his illness is often spoken of as * simple continued fever ; ' but very often he becomes suddenly and alarmingly ill.^ Acute maniacal delirium sets in ; a profuse haemorrhage from the bowels takes place, which may terminate fatally ; or more com- monly symptoms of perforation show themselves, which after a few hours terminate in death. (Cases LXIV. and LXV.) Before the alarming symptoms occur no anxiety is felt about the patient, and his prostration may be so slight that he is able to follow his ordinary avocations, or to attend as an out-patient at some hospital, until within a few hours of the fatal event (see p. 570). Hence cases of this sort have been designated by German writers. Typhus amhulatorius . The very fact of the patient walking about is calculated to rupture the denuded peritoneum forming the base of the intestinal ulcers. (See p. 569.) 3. Gastric or Bilious Fever. It is still a common belief that ' gastric fever ' is an idiopathic fever distinct from enteric.^ Medical literature, however, contains no facts in support of such a view. The gastric and stomachic fevers described in the last century by Ballonius, Heister, and Burserius^ were unquestion- ably enteric fever. Cheyne*' and Craigie'^ were the first to employ the term ' gastric fever ' in this country, and their de- scriptions of the symptoms and anatomical lesions show plainly that the disease which they had in view was also enteric fever ; ' A similar observation is made by Trousseau, who also remarks that the fever may continue for from twelve to thirty days, without the symptoms being suffi- ciently urgent to oblige the patient to take to bed, the bowels all the time being either regular or constipated {Clin. Led. Eng. Transl. ii. 318). » The Registrar-General for Scotland, in his division of Continued Fevers, makes gastric distinct from enteric (see Stark, 1865). '' BuESEEius, 1785. = Cheyne, 1833. "* Ceaigie, 1837 (i). Q Q 594 ENTEEIC OR PYTHOGENIC FEVER. and the same remark applies to the gastric fever described by the late Dr. Anderson of Glasgow.*^ What many modern prac- titioners mean by ' gastric fever ' is a mild continued fever accompanied by symptoms of gastric irritability ; but so far as my experience extends, if we except a few instances in which febrile symptoms are symptomatic of gastric or biliary derangement from non-specific causes, what is commonly called ' gastric ' is really enteric fever in an abortive or latent form, with retching or other gastric symptoms. Many facts attest the correctness of this view. Cases answering to the description of ' gastric fever ' constantly occur in the same house with typical enteric fever ; rose-spots are present in many cases ; a case may run the course of gastric fever, and be followed by a relapse of well- marked enteric fever ; and, lastly, cases are not uncommon which for the first two or three weeks would be regarded as gastric, but which ultimately pass into the typhoid state and prove fatal, the lesions of enteric fever being found in the dead body. Such cases are often spoken of as * gastric fever passing into typhoid,' but this very expression is opposed to the individu- ality of ' gastric fever,' for one acute specific disease is not con- vertible into another. 4. The acute form of enteric fever is that in which the disease commences abruptly and with great violence. Within a day or two, and sometimes from the commencement, there is acute delirium, with or without diarrhoea. Pulmonary congestion sets in early, and often extends with great rapidity ; and death may occur in the first, or early in the second week, before ulceration has commenced in the bowel.® (See Cases XLIV., LV., and p. 549-) 5. Infaniile Remittent Fever. Children have long been known to be very liable to fever attended by gastric and intestinal disorder, to which the terms Worm Fever, Infantile Hectic, Infantile Gastric, and Infantile Eemittent Fever have been applied. Abercrombie,^ Wendt,^ Billard,^ Meissner,^ Evanson and MaunsellJ accurately described both its symptoms and ana- tomical lesions, but they regarded the fever as symptomatic of the local disease, and as peculiar to children. So little was it thought to be the same as the enteric fever of adults, that Chomel, in 1834, wrote concerning the latter affection as follows : ' Nous "^ Anderson, 1861, p. 122. ■= See also Teousseau, Clin. Med. Syd. Soc. Transl. ii. 358. ' AbERCROMBIE, 1820. 6 WeNDT, 1822. '' BiLLARD, 1828. ' Meissnee, 1838. ' Evanson and Maunsell, 1S36. VARIETIES. 595 ne craignons pas cle nous tromper en disant, que ce nombre va eontinuellement en diminuant jusqu'a I'age de dix ans, au-dessous duqnel il parait que les enfans ne sont que tres rarement atteints de cette affection.' In 1836, M. Hutin'' published the account of an epidemic of enteric fever in children ; but it is to Messrs. Killiet,' Taupin,*" Loschner,"^ and Stoeber," and to the writings of our countryman, Dr. West,? that we are indebted for establishing the identity of infantile remittent fever with the enteric fever of adults. It is now known that children are particularly liable to enteric fever, for they are often attacked when other members of the family escape. The symptoms and complications are, to some extent, modified by the age of the patient, as has already been shown, and the remittent type of the pyrexia is even more marked than in adults. It does not follow, however, that all remittent fevers in children are really examples of enteric fever. Children are liable to feverish attacks which may assume a remittent type, and which are independent of any specific poison, and merely symptomatic of some gastro-intestinal disturbance ; but under proper treatment these attacks may be expected to subside within a week. In aguish countries, also, children as well as adults are liable to malarious remittent fever. But it is contended by some observers that many cases of remittent fever in children in London, and other parts of the country where ague is unknown, are malarious and curable by quinine.*^ The question can only be settled by post-mortem examinations, which are still wanting ; but it may be mentioned that true enteric fever with rose-spots often assumes a very remittent character, especially in children, and is then sometimes benefited by quinine. According to my experience, idiopathic remittent fever in children is almost invariably enteric. 6. Enteric Fever in Aged Persons. When enteric fever occurs in persons over fifty, the onset is usually insidious ; debility and tremors are often prominent symptoms ; the type of the fever is essentially adynamic. Rose spots, acute delirium, and urgent diarrhoea are rarely observed. The pyrexia is usually protracted, but the temperature, even in fatal cases, is rarely so high as in younger persons, and more often falls below normal in convales- cence. Collapse is not uncommon. ^ HUTIN, 1836. ' ElLLIET, 1840. " TaUPIN, 1 839. " LoSCHNER, 1846. " StCEBEE, 1 84 1. P WeST, 1 848. 1 See C. H. Jones, Brit. Med. Journ. July 1858, and January 25, 1862; Wiles, lb. June 25, 1870. Q Q 2 596 ENTERIC OR PYTHOGENIC FEYER. Sect. X. Diagnosis of Enteric Fever. During the first week of the disease it may be impossible to form a positive diagnosis ; but even then enteric fever may be suspected if there be pyrexia, with nocturnal exacerbations each night becoming more severe, and especially if this be attended by diarrhoea, enlarged spleen, or epistaxis. When, after febrile symptoms of about a week's duration, lenticular rose spots appear in successive crops as described at p. 510, the diagnosis of enteric fever is certain, whatever be the other symptoms. Two or three characteristic spots will be sufficient. Even if there be no spots, or if those present be not charac- teristic, the diagnosis of enteric fever may be positive in a case where pyrexia of a remittent type has lasted upwards of a week and is associated with diarrhoea, ochrey stools, tympanites, and abdominal pain, enlarged spleen, or epistaxis. If both the eruption and abdominal symptoms be absent, the diagnosis of enteric fever can only be arrived at by a process of exclusion, after carefully comparing the sj^mptoms with those of the other diseases with which enteric fever is most apt to be con- founded ; but practically this rule will be found to hold good : — A fever which in this country (aguish districts excepted) persists beyond seven days, and is unattended b}^ cutaneous eruption, or by signs of local disease in the head, chest, or elsewhere, is in all probability enteric fever, even though there be no symptoms of intestinal lesion. Almost the only source of fallacy is latent tuberculosis (p. 601). The diseases most aj^t to be confounded with enteric fever are the following : - - I. Typhus. The diagnosis of typhus from enteric fever is rarely a matter of much difficulty. It must be remembered, however, that the typhoid state may be as developed in enteric fever as in typhus, and also that the presence of diarrhoea does not distinguish the former malady from the latter. Typhus may be complicated with diarrhoea (p. 208), and the bowels may be constipated in enteric fever (p. 525). The eruptions are the grand distinguishing marks between the two diseases ; when they are present there can be no difficulty in forming a diagnosis (p. 513) J ^i^d although, unfortunately, the eruption of enteric fever is often absent, that of typhus is rarely so, so that the mere fact of there being no eruption by the fifth or sixth day DIAGNOSIS. 597 would in itself be in favour of typhus. Typhus also will be dis- tinguished by its more sudden onset (pp. 179 and 545), by the less remittent character of the pyrexia (pp. 136, 517), by its shorter duration (pp. 185, 548), and by its terminating by crisis rather than by lysis (pp. 183 and 547). When diarrhoea co- exists with tympanites and abdominal pain and the stools are ochrey, it may be concluded that the case is enteric fever, and this opinion will be strengthened by the occurrence of epistaxis or of intestinal haemorrhage. The circumscribed pink flush often seen in the sunken cheek of enteric fever contrasts strongly with the heavy expression, the dusky countenance, and the injected conjunctivae of typhus. The diagnosis is also assisted by the appearances of the tongue (pp. 145 and 522) and pupil (pp. 177 and 542), and by the circumstances under which the disease is contracted (pp. 119 and 499). 2. Relcqjsing Fever. Cases of enteric fever followed by a relapse are occasionally designated ' Eelapsing Fever.' The clinical histories, however, of enteric and true relapsing fever are so very different, that it is impossible for any person practi- cally acquainted with both to mistake one for the other (pp. 3 1 1 and 416). 3. Remittent Fever. The diagnosis between enteric and re- mittent fever is often extremely difficult in countries where both prevail together. The pyrexia of enteric fever is essentially remittent (pp. 517 and 547), and cases have occurred in my own practice and been noted by Trousseau'" and other observers,® especially in malarious countries, in which it has put on at first an intermittent type (p. 547). Moreover, vomiting and diarrhoea may occur in both diseases ; while enlargement of the spleen, cerebral symptoms, and the typhoid state are common to both. The eruption is perhaps the only distinctive mark of enteric fever to be relied on, and in every case of remittent fever com- plicated with abdominal symptoms it ought to be carefully looked for. The close resemblance of enteric to remittent fever accounts for the fact that it is only within the last few years that the former malady has been recognised as occurring in India. (See P- 43S-) 4. Scarlatina. Cases of enteric fever in which the lenticular spots are preceded by a uniform scarlet rash (p. 516) are some- times mistaken for scarlatina, especially if there be at the same "■ Teousseau, 1S61, p. 171 ; and Syd. Soc. Transl. ii. 364. ' Bartlett, 1856, p. 134. 598 ENTEKIC OK PYTHOaENIC rE"\TEE. time sore throat. But the mistake is easily avoided. As a rule, the throat is not sore, but merely dry ; the tongue and throat do not present the appearances of scarlatina ; while the rash does not make its appearance until the fourth or fifth day of the disease. The gradual rise of temperature in enteric fever is also very different from the abrupt invasion of scarlatina. 5. Variola. More than once I have known a copious eruption of lenticular spots mistaken for variola. But the spots are never hard, gritty, nor acuminated ; they do not appear before the seventh day of illness, and they are absent from the face ; and they are not preceded b}^ the severe lumbar pain marking the invasion of small-pox. 6. Pycemia may simulate enteric fever very closely,* although the absence of lenticular spots, the icteric tint, the rigors and profuse sweatings, and the circumstances under which it appears, usually suffice to distinguish the former malady. M^iUy cases of Puerperal Fever put on the ordinary symptoms of enteric fever, such as pyrexia with the typhoid state, a distended abdomen and diarrhoea ; and seeing that lenticular spots may be absent in enteric fever, and rigors in puerj)eral fever, it is obvious that it may sometimes be imj)0ssible to form a positive diagnosis between the two maladies. Moreover, the difficulty may be enhanced by the circumstance of enteric fever in the puerperal state bemg followed by pyaemia. According to my experience, even in those cases of pysemia which most closely simulate enteric fever, the variations of temperature are much gTeater. 7. Influenza, especially when epidemic, ma}^ I have reason to think, sometimes closely simulate enteric fever. In both maladies there is fever with great prostration, occasional per- spirations, and not unfrequently sleeplessness, delh'ium, and the typhoid state. Bronchial catarrh, pleuro-pneumonia, deaf- ness and discharge from the ears, so common in influenza, are far from being unknown in enteric fever ; while epistaxis, a red, and even glazed, dry tongue, and diarrhoea may be observed in influenza." Some years ago I was consulted about an outbreak in a country house, in which there was difficulty in pronouncing an opinion between enteric fever and influenza. An entire family, consisting of father, mother, and six children, * See a case observed by author, Med. Times and Gaz. March 19, 1S64. I have also known several instances of pyemia due to caries of the temporal bone run a course very like that of enteric fever. " Consult Aimals of Influenza, published by Syd. Society, Lond. 1S52. DIAGNOSIS. 599 as well as a servant, were taken severely ill within a few clays. In 8 of the 9 cases there was pyrexia, and in several perspira- tions, great prostration, and a tendency to delirium. In 8 of the cases the attack commenced with acute bronchitis, in 3 there was acute pleuro-pneumonia, and in 5 earache with deaf- ness and more or less purulent discharge from the ears, while in one case these last were the only symptoms. In none was there any eruption, but in 3 of the cases there was copious epi- staxis, in 2 there was a dry red tongue, with distended abdomen, diarrhoea, and ochrey stools, and in one slight hsemorrhage from the bowels. All recovered, several within a week, and in none did the disease run the protracted course of enteric fever. 8. Tuberculosis. The various manifestations of tuberculosis constitute the maladies most difficult to distinguish from enteric fever. a. Tubercular meningitis. Many writers have laid down rules for distinguishing this disease from enteric fever,'' but at the bedside all these rules are sometimes unavailing. Pyrexia with remissions, headache, delirium, vomiting, cerebral maculse,"^ and even partial palsy, inequality of pupils, rolling the head from side to side, and the hydrocephalic cry'' may occur in both diseases ; while rose spots are oftenest absent in enteric fever at the age when the difficulty in diagnosis is most likely to arise. In cases of difficulty, the following are the points of distmction most to be relied on : — In meningitis the vomiting at the outset is usually more urgent ; the tongue is rarely dry and brown, as it is in most cases of fever with severe cerebral symptoms ; the temperature does not follow the course observed in enteric fever ; it is liable to sudden falls, and for several days it may be normal, while the other symptoms are getting worse, and towards the end the temperature may sink, while the pulse is rising ; the bowels are usually constipated, or if there be diarrhoea the stools are not ochrey as in fever ; the abdomen is retracted and painless, instead of being distended and tympanitic ; enlargement of the spleen, intestinal hsemorrhage, ^ West, 1848, 5th ed. 1865, p. 91 ; Teousseau, Clin. Led. Eng. Ed. vol. i. p. 468. " These are produced by gently scratching the skua with a pencil or the finger- nail. The part touched rapidly becomes bright red, and this colour persists for ten or fifteen minutes. Trousseau lays great stress on these maculas as diagnostic of meningitis ; but in those cases of enteric fever in which any difficulty in dia- gnosis is likely to arise, they may be produced as readily as in meningitis. =" See a case observed by Dr. H. Eoger of Paris. A child aged 23 months had pyrexia with acute headache, hydrocephalic screams, meningeal maculas, strabis- mus, persistent voniitnig, and constipation. The lesions of enteric fever were found in the bowel, but the brain and membranes were healthy {Lancet, November 7, 186S, p. 601). 6oO ENTERIC OR PYTHOGENIC FEVER. and epistaxis, often observed in fever, are not met with in meningitis ; the headache is more acute in meningitis, persists after the occurrence of dehrium, and is often associated with intolerance of hght and sound, which is not the case in fever ; in meningitis the patient rolls his head from side to side, while children utter from time to time the hydrocephalic cry ; partial paralysis and irregularity of respiration point to meningitis rather than to fever ; and lastly, in meningitis the patient is more irritable, and offers greater resistance to any examination. Another distinctive mark has been recently discovered by Cohn- heim, who, with the ophthalmoscope, has found minute tubercles in the choroid in a large number of cases of acute tuberculosis.^ The occurrence of other cases of fever in the same house would favour the supposition of fever, while the chcumstance of other children in the same famOy having died of tubercle would support the diagnosis of tubercle. b. Tubercular Peritonitis. I have met with several cases of tubercular peritonitis, which at first closely resembled enteric fever, the symptoms being fever, occasional perspirations, vomit- ing, abdominal pain, diarrhoea, great prostration and emaciation, hectic flush on the cheeks, bronchitic rales, and ultimately de- lirium. In many cases, however, the abdomen is retracted,^ and the temperature usually after a time becomes sub-normal. c. Acute Tuberculosis of the Lungs may be mistaken for enteric fever. Pyrexia of a remittent type, perspirations, great emaciation, and muscular prostration, circumscribed flushes on the cheeks, a dry tongue, delirium, stupor, dyspnoea, and bron- chitic rales are phenomena which may be common to both affections. Even pulmonary consolidation may occur in enteric fever, and cases occur in which from the physical signs of the lungs it is impossible to distinguish between the two diseases ; while diarrhoea may be absent in fever, or may be present, even with ochrey stools, in acute phthisis when there are tubercular ulcers of the bowel, although the abdomen is usually retracted, instead of being distended and tj^mpanitic as in fever. The presence of characteristic rose spots^ and enlargement of the y Letter from Dr. Zuelzer of Berlin. See also Wells, Path. Trans, xix. 359. ^ On the other hand, Dr. Hudson remarks that he has usually found the abdomen distended in tubercular peritonitis (Hudson, 1867, p. 162). " Spots somewhat resembling those of enteric fever have been olaserved in acute phthisis by Waller of Prague, Barthez and Eilliet (Jenner, 1S53, p. 465), and E. L. Fox {Brit. Med. Journ. December 13, 1862). I have looked for them in a large number of cases, but only in one instance found anything resembling them (Case LXXXVI.). DIAGNOSIS. , 60 1 spleen would be evidence of fever, but their absence does not prove the contrary. In all doubtful cases, the family history and the circumstances under which the disease has apj)eared ought to be carefully investigated, and it will be well to determine by the ophthalmoscope the presence or absence of tubercles in the choroid (p. 600) ; while the fact that acute phthisis may be a sequel of enteric fever must not be lost sight of (p. 558). d. Latent Tubercle. It now and then happens that tubercle is deposited in different parts of the body, although careful ex- amination of the lungs and other organs may for many weeks fail to disclose its site. Under these circumstances the patient emaciates, loses strength, and has pyrexia with nocturnal ex- acerbations, and from the absence of any signs of local disease he is thought to be suffering from ' low fever.' Several cases of this sort have come under my notice, and one I saw in con- sultation with Sir W. Jenner, in which enteric fever was first excluded from the diagnosis by the duration of the febrile symptoms exceeding a month ; this patient ultimately died of pulmonary phthisis. Case LXXXV. Enteric Fever, simulating acute Tuberculosis. Mary Ann B , aged 25, adm. into Middlesex Hosp. Oct. it, and died Oct. 17, 1870. She was an only child, her mother having died early in life of consumption. The patient's own previous history also pointed to chronic pulmonary phthisis. She had never been strong, and for many years had suffered from cough, which for twelve months had been much worse, and accompanied by emaciation and night-sweats. Her friends stated that about twelve days before admission she had become feverish, and at the same time the cough had become worse, and attended by purulent expectoration, profuse perspirations, rapid emaciation, and great prostration. When in hospital she had exactly the appearance of a person in an advanced stage of phthisis. She was extremely emaciated, and had a circumscribed pink flush on the cheeks, Avhicli came and went. Pulse varied from 120 to 140, and temperature from 101° to io3"5°. During sleep she was bathed in profuse perspira- tion, with which hands were quite sodden. Kespirations 40 ; great dyspnoea ; expectoration of a large quantity of creamy pus ; voice husky ; coarse moist rales heard everywhere over both lungs ; tongue dry and red ; abdomen flat ; no diarrhoea. Skin of trunk covered with miliary vesicles, but no other eruption. Constant deliriuia and sleeplessness. The treatment consisted in stimulants, quinine, mineral acids, and hydrate of chloral to induce sleep. No improvement took place. On Oct. 15 upwards of a pint of liquid blood was passed from the boAvel, and after this patient rapidly sank and died on Oct. 17. With the 602 EXTEEIC OR PYTHOGEXIC FEVER. exception of the intestinal haemorrhage two days before death, all the facts in this case pointed to phthisis rather than to enteric fever. Autopsy. No tubercle anywhere. Numerous t}-phoid ulcers at lower end of ileum, their margins formed by loose frmges of mucous mem- brane free from any morbid deposit. Lungs intensely congested and oedematous ; commencing lobular pneumonia in lower lobes of both, and recent lymph on surface of left. At entrance to lamyx several small ulcers, the largest forming a deep excavation below the epiglottis, and being the apparent source of the pus expectorated during life. Case LXXXVI. Acute Titberculosis ivith Eruption and other Symptoms simulating those of Enteric Fever. "Walter P , aged 17, died in L. F. Hosp. on July 26, iS6g, on 43rd day of a feverish attack, for which he had been admitted into the hospital on June 16. His symptoms were — pulse varying from 84 to 96 ; hot skin ; a dry tongue, red at the tip and edges, and in the first instance diarrhoea ; enlargement of the spleen ; restlessness and dehrium ; and bronchial rales over chest. There was no acute headache, scream- ing, rolling of the head, inequaHty of the pupils, or paralysis ; but from the 4th day mitil death there were successive crops of circular reddish spots disappearing on pressure, and very hke those of enteric fever. They differed, however, from those of enteric fever in their early ap- pearance, and in the long period over which they kept coming out. Still, during life, the ease was regarded as one of enteric fever. In the night of Jiily 25 the patient was taken suddenly worse with symptoms of congestion of the lungs, and died within two or three hours. Autopsy. No sign of ulceration m ileum. Lungs, liver, spleen, kidneys, and peritoneum studded with mihary tubercles. Spleen weighed 19I oz. Mesenteric glands, and some of solitary glands hi ileum also, enlarged from tubercular deposit. Head not examined. 9. Mania. Where acute delirium sets in suddenly at the commencement of enteric fever, or in a case where the previous sj'mptoms have been mild, the illness is sometimes mistaken for insanity. I have known this mistake committed in several instances (p. 537), but the presence of pyrexia and of some of the other symptoms of enteric fever removes all real difficulty from the diagnosis. 10. Pneumonia with typhoid symptoms is sometimes mis- taken for enteric fever, as well as for typhus. In children pneumonia is often accompanied by great sympathetic disturb- ance of the stomach and bowels, which obscures the primary disease ;^ while in adults pneumonia is occasionally complicated '' West, 1S4S, 5th ed. 1865, p. 338 ; Bakthez and Eilliet, 1853, ii. 699. DIAGNOSIS. 603 ■with d3^seiitery.° On the other hand, enteric fever may be com- plicated with pneumonia. When the pneumonia appears late in the disease, the diagnosis is sufficiently easy ; but when, as rarely happens, the pneumonia occurs within the first week or ten days, there may be some difficulty in deciding whether it be primary or secondary. 1 1 . Gastro-enteritis. Under this term may be included all those derangements of the stomach and bowels accompanied by fever, but where the pyrexia is secondary instead of primary. The enteric symj)toms of fever may be mistaken for those of an irritant poison (pp. 469 and 481), or for enteritis, colitis, typhlitis, or gastric irritation, or each of these conditions may be mistaken for enteric fever. In several instances I have known patients sent into the Fever Hospital with typhlitis, who were supposed to have enteric fever. In adults enteric fever is usually distinguished without difficulty from these local affections by the peculiar range of temperature, b}^ the eruption, the greater degree of muscular prostration, headache, cerebral symptoms, epistaxis, enlargement of the spleen, and by the characters of the stools (p. 526).*^ In children, however, under five years of age, in whom general disturbance and delirium are more apt to result from local causes, the diagnosis may be more difficult f but even in them enlargement of the spleen would favour fever, and the presence of rose spots would settle the question. 12. A 'Bilious Attack.' One of the most common errors in diagnosis is to mistake the early symptoms of enteric fever for those of a common bilious attack, and in consequence much mischief is often done by the injudicious use of purgatives. This error would be avoided by recourse to the thermometer in any case of doubt. 1 3 . Tridmiiasis excites a group of symptoms very similar to those of enteric fever, viz., pyrexia with vomiting and diarrhoea followed by typhoid symptoms. Hence it is believed that some of the reported outbreq^ks of enteric fever have been really out- breaks of trichiniasis.^ The latter disease, however, is distin- guished by severe muscular pains, oedema of the eyelids and sometimes of the whole body, and the absence of rose spots, enlargement of the sj)leen, and epistaxis. " Beistowe, Trans. Path. Soc. viii. 66. '^ The reader is referred to a Table, in which Louis contrasts tlie symptoms of 17 cases of enteric fever ^^dth 23 of enteritis (Louis, 1841, ii. 409). " See Bakthez and Eilliet, 1853, ii. 699. ' See a msmoir by Prof. Liebermeister, Deutsch. ArcMv, 1867, iii. 223. 6o4 ENTERIC OR PYTHOGENIC FEVER. Sect. XI. Prognosis and Mortality. a. Rate of Mortality. Table LIII. gives the rate of mortality among the cases of enteric fever admitted into the London Fever Hospital during TABLE Llll.g Years Admissions Deaths Mortality j per cent. 1 Years Admissions Deaths Mortality per cent. 1848 1849 1850 1851 1852 1853 1854 1855 1856 1857 1858 1859 152 138 137 234 140 212 228 217 149 214 180 176 41 26 24 30 2-5 59 42 28 23 30 26 34 26-97 18-84 17-51 I2--82 17-85 27-83 18-42 12-90 15-43 14-02 14-44 19-31 i860 1861 1862 1863 1S64 1865 i866 1867 j868 1869 1870 95 161 220 174 253 523 582 380 459 369 595 27 32 30 25 52 103 lOI 53 72 58 93 28-42 19-87 13-63 14-36 20-55 19-69 17-35 13-94 15-68 15-71 15-63 Total . ....... 5,988 1,034 17-26 Deducting i patient dead before reaching hospital, and 47 who died within 24 hours 5>940 986 16-59 Deducting 55 additional, who died within 48 hours 5,885 931 15-82 twenty-three years. It appears that out of 5,988 cases, 1,034 died, making a mortality of 17-26 per cent., or of i in 5*79; but, deducting those patients v^ho were moribund on admission, the mortality falls to 15*82 per cent., or to i in 6-32. The mortality, in fact, was about the same as that of typhus (see p. 234). In comparing these results with those observed else- where, it will be necessary to keep in view three facts : i. Every patient admitted with enteric fever and dying in the hospital has been registered as a death from enteric fever, although death may have been due to some sequel, months after recovery from the primary attack. 2. Many abortive cases, all of which re- covered, have been registered as * febricula ' a;nd not as enteric fever. 3. A large proportion of the slightei'' eases were never brought to the hospital at all. The death-rate of enteric fever in different hospitals is in- fluenced by the same cu'cumstances as that of typhus (p. 235), and varies considerably, as will appear from the following Table. 8 See note, p. 234. PEOGNOSIS AND MORTALITY. 605 TABLE LIV. Hospitals Cases Deaths Mortality per cent. Paris, Chomel'' Strasbourg, Forget ' . Paris, 1854^ . . . . King's College Hospital, 18 years, Dr. Todd '^ . Guy's Hospital, 1 861 -70' St. Thomas's Hospital, Peacock" Glasgow Eoyal Infirmary, 1847-53 and 1857-69" Provinces of France, 1841-6° .... Nine Hospitals in Germany p . . . . St. Bartholomew's Hospital, 1860-7 and 1869 1 Aberdeen Eoyal Infirmary, 1865-9'' • Edinburgh Eoyal Infirmary, 1860-70" City of Glasgow Fever Hospital, 1865-70' Dundee Koyal Infirmary, 1857-70'' . 147 190 4,611 131 280 74 1,290 9,974 7.963 464 138 880 304 148 457 47 44 1,002 27 54 14 237 1,667 1.324 73 20 no 35 17 52 32- 23-15 2173 20-6l 19-28 18-92 18-37 16-71 16-62 1573 14-49 12-5 II-5I n-48 11-37 Total 27,051 4,723 17-45 [The following are more recent statistics of the rate of mortality in the principal London Hospitals : — London Fever Hospital, 1871-82, since the exclusion of the pauper patients : cases 905, deaths 144, mortality i5'9. Stockwell Pauper Fever Asylum : cases 1,223, deaths 301, rate of mortality 22-2. Homer- ton Pauper Fever Asylum: cases 1,509, deaths 225, rate of mortality i6"8. Principal General Hospitals of London : cases 2,704, deaths 447, rate 16 "5 nearly.] b. Circumstances Influencing the Rate of Mortality. I. Age. The influence of age on the mortality of enteric fever is shown in Tables LV. and LVI. Table LV. shows the mean age of the cases admitted into the London Fever Hospital dm'ing ten years (1848-57). TABLE LV. Cases Knmber Mean Age Total admissions in which age known . Cases which recovered ..... Cases which died 1,772 1.444 328 21-25 20-7 23-54 Table LYI. gives the death-rate in each quinquennial period of life of all the cases admitted during twenty-three years. ChOMEL, 1834. ' FOEGET, 184I, p. 44O. J DaVENXE, Brit, and For. Med. Chir. Bev.J)ctoher i860, p. 332. ' Beports. Peacock, 1856 (No. i). "" McGhie, 1855, p. 161, and Beports. De Claubky, 1849, p. 31. P Zuelzer, 1869, p. 24. ■> Beports. Ibid. ' Letter from Superintendent. ' Beports. Ibid. " Ibid. 1854. 6o6 ENTEEIC OR PYTHOGEXIC FE^-ER. TABLE LVI. Age Males Females ! Total ^ii §^ c3 =^ s - 'S ^ -^ u I74 151 12-86 „ 15 to 19 „ 744 95 1276 844 151 17-89 1,588 246 15-48 „ 20 to 24 ,, 545 127 23-30 619 III I7"93 1.164 238 2036 ,, 25 to 29 ,, 297 51 17 17 303 72 23-76 600 123 20-50 „ 30 to 34 „ 156 51 32-69 141 25 1773 297 76 25-59 „ 35 to 39 „ 96 25 26-04 105 28 26-66 201 53 26-36 ,, 40 to 44 „ 64 18 28 12 60 15 25*00 124 33 2661 „ 45 to 49 „ 27 9 33'33 37 5 13-51 64 14 21 87 ,, 50 to 54 ., 13 3 23-07 23 5 21-73 36 8 22-22 „ 55 to 5Q „ 12 6 50-00 8 3 37-50 20 9 45-00 ,, 60 to 64 ., 12 6 50-00 a 3 37-50 20 9 45-00 ,, 65 to 69 „ I 33'33 2 I 50-00 5 2 40-00 „ 70 to 74 „ „ 75 to 79 „ 2 I 50-00 2 I 50-00 Age doubtful 46 I 2-17 31 o' 77 I 1-29 Total, including 1 doubtful cases j 3,001 504 16-79 2,987 53® 17-74 5>988 1,034 17-26 From these tables it appears that the death-rate of enteric fever is not influenced by age to the same extent as that of typhus. (See pp. 236, 396) ; and compare Diagrams II. and YIII. with XII. and XIX.) There is a greater uniformity in the rate of mortality at different periods of life in enteric fever. The death-rate increases with age to a much less extent than in typhus, and the small rate of mortality observed in early hfe in typhus does not occur in enteric fever. This contrast between the two diseases is well shown in the following comparison of the cases admitted into the London Fever Hospital. TABLE LVII. Typhus Enteric Fever Cases DeattLS llortality per cent. Cases Deaths Mortality per cent. Under lo years From 10 to 14 „ „ 15 to 19 ,, „ 20 to 29 „ „ 30 to 39 „ ,, 40 to 49 ,, Above 50 ,, 1,221 1,812 2,348 3,257 2,346 2,010 1,499 40 30 93 402 531 723 855 3-27 1-65 3-96 12-34 22-63 35-97 57-03 616 1. 174 1,588 1,764 ^98 188 83 70 151 246 361 129 47 29 11-36 12-86 15-48 20-46 25-90 25- 34-94 From this it appears that up to 40 years of age enteric fever is a much more fatal disease than t^'phus, and that the cir- 100 ^ s: ^ Q - r^ s^ ^ -*- uo .s S ^ lo Cj ■S ^ o^ ^ ^ cy> ?^ ^M c^:) ^ ^ wo .^^ ^ -a o R -S S -R '.-^ •-V-0 § Vo o 1^ c:^ ^ CO) ^ v^ ■-o rb Fever HospitaL.({hmparewithI)iaqr:YI/I. Oinh/' 4-7 of vciuents -were. oJjovt 55 ytars) PROGNOSIS AND MORTALITY. 607 cumstance of the gross mortality of the latter being somewhat greater is due to the much larger proportion of typhus patients exceeding 40 years of age, and to the death-rate after that period of life being much in excess of that in enteric fever. Louis states that none perished out of 6 of his patients under 1 7 years, and that during ten years' hospital experience he had only known i case prove fatal under 20 ;^ but, probably, few cases were admitted into the Hotel-Dieu at an early age. Barthez and Eilliet ascertained that 29 out of 1 1 1 children attacked with enteric fever died.-'' Of 2,282 cases under 15 years in the pro- vinces of France 256, or 11 -22 per cent., died ; whereas of 7,692 cases above 15, 1,411, or 18*34 V^^ cent., died.^ In Paris, in 1854, the deaths among 260 cases under 15 were 68 (26-I5 per cent.); among 4,275 cases between 15 and 50, 911 (21-31 per cent.) ; and among ^6 cases above 50, 23 (30"26 per cent.)^ 2. Sex. From Table LVI. it appears that the mortality from enteric fever in the London Fever Hospital has been about i per cent, higher among females than among males, this result being the reverse of that obtained in the case of typhus (see p. 239). The excess of mortality among females is not accounted for by the influence of child-bearing upon the course of the fever, for it was much more decided between the ages of 5 and 1 5 than in the period of child-bearing (15-45), and in three lustra of this period there was an excess of mortality among males. After the age of 40 the mortality among males was considerably more than that of females. TABLE LVIII. Ages Males Females Cases Deaths Mortality per cent. Cases Deaths Mortality r-er cent. From 5 to 14 years . „ 15 to 39 „ 40 years and upwards 960 1,838 133 107 349 44 11-14 18-98 33-08 772 2,012 138 107 3S7 32 13-86 19-89 23-18 Most of the published statistics of enteric fever show a slight excess in the female mortality. Of 1,687 male cases in the provinces of France 227, or 13-4 per cent., died; while of 2,307 females 336, or 14' 5 per cent., died.^ The statistics given by Forget^ and Chomel,'^ although on a smaller scale, also make the mortality greater in females ; and according to Friedrich*^ " LoTJis, 1841, ii. 354. "" Baethez and Eilliet, 1853. ^ De Cladbet, 1849, p. 31. * Davenne, 1854. See also Zuelzer, 1869, p. 52. ^ De Claubry, 1849, p. 31. " FoBGEX, 1841, p. 403. ° Chomel, 1834, p. 357. '' Feiedkich, 1856. 6o8 ENTEKIC OE PYTHOGENIC FEVEK. and Friedleben,^ the mortality is greater in girls than in boys. On the other hand, Griesinger has noted a slight excess of mor- tality among males (males \']"j per cent. ; females i/'o per cent.) f while in the Glasgow Eoyal Infirmary, over a period of thirteen years (1857-69), the male has considerably exceeded the female mortality (males 556 cases, 102 deaths, i8'34 per cent.; females 378 cases, 58 deaths, i5'34 per cent.).^ 3. Months and Seasons. Table LIX. shows the rate of mor- tality, according to months and seasons, of the cases admitted into the London Fever Hospital during twenty-three years (1848-70). TABLE LIX. Iilonths and Seasons Admissions Deatbs Mortality per cent. January February March April . . , May . . ' . June July August ..... September October November ..... December ..... 433 306 318 209 232 335 434 721 803 839 819 539 81 48 59 41 39 55 79 134 129 135 146 88 18-70 15-68 18-55 19-58 16-81 16-41 18-20 18-58 16-06 16-09 17-82 16-32 Spring Summer ..... Autumn . . . Winter 759 1,490 2,461 1,278 139 268 410 217 15-99 17-98 16-66 16-90 Total .... 5,988 1.034 17-26 From this Table it appears that the mortality was slightly less in autumn, when the disease was most prevalent. This result, however, was far from uniform in different years, and I'ebruary was the month in which the death-rate was actually smallest. Chomel,'^ Forget,' and BartlettJ have endeavoured to show that the mortality in France and America is almost double in the cold months of the year what it is in the warm ; but this inference is drawn from a limited number of cases. Of 3,364 cases admitted into the London Fever Hospital during the warm « Brit, and For. Med. Chir. Rev. July 1858, p. 161. ' Griesinger, 1864, p. 251. s Hosp. Reports. But in the City of Glasgow Fever Hospital the mortality has been greater among females. '' Chomel, 1834. ' Forget, 1S41, p. 410. ■> Baktlett, 1856, p. 125. PROGNOSIS AND MORTALITY. 609 months (May to October) the mortahty was 16-97 pei" cent., while of 2,624 cases admitted during the rest of the year the death-rate was 17*64 per cent. As regards different years the death-rate of enteric fever in the London Fever Hospital was much more equable than that of typhus. Thus, while in typhus the mortality in one year was only 8*82 per cent., and in another as high as 60 per cent, (see p. 234), in enteric fever it was in no year under 12-82 per cent. or higher than 28-42 per cent. 4. Station in Life. Dividing the patients in the London Fever Hospital into three classes, viz.: — i. Paying patients; 2. Free patients and those who have not been in the receipt of parish re- lief prior to their illness ; and 3. Parochial paupers — the mortality of enteric fever in each class during fourteen years (1848-61) was as follows : — TABLE LX. No. of Cases Deaths Mortality per cent. Mortality per ceut. of Typhus First Class . . . 281 Second Class . . . i,454 Third Class . . . ] 85 47 273 13 1672 1877 15-29 14-89 18-58 27-64 The rate of mortality was not greater among the destitute than in the better classes. In private practice enteric fever is probably more fatal among the upper classes than among the very poor. ChomeP' and Forget' both regard debility from destitution a favourable circumstance, as regards prognosis. Enteric fever is as prevalent and as fatal among the rich as among the poor ; typhus is not only most prevalent, but most mortal, among the very poor (see p. 242). 5 . Recent Residence in an Infected Locality. Of i ,y8y patients affected with enteric fever who had resided in London more tiian six months prior to their admission into the Fever Hospital, 279, or 15-61 per cent., died; whereas of 191 patients who had resided in London less than six months, 37, or 19-37 per cent., died. The difference was not accounted for by difference in age. Of 68 patients under Louis and Chomel who had resided in Paris less than six months, 27, or 39-7 per cent., died; whereas of 1 5 1 patients who had resided a longer time, 46, or 30-46 per cent., died."^ As far as these figures go, they show that recent ^ Chomel, 1834. ' Forget, 1841, p. 404. "> Louis, 1841, ii. p. 357 ; Chomel, 1834, p. 358. R R 6io ENTEKIC OE PYTHOGENIC FEVEE. residence in an infected locality increases the fatality of enteric fever (see p. 242). 6. Place of Birth and Race. Of the patients admitted into the London Fever Hospital during twenty years (1848-67), the mortality, according to bh'thplace, was as follows : — TABLE LXL English Irish Scotch . Foreigners No. of Cases Deaths Mortality per ceut. 3.597 591 225 18 24 4 41 6 16-42 8- 16-66 14-63 The small rate of mortality among the L:ish is remarkable (see pp. 243, 398). 7. Intensity of the Poison and Family Constitution. Several deaths often occm^ in the same family from enteric fever, whereas many members of other families often recover. This circum- stance seems to be partly due to family constitution, for occa- sionally several members of the same family die of the disease at distant places, and at long intervals ; but this explanation is not sufficient, for the remark applies also to members of different families residing in the same house, and it is often found that the mortality is much greater in one village than in another a few miles off. Such observations point to differences in the intensity of the poison (see p. 496). 8. Debility from pre\dous diseases, or from any other cause, has not the same unfavom-able effect on the mortality of enteric fever as it has on that of typhus. On the contrary, it has been a common observation on the part of almost every writer who has paid attention to the subject, that the strong and robust succumb more readily to it than the feeble. ** The prognosis, however, is bad in persons who are very fat, or have large ynus- cular development, whose habits have been intemperate, or who are the subjects oi gout, or of diseases of the kidneys (see pp. 242-3). c. Presence of certain Symptoms and Complications. "With a few exceptions mentioned below, the rules for jDro- gnosis laid down under typhus (p. 245) hold good in enteric fever. A few rules may be added, which apply to enteric fever alone. CnoiiEL, 1834 ; Forget, 1841, p. 404 ; Baekalliek, 1S61, p. 2S2. PROGNOSIS AND MORTALITY. 6 1 I 1. The mode of invasion must not be allowed to influence the prognosis. The disease may set in severely, and yet its sub- sequent course may be mild, and still oftener the reverse of this observation is made. It must ever be kept in mind that enteric fever is often latent, and that the mildest cases may terminate suddenly in death (p. 593). 2. In all cases the prognosis is bad in proportion as the morning remissions of temperature are slight and of short dura- tion. A temperature at anytime of 105° Fahr, indicates a severe case, although recovery has been known to follow a temperature of nearly 108°. A sudden rise or an irregular range of tem- perature is always unfavourable, while, on the other hand, a sudden and great fall of temperature may be due to collapse from intestinal haemorrhage or to some other cause (pp. 519, 527). 3. A fall in the pulse is a less favourable indication than in typhus, as its frequency may vary greatly before the cessation of the fever (p. 520). 4. Perspirations may occur at any stage of the fever, and are not necessarily critical or favourable (p. 519). 5. An abundant eruption does not betoken a grave case as in typhus, and many patients die in whom there has been no eruption (p. 513). 6. Many more patients die in whom the tongue has been at no time dry and brown than in the case of typhus (p. 522). 7. Vomiting early in the attack is not unfavourable, but when it occurs after the fourteenth day it may be the first symptom of peritonitis (p. 523). 8. Diarrhoea is unfavourable in proportion to its severity and duration (p. 525). 9. Abdominal pain and great meteorism are also unfavour- able (p. 523). 10. Copious haemorrhage from the bowels often induces fatal collapse, or is followed by perforation ; slight haemorrhage adds little to the danger, but may become suddenly profuse (p. 527). 1 1 . When peritonitis supervenes the case is almost hopeless ; but in rare instances patients have recovered after all the symp- toms of perforation (p. 571). 1 2. Severe and protracted muscular tremors, especially where the mind is clear, indicate deep and rapid ulceration of the bowel. 13. Sudden collapse is most likely to result from perforation or from copious bleeding into the bowel, though there be no abdominal pain, and is usually fatal. E E 2 6l2 ENTERIC OR PYTHOGENIC FEVER. 14. When coma and congestion of the lungs supervene during the first week, the patient often dies before the four- teenth day (p. 556). 15. Epistaxis is in most cases of little moment; but if pro- fuse it may be fatal (p. 544). 16. Pregnancy is a less serious complication than is com- monty imagined, but the mother usually aborts or miscarries (p. 582). 17. A temporary remission during the second or third week, followed by a return of pyrexia and an aggravation of the other symptoms, often terminates fatally. Louis and Chomel make a similar remark." 18. Even after convalescence seems to be fairly established, all cause for anxiety is not removed. A relapse may occur, or the intestinal ulcers, instead of cicatrising, may give rise to exhausting diarrhoea or hsemorrhage, or may advance to per- foration. d. Mode of Fatal Termination. As in tj^Dhus (p. 248) death may take place by asthenia or by coma, or by a combination of these modes. Coma, resulting from deficient aeration of the blood, or from non-elimination of urinary products, most commonly causes death by the end of the second, or the beginning of the third, week. But death occurs by pure asthenia or ansemia far more commonly than in typhus, and then it may not take place until the third or fourth week, or even later, and is usually preceded by severe intestinal symptoms. Death by sudden collapse, where the previous symp- toms have not indicated danger, is also more common in enteric fever. Although this result is usually traceable to haemorrhage or perforation, I have known it occur during the third week independently of either of these causes, and similar facts have been noted by other observers.^ Sect. XII. Anatomical Lesions. The anatomical lesions of few diseases have been studied with greater care than those of enteric fever. My own observa- tions confirm for the most part those contained in the classical works of Louis, Chomel, Kokitansky, Jenner, and Hoffmann.^ « Louis, 1841, ii. 349; Chomel, 1834. p Lancet, 1S67, ii. pp. 540, 600. 1 Louis, 1841 ; Chomel, 1834 ; Kokitansky, Path. Anat. Syd, Sec. Transl. ii. 68 ; Jexnek, 1S49 (2) ; HoEEMANX, 1869. ANATOMICAL LESIONS. 613 Enteric differs from typhus and relapsing fevers in the in- variable presence of specific lesions, which are often associated with others of an accidental or less constant character. a. Generalities. 1. The Cadaveric Rigidity is more marked and of longer duration than in typhus. Of lo cases, where I have noted the circumstance within thirty-six hours after death, there was marked rigidity in all but i . 2. Emaciation. Owing to the lengthened duration of the ill- ness the emaciation is often extreme. 3. Putrefaction. There is less tendency to rapid putrefaction of the dead body than in typhus, except in cases where the typhoid state has existed for some days prior to death. h. Integuments arid Muscles. 1. Discoloration s. Livid discoloration of the integum^ents on the dependent parts of the body is less common than in typhus, and rarely extends up along the sides of the trunk when the body has been laid on the back. The face is rarely livid, except where there have been pulmonary complications. Discoloration of the integuments along the course of the subcutaneous veins is also rarely observed. Greenish discoloration of the integu- ments covering the abdomen, within forty-eight hours of death, is also rarer than in typhus. Louis and Jenner noted this appearance in only 6 of 46 cases. (See p. 249.) 2. The Eruption. The lenticular rose-spots are never observed on the dead body, although they may have been present in large numbers immediately before death. (See p. 511.) 3. Sudamina are not uncommon. Jenner noted them in 4 out of 23 cases. (See p. 516.) 4. The Muscles. The changes in the voluntary muscles de- scribed under the head of typhus are also met with in enteric fever. (See p. 249.) As in typhus, I have occasionally observed haemorrhages and pseudo-abscesses in the substance of the muscles consequent on rupture of their diseased fibres. Zenker found extravasations of blood in the substance of the muscles in II cases, and Hoffmann in 11 out of 250 autopsies. Their chief seats are the rectus and transversalis abdominis, the psoas and pectoral muscles. 6l4 ENTEEIC OK PYTHOGENIC FEVEE. c. Organs of Digestion. I . Pharynx and (Esophagus. The pharynx is in many cases found to be healthy (in 38 of 46 cases by Louis, and in 7 of 15 cases by Jenner), but not unfrequently it exhibits signs of recent inflammation and sometimes distinct ulcers. Louis found recent ulcers in 6 out of 46 cases/ and Jenner in 5 out of 15 cases. These ulcers are seated chiefly at the lower part of the pharynx ; they have a round, oval, or irregular outline, and they vary in diameter from two lines to three-quarters of an inch. They are usually very superficial, but occasionally their base is formed by the muscular coat. Their edges are not thickened, and the surrounding mucous membrane is either normal or slightly in- jected. In cases where there is no ulceration the mucous mem- brane is occasionally found to be abnormally injected or coated with diphtheritic false membrane, or the sub-mucous tissue is infiltrated with serum or pus. The oesophagus is in most cases healthy ; but it occasionally exhibits ulcers similar to those met with in the pharynx (in 7 of 46 cases, Louis ; in i of 1 5, Jenner). These ulcers are usually largest and most numerous at the lower, or cardiac, extremity. They may be mere excoriations, or they may penetrate to the muscular coat, but they have never been found to end in per- foration. The ulcers in the pharynx and oesophagus are never found when death occurs before the third week of the disease. Al- though they are not met with after death from tj^phus or from other acute diseases, they must not be confounded with the specific lesions of enteric fever, to which they are secondary. There is no evidence that they are preceded by any morbid deposit like what occurs in the intestines, although statements to this effect are commonly made. Chomel remarks : — ' Toutes les ulcerations, dont nous avons parle jusqu'ici, succedent a une alteration des follicules : dans celles dont nous nous occupons maintenant, cette alteration n'a point ete constatee ; on n'a jamais rien observe dans ces parties d'analogue aux plaques gauffrees ou aux follicules isoles engorges de I'intestin.'^ Louis expresses himself in almost the same terms.* 2. The Stomach is in many cases healthy. The morbid ap- X)earances which it sometimes presents are increased vascularity, ■" Louis, 1841, i. 135. ' Chomel, 1834, p. 192. ' Louis, 1S41, i. 136. ANATOMICAL LESIONS. 615 softening, mammillation, and superficial ulcers. These lesions, however, are far from constant, and are observed with almost equal frequency after death from other diseases. Louis pointed out, long ago, that ' typhoid fever ' has no more right to be designated g astro- entente than pneumonia has to be called gastro-jjeripneumonie. Increased vascularity was noted by Jenner in 5 out of 1 5 cases, but in 6 cases the membrane was pale. Chomel found the mucous membrane of the stomach in some cases pale throughout. Softening of the mucous membrane was noted by Louis in 16 of 46 cases; by Chomel in 14 of 42 cases, and by Jenner in 5 of 1 5 cases. This softening is in most cases confined to the great cul cle sac, but it is occasionally general. Sometimes the membrane is attenuated, as well as softened. In two cases Chomel found the membrane entirely destroyed, fragments only remaining, which were readily washed off by a stream of water ; while in a third case the softening had extended through the entire coats, over a space the size of a half-crown piece, so that very slight pressure caused it to rupture. This softening of the coats of the stomach is probably nothing more than the result of -post-mortem digestion. Chomel showed that there was no relation between it and the presence of gastric symptoms during life. Mammillation of the mucous membrane was observed by Louis in 1 3 out of 46 cases, and by Jenner in 6 out of 8 cases. Ulceration is extremely rare. I have never met with it in upwards of 40 cases, in which I have examined the stomach, Chomel failed to find it in any of 42 cases examined by him. Jenner met with it only once in 20 cases ; and Louis, four times in 46 cases. The ulcers are not confined to any particular part of the stomach. They may exceed twenty in number, but they are always minute, varying from the size of a pin's head to two or three lines in diameter. They are also quite super- ficial, and are not preceded by any deposit in the mucous mem- brane. These minute superficial ulcers of the stomach are not uncommon after death from various diseases, especially of the heart or liver, and Dr. G. Budd says that he has several times had reason to ascribe them ' to an excessive use of stimulants, given in the hope of remedying the sense of sinking in the last days of life.'" (See p. 250.)" " Budd, Dis. of Stomach, 1855, p. 153. 6l6 ENTEEIC OR PYTHOGENIC FEVER. 3. The Duodenum is in most cases healthy. Sometimes its Hning membrane appears abnormally vascular, or its mucous follicles are enlarged ; but these conditions were ascertained by Louis to be equally common after death from other acute diseases. In 2 out of 22 cases, Louis found one or two minute superficial ulcers close to the pylorus, similar to those met with in the stomach. There was no ulceration in any of 1 5 cases examined by Jenner, or in 40 cases dissected by myself. 4. The Jejunum and Ileum do not usually contain much gas. On the contrary, the lower part of the ileum is often collapsed and empty. The tympanites during life is due to the presence of gas in the colon, except in cases where there is peritonitis, when the intestines may be uniformly distended ; excluding cases of perforation, Louis found slight tympanites of the small intestine in only 14 out of 39 cases. The fsecal contents are liquid and of an ochrey or orange colour, and they often contain yellowish- brown sloughs detached from the mucous membrane, large quan- tities of ammoniaco-magnesian phosphate, and occasionally small masses of blood. A considerable quantity of intestinal mucus may be found in the upper part of the small intestine. Louis states that worms (ascaris lumhricoides) are often passed by patients labouring under enteric fever, and that he has often found them in the small intestine after death. I have repeatedly known either round or tape worms voided during the attack, and the observation is interesting in connection with some of the names formerly given to enteric fever. (See pp. 418 and 421.) In 3 out of 46 cases, Louis found a portion of the small in- testine invaginated into the portion below, to the extent of from one to two feet. These invaginations are not accompanied by any signs of inflammation, and are produced in the death-struggle of many diseases in which there is much torpor of the cerebro- spinal system. I have met with them in several cases of enteric fever » (See Case XLV. p. 507.) The colour of the mucous membrane varies. Its vascularity is not necessarily increased. Louis observed it of its natural pale- ness, or merely tinged with bile, in 1 7 out of 46 cases ; and Jenner, in 1 1 out of 17 cases. In one-third of Louis' 46 cases there was increased redness of the mucous membrane. This redness may be either uniform or in patches, and it is almost always most marked towards the lower extremity. When death does not occur until after the third or fourth week of the disease, the mucous membrane often presents a greyish or slate-coloured aspect. Chomel found the mucous membrane of the small intestine in- ANATOMICAL LESIONS. 61/ filtrated with a bloody fluid, over a space varying from four inches to three feet, in 7 out of 42 cases. The membrane was much increased in thickness, and presented a gelatinous glistening aspect, and a rose or reddish black colour. When squeezed, a bloody fluid oozed out, and the membrane regained its natural thickness. This appearance was uniform all round the bowel, and was not limited to the dependent portions of the coils. In most cases there had been intestinal haemorrhage during life, or blood was found in the intestines after death. I have met with a similar condition in several cases. As to consistence, Louis found the mucous membrane softened in all except 9 of 42 cases. Chomel noted this condition in only 5 of 42 cases; and Jenner in 3 of 15 casest Like the softening in the stomach, it is probably a post-mortem change,^ although Louis was inclined to think that in certain cases, where it was associated with redness and thickening, it was inflammatory. None of the above lesions are constant in, or peculiar to, en- teric fever (see p. 251). The specific lesions, which are invariably present, and which consist in a disease of the agminated and solitary glands of the ileum, have now to be described. These lesions present different appearances according to the duration of the illness prior to death. They may be described as passing through four stages, although the disease is often arrested at the end of the first. The stages are: — i. The stage of enlarge- ment of the intestinal glands. 2. The stage of softening and ulceration. 3. The stage of the genuine 'typhoid ulcer;' and 4. The stage of cicatrisation. Two or more of these stages may often be traced in the same body ; for the morbid process, as well as the process of reparation, always commences at the extremity of the ileum nearest the csecum, and proceeds upwards. a. First Stage. This consists in the enlargement of the agmi- nated and solitary glands. Eokitansky maintains that the en- largement of the glands is preceded by a ' congestive stage ; ' and Trousseau states that enlargement does not commence before the fourth or fifth day of the disease,^ while Louis and Chomel held that it did not commence until the seventh or eighth day. But there is no evidence that the enlargement of the glands is preceded by increased vascularity^ while there are facts to show that it commences with the disease, and continues to progress until about the ninth day. In no case, where death has occurred at an early stage of the disease, has there been increased vascularity " See BcDD, Dis. of Stomach, 1855, p. 46. * Teousseau, 1S61, p. 139. 6i8 ENTEEIC OE PYTHOGENIC FEVEE. Fig. i3.-^Lower two inches of ileum from a case of enteric fever fatal at the end of the second day. without enlargement of the glands ; and, indeed, in no instance has the latter appearance been wanting. In one case under my care, where death occurred on the sixth day, great en- largement had already taken place (see Case XL VII.). Con- siderable deposition had also taken place in five cases re- corded by Bretonneau,'' For- get,yBristowe,^and Hoffmann,* which were fatal on the fifth day. In Case LIV. (p. 551), where death occurred at the end of the second day, there was also considerable enlarge- ment of the solitary glands, as represented in the annexed woodcut. Lastly, in the cases which occurred at Clapham in 18.29 (see p. 473) considerable enlargement was found at the end of the first day. Moreover, in cases fatal at a more advanced stage, it is not found that in the agminated glands at the uppermost limit of the disease there is increased vascularity without enlargement ; while, on the other hand, slight enlargement without any increase of vascularity is not uncommon. At all events, mere increase of the vascularity of the agminated and solitary glands, without any enlargement, will not justify the opinion that a patient has died of enteric fever, however short may have been the duration of the illness. An opportunity is rarely offered of examining the intestines before the eighth or tenth day of the disease. Peyer's patches are then found to be indurated and elevated from half a Ime to two lines above the surface of the bowel (Fig. 14). The membrane covering them is of a pinkish -grey or purplish colour, and is often softened; while that between the diseased patches may have its natural hue, or may present every grade of vascularity up to the most intense injection. The peritoneum corresponding to the patches is usually much injected, and of a bright-red or pale- purple colour. Two varieties of diseased patches have been de- scribed b}^ most French writers since the time of Louis. These '^ BeETONNEAU, 1829, p. 70. y FOHGET, 184I, J^. II9. ^ Lancet, April 28, i860 ; and Path. Soc. January 7, 1S62. * HOEFMAXN, 1869, p. 38. ANATOMICAL LESIONS. 619 are the plaques molles and the plaques dures of Louis ; or the plaques reticulees and plaques gauffrees of Chomel. In the former, the enlargement is comparatively slight, its consistence is soft, and the mucous membrane covering the patch is more or less red, and has a rugose or granular aspect. In the latter, the patch is more elevated, thicker and harder, and the super- imposed mucous membrane is paler and presents a smoother and more uniform aspect. Louis was of opi- nion that the plaques dures were less common than i\ie])laques molles. He found them in only 1 3 of 46 fatal cases, and from the circumstance that they were most common in cases fatal before the fifteenth day, he concluded that they constituted a more dangerous form of the dis- ease than the other. The cor- rectness of this opinion may be doubted. At an advanced stage of the disease, after the morbid mate- rial has sloughed out, it is impos- sible to say which of the two forms of the lesion has existed at first. From my own observations, I am inclined to think that in fatal cases the plaques dures constitute the more common form in adults. But after all the differences between the two forms are differences merely of de- gree ; the morbid process is the sp-me in both. Gradations may be ob- served between them, and they con- stantly co-exist in the same intes- Kg. , ^-Portion of the i tine.^ The solitary glands at the lower end of the ileum are often affected in a manner similar to leiim, from a case of enteric fever fatal on the tenth day, showing the enlarged agminated and soli- tary glands, not jet ulcerated. *" Dr. T. J. Maclagan thinks that there must be a reason why the morbid pro- cess should present two distinct forms in the same individual, and has endeavoured to show that the i^laq^ues molles are always excited by a secondary inoculation with 620 ENTEEIC OE PYTHOGENIC FEYEE. Peyer's patches. Louis found them diseased in 12 out of 46 cases ; and, in my experience, the proportion of cases in which they are imphcated is even greater. They may be as large as a hemp-seed or a spht-pea, or they may be larger ; and then- pale colour and flattened surface often impart to them an appearance not unlike the pustules of variola. The diseased solitary glands are usually limited to the lower twelve inches of the ileum, but they may extend higher. In exceptional cases, of which I have seen two, the solitary glands are diseased, while Peyer's patches remain intact. Cruveilhier designated this variety 'forme i)us- tuleuse.' The precise manner in which the intestinal glands are affected is a point of some interest, on which different opinions have been expressed. Boehm, in his admirable description of these glands,*^ stated that in enteric fever the morbid material was deposited in poison thrown off by a plaque dure, or, in other words, that the plaq^ces dures are primary, and the jilaques vwlles secondary, lesions, and that a plaque molle can never be found j)rior to sloughing of at least one plaque dure. These secondary lesions he believes to run a more rapid course than the primary (so that at the end of the third week it is impossibletodistinguishbetween the two), and to be the chief cause of haemorrhage, ^perforation, and relapses. This view, in his opinion, is necessary to explain why the lesion is always so extensive at the lower end of the ileum (the ileo-colic valve like a sphincter detaining the poison from the primary lesions and so favouring secondary inoculation), why healthy Peyer's patches are not found below those that are diseased, and why the frequency of haemorrhage, perforations, and relapses is in a direct ratio to a constipated state of the bowels, the retention of the poison given off by the primary lesions favour- ing the occurrence of those which are secondary but more dangerous. (See T. J. MACLAGA^^ 1871 and 1873.) In reference to these views I would observe : — i. Minute examination of the plaques dures and p)laques molles shows that the former are merely a more severe form of inflammation of the glands that the latter. In the same bowel the two forms may be seen passing by insensible gradations into one another. 2. When death occurs before ulceration or sloughing, plaques molles may be seen inter- spersed among plaqites dures^ or even, as was long since shown by Louis, without any plaques dures. 3. After ulceration, the lesion highest in the bowel is not always, as in the one case examined by Dr. Maclagan, a plaque dure, but, accord- ing to my observation, is far oftener a plaque molle, the disease in fact becoming less intense as we proceed upwards. 4. The concentration of the lesion imme- diately above the valve is a feature of the disease from its commencement, before ulceration or sloughing, and is not the result of any secondary inoculation. 5. The lesion is not only most abundant, but most advanced, in the lower jjart of the ileum. I have repeatedly known extensive ulceration at the valve, and plaques molles not yet ulcerated several feet above it. The reason why healthy Peyer's patches are not found below those that are diseased is that the lesion advances from below upwards, and not from above downwards. 6. In two-thirds of the cases of enteric fever the glands of the colon escape. This exemption, according to Dr. Maclagan, may be due to dilution or neutralisation of the poison by the acid secre- tion of the colon, but the explanation is unsatisfactory. It may be added that in my experience the colic glands have been as frequently affected in cases dying early, as in those dying late in the disease. 7. Although haemorrhage and per- foration may occur in cases where there has been constipation, they are far more common where there has been diarrhoea (see pp. 525 and 568). 8. In relapses which are fatal, the fresh lesions may be found higher up in the bowel than those of the primary attack (see p. 554). ' Dc Gland. Iniestin. Berol. 1835. ANATOMICAL LESIONS. 621 the sub-mucous tissue external to the glandules, and this view has been commonly adopted. '^ On the other hand, John Goodsir, from careful observations, concluded that the morbid products were in the first place deposited in the interior of the glandules, which became much distended and ultimately burst, discharging their contents into the sub-mucous tissue.® Goodsir's observations approach nearest to the truth, but modern means of research have shown that the glandules are not, as was imagined by most physi- ologists of his day, closed vesicles which periodically discharge their contents into the bowel, but that they are in reality small lymphatic glands. Each glandule is composed of a delicate fibrous reticulum, enclosing lymph-corpuscles in its meshes.^ In enteric fever the proper structure of the gland first becomes enlarged by a proliferation of its cellular elements, and as the process advances the surrounding connective tissue becomes implicated, until at last the whole patch becomes converted into a continuous mass of altered gland-tissues. This is what happens in the case of the plaques dures. In the plaques molles the morbid process stops short of this ; the glandules become enlarged, but not to such an extent as to run into one another. [For the presence of microzymes in the infiltrated portions, see p. 646.] The enlargement of the intestinal glands does not of necessity lead to ulceration. The morbid products to which the enlarge- ment is due may be re-absorbed, ^ absorption commencing about the tenth or twelfth day of the disease, and by the end of the third week being complete. This is what probably occurs in those cases already alluded to, where the disease is mild and of short duration (see pp. 549 and 592), convalescence commencing about the middle or end of the second week. According to Aitken, the material in the glands is most often got rid of by the vesicles rupturing ' in the ordinary way,' and discharging their contents into the bowel ; but from what has been already stated, it follows that this view is founded on a misconception of the normal struc- ture of the glands. The function of the glands, moreover, is that of absorption, not of secretion or elimination. h. Second Stage. Ulceration of the diseased Peyer's patches may commence in two ways. The mucous membrane becomes * See, for example, J. Haeley, 1866, p. 575. " Goodsie, 1842. Steickee's Man. of Histology, Syd. Soc. Ed. 1870, p. 567. s On this subject see Chomel, 1834, Obs. 14 and 15 ; Loms, 1841, i. 181 ; Bae- THEz and EiLLiET, 1853, ii. 667; Lyons, 1861, p. 243; Teousseau, 1861, p. 139; Aitken, Pract. of Med. 2nd ed. 1863, p. 396. 622 ENTERIC OR PYTHOGENIC FEVER. softened, and one or more superficial abrasions appear on the surface of the diseased patch, which extend and unite into one large ulcer, and this ulcer proceeds to various depths through the coats of the bowel and even to complete perforation. This is what happens in the case of the plaques molles. In the case of the ijlaques dures, the whole of the morbid material in the sub- mucous tissue, as well as the super-imposed mucous membrane, becomes detached in the form of a slough, leaving behmd an ulcerated surface. This, according to my observation, is the more common mode. The whole of a diseased patch may slough out at once, or it may slough in successive portions. Occasionally, the sloughing appears to extend at once through the entire coats of the intestine, so as to produce perforation. When death occurs between the twelfth and twenty-first days, the sloughs may be seen loosely attached to the intestinal ulcers, as repre- sented in the annexed figure (Fig. 15). These sloughs have usually a yellowish-brown colour from saturation with bile; occasionally they present a dark, spongy, fungating aspect, from being infiltrated with blood. It is important to determine at what stage ulceration com- mences. In fatal cases, this appears to be about the ninth or tenth day, but in this respect there are considerable differences accordmg to the intensity of the morbid process, which is, no doubt, more intense in cases fatal within the first fourteen days of the disease than in those which survive longer. Louis, Chomel, Forget, and Hoffmann each record a case where death occurred on the eighth day, but in none had ulceration com- menced, although in Forget's case the agminated glands are described as on the point of ulcerating.'' There are several cases on record where ulceration has been found as early as the ninth or tenth day ;' but it may commence earlier or later. In Case LV. it had commenced on the seventh day ; Louis men- tions two cases where it had commenced on the eighth day, and in one of Forget's cases it was found on the ninth day to be very extensive. Cases have been already referred to (p. 569) where the ulceration had advanced to perforation as early as the eighth or nmth day. Stoll relates a case where extensive sloughs were formed in the ileum as early as the seventh day,J and Boudet has published minute particulars of a case, fatal at the end of five and a-half days, in which deep ulcers, with •> FoEGET, 1S41, p. 122. ' Louis, 1841, ii. 60; Hoffjiaxx, 1S69, p. 39. J Forget, 1841, p. 116. ANATOMICAL LESIONS. 623 Pig. 15.— Portion of Ueum, from a case of enteric fever fatal on the seventeenth dajr, showing the partially detached sloughs. The morbid process has advanced further iai the agminated than in the solitary glands. The mesenteric glands are much enlarged. 624 EXTEPJC OE PYTHOGENIC FEYEPv. partially^ detached sloughs, "were found in the boweL^ There is reason to beheve that in rare cases ulceration may commence as early as the first or second da}^ (see p, 473). On the other hand, of four cases examined b}^ Chomel in which ulceration had not commenced, 2 died on the eighth, i on the eleventh, and I on the twelfth day. Louis and Hoffmann each record a case where ulceration had not commenced on the twelfth day, and one has occurred in try own practice. (Case LVI.) The ulceration always commences in the glands nearest to the caecum ; these are often found extensively ulcerated, though ulceration may not have commenced in the glands higher up.^ c. Third Stage. The stage of the ' typhoid ulcer ' is that which intervenes between commencement of ulceration and the commencement of cicatrisation. It is impossible to fix its limits, as they vary in different patients and in different ulcers of the same bowel. The sloughs may be found detached from the ulcers nearest to the cscum as early as the fourteenth or fifteenth day, but adherent to the ulcers higher up as late as the thh-d week, or even later. The ulcers maybe distinguished from other ulcers of the bowel by the following characters: — i. They have their seat in the lower third of the small intestine, and theh number and size increase towards the ileo-cfecal valve. 2. They vary in diameter from a line to an inch and a-half. Close to the caecum a number of ulcers often unite to form a mass of ulceration, several inches in extent. 3. Their form is elliptical, circular, or irregular. They are elliptical, when they correspond to an enthe Peyer's patch ; circular, when they correspond to a solitary gland; and irregular, when they correspond to a portion of a Peyer's patch, or when several ulcers unite to form one. 4. The elliptical ulcers are always opposite to the attachment of the mesentery. They do not form a zone encircling the gut (as may be observed in the tubercular ulcer), but their long diameter corresponds to its longitudinal axis. An elongated ulcer, how- ever, running transversely may result from the confluence of several ulcers originating in the solitary glands, especially in the large bowel. 5. Then- margin is formed by a well-defined fringe of mucous membrane, detached from the sub-mucous tissue, a line or more in width, and of a purple or slaty-grey colour : this is best seen when the bowel is floated in water. After the separation of the sloughs, there is no thickening or ^ BOTJDET, 1846. ' Chomel records one case, fatal on the tenth day, in which ulceration commenced in the jjatches farthest from the ciecum, but such an occurrence is quite exceptional (CnoiJEL, 1834, Obs. 4). ANATOMICAL LESIONS. 625 induration of the edge, as in the tubercular ulcer. 6. Their "base is formed by a layer of sub-mucous tissue, by the muscular coat, or by the peritoneum. There is no deposit of morbid tissue at the base of the ulcer, although sometimes fragments of the yellow sloughs may be seen adhering both to the base and edges (Fig. 15). d. Fourth Stage. The cicatrisation of the ' typhoid ulcer ' takes place in this way: — The surface of the ulcer becomes covered with a delicate shining layer of granulation tissue, which is dove-tailed, so to speak, between the muscular coat and the detached fringe of mucous membrane. The latter becomes ad- herent from the circumference towards the centre to the sub- jacent new issue, and an epithelial covering is gradually formed over the ulcer. This covering cannot at first, like ordinary mucous membrane, be moved upon the subjacent coat ; but after a time it does become movable, and, according to Eokitansky, it is even coated with villi, but the gland-structure which has sloughed out is of course not regenerated. The resulting cicatrix has the following characters: — It is slightly depressed, firmer, less vascular, and smoother than the surrounding mucous mem- brane. When held up to the light, the bowel appears thinner at the part. The depressed spot seldom exceeds two or three lines, but may amount to half an inch, in diameter. It is never surrounded by any puckering, and it never causes any diminu- tion in the calibre of the gut. According to Chomel,"* all traces of the ulcers after a short time disappear ; but Barrallier"^ men- tions cases where the cicatrised ulcers were distinct at the end of four or five years, and Eokitansky" remarks that he has discovered cicatrices answering to the above description thirty years after an attack of enteric fever. The period between the separation of the sloughs and the commencement of cicatrisation varies ; but, as a rule, the repa- rative process does not commence until some time during the fourth week of the disease. The time necessary for the cicatri- sation of each ulcer is probably about a fortnight. In one case, where the primary fever lasted three weeks, but where death occurred from complications about the fortieth day, I found all the ulcers in the ilium cicatrised. Cicatrisation commences in the ulcers nearest to the csecum, and proceeds upwards. Con- sequently, when death occurs in the fourth or fifth week of the Chomel, 1834, p. 128. ° Baeeallteb, 1861, p. 105. ° O}]. cit. ii. 73. 626 ENTEEIC OR PYTHOGENIC FEVER. fever, the intestine may appear at first sight most diseased one' or two feet above the caecum. As abeady stated, in cases where death occm's during a relapse, the cicatrices of the first attack may be found co-existing with the fresh deposit and recent ulcers of the relapse (see p. 554). But the process of cicatrisation is occasionally delayed, sometimes for weeks after the termination of the primary fever. The ulcers become chronic, or, as some j)athologists say, atonic. All ulcers found after the fourth week of the disease not undergoing cicatrisation may be regarded as Fig. 16. — Pin-hole perforation in the ileum of a girl aged lo, who died on the eighteenth day of an attack of enteric fever. The perforation is seen in the centre of the tdcer, on the right-hand side of the cut. atonic. These chronic ulcers may cause severe diarrhoea, or may advance to perforation. (See pp. 565 and 569.) Perforation. The ulcer of enteric fever frequently extends through both layers of the muscular coat, leaving nothing but the peritoneum, and occasionally the peritoneum itself is per- forated. Perforation may take place in three ways. i. In the first place, it may be due to molecular disintegration, or to an extension of the ulcerative process. The opening is then always minute and rounded, just large enough to admit a pin or a stocking-wire. One or two small perforations of this sort may be seen at the base of the ulcer (Fig. 16). This, in my experience, is the most common mode, having been observed in 15 of 29 cases in which I have notes on the matter. 2. A considerable portion of the peritoneum may slough, and the perforation may result from the partial or complete detachment of the slough ANATOMICAL LESIONS. 627 (Fig. 17). This was noted in 10 of 29 of my cases. In this ease the opening may be of considerable size, and there are often more than one. In several instances I have found that on opening the bowel sloughs corresponding to several entire Peyer's patches and including the peritoneum have fallen out, leaving large oval apertures. Lyons mentions a similar case.P 3. The perforation may result from rupture of the denuded peritoneum (4 of 29 cases). Some observers have doubted if this ever occurs, but the elongated linear appearance of the open- ing in certain cases admits only of this explanation. BristowC;, Pig. 17.— Semilunar perforation formed by the partial detachment of a slough of the peritoneum. a. Enlarged mesenteric gland, b. Dead, white portion of peritoneum, surrounded by inpreased vascularity ; the opening is seen at lower end. c. Flakes of lymph. (See Case LXI., p. 573.) indeed, thinks that the perforation is in most cases due to lacera- tion ;•! and this mode of perforation may account for the circum- stance that perforation is common in cases of a latent character, where the patients have not been sufficiently prostrate to confine them to the recumbent posture (Fig. i8). In the majority of cases the perforation is in the ileum ; more rarely it is in the appendix vermiformis (Case LXVII.), or p Lyons, 1861, p. 245. •> Beistowe. i860, p. 113. s s 2 628 ENTEKIC OE PYTHOGENIC FEVER. in the colon (Cases LXVIII. and LXIX.). Of lo cases collected by Louis the opening was in the lower foot of the ileum in all. Of 39 cases in which I have noted the situation of the perfora- tion, it was in the ileum in 34 ; in the appendix vermiformis in I, and in the colon in 4. Morin, in his memoir, has tabulated 64 cases collected from different sources with somewhat different results. Of the 64 cases, the perforation was in the jejunum in 2; in the ileum in 36; in the appendix vermiformis in 12; and in the colon in 14.'" Of my 34 cases where the perforation was in the ileum, in 27 it was within twelve inches of the ileo- colic valve ; in 6 it was between twelve and twenty- four inches above the valve ; and in i it was thirty inches above the valve. I have never met with a perforation higher than this ; but Fig. 18.— Perforation produced by rupture of the denuded peritoneum, Bartlett mentions a case where it was as high as 44 inches,^ and Bristowe another where it was 72 inches* above the valve, while Morin cites two instances of enteric fever, one on the authority of Lebert, in which a perforation was found in the jejunum. The perforation has also been known to occur at the apex of a diverticulum ilei." Of my 4 cases of perforation of the colon the opening was in the caecum in i, at the junction of the ascending and transverse colon in i , and in the sigmoid flexure in i ; while in the fourth there was one perforation in the caecum and 2 in the sigmoid flexure. Of 14 cases of perforation of the colon ' Morin, 1869, p. 37. The large proportion of perforations of the appendix vermiformis suggests the question whether all of them were in cases of enteric fever. ' Bartlett, 1856, p. 79. ' Bristowe, i860, p. 113. " Path. Trans, vol. xxiii. p. 103. ANATOMICAL LESIONS. 629 collected by Morin it was situated in the csecum in 2 ; in the ascending colon in 7 ; in the transverse colon in i ; and in the sigmoid flexure in 4/ As to the number of perforations, there was only one in 28 of my cases ; two in 5 ; and three in 4 cases. Occasionally they are more numerous, and Hoffmann has recorded a case in which there were more than twenty-flve of them."^ When the perforation is large several pints of fgecal matter and even intestinal worms may be found in the peritoneal cavity ; but more commonly the contents of the bowel are prevented escaping into the peritoneum in large quantity by surrounding adhesions, and the peritonitis has a tendency to be circumscribed. The perforation also, when small, is sometimes closed by lymph, as if undergoing a spontaneous cure. Circumscribed peritoneal abscesses occasionally result from perforation, which may induce ulceration or sloughing of the parietal peritoneum, or may even open externally into another portion of the intestinal canal, and after the discharge of the matter in any of these ways recovery may take place (see p. 572). In rare instances, perhaps, such an abscess may open into the gall-bladder or urinary bladder.'' TJie extent of the intestinal disease in enteric fever varies greatly in different cases. The number of diseased Peyer's. patches may vary from two or three to thirty or forty. At the upper part, the transition between the diseased and the healthy patches is usually rather abrupt ; and proceeding downwards, after the first diseased patch all are usually diseased, but the morbid process is always farther advanced the lower we go down. An extensive mass of disease is usually found at the lower end of the ileum, terminating abruptly at the valve. There is no relation between the extent of the disease of the intestinal glands and the severity of the cerebral or abdominal symptoms (see pp. 525 and 532); but where there has been excessive diarrhoea,, there are usually signs of extensive inflammation of the mucous membrane, or ulceration of the glands. " For other examples of perforation in the colon, see Path. Trans, ix. 199, and xiii. 65. '" Hoffmann, 1869, p. 121. » In the Path. Trans, (vol. xiii. p. 65), I have recorded a case where such an abscess opened into the sigmoid flexure, and a second case (vol. xix. p. 226) where it opened into the caecum. In case LXIX. (p. 579), one can easily conceive that the abscess might have ultimately opened into the gall-bladder. Lastly, a case has been communicated to me of a^ gentleman, aged 60, in whom an attack of ' typhoid fever ' with diarrhoea, slight intestinal hemorrhage, and ' several crops of eruption,' was followed by a discharge of faeces and a thin piece of bone per Tirethram. The patient recovered, but there were some reasons for doubting ■whether the case was not one of typhlitis rather than enteric fever. 630 ENTEEIC OR PYTHOGENIC FEVEE. The intestinal lesions are the same in children as in adults. Extensive deposit, however, in the submucous tissue, followed by sloughing of the diseased patches in large masses, is less com- mon. The solitary glands, also, have a greater tendency to be attacked, and extensive ulceration, or perforation, is said to be comparatively rare (see p. 568). The morbid appearances presented by the agminated and solitary glands of the ileum, above described, are constant in, and peculiar to, enteric fever. They characterise neither typhus, nor any other disease. ' JZ faut,'' says Louis, ' non seulement la considerei- comme propre a Vaffection typhdide, mais comme en formant le caractere anatomiqiie, ainsi que les tuber cides forment celui de la phthisie.' ^ But care must be taken not to set down every unusual appearance of the parts in question to enteric fever, i. In young children, Peyer's patches are naturally more distinct than in adults ; but this condition bears no resemblance to that resulting from enteric fever. 2. The appearance likened by French pathologists to a shaven beard is now well known not to be characteristic of enteric fever, but to be met with after death from many diseases, and even to be compatible with perfect health. This circumstance was pointed out forty years ago by Chomel,'^ and has been insisted on by many subsequent observers."' The appearance in question is simply the result of pigmentary deposit. 3. The agminated and solitary glands of the ileum may be the seat of tubercular deposit and ulceration ; but I am sur- prised that experienced pathologists like Dr. J. Harley ^ and Dr. H. Kennedy*' should be unable to distinguish the tubercular ulcer, with its edges and base indurated from deposit of tubercle, from the ulcer of enteric fever already described. 4. The appear- ances which are most likely to be mistaken for the lesions of enteric fever are those which are occasionally met with after death from cholera, variola, scarlatina, erysipelas, and pyaemia. In these diseases, the solitary and agminated glands are occasionally found slightly thickened and elevated. The enlargement, how- ever, is always slight ; it does not pass through the successive stages observed in the lesions of enteric fever; it very rarely produces ulceration ; ^ and it is not accompanied by enlargement of the mesenteric glands.® These are not the lesions of enteric fever in an early stage, for they are not found any more advanced ' Louis, 1841, 1. 199. * Chomel, 1834, p. 149. • Jennek, 1853, p. 287 ; Jacquot, 1858, p. 252 ; Baeeallier, 1861. ' J. Haeley, 1873. = H. Kennedy, 1873. "^ Anderson, 1861, p. 115. ' RoKiTANSKY, Path. Anat. Syd. Sec. Transl. ii. 89. ANATOMICAL LESIONS. 63 I ivhen death does not occur until the twentieth or thirtieth day •of the illness. Moreover, they are only present in exceptional biases of the diseases in question; whereas the lesions above described are never absent in enteric fever. At the same time, the possibility must be borne in mind of enteric fever coexisting with the diseases just mentioned. (See pp. 453 and 586.) Such •combinations do not justify the doctrine that the transition from scarlet to enteric fever is but a natural pathological sequence, or that the lesions of enteric fever may become a part of any other acute disease. The recent enunciation of this doctrine appears to me to be a retrogade step in pathology. (See p. 453.) 5. The Large Intestines. The colon is in most cases more or less distended with gas, and sometimes to such an extent that it forms numerous coils, which obscure and displace the other viscera. Louis mentions a case in which the liver was displaced in this way so high, that the hepatic dulness was mistaken during life for pneumonia. The mucous membrane of the colon presents the same varieties as to colour and consistence as were observed in the small intestine. These abnormal appearances are common in many other diseases than enteric fever. The solitary glands of the colon are enlarged or ulcerated, like those of the ileum, in one-third of the cases which are fatal. This was found to be the case in 14 out of 46 cases observed by Louis, in 7 out of 20 cases by Jenner, and in 184 out of 539 observed or collected from different German sources by Hoffmann. As a rule, the disease is confined to the caecum and ascending colon, but it may reach as far as the sigmoid flexure. The ulcers are usually small and round, but they sometimes measure fully an inch and a-half in length, and then their long diameter is transverse, corresponding to the folds of the gut. In exceptional cases the disease is more extensive in the large intestine than in the small, and Hoffmann has recorded one case in which it was restricted to the large bowel. ^ The lesions of dysentery occasionally co-exist with those of enteric fever (see p. 565). 6. The Mesenteric Glands are invariably enlarged,^ but their appearance varies according to the stage of the disease at which death occurs. They begin to enlarge at the very commencement of the fever (see p. 617), and go on increasing in size, contem- poraneously with the intestinal glands, until about the twelfth ' Hoffmann, 1869, p. 85. e Hence the designation ' Febris mesenterica,' applied to the disease by many writers. (See iDp. 418, 421, 425.) 632 ENTEKIC OR PYTHOGENIC FEVEE. or fourteenth day. At this time they are sometimes found equaUing or exceeding a pigeon's egg in size, their consistence is tolerably firm or slightly softened, and their colom- is rosy-red or pm'plish. As soon as the morbid material begins to be de- tached from the intestinal glands, the mesenteric glands usually decrease in size, and become softer ; but they are found to be considerably larger than natural as late as the thirtieth day, or later. When death does not occur until after the sixth week, they are often unusually small, shrivelled, tough, and either very pale, or of a grey or bluish colour. In cases, howeyer, where death is due to a relapse of the primary fever, many of them may be found enlarged, as late as eight or twelve weeks from the first commencement of the illness (see pp. 554 and 626). The minute structure of these enlarged glands resembles that of the glands in the bowel to be presently described. In some instances, when a section of one of the glands is examined about the twelfth or fourteenth day, small circumscribed masses of opaque, pale-j-ellow, friable material may be observed. After a time, these masses become softened at their edges into a fluid resembling pus, and then, on cutting across the gland, a number of little drops of puriform fluid may be seen, each with a central yellow slough. In rare cases, an entire gland may become con- verted into a collection of puriform matter, as large as a walnut, in the centre of which are detached sloughs of considerable size. These pseudo-abscesses are usually formed in one of the glands at the termination of the ileum, and they may be found as late as the sixth or eighth week of the disease. Now and then, they may be seen with nothing more than a thin layer of peritoneum separatmg then- contents from the abdominal cavity, and occa- sionally they burst through the peritoneum and excite general peritonitis^^ (see p. 566), but more commonly they slowly desic- cate into a cheesy or calcareous mass. The morbid changes now described are usually most marked in the glands corresponding to the most diseased portions of the bowel, or to the lower end of the ileum. From this situation they gradually diminish in size as we proceed upwards. The mesocolic glands are also enlarged in cases where the mucous membrane of the colon is diseased. Stih the enlargement of the mesenteric glands is not merely the result of intestinal irritation, but must be viewed as a primary anatomical lesion, like that of ^ See Louis, i84i,i. 240; Jenker, 1849 (2); Kokitansky, Palh. Anat. Syd. Soc. Transl. ii. 78. ANATOMICAL LESIONS. 6^2i', the intestinal glands. In lo of Louis's 46 cases, there were dis- eased mesenteric glands corresponding to perfectly healthy por- tions of intestine ; while in another patient, who died on the eighth day of the disease, the mesocolic glands were enlarged and softened, although the mucous membrane of the colon was perfectly healthy. Moreover, as above stated, it is probable that, the mesenteric glands become enlarged as early as those in the intestine. (Case LIV., p. 551.) The glands in the fissure of the liver, the gastric, cesophageal,. lumbar, and inguinal glands, are occasionally found enlarged; but these enlargements are usually due to irritation from ulcers in the stomach or oesophagus, from erysipelas, or from blistered surfaces on the legs.^ 7. The Sjjleen is almost always found to be hypertrophied when death occurs before the thirtieth day. Of 35 cases, in which death occurred before that date, I found the spleen en- larged in all but one, its normal weight being 4^ ounces : the average of 30 cases was 12^ ounces; the largest weighed 20 ounces. On the other hand, in 15 cases where death did not take place until after the thirtieth day, the average weight of the spleen was only 5-9 ounces. In 11 cases where death occurred before the thhty-fifth day, Jenner found the average weight of the spleen to be 10 oz, 3 dr. avoird. ; the smaUest was 6 ounces, and the largest 14 ounces. Louis found the spleen enlarged in at least 36 out of 46 cases, and in 17 it was three, four, or five times its normal size ; most of the cases in which it was not enlarged were fatal after the thirtieth day. Of 117 cases fatal within the first four weeks and examined by Hoffmann, the spleen was enlarged in 95. The enlargement is usually greatest in per- sons under thirty years of age ; this difference according to age may account for the circumstance that the organ is larger in enteric fever than in typhus. The consistence is at first firm, but in the advanced stages of the disease it is usually reduced. Louis found the spleen softened in 34 out of 46 cases ; and in 7 it was reduced to a mass of ' putril- age.' It was decidedly softened in 4 out of 14 cases examined by Jenner, and in 23 out of 52 cases dissected by myself. According to Eokitansky, the enlarged softened spleen is liable to spon- taneous rupture. The colour is usually at first dark purple, but in the advanced stages it becomes paler. See Louis, 1841, i. 254. '634 ENTERIC OR PYTHOGENIC FEVER. Infarctions are occasionally met with in the spleen. I have noted them twice in 61 cases, and Hoffmann found them in 9 of 250 cases at Bale. They are liable to soften into a puriform fluid and may then excite peritonitis. (See p. 556.) They have been erroneously thought to consist of a material similar to what is deposited in the intestinal glands ; but they exactly resemble the so-called ' embolic masses ' met with in typhus, relapsing fever, and other diseases. [For the xDresence of microzymes in the spleen see p. 646.] 8. The Liver and Gall-hladder. The liver is occasionally hyperfemic : it was so in 8 out of 46 cases examined b}^ Louis, in 2 out of 1 5 dissected by Jenner, and in 3 out of 1 2 cases noted by myself ; but in most cases its colour is normal, or it is un- usually pale. The organ was softer than natural in 32 out of 73 cases examined by Louis, Jenner, and myself. This softening is often associated with an indistinctness of the outlines of the lobules, while the microscope shows that the secreting cells are loaded with pigment and oil-granules, or are undergoing dism- tegration. Similar microscopic appearances may be seen in many cases even when the organ is not obviously softened. In advanced stages of the disease Hoffmann has found many of the hepatic cells of large size and containing several nuclei. Frerichs has met with cases in which the liver was in a state of acute atrophy, and he remarks that it not unfrequently contains leucine, tyrosine, and other products of disintegrated tissue.^ Louis and Frerichs each record a case where the liver contained a number of ch-cum- scribed pygemic deposits,^ and a case of acute hepatic abscess in en- teric fever is also referred to by Hudson.^ In one instance I found the liver to contain an opaque yellow mass the size of a pigeon's egg, apparently due to embolism .°^ Emphysema of the liver in conjunction with emphysema of the subcutaneous areolar tissue has been observed by Dr. J. F. Meigs," of Philadelphia (vide ante, p. 559). The lining membrane of the gall-bladder is very liable to become inflamed in enteric fever, without producing any marked symptoms during life. Illustrative cases have been recorded by Andral,° Louis,? Budd,*! Piokitansky,^ Frerichs," &c. The inflam- j Dis. of Liver, Syd. Soc. Traiisl. i. 215. "^ Louis, 1841, i. 118 ; Feeeichs, Ojj. cit. i. 172. ' Hudson, 1867, p. 96. ■" Trans. Path. Soc. vol. xv. p. 132. See also Budd, Dis. of Liver, 3rd ed. p. 169. " Lancet, Dec. 7, 1872. " Clin. Med. 4me ed. ii. 549. p Louis, 1841, i. 281. 1 Dis. of Liver, 3rd ed. pp. 195, 207. ' Path. Aiiat. Syd. Soc. Transl. ii. 160. • Op. cit. ii. 454. ANATOMICAL LESIONS. 635 onatiou assumes different forms. Sometimes it is catarrhal, and the gall-bladder is found to contain pus, as in three cases recorded by Louis and in several which have occurred in my own practice. At other times, according to Kokitansky, it is diphtheritic, and the gall-bladder and biliary passages are found lined with tubular investments of exudation, which may block up the latter, and <;ause dilatation of the smaller ducts. Thirdly, it may take the form of ulceration : cases where the mucous membrane has been found ulcerated have been recorded by Andral, Jenner,* and Trousseau ; " and instances have been already referred to, where the ulceration ended in perforation and fatal peritonitis (see p. 566). There is no evidence that these morbid conditions of the gall-bladder are due to any morbid deposit, like that in the intestinal glands. As Frerichs has shown, they are met with in other febrile diseases besides enteric fever. In a large proportion of cases, where the disease has lasted for three or four weeks, the bile is thin, watery, almost colourless, and of low specific gravity (1010-1016, instead of 1026- 1030). These characters have been noticed by many observers ; but I have rarely, if ever, met with them in typhus. According to Martin Solon, the contents of the gall-bladder, when they present the appearances now described, are of acid reaction^ 9. The Pancreas is usually healthy, but occasionally it is of a rosy or livid hue from hypergemia, or its consistence is reduced. 10. Peritoneum. From the remarks already made, it is obvious that recent peritonitis is far from being an uncommon lesion in enteric fever (see p. 565). d. Organs of Circulation and Blood. 1. The Perica,rdviim is usually healthy. Occasionally it con- tains a few drachms of serous fluid ; but out of 84 cases noted by Louis, Jenner, and myself, in only one (Louis) was the fluid of a sanguinolent hue ; and in only one (Jenner) did it contain shreds of lymph, indicative of recent pericarditis (see p. 257). 2. The Heart. Softening of the muscular tissue of the heart similar to what is observed in typhus is very common after death from enteric fever. Eokitansky observes that, although it may be flabby and pale, it is free from ' that softening of its substance, described by Stokes as occurring in the typhus fevers of Ireland ; * Jennek, 1849 (2). " Trousseau, 1861, p. 203. ^ Solon, 1847. 636 ENTERIC OR PYTHOGENIC FEVER. but this statement is now known to be an error, although extremB' softening is certainly less frequent than in typhus. Louis found, marked softening, sometimes associated with thinning of the walls, in 15 out of 47 cases. Jenner found the heart soft and flabby, or flabby only, in 6 out of 1 1 cases ; and Chomel noted, marked softening in 7 out of 30 cases. As in typhus, the softening, may extend over the whole heart, or it may be limited to the left. Yentricle. Zenker has shown that the softening is due to similar changes to those which he has found in the voluntary muscles, (see pp. 249, 257), and Hoffmann has discovered either waxy or granular degeneration of the muscular tissue of the heart in. 103 out of 159 cases. [The changes which occur in the heart in enteric fever have been carefully investigated by Dr. Hayem,^ and they appear to consist, not- only m a granular and fatty mfiltration of the muscular fibres, but, also in inflammatory changes ; a proliferation of the muscle nuclei ap- pears to take place, and a small celled infiltration is often seen between the muscular fibres, due either to exudation or to prohferation of the connective tissue. Not unfrequently there is a difi^used sanguineous infiltration of the intermuscular connective tissue. He also describes a proliferation of the cells of the tunica intima of the small arteries, which be ascribes to an endo-arteritis. These changes are frequently scattered in patches through the walls of the heart, and are often well marked in the musculi papillares of the mitral valve.] 3. TJie Endocajxlitim presents a dusky-red discoloration more rarely than in typhus. Jenner noted this appearance in only 3 of 16 cases, and in all it was slight (see p. 258). According to Hoffmann the endocardium is often opaque and thickened, owing to a fatty degeneration of its lining epithelium, and in several instances he has found recent endocarditis, with vegetations on the aortic or mitral valves. 4. The Vessels. Hoffmann has made the important observa- tion that the minute arteries of the brain, kidneys, and other organs are often in a state of extreme fatty degeneration. 5 . The Blood. A dark, liquid condition of the blood is rarer than in typhus, and firm white coagula are more common. Louis found white coagula in the heart in more than one-half of his. cases. Out of 14 cases Jenner found the blood fluid in 3, and coagulated into pale fibrinous clots in 10. Of 9 cases noted by myself, the blood in the right side of the heart contained pale fibrinous clots in 6 ; in i, it resembled currant jelly ; and in 2, it was dark and fluid. On the other hand, Chomel found the blood " Hatem, 1874. ANATOMICAL LESIONS. 63/ "black and fluid in 1 5 out of 30 cases, and containing fibrinous clots in only 6. There is a close relation between the condition 'of the blood and the symptoms during life. When death has been preceded for some days by the typhoid state (see p. 532), the iDlood is usually dark and fluid ; in other cases, as for example ivhen death is due to perforation or pneumonia, it often contains iibrinous coagula. Lehmann states, that during the first week of enteric fever the blood resembles that of plethora, the corpuscles and solids of the serum, especially the albumen, being increased, but that from about the ninth day the corpuscles and the solids of the serum diminish with a rapidity proportionate to the intensity of the intestinal affection.'^ Virchow maintains that the number of white corpuscles is always increased, while the fibrine is diminished. The increase of the white corpuscles he attributes to the enlarge- ment of the mesenteric and Peyerian glands.^ He and other observers have also discovered in the blood of enteric fever and of 'Other typhoid diseases minute reddish-black bodies, smaller than Ted corpuscles, which they regard as red corpuscles undergoing •disintegration."^ Virchow's observations have been confirmed by Hoffmann, who has found white corpuscles and pigment-granules in large numbers in the blood, especially in that of the portal ^'ein. (See p. 16.) e. Organs of Resjm'ation. 1. The Epiglottis was found by Louis to present signs of recent inflammation in 10 out of 46 cases. It was oedematous, con- gested, ulcerated, or covered with false membrane. In all of the cases, death occurred at an advanced stage of the disease. 2. Larynx and Trachea. The various forms of inflammation to which the larynx is liable, in the course of enteric fever, have been already alluded to (p. 558). It is only necessaiy now to add a few words concerning that form, in which the mucous mem- brane is found to be ulcerated. This lesion seems to vary greatly in frequency at different places. I have only met with it in three or four instances. Louis met with it in only 3 of 96 cases ; Chomel, in i of 42 cases ; and Jenner, in i of 1 5 cases, examined after death. On the other hand, Griesinger found laryngeal ulcer in 31 out of 118 autopsies,^ and Eoldtansky observes that ^ Physiol. CJiem. Day's Transl. ii. 266. y Cellular Path. Chance's Transl. p. 167. » Ibid. p. 225. " Geiesingee, 1864, p. 211. 638 ENTEKIC OR PYTHOGENIC FEVER. ' secondary pharyngeal typhus occurs much more rarely than secondary laryngeal typhus,'^ although Louis and Jenner found ulcers m the pharynx and oesophagus to be far more common, than ulcers m the larynx (see p. 614). The ulcers m the larynx: are usually situated near the posterior junction of the vocal cords. They are sometimes superficial ; at other times they spread by sloughing, and are so deep as to destroy the subjacent cartilages,, or perforate the larynx, permitting air to escape into the cellular tissue (see p. 559). They are rarely found before the fifteenth day of the disease. Like the ulcers in the pharynx and oeso- phagus (see p. 614), there is no evidence that they are due to th& sloughing out of any morbid material (' typhus matter ') deposited in the sub-mucous tissue. When we remember the remarkable- tendency to ulceration exhibited by the pharynx, the oesophagus, the stomach, and the gall-bladder, in the advanced stages of enteric fever, it is not surprising that inflammation of the larynr should occasionally lead to the same result. Trousseau says that laryngeal ulcers are most common in persons who have been kept on too low diet, and he quotes the experiments of Chossat, to- the effect that the production of ulceration is one of the effects- of inanition. Moreover, ulceration of the larnyx is occasionallj found in typhus (p. 259). Trousseau justly observes : ' Ces lesions s'expliquent sans qu'il soit besoin d'invoquer une localisation speciale de la maladie, analogue a celle qui se fait du cote de I'intestin.' ° 3. The Bronchi are often filled with frothy mucus, while their lining membrane is much congested ; but these appearances are, on the whole, less common than in typhus (see p. 260). 4. The Lungs are occasionally found healthy, especially when death takes place suddenly by peritonitis ; but in most cases thej exhibit one or other of the morbid conditions described under the head of typhus. Hypostatic consolidation is less common than in typhus. Jenner did not observe it in any of 1 5 cases. I have noted it, however, in 7 out of 19 cases ; and in 4 of the 7 cases the con- solidation was so great that the most dependent portions of the lungs sank in water. In all of the 7 cases the typhoid state had been well-marked prior to death. Louis also noted hypostatic condensation in 19 out of 46 cases. He applied to it the designa- tions * splenisation ou carnification' (terms which are now given to two entirely different lesions) ; but he accurately described its »• GniESiNGEE, 1864, ii. 79. ' Tkousseau, 1 86 1, p. 203. ANATOMICAL LESIONS. 639 characters, and its jDoints of distinction from true pneumonia. Thus, it was hmited to the most dependent portions of the hmgs ; its cut surface was non-granular, and discharged, when squeezed, a quantity of reddish serum without any bubbles of air ; and the condensed tissue not only sank in water, but was more tenacious than in the natural state (see pp. 142 and 260). (Edema of the lungs is occasionally met with, and, according to my observations, is most common in the upper lobes (see p. 260). True pneumonia is much more common than in typhus. It existed in 8 out of 19 cases noted by myself; in 17 out of 46 cases examined by Louis, and in 1 2 out of 1 5 cases dissected by Jenner. It is usually lobular. Hoffmann found lobar pneu- monia in 18, and lobular pneumonia in 38 of 250 autopsies. In several instances I have known the circumscribed patches of lobular pneumonia become converted into smah abscesses, or pass into gangrene. Similar appearances may sometimes be traced to hEemorrhagic infarctions of the lungs, consequent on embolisms of the branches of the pulmonary artery. I have never met with any appearance to justify the appellation of typlwid jmeumoriia on anatomical grounds. It has been stated that the exudation thrown out into the lungs sometimes presents the same minute structure as the matter deposited in the intestines, but the intestinal deposits themselves have no peculiarity of structure by v/hieli they can be recognised. Eecent tubercle is occasionally met with in the lungs in pro- tracted cases of enteric fever (see p. 558). 5. The Pleurce exhibit signs of recent inflammation oftener than in tj'-phus. Eecent adhesions or effusion of lymph existed in 6 out of 1 9 cases examined by myself, and in 6 of 1 5 cases noted by Jenner, but only in 2 of 46 cases recorded by Louis. In 19 out of 46 cases, Louis found a greater or less amount of reddish serous effusion in the pleurae ; in most of these cases there was hypostatic consolidation of the lungs (see p. 577). 6. The Broncldal Glcmds are occasionally enlarged when the Jungs are inflamed, as is often the case in ordinary pneumonia. /. Nervous System. I . Tlie Cerebral Membranes are less frequently congested than in typhus. Jenner found the dura mater normal in every one of 1 5 cases ; the pia mater was congested in 5 cases, but in 4 of the 5 cases the congestion was confined to the larger vessels. 640 ENTERIC OR PYTHOGENIC FEVER. Louis found increased vascularity in almost one-half of 46 cases, but in only 11 was the congestion considerable. There is no relation between the severity of the cerebral symptoms during life and the vascularity of the cerebral membranes found after death. The same remarks are applicable here as in typhus (p. 261). I have never met with haemorrhage into the cavity of the arachnoid in enteric fever. Louis makes no mention of it, and it did not exist in any of 1 9 cases examined by Jenner. Chomel, however, observed it in one case,*^ and Griesinger and Buhl in 8 of 418 autopsies^ (see p. 262). It is not often that the membranes can be torn from the brain with increased facility. Jenner noted this condition in only I of 9 cases (see p. 262). 2. Intra-Cranial Fluid. Effusion of serous fluid at the base of the brain, into the lateral ventricles, and beneath the arach- noid, is almost as common as in typhus, although the quantity is on the whole less. Louis and Jenner met with more or less sub-arachnoid serosity in 37 out of 61 cases, but in only 5 of the cases was it considerable in amount. The fluid thrown out into the several localities mentioned is colourless and transiKire7it, and is no more a sign of inflammation than it is in typhus (p. 263). It is only in very rare cases that signs of true meningitis are found, and they are usually associated with other signs of pyaemia, with disease of the temporal bone, or with tubercular deposit. Two cases of meningitis are recorded by Louis {Ohs. 17 and 25) : in one, the fluid in the arachnoid was turbid and contained a few albuminous flakes, but the vascularity of the membranes was not increased ; in the other, a recent false membrane was found on -the visceral surface of the dura mater, but here there was pygemia, and the symptoms of meningitis did not supervene until after convalescence had commenced. Other cases of menin- gitis have been observed by Griesinger, Buhl, and Hoffmann (see also p. 561.) 3. The Cerehrum and Cerebellum are usually normal. In- creased vascularity of the cortical substance (in 17 of 46 cases, Louis) or of the medullary portion (in 9 of 61 cases, Louis and Jenner) is occasionally met with. There was no trace of soften- infy or induration of the cerebral substance in any of 1 5 cases examined by Jenner. Louis found induration of the brain in 7, and softening in 7, out of 46 cases ; but these appearances * Chomel, 1S34, Case iS. " Gkiesingee, 1864, p. 224. ANATOMICAL LESIONS. 64 1 were mostly uniform over the entire brain, and no relation could be traced between them and the severity of the cerebral symp- toms during life. The remarks (p. 263) made under the head of typhus are also applicable here. It was clearly shown by Louis and Chomel that the morbid appearances found in the brain and its membranes in enteric fever were equally common after death from other acute diseases, especially pneumonia, and that no relation existed between them and the intensity of the cerebral symptoms. My own observa- tions agree entirely with their statements (see pp. 263 and 532). 4. The Spinal Cord was examined by Louis in 6 cases, but presented nothing abnormal. 5. The Sympathetic Ganglia, according to Virchow, often contain an unusual amount of pigment in the interior of the ganglion-cells^ (see p. 265). g. Urinary Organs. 1. The Kidneys are often congested; in several instances I have found the hypersemia so intense, that the organs presented a dark chocolate colour. At other times the kidneys are pale and increased in size, and the uriniferous tubes are crammed with granular epithelium. These appearances are rarer than in typhus. Louis found the kidnej^s hypertemic in 17, and un- usually pale in 5 , out of 42 cases ; the former appearance was most common in cases fatal between the eighth and the fifteenth days ; in all the cases where the kidneys were pale, the duration of the illness had been considerably longer. Hoffmann noted infarctions of the kidneys in 10 out of 250 cases. I have noted them in only two cases.^ 2. The Bladder. The mucous membrane of the bladder is normal or slightly congested. In one instance Louis found a minute ulcer near the opening of the urethra. Diphtheritic inflammation and ecchymoses of the bladder are occasionally met with. Nature of the Disease of the Intestinal and Mesenteric Glands, dc. While many French, and some English, writers have erro- neously regarded the intestinal affection as an exanthem, and compared it to the eruption of variola, the pathologists of the Vienna School taught for many years that the morbid deposit (Typhus-masse) occurring in the intestinal glands and elsewhere ' Cellular Path. Eng. Ed. p. 257. 6 One of which is recorded in Path. Trans, xv. 145. T T 642 ENTERIC OR PYTHOGENIC FEVER. was an albuminous exudation, which, Hke tubercle or cancer, depended on a morbid condition of the blood, and underwent a peculiar development, A specific ' typhous cell ' was described and figured by Gruby, Yogel, J. H. Bennett, and others. It was maintained, that the deposition of this ' typhous matter ' was not restricted to the intestinal and mesenteric glands, but that it was met with in the spleen, gall-bladder, stomach, oesophagus, larynx, lungs, &c. But, as already stated, there is no evidence that the lesions found in these organs are due to the deposit of a material resembling that found in the intestinal glands. More- over, the morbid material found in the intestinal and mesenteric glands has no specific structure. Microscopic examination shows •~o' i^^ ^-■.■^- -:■:-■;■:■ A -& ^-»e^-., '■•■'Ci:". ■.■"■J!i, '^^im •^»« © Fig. 10. — Corpuscles from one of the solitary glands in the ileum in a case of enteric fever, magnified 400 diameters. clearly that the enlargement of both the intestinal and mesen- teric glands is due to a proliferation of the lymph-corpuscles, which constitute the natural cellular element of the gland-tissue. Most of the lymph-corpuscles are larger than in the normal state, and full of granular matter, while many may be seen as large as yVq-o" i^^^^ ^^ diameter, and containing one, two, three, or many rounded nuclei (see fig. 19). These are the appearances seen in the early stages of the disease ; when the glands become softened, the cells undergo disintegration, and mixed up with them is a large quantity of granular and oily matter. The lesions described as occurring in the spleen are partly due to changes in the quantity of contained blood, and partty to changes in the glandular elements similar to what occur in the intestinal and mesenteric glands. The Malpighian bodies are enlarged, and the splenic pulp, in addition to the ordinary lymph-cells, contains many other cells of larger size, and in- ANATOMICAL LESIONS. 643 eluding several nuclei. These are found in largest number during the first fortnight or three weeks of the disease, while the organ is still firm ; when the spleen becomes soft, the small lymph- corj)uscles are more numerous, and are mixed up with much granular matter, and at the same time yellowish-brown pigment granules are often found in the cells and in the trabecular tissue. It is to be remarked that the seats of the essential disease in enteric fever all belong to the lymphatic system. It is needless, at the present day, to insist on this connection as regards the spleen. Kolliker was one of the first to point out the close re- semblance in structure which Peyer's patches bear to lymphatic glands, and he further showed that their period of greatest activity corresponded to that of intestinal absorption.^ Briicke succeeded in injecting the Peyerian glands from the lacteals ; ^ while Virchow has long insisted that the solitary and agminated glands have nothing in common with the glands which pour their secretion into the intestinal canal, and that a Peyer's patch is merely a lymphatic gland spread out in the coats of the intes- tine.J Among anatomists and physiologists, this view as to the nature of the agminated and solitary glands of the bowel is now generally accepted, but it is remarkable how commonly it has been ignored by practical physicians in discussing the intestinal lesions of enteric fever. These glands are commonly believed to eliminate from the system the poison of the fever, and in this way to become diseased, somewhat in the same way as it is argued that the kidneys are liable to become diseased while eliminating the poison of scarlet fever. The discharge of the poison by these glands into the bowel is also thought to account for the highly poisonous properties which the stools of enteric fever are said by some writers to possess. These views, how- ever, are opposed to the normal functions of the glands in ques- tion, for it is difficult to imagine how glands can eliminate a poison from the blood into the bowel, whose proper function is to absorb from the bowel into the blood. It is true that the substance of the glands may by ulceration or sloughing be cast into the bowel ; but, while their destruction is little calculated to promote the eliminatory functions which they are thought to possess, it is incompatible with the maintenance of any poisonous property of a specific character like that of small-pox, and it is remarkable that the cases which do not go on to ulceration or '' Man. of Hum. Histology, Syd. Soc. Transl. ii. 106. ' Caepenter's Frincip. of Hum. Phys. 5th ed. 119. J Cellular Path. Eng. Transl. p. 192. T T 2 644 ENTERIC OE PYTHOGENIC FEVER. sloughing, but where the whole of the supposed poison is absorbed into the blood, are always the shortest and the mildest. But if the enlargement of the intestinal glands be not due to eliminatory efforts, how are we to account for it ? Minute examination of the enlarged glands shows that they are in a state of inflammation, and this inflammation appears to be due to the irritation of some poison absorbed from the bowel — not vitiated bile or intestinal secretions, which some writers imagine to be the cause of the lesions in the lower part of the ileum — but the actual poison of the fever, which is frequently, if not always,'' swallowed with the ingesta, and for which the agminated and solitary glands may be said to have an elective affinity. The inflammation of these glands is similar to what takes place in other lymphatic glands from absorption of the poisons of syphilis, pyaemia, and tubercle. The more actively the normal functions of the glands are performed, the more probably will they absorb the poison, and thus it is that enteric fever is most common in persons under 30 years of age. The intestinal and mesenteric glands, as we have found, become enlarged from the commence- ment of the disease, and it is through them that the system becomes infected, while, at the same time, the inflammation may spread from the former to the mucous membrane, and so excite intestinal catarrh and diarrhoea. The fever which is lighted up by the absorption of the poison into the system has a tendency to subside about the middle or end of the second week, when the inflammation of the intestinah and mesenteric glands and of the spleen undergoes resolution ; but when the inflammation proceeds to gangrene, ulceration, or softening, the fever is main- tained or increased (p. 548). The morbid anatomy of enteric fever may be summed up as follows : — 1. The agminated or solitary glands of the ileum, the mes- enteric glands, and probably the spleen, are invariably diseased. 2. Many other secondary lesions are found, which are not constant or essential. The chief of these are peritonitis, granular or other degenerations of the liver, kidneys, heart and voluntary muscles, ulcerations of various mucous surfaces, pneumonia, bronchitis and hypostatic congestion of the lungs, and an in- crease of intra-cranial fluid. There are no signs of inflamma- tion in the brain, or of its membranes, to account for the cerebral symptoms. ^ Not always, if the foetus in utero may be attacked. (See p. 440.) ANATOMICAL LESIONS. 645 3. There is no specific 'typhus exudation,' and no evidence that the secondary lesions are due to the deposit of a material like that found in the intestinal and mesenteric glands. 4. The enlargement of the intestinal and mesenteric glands is not due to any effort at elimination, but to inflammation which is probably excited by absorption of a poison in the bowel. [Since this statement of the views of Dr. Murchison on the morbid anatomy of enteric fever, the discovery of bacilli in the mesenteric glands, spleen, and other organs has given some support to the view that these constitute the specific poison to which the local and general effects of the disease are due, though the subject is one which still requires further investigation. The following account of the supposed microbes of enteric fever has been contributed by Dr. Heneage Gibbes.] The Organisms of Typhoid. [See Plate VI.) Fischl, Letzerichji and others have described micrococci in typhoid ulcers and elsewhere. Klebs has also described a form of bacillus he found in diseased patches of the intestine. The observations of Eberth'" are, however, the most important. The following is the process he used : — A few lymphatic glands, small portions of spleen and of the characteristically changed intestine, with occasionally portions of other organs (liver, kidney, and lung), were removed with clean hands and instruments and placed, each separately, in alcohol, which was frequently changed. In those cases where a few sections of lymphatic glands or spleen yielded a large number of organisms the investigation was compara- tively easy. In many, however, a large number of sections had to be examined, and here the organisms were very few. In these investigations it was not only necessary to determine the presence or absence of the organisms, but also to find a ratio between the intensity and duration of the disease on the one hand, and the variable proportion of these organisms in the tissues on the other. He breaks up his results into three groups, according to the pro- portion of organisms detected. In the first he places those glands which only gave 1-2 groups to 5-6 sections. The next includes those where five sections give about one group per section. In the highest those which showed two or more groups in every section. In one case every longitudinal section of the ilio-csecal glands gave 20-25 groups. The distribution of the organisms is very irregular. One gland would yield three groups per section, its neighbour none at all. In the demonstration of the organisms he obtained the best results by treating alcohol preparations with concentrated acetic acid. He > Letzeeich, 1880. ™ Eberth, 1880-82. 646 ENTERIC OR PYTHOGENIC FEVER. tried methyl violet and Bismarck brown, but did not get sucli good results. A moderate magnifying power (system 4, ocul 3, Hartnack) shows the organisms as greyish brown patches in the spirit -hardened sec- tions. If they are compared with the organisms of pyaemia and diph- theria they are easily distinguished by their lighter grey-brown colour and irregular form. The size of the groups vary from that of a mucus corpuscle to that of a large ganglion cell. In the lymphatic glands he found the organisms generally between the lymph-cells, rarely in the lymphatic vessels. In the spleen and intestine they also lay free between the cells. With regard to their distribution in the lymphatic glands and spleen, Eberth found, out of twenty-three cases, the organism twelve times in the lymphatic glands, six times in the spleen. The pro- portion of organisms was also always greater in the glands than in the spleen, which contained only small groups. He considers that these organisms should be called bacilli, as, although at first sight they resemble sphferococci, on examining isolated specimens they are found to be staff-shaped bodies. He mentions that they resemble the bacilli found in putrefying blood, with this difference : they are occasionally narrowed ovoids or delicate spindles with truncated extremities rather than definite cylinders. He says that he has never found undoubted sphaerococci. Another dis- tinctive point mentioned is their delicate outline. Lastly, he considers that they stain so much more lightly with methyl violet than do the putrefactive bacteria found in the necrosed part of the intestine that they are easily distinguishable. He then gives an analysis of the twenty-three cases examined, and shows that the twelve cases where bacilli were found show a much shorter duration than the eleven cases where there were none. The inference is that the proportion of bacilli decreases with the duration of the disease. He considers that from the localisation of these bacilli, their behaviour with certain re- agents and their delicate outline when com- pared with undoubted putrefactive bacteria, the balance of evidence is in favour of their being specific formations. In Vol. LXXXIII. of ' Virchow's Archiv,' Eberth gives particulars of seventeen additional cases, together with eleven cases of various infective processes and thirteen cases of pulmonary phthisis. All these gave entirely negative results in those organs generally affected in early typhoid. Many of the cases of phthisis had extensive ulcera- tion of the intestine, but no bacilli were found, either in the spleen or lymphatic glands. Of the seventeen cases of typhoid six had bacilli, eleven none. The average duration of illness was, however, longer in those cases than in the earlier series, and fully harmonises with the view formed, that the number of bacilli decrease with the duration of the disease. One case is mentioned which only lasted eleven days, and the bacilli were so numerous that each section of a small gland showed PlsLte YT. Fiq .1 ••/ / r- ^ r''- Faq.2 Fig. 3 J \\ / Fig.^. O Or „ " O O ° O Q S '■ - 'r " ; " 1 - '/ T ^ , „ ° '0 , V ° o P,o^, :i^' 3 O o ^^ <2o ., r-" Goo n rin"0 OfJ JgO > o c o ° ( 3 O Oo" ITlg e. _ Fiq. 5 Fxq .7. 'V^'^st-,,I>re-vKcafiaa-'?iCo. so . ANATOMICAL LESIONS. 64/ 10-20 groups. From the above it will be seen that the differences betv/een putrefactive bacteria and these so-called specific bacilli 'of typhoid are very small. I have examined a number of cases of short duration, all under twenty-one days, and I find that these bacilli are the exception rather than the rule. In a number of cases I have failed to find any after careful search through a large number of sections of various lymphatic glands, portions of intestine and spleen, while in others they are very numerous. The point, however, on which Eberth lays so much stress, namely, the difference between the stainmg of putrefactive and specific bacteria, is one which I have care- fully worked out, and I cannot find any difference between the staining of the bacilli in the lymphatic spaces of a gland- with those in the loose connective tissue surrounduig the same gland, which are undoubtedly putrefactive ; that is, when gentian violet or Spiller's purple was used. With logwood or Bismarck brown, the bacilli in the gland were certainly stauied more deeply than those in the periphery ; but I foimd precisely the same result on staining sections of an organ filled Avith bacilli of undoubted putrefactive origm. With regard to the localisation of these bacilli, if they were constant it would be of some value ; but I have examined so many cases with negative results, I cannot help thmldng their specific function will be ultimately disproved. Maragiiano, of Genoa, has published in the Centralblatt filr die Med. Wissenschaften an accomit of organisms which he has foimd in the blood of the spleen, as well as in that of the general circulation. He obtained the blood by means of a hypodermic syringe passed through the abdominal wall into the spleen. The blood of the general circulation was taken from the tip of the finger. Every precaution was taken against accidental contammation. Fifteen patients exammed in this way gave the following results : — At the height of the disease the blood contained spherical bodies sunilar to micrococci, isolated and in groups. Some of these were mobile. Similar organisms were found in the blood of the spleen, and with them oval-shaped bodies resembling those described by Eberth. During convalescence and the exhibition of quinine these organisms became much lessened in num- ber. Fractional culture gave a nimiber of rods similar to those seen in the blood, except that some were much longer. DESCRIPTIOX OF PLATE VI. (P. 646). ■ Figs. 1-5. Spirochaete of relapsing fever. (After Heydenreich.) Fig. i. An agglomeration of the spirochfete in the blood with globules entangled. Filaments were in active vibratile motion. Fig. 2. Isolated lilameuts varying in length from "oiy to "042 mil. Fig. 3. An agglomeration of dead spirochaite in the blood. Fig. 4. A stellate agglo- meration of the spirochsete in the blQod. Fig. 5. Filaments adhering together by one extremity. Fig. 6. Spirilla from decaying animal matter x 400. (Heneage Gibbes.) Figs. 6-8. Bacilli of enteric fever. (Heneage Gibbes.) Fig. 7. Bacilli in a small Ijonphatic vessel X 800. Fig. 8. Section of mesenteric gland x 240. Bacilli in lymphatic space. From the same specimen. 648 ENTEEIC OE PYTHOGENIC FEYEE. Sect. XIII. Teeatment. A. Prophylactic Treatment. As in typhus, the prophylaxis of enteric fever involves the measures calculated to prevent the origin, as well as the pro- pagation, of the poison. I. Measures for 'preventing the Generation of the Poison of Enteric Fever. Instead of cutting off thousands annually, enteric fever would be a rare disease if we could prevent the products of faecal fer- mentation entering our houses, and polluting our drinking water. The chief rules to be attended to are these : — 1. The cisterns and water-butts in every dwelling ought to be scrupulously cleansed from time to time, and care must be taken that the waste-pipe of the cistern does not pass down directly into a drain, and thus become the means of ventilating the drain into the cistern. When drinking water is derived from surface-wells or running streams, there must be no cesspool, drain, or other nuisance in the vicinity, from which organic impurities may percolate through the soil into the water. Water- companies ought to be criminally responsible for supplying drinking water polluted with organic matter at its source or in its transit. From whatever source derived, it is a good pre- caution always to filter drinking water, and persons travelling much will do well to provide themselves with a portable filter. Drinking water ought to be tested from time to time to discover if there be any organic taint. All that is necessary is to add to a tumblerful one or two drops of Condy's (crimson) Fluid, which will give it a very faint pink hue. If, after standing for half an hour, the pink colour has gone or turned to yellowish, the water is tainted and cannot be drunk with safety ; but if the pink hue maintains itself, it is free from organic impurity. When no filter is within reach, it is a good plan to add to any suspicious drinking water a drop or two of Condy's Fluid. 2. Care must be taken to keep all house-drains in good order, free from leakage and obstruction, and with all water-closets, sinks, and other openings into them properly trapped. It must be remembered also that the trapping may be perfect, and yet effluvia may escape from drains if the supply of water be TEEATMENT. 649 deficient, or if the drain beyond the trap be not properly ventilated. The waste-pipes of baths, basins, and sinks ought,, therefore, to be disconnected from the main drain, as well as trapped ; while the drain-pipes of all closets before entering the main drain should be ventilated and deodorised." When bad smells escape from sinks or drains, chemical disinfectants ought to be used, and thorough house-ventilation carried out, until the causa of the escape is investigated and removed ; but it must not be forgotten that the poison of enteric fever, although often accom- panied by bad smells, may be itself inodorous. It is a good precaution to flush all house-drains, and scrub and cleanse all sinks, once or twice a week with abundance of water containing some disinfectant. No cesspool ought to be tolerated within the walls of any dwelling-house. 3. "When the drains or cesspools of a house are opened for the purpose of repair or cleansing, chemical disinfectants ought, to be applied freely to their contents, and thorough ventilation enforced, and the residents will do well to absent themselves, while these operations are going on. From neglect of this rule,, enteric fever has often broken out in consequence of the mea- sures resorted to for its prevention. 4. The best chemical agents for preventing fsecal ferment- ation are carbolic acid, copperas or sulphate of iron, Burnett's Fluid (which is a solution of chloride of zinc), and the chloride of lime. The liquid carbolic acid may be diluted with water in the proportion of i to 40, or it may be mixed with sand or saw- dust. Copperas is to be used in the proportion of 2 ounces to a pint of water. Condy's Fluid is also a good disinfectant. It acts by liberating a large amount of oxygen, which combines with and destroys the products of decomposition, but it is not an antiseptic ; and the same remark applies to chloralum and charcoal, which absorb the volatile products of decomposition. 5. The preventive measures now referred to, and others which will suggest themselves according to circumstances, are especially called for in the autumn and in hot seasons, and in the case of exposure to the nuisances specified of persons below the age of thirty. " Different methods for effecting this are described in a useful little work entitled Healthy Houses, by W. Eassie, C.E. London, 1872. 650 ENTERIC OR PYTHOGENIC FEVER. II. Measures for ijreventing the Propagation of the Poison of Enteric Fever. I. When enteric fever is propagated by the sick to persons in health, the alvine evacuations are the chief, if not the only, medium of communication. These excreta ought, therefore, to be disinfected by one of the chemical substances already men- tioned, of which the best is carbolic acid ( i to 40 of water) from its power of arresting fermentation, as soon as they escape from the body, and before they are emptied into water-closets or privies, and they ought never to be thrown on places whence they can find their way into the sources of drinking water. All bedding and body-linen soiled with the excreta of the sick ought to be soaked in a tub of water containing carbolic acid (4 fluid ounces to a gallon), or be boiled, or baked in a dis- infecting oven or before the fire, or in the sun, before being washed. 3. The sick-room ought to be thoroughly ventilated, and vessels placed in it containing Condy's Fluid or chloralum, for the purpose of decomposing or absorbing any noxious exha- lations. 4. But in addition to these precautions, attention must be directed to the original cause of the first case of fever in the house, the persistence of which is probably a more fertile source of fresh cases than any poison derived from the person first infected. Such nuisances as have been mentioned under the head of Etiology are to be sought for and remedied ; and while this is being done, it will be often advisable that all the inmates below thirty years of age should absent themselves from the infected house. B. Curative Treatment. There is no specific for enteric fever any more than for iyphus. Baglivi's remark on ' mesenteric fever,' made two centuries ago, holds good at the present day : — ' Sed quod prte c£eteris animadverto, in nullo morborum genere, tanta opus est patientia, expectatione, cuncfcationeque, ad bene et felicitcr medendum, tamquam ad bene curandum febres mesentericas.' *" But though much mischief may be done by the nimia diligentia " Baglivi, 1696, ed. 1704, p. 51. TREATMENT. 65 1 m,edici, by depletion on the one hand, or by over- stimulation on the other, it must not be thought that the best treatment is one of mere expectancy. Although we cannot cure the disease, we must treat it ; and with increasing experience scepticism gives way to the belief that many lives are saved by medical inter- ference at the proper time and in the proper way. If we can keep the patient alive a certain time, the disorder will pass away ; and hence it is always important to determine the precise duration of the attack, and to study the tendencies to death, by obviating which the patient may be enabled to tide over the critical period. The objects to be aimed at are very similar to those referred to in discussing the treatment of typhus. (See -p. 272.) I. Neutralize the Poison and Improve the State of the Blood. 1, The Mineral Acids are as useful in the treatment of enteric fever as in that of typhus, and the remarks already made on the subject may be referred to (p. 274). It may be well, however, to repeat that we are ignorant of the precise manner in which they act, and that they are not specifics for enteric fever, as might be inferred from assertions repeatedly made of late years in the medical journals. I have not observed that they increased the severity of the abdominal symptoms ; and for diarrhcEa, the dilute, or the aromatic, sulphuric acid is one of the best astringents. 2. AntiseiJtics. Creasote, carbolic acid, sulphurous acid and its salts, iodine, and chlorine have all in turn been recom- mended in the treatment of enteric fever ; and they have this to recommend them, that they might be expected to act directly upon the poison in the intestinal canal. I have tried them all in a considerable number of cases, but without any marked result, excejDt that of moderating tympanites and diarrhoea. Carbolic acid I have given in frequent doses of 2 minims, with chloric ether and syrup in mint water. Of 9 cases treated in this way, 2 died, and 2 had a relai)se. M. Pecholier, of Montpellier, tried creasote, both by the mouth and in enemata, in 60 cases, and came to the conclusion that, when the treatment was commenced early, it diminished the intensity and shortened the duration of the fever.? [Eecently carbolic acid lias been extensively used in the treatment of enteric fever, and, according to the accounts published, with favourable p Gaz. Hehdom. 1869, p. 200; and Med. Times and Gaz. 1S69, i. 362. 652 ENTEEIC OR PYTHOGENIC FEVER. results. Not only is it antiseptic, but it also lowers the temperature, though its antipyretic action is less powerful than that of many other drugs, as quinine. It is, however, impossible to believe that a sufficient quantity could be introduced into the system to act on the typhoid poison without at the same time producing poisonous effects. Dr. Kothi combines it with iodine. Dr. Kamonef* gives it in the form of an enema, i gramme to 150 grammes of water one to three times daily; other observers have found this plan not unattended with danger.^ Dr. Warren* gives half a drachm to i drachm daily, freely diluted.] The sulphites, strongly commended by Polli, of Milan, for the treatment of zymotic diseases in general, have been stated by many observers to be of service in enteric fever." A scruple of the sulphite of soda, or from i to 2 drachms of sulphurous acid, largely diluted, may be given every four hours. I cannot say that I have found them to shorten the duration or intensity of the fever, while, in some instances, they have seemed to me to excite diarrhoea. In 1859 M. Magonty, of Paris, published a work announcing a specific method for the treatment of enteric fever, which con- sisted in the administration of iodine and iodide of potassium, both by the mouth and in enemata, with the object of destroying the putridity of the intestinal contents.'^ The iodine treatment has lately been revived by Willebrand"^ and Liebermeister."^ Willebrand dissolves 6 grains of iodine and 12 of iodide of potassium in i drachm of water, and gives 3 or 4 drops of this solution in a wine-glass of water every two hours ; he believes that by this treatment the duration of the fever may be shortened. Several years ago I tried Magonty's plan in several cases without any apparent advantage, and one of the patients died of intestinal hsemorrhage. Of all the remedies belonging to this class, free chlorine has appeared to me to be most useful. Highly commended many years ago by Professor Schonlein, of Berlin,^ it has since then been used with advantage by many physicians,'' and I have repeatedly found it to have a beneficial influence upon the abdo- minal symptoms. Twenty minims of the liquor chlori may be < Both, 1880. ' Eamonet, 1882. ' Lancet, Aug. 26, 1882. ' Waeken, 1SS2. " J. F. NicHOLLS, Trans. St. And. Med. Grad. Assoc, vol. i. ; E. S. Ceoss, Lancet, 1868, i. 81 ; P. W. Jones, Lancet, 1869, i. 45, 126. "" Magonty, 1859. ■" Willebrand, 1865. ^ Niemeyee, Text Booh Pract. Med. Amer. Transl. ii. 596. y Ed. Med. Journ. Sept. 1862, p. 227. » NiEMETEB, op. cit. u. 598; Yeo, Med. Times and Gaz. 1868, i. 117. TREATMENT. 653 added to each dose of the hydrochloric acid mixture (p. 274), or a mixture may be ordered as follows : — Take of chlorate of potash gr. vj. and strong hydrochloric acid ij^xxxvij. ; introduce both into a bottle and cork tightly. After five minutes add water gradually to §xj., agitate well after each addition of water, and then add acid, hydrochlor. dil. 3iv., spirit of chloroform 5iv. Dose one or two tablespoonfuls in water. II. Promote Elimination not merely of the Fever-poison, but of the Products of Metamorphosis. 1. Fresh Air. (See p. 275.) 2. Diluents. (See p. 276.) 3. Diuretics. (See p. 276.) The nitrate, bitartrate, and acetate of potash ought to be avoided owing to the condition of the bowels, but the flow of urine may be maintained by digitalis, nitrous ether, gin, &c. 4. Salines. (See p. 277.) 5. Diaphoretics (see p. 278) are sometimes useful for mode- rating the pyrexia in the early stage of the attack, but it must be remembered that periodical perspirations often occur naturally without affording much relief (p. 184). 6. Emetics (see p. 278) have been recommended in the treatment of enteric fever from time immemorial, and are still favourite remedies with many practitioners. Dr. James Jackson, of America, by a comparison of a large number of cases treated with and without emetics, has endeavoured to show that they reduce the duration as well as the severity and rate of mortality of the disease. His remarks are well worthy of perusal.^ I have repeatedly observed that an emetic given during the first week in apparently severe cases was followed by an abortive attack, although of course such cases are open to the objection that cases which set in severely may abort independently of an emetic (pp. 592, 611). Emetics administered within the first ten days often relieve the headache and gastric disturbance. Indeed, they constitute one of the best remedies for vomiting in the early stage. They ought never to be given after the twelfth day, for when the peritoneum is laid bare by the intestinal ulcers, the act of vomiting may induce perforation. 7. Laxatives. The ordinary practice in this country has been to avoid laxatives in the treatment of enteric fever, and the advice given by the late Dr. Todd in the following words has * Letters to a Young _Plnjsician, Boston, 1855, p. 326. 654 ENTERIC OR PYTHOGENIC FEVER. been generally accepted : — ' Eestrain diarrhcBa and haemorrliage in typhoid fever, and when you have fairly locked np the bowels, keep them so. Patients will go for four or six days, or even longer, without suffering inconvenience from this state of con- stipation.' ^ On the other hand, many physicians, including Andral, Bretonneau, Louis, and Trousseau, have recommended the frequent administration of laxatives. The treatment which was long famous at Paris as the method of M. de Larroque- consisted in the administration of an antimonial emetic, fol- lowed by frequent doses of calomel, castor-oU, or seidlitz-water, laxative enemata, and cataplasms to the abdomen. DiarrhcBa, meteorism, and abdominal pain were not regarded as contra- indications, but when the purging was excessive the treatment was suspended for twenty- four hours. The practice was founded on the belief that the typhoid symptoms of enteric fever were due to the retention of decomposing matters in the intestines. ° Andral reported favourably on this treatment, and Louis, in the second edition of his work, gave an analysis of 38 cases in which he had tried it, and arrived at the conclusion that it was superior to all other methods in every form of the malady. More recently, laxatives in enteric fever have been recommended in this country by W. T. Gairdner,*^ G. Johnson,® and T. J. Maclagan,^ and calomel has long been a favourite remedy with many practitioners in Germany. My experience in many thousand cases has led me to the conclusion that the cerebral symptoms of enteric fever are not due to the absorption of putrid substances from the intestine, and that diarrhoea is not a process of elimination to be encouraged. The most urgent diarrhoea often coexists with great tympanites and the most severe cerebral symptoms, and is very apt to be followed by haemorrhage or perforation ; the danger in fact is in direct pro- portion to the severity and duration of the diarrhoea,^ and in cases which have been doing well, I have repeatedly known the most alarming symptoms, induced by a severe attack of diarrhoea, coming on spontaneously or after a strong purgative. Dr. Parkes's observations also go to show" that the quantity of urea excreted by the kidneys in enteric fever is not affected by the diarrhoea. On the other hand, in most of the mildest cases of " Todd, iS6o, p. 180. ° L.uieoqoe, 1835. "• Gaiednee, 1862 (2), p. 202. • Brit. Med. Journ. 1S67, i. 279. ' Maclagan, 1 87 1. s Even the cases recorded by Louis show that the disease was most severe when there was the greatest purging. TREATMENT. 655 enteric fever there is never at any time diarrhoea, the absence of which is in itself a favourable indication. It does not follow, however, that no interference is justifiable when the bowels are constipated. When there is constipation at the commencement of the attack, it is well to commence the treatment by a small dose of castor-oil, or of rhubarb in peppermint water. In this way we may possibly succeed in expelling some portion of the poison which has been swallowed, but has not yet been absorbed. According to Wunderlich, Pfeuffer, and Niemeyer,^' one or two- 5 -grain doses of calomel given in the first week, before there is. much diarrhoea, often render the disease milder and shorter, and in a few instances seem to cut it short. When the bowels^ are confined at a later stage, I am in the habit of prescribing every second or third day one or two teaspoonfuls of castor-oil,, or a simple enema. But when constipation succeeds to severe diarrhoea, the best practice, I believe, is to abstain from inter- fering for four or five days, and then only to prescribe a simple enema, or one teaspoonful of castor-oil, if the patient has any abdominal discomfort. Under all circumstances, jalap, colocynth,. and all drastic purgatives, are, as Bagiivi long ago remarked^ ' to be shunned like the plague ' (p. 421). III. Reduce the TemiJerature and the frequency of the Action of the Heart. 1. Blood-letting was long resorted to for these objects, but there are the same objections to it as in typhus, and it has now fallen into general disuse. It is worth remembering also, that although the temjjerature falls on copious haemorrhage taking place from the bowels, it very soon rises again. When, how- ever, the disease sets in with urgent abdominal symptoms, the application of a few leeches to the abdomen or around the anus will sometimes relieve the pain and moderate the diarrhoea. 2. The Cold Water Treatment. (See p. 280.) Currie practised the cold affusion in all forms of continued fever ; but he looked upon severe diarrhoea as a contra-indication. In 1846 Dr. Stallard treated a number of cases of enteric fever with the ' cold pack.' The patient was enveloped in a cold wet sheet and covered with a blanket. After ten or fifteen minutes he was transferred to a blanket heated before the fire, and covered with ^ Text-Booh of Pract. Med. Amer. Transl. 1869, ii. 595. 656 ENTERIC OR PYTHOGENIC FEVER. "bed-clothes. He soon began to perspire, and sank into an undisturbed sleep, from which he awoke free from headache and pain, and greatly refreshed. One effect of the treatment was to confine the bowels.^ In Germany the common treatment of enteric fever is now the external application of cold according to one or other of the methods already described, and the reader is referred to the remarks upon this subject at p. 280. When the cold water treatment is not resorted to, the body ought to be sponged two or three times daily with tepid water containing one-fourth part of vinegar, or a little Condy's Fluid. This is often a som-ce of great comfort to the patient, and con- duces to sleep. [During the last fifteen years the antipyretic treatment of enteric fever, as it is termed, has been widely introduced, and it is impossible to resist the evidence that by its means the rate of mortality is very greatly diminished. J The principle on which it rests is that the high temperature itself is an important factor in the injurious effects of the disease, and the object of the treatment is to mamtain the temperature throughout the whole course of the fever, fi-om its commencement to its termination, under a moderate fever heat. The means for eft'ecting this are first cold or tepid baths in various forms. This, the psychrolutic treatment, as it was termed by the ancients, is of high antiquity. Antonius Musa, as is well known, obtamed great fame by thus curing the Emperor Augustus. It was revived by Currie at the begmning of this century, and in recent times was again introduced by Dr. Brand of Stettin. According to this plan the patient should be kept very lightly covered, no blankets being allowed, the temperature taken every four hours, day and night, and whenever it rises about 102° Fahr. in the axilla, a tepid bath should be given. The temperature of the bath and its duration must depend upon the different circumstances of the case. Dr. Brand considers that it should not exceed 70° ; others, as Juer- gensen, employ much lower temperatures. The bath should be continued till distinct shivering is produced, and according to Brand for some nttle time after. According to its effect, from five to twenty minutes will usually be required. I generally employ a bath of a temperature from 70° to 75° for about ten to fifteen minutes. The bath should reduce the temperature at least 2 or 3 degrees. If this effect is not produced the next bath should be of a lower temperature or of longer duration. In children the temperature of the bath should be higher. I gene- rally prefer a temperature of about 80° Fahr. The effects of reducing the temperature by the abstraction of heat ' Brit, and For. Med. Chir. Rev. Jan. 1847, p. 269. J This has been the case in all hospitals where it has been systematically em- ployed. It has been stated that at Vienna it has failed, but this is an error. See WiNTERNiTZ, 1874. TREATMENT. 65/ in enteric fever are very marked. Febrile oppression, headache, de- lirium, stupor, are usually much relieved, the dry brown tongue becomes moister, and the relaxation and paralysis of the vaso-motor system is counteracted probably by the stimulation of the vaso-motor nerves and centres. The excretion of carbonic acid and urea appears to be diminished, and the assimilation of food increased, and so the febrile consumption of the body is checked.^ If the treatment be adopted from the commencement of the disease, the so-called typhoid symptoms seldom occur, and as Dr. Flint says, ' the old picture of the typhoid patient is no longer to be seen.' It has now been tried so extensively and by so many different physicians that its effects in diminishing the mortality can hardly be denied by the most sceptical, making every allowance for the enthu- siasm of its first introducers. In the Grerman and Swiss hospitals it may be said that the rate of mortality has been reduced from an average of about 20 per cent, to one varying from 6 to 13 per cent., and in military hospitals and private practice, where the patients come under treatment earlier, the results have been even more favourable. ^ Among the most important recent series of statistics is that of the Bethanien Hospital of Berlin, drawn up by Dr. Goltdammer.'" It com- prises 2,228 cases treated between 1848 and 1867 before the cold bathing was introduced, of which 405 died, giving a mortality of iSt per cent., and 2,068 cases between 1868 and 1876 after the introduction of the cold bathing ; of these 267 died, giving a mortality of iy2 per cent., or if 64 cases admitted moribund be deducted, a mortality of io"5 per cent. In one respect important point Dr. Brand's plan was departed from, inasmuch as the patients were not bathed at night. In the Prussian Army from 1868-74, before the introduction of the cold bathing treatment, the mortality was 15 per cent. From 1874-81, since its introduction, 9*7 per cent. My own experience has been limited to the London Fever Hospital and the Middlesex Hospital, in both of which institutions, however, the treatment has only been partially carried out. At the London Fever Hospital during the seven years 1872, when pauper patients ceased to be admitted, to 1878, there were 550 cases and 93 deaths, giving a mortality of nearly 17 per cent. During the four years 1879-82, during which the severer cases have been for the most part partially at least treated by bathing, there have been 458 cases and 65 deaths, giving a mortality of 13 '9 per cent. If from these 7 cases be deducted which were admitted moribund, 3 from perforation, 1 from pyaemia, i from meningitis, and 2 from pneumonia, and also 2 cases which recovered from the fever but died from the effects of other diseases, the mortality becomes 12*5 per cent. At the Middlesex Hospital during the eleven years 1867-77, during which bathing was only occasionally employed, there were 423 cases and 69 deaths, giving a mortality of 16-3 per cent. During the six ^ SCHEODEE, 1870. SaSSETZKY, 1 883. 1 Brand, 1877. "■ Goltdammee, 1877. U U 658 ENTERIC OR PYTHOGENIC FEVER. years 1878-83, when bathing has been more generally resorted to", cases 400, deaths 53, mortality i3'2 per cent. Many cases admitted moribund are also included in these numbers. The average rate of mortality in the London Hospitals is about 17 per cent. (See p. 605). Notwithstanding the effect of this mode of treatment in diminishing the mortality, it is open to such obvious objections that it has met with but little acceptance in this country, and many high authorities have expressed themselves doubtfully or unfavourably as to its advan- tages,'^ though I think without giving it a sufficient trial. The objections fall under three heads. First, it is dangerous to the patient from its being likely to cause collapse, intestinal haemorrhage, congestion, and inflammation of the lungs. Secondly, the great mechanical difficulty in carrying it out. Thirdly, the discomfort and pain it causes the patients, and their consequent repugnance to submit to it. With regard to the risk of causing fatal collapse, it may be said that this is only likely to take place if the treatment has been deferred till the later stages of the fever, when the system has been com- pletely shattered by its effects, or if the patient be suffering from some organic disease. It is, however, important to distinguish between the prostration of the typhoid state, delirium, stupor, twitching of the muscles, muscular weakness, dicrotic pulse, &c., and cases where the circulation is beginning to fail, as shown by cold extremities, with perhaps high internal temperature, lividity with pallor of the face, jerking respiration. In the former the bath often has the most beneficial effect ; in the latter the time for it has passed, unless by stimulants we can rally the circulation. I have never myself seen a case of fatal collapse from the bath, and in the 2,068 cases reported by Dr. Goltdammer, only one occurred. Should we have reason to fear collapse, baths of a higher temperature, or the graduated bath, must be employed, or recourse had to some of the other means of anti-pyretic means. It is generally advisable to administer some stimulant before or during the bath, "With regard to haemorrhage, it may I think be stated that its fre- quency is not increased. The only haemorrhage in enteric fever which is of moment is not congestive, but the result of the sloughing or ulcera- tion of arteries of considerable size, a process little under the influence of external conditions. Indeed, there is reason to believe that the ex- ternal application of cold tends rather to contract the mesenteric vessels. Should, however, haemorrhage or peritonitis occur, the bath- ing must be at once intermitted, as perfect quiet is necessary. "With regard to pulmonary congestion and pneumonia, I think it cannot be doubted but that when the bathing treatment is begun early it has a marked eflect in preventing them. When they are already developed we must be guided by the general condition of the patient. To reduce the temperature in such cases, if it be high, is of the utmost ° Collie, 1878. Gaiedner, 1878. Jennek, 1879. Bkistowe, 18S3. TREATMENT. 659 importance, and where bathing is inadmissible some of the other means must be employed. Cases of a fatal collapse of the lung have been published, and therefore no doubt caution is required. With regard to the second point, the repugnance of the patient, it is at once evident that the bathing treatment may be S3 conducted, and indeed it has been so conducted, as to render it a veritable torture ; but with judicious management I have met with very little difficulty from this cause. In a large number of cases the relief given to the febrile oppression is so great that the bath is grateful ; in other cases, though disagreeable, the patients are quite willing to submit from the after relief. When it becomes necessary, as it sometimes occurs in very severe and obstinate cases, to administer it very frequently, as every four or six hours, the frequent disturbance of the patient is always unpleasant. Commonly, however, a few repetitions of the bath, especially with the aid of an occasional dose of quinme, the obstinacy of the temperature is overcome, and the frequency can be diminished. In all cases the temperature and duration of the bath must be adapted to the condition and feelings of the patient and the effect it produces. If there be an invincible repugnance, or the bath produce unfavourable symptoms, other means of reducing temperature must be employed. With regard to the mechanical difficulties of carrying out the treat- ment, it is evident that a sufficient number of attendants are required ; but in hospital practice there should be no difficulty on this point. In private practice, too, where the patients are in good circumstances, no real difficulty need occur. Among poorer persons, no doubt it may be insuperable, and such cases should on all grounds, if possible, be removed to a hospital. In all cases the bath should be brought to the bedside, and the patient lifted in and out. In hospitals where the attendants are females and the patient is heavy, this often throws a great strain on the strength of the nurses, and to obviate this, Mr. Hawksley, the surgical instrument maker of Oxford Street, has constructed an apparatus, planned by Mr. E. A. Fardon, the resident medical officer of the Middlesex Hospital, a drawing of which is appended (fig. 20). It consists of two uprights, which move on wheels, and a cross-bar. A kind of hammock made of strips of webbing is placed under the patient, and then attached by a sus- pender to the cross-bar. By means of pulleys and an endless chain the hammock is lifted from the bed, then slid along the bar till it is over the bath, and let down into it and drawn up again in the same manner. Not only does this entirely relieve the nurses of any strain, but it is both safer and more comfortable for the patient. It takes, however, longer to bathe a patient in this manner than by simply lifting him into the bath. The apparatus has been largely used in the Middlesex Hospital, and is also employed at the London Fever Hospital. On the whole, I think it cannot be doubted but that in a protracted fever like enteric, the temperatuYe is an important factor, and that by at once reducing it when it rises beyond a very moderate height, we render the whole course of the disease much milder, prevent many serious complications, and greatly diminish the rate of mortality. u u 2 66o ENTEEIC OK PYTHOGENIC FEVEE. In order, however, to effectually modify the disease, the treatment must be begun early and kept up steadily. When had recourse to in the later stages, or only employed occasionally to reheve urgent symptoms, its effects in reducing the mortality are comparatively slight. The class of cases in which it is most beneficial are the acute forms, where the febrile disturbance is great. Those more insidious cases where with shght febrile disturbance there is deep intestinal ulceration are less likely to be benefited. Of all the means of reducmg temperature the oiie by cold bathing gives the best results, and is the Fig. 20. one most generally applicable ; but it cannot always be employed, and the mode of reducing the temperature must be adapted to the circum- stances of each case. Other means of abstracting temperature, which may be employed m addition to or instead of cold baths, are graduated baths — i.e. placing the patient in a bath 10 degrees below the temperature of the body, and gradually cooling it down. This method is more troublesome to administer and less effectual, but may be used with advantage where the patient is very feeble and there is danger of collapse, or where the repugnance to a very cold bath is very great." It is, however, often advantageous to begin the treatment by baths of a higher tempera- ture, in order to accustom the patient to them. This is especially the case with children. ° For cases so treated see St. TJionias's Hosp. Bep. vols. x. and xi. TREATMENT. 66 I Other methods are cold affusion, the method principally employed by Currie ; but this is on the whole more disagreeable to the patient. Cold packing, the indications for which are much the same as for the graduated bath. Cold sponging, ice compresses to the abdomen and axillae. These are especially indicated when there is great abdominal distension, peritonitis, or haemorrhage, and may be advantageously employed between the baths when the temperature is very obstinate. The constant application of cold to the head by means of an ice-bag or irrigating cap. Exposure to cold air. Dr. Fenwick informs me that at the London Hospital, after the patient has been sponged, a cradle is put on the bed so as to prevent contact with the bedclothes ; this is left open at both ends and bags of ice are suspended inside it. In this manner the patient is kept sur- rounded by a cold atmosphere, and the necessity for bathing is rendered much less frequent. Many other methods have been proposed. Enemas of cold water — a dangerous proceeding ; iced water beds, various forms of double cuirasses or refrigerating envelopes, with means for keeping up a flow of cold water through them, permanent tepid baths,P but these have not yet attained a place in practical medicine. Case LXXXVIL — Severe Enteric Fever. Ulceration of Fauces. Treatment by Cold Baths. Henry G , aged 21, a carpenter, admitted into Middlesex Hospital June 22, 1880. Previous health good. On June 15, on return from work, felt ill and complained of giddmess and loss of appetite. He went to his work on the following day, but on the 1 7th became so ill that he took to his bed ; on the 19th, however, he got up and went to a chemist, who gave him some purgative medicine which caused profuse diarrhoea ; this has continued up to his admission. State on admission. — Patient is well nourished and of good muscular development, but is very languid and prostrate. He complains chiefly of sore throat, and has a troublesome cough. Over the anterior pillar of the fauces on the right side is a patch of superficial ulceration with a grey surface, and the glands at the angle of the jaw are enlarged. Tongue thickly coated, edges and tip red. Abdomen flaccid ; scattered over the trunk are numerous rose spots disappearing on pressure ;, during the next few days similar spots appeared on tlie forehead and arms. Splenic dulness measures 3^ inches vertically. Heart and breath sounds normal. Bowels very loose, motions light and liquid. Pulse 120, very dicrotic. Temperature on admission 103-2°, at 6 p.m. 104-6°. Patient was ordered 6 ounces of brandy daily, and to have a ten minutes bath at 65° Fahr. whenever the temperature exceeded 102-5°. The following table shows the range o-f temperature and the number of baths. The temperature in this case was taken for purposes of observation much more frequently than would be necessary in actual practi<;e. p RiEss, 1880. 662 ENTERIC OR PYTHOGENIC FETER. Tlie temperature in tliis case was remarkably obstinate, but the baths Ti-ere well borne, and he had much quiet sleep bet^Yeen them, and though very prostrate he was free from delirium. At 9 p.m. on •June 23 he was giren 30 grains of quinine "«"ith 2 c mmims of lau- danum. This was repeated the next day at the same hour, and on June 30, 40 grains were given in divided doses. On July 2, 20 grains of saHcylate of soda were given, and on July 3, 40 gi'ains of quinine, and ice compresses were appHed to the abdomen. On June 23 the brandy was increased to 8 ounces daily, and on the 26th to 10 ounces. June 24. It was noted that the ulceration of the fauces had ex- tended, and there was some hoarseness with the cough, and he com- plained of a sensation of something sticking in his larynx. Pulse 120, less dicrotic. ■June 26. Ulceration has further extended. Pulse 120. Bowels have been opened three times in last 24 hours. Patient slept several houi's in the night. Many fresh spots. The pulse in the course of the day rose to 136, and became very feeble. June 27. Pulse 120, of better quahty. Patient slept dui'ing the night between each bath. No extension of ulceration. June 29. Ulceration has again extended ; there is now aphonia and some laryngeal spasm. June 30. Patient slept between each bath. Laryngeal spasms less severe, but ulceration has extended further upwards over the soft palate, ^vith an ashy grey surface, but no distmct false membrane. Pulse 132. Bowels open twice. July 1. Pulse 120. Feels better, voice improving. No extension of ulceration, rash fading. Slept well during the night between the baths. July 2. Pulse 116. No extension of ulceration. Bowels open twice, motions light but- formed. Piash fainter, no h^esh spots. July 3. Pulse 100. Cough troublesome, but fauces and laryngeal symptoms better. Tongue still dry and coated, but says he feels hungry. July 4. Pulse 102. Continues to improve, ulceration diminishing. Tongue moister. Brandy omitted, and 10 ounces of port substituted. The patient now steadily improved, the ulceration of the fauces gradually healed, and dm'hig the tlurd week of July quite disappeared. The glands, however, at the right angle of the jaw suppm-ated and retarded his convalescence. On July 7 he was attacked by very severe pains in his great toes, which continued for several days, and two red patches formed on the dorsum of the right one, but no sloughing or ulceration took place. He was discharged on August 6. The urine throughout was free h'om albumen. I think that in this case if the temperature had been allowed to main- tam itself at degrees varying from 103 to 105 and upwards, the patient would have sunk into a state of typhoid oppression and succumbed. The effect of the baths in relieving the febrile oppression and in- ducing sleep was most marked, and though given \dx\i unusual frequency they caused no bad symptoms, and very little or no distress to the patient. They usually depressed the temperature about three degrees. TREATMENT. 66z TABLE LXn. Date and day of disease ; ! Hour Temperature Baths Date and day of disease Hour Temperature : Baths June 22 ' 6 P.M. 104-6 I June 27 5 P-il- 103-4 i 33 (eighth 8 „ IOO-6 (thirteenth 6 „ 102-8 day) 10 „ 105 2 day) 8 „ 103-6 34 II ,1 IOI-2 9 .. 102-4 June 23 I A.M. 104-4 3 II ,1 104-4 35 (ninth 2 ,, 100-6 12 „ 102-2 day) 4 „ 103-3 4 June 28 2 A.M. 103-6 36 5 ,. 101-2 (fourteenth 5 .. 104-4 37 7 „ 103 5 day) 8 „ 102-2 8 „ 103-4 6 10 ,, 103-2 38 9 ., 101-6 II „ 103 39 12 „ 103-6 7 I P.M. 103-6 40 I P.M. I02-2 2 „ IOI-6 6 „ 104 8 3 .. 103-4 41 7 „ I02-2 8 „ I02-2 9 „ 103-4 9 10 ,, 105 42 10 „ IOO-6 II )I 102-4 June 24 I A.M. 103 10 June 29 I A.M. 104-4 43 (tenth day) 2 ,, 101-4 (fifteenth 3 - 102-2 4 „ 103-4 II day) 4 „ 103-6 44 7 „ 103-2 12 6 „ 102-4 10 „ I02-2 7 „ 104-6 45 I P.M. 102-8 8 „ IOI-6 3 » 102 10 „ 102-8 46 5 ,. 103-2 13 12 „ 102-7 9 „ 103-4 14 2 P.3I. 103-6 47 June 25 I A.M. 103-4 15 3 » 100-8 (eleventh 2 „ I0I-8 7 „ 104-6 48 day) 4 „ I02-8 16 8 „ 102 5 „ 102 II „ 103-6 49 7 „ 102-6 17 June 30 2 A.M. 102-4 10 „ 102 (sixteenth 4 „ 104 50 12 ,, 103-2 18 day) 7 „ 102-4 3 P-ii- 102-8 19 9 „ 100 5 n I0I-6 II ,, 103-4 51 7 „ 104 20 2 P.M. lOI 10 „ 102-4 4 „ 104-2 52 June 26 I A.M. 104-2 21 6 „ 102-8 (twelfth 4 ,, 103-6 22 8 „ 103-8 53 day) 5 „ 102 II ,, 102-6 7 „ 103-4 23 1 July I 3 A.M. 104 54 8 „ 102 (seven- 7 „ 101-4 10 „ 103-8 24 teenth day) 9 „ 102-6 II „ 103-8 25 II „ 103 55 2 P.M. 104-4 26 2 P.M. IOI-6 5 „ 104-4 27 6 „ 102-6 7 » 104-4 8 „ 104-6 56 II ,, 104-4 28 10 „ 102 June 27 2 A.M. 104 29 July 2 4 A.M. 103-6 57 (thirteenth 3 n 102 (eighteenth 7 ., 100-8 day) 5 „ 103 30 day) II ,1 102-6 6 „ 102-4 3 P-ii- 103-2 58 8 „ 103-8 31 6 „ lOI 9 .. 101-8 8 „ 102-6 I P.M. 103-4 10 ,, 104-2 59 2 „ 104 32 12 ,, IOI-6 3 .. 102-8 , 664 ENTERIC OE PYTHOGENIC FEVER. TABLE LXII. (continued). Date and day of disease Hour Temperature Baths Date and day of disease Hour Temperature Baths Julys 4 A.M. I02-6 Julys 4 A.M. I02-8 (nineteenth 6 „ I03-6 60 (twenty- 10 ,, 100 clay) 8 „ IOO-4 fourth day) 6 P.M. 103 12 ,, 103-6 9 ., 103-6 4 P.M. 103-6 II ,, 103-6 64 6 „ 104 61 July 9 2 A.M. 100 7 „ 101-4 (twenty- 8 „ 99-6 9 .. 103-4 62 fifth day) 2 P.M. lOI 12 „ 102-4 10 „ 100-2 July 4 4 A.M. I02-8 July 10 4 A.M. 99-8 (twentieth 6 „ 104 63 (twenty- 10 ,, 98-6 day) lO „ 98-4 sixth day) 2 P.M. 100-4 2 P.M. 100-4 10 „ 101-6 8 „ 102 July II 6 A.M. 100 12 ,, 102-8 (twenty- 6 P.M. lOI Julys 4 A.M. lOI seventh (twenty- ro ,, 100-2 day) first day) 4 P.M. 102 July 12 6 A.M. 98-4 lO „ 100-2 (twenty- 6 P.M. 99-2 July 6 2 A.M. I02-6 eighth day) (twenty- lO „ IOI-8 July 13 6 A.M. 98-6 second day) 4 P.M. lO ,, 102-4 100 (twenty- ninth day) 6 P.M. 98-6 July 7 2 A.M. 101-6 July 14 6 A.M. 97-4 (twenty - lO „ 101-6 (thirtieth 6 P.M. 98-6 third day) 2 P.M. lO „ 102-6 102-6 day) 3. The second mode of reducing temperature is by the action of drugs, the most important of which are quinme, sahciiie salicyHc acid and its soda salt, kairin, and digitaHs. These should be looked upon rather as adjuncts to the abstraction of cold, or as indicated under special circumstances ; and the results of attempts to keep dowia the temperature persistently through the whole course of the fever by their means have been much less favourable than those obtained by the abstraction of heat. Dr. Brand is opposed to their use. Liebermeister on the contrary considers them valuable adjuncts to the bath. All these drugs, when given in doses sufficiently large to produce a decided effect on the temperature, have the disadvantage of causing more or less distm'bance of many of the functions of the body, and their effect in relieving the headache, delirium and stupor, and dry tongue of the febrile condition is certainly very inferior to that of the cold bath. With regard to their physiological action, Dr. Sassetzkyi found that quinine and salicylate of soda had a much less effect in diminishing the excretion of urea, and in increasing the assimilation of milk, in the febrile state than the cold bath. In my opinion quinine is as a rule to be preferred to salicylate of soda in enteric fever, as the latter drug given in repeated doses is liable « Sassetzky, I J TREATMENT. 665 to cause depression of the heart, and sometimes induces dehrium and albuminuria. Quinine given in large doses in fever sometimes causes vomiting, and produces the usual disagreeable effects of cinchonism, but does not seem otherwise injuriously to affect the patient. Quinine may be given in doses of gr. xv. to gr. xl. Salicylate of soda in doses of gr. xx. to 3J. Quinine is best given in suspension, and when very large doses are employed they may advantageously be divided into separate portions given every ten minutes till the amount required has been taken. When they induce vomiting a little opium may be added. Liebermeister considers it of more importance to produce a complete morning remission than to prevent the evening exacerba- tion, and therefore recommends quinine to be given towards evening. The maximum effect in reducing the temperature usually occurs in about eight hours. Quinine is especially useful in the later stages of the disease, when the fever has a decided remittent type, and it is well borne by children.'" Eecently kairin, Cio H,3 NO, oxyhydromethylchinoline, has been introduced into practice as an anti-pyretic by Dr, Wilhelm Filehne.^ It has been largely experimented upon and used in many kinds of fevers, and promises to be a useful remedy. Its effects in reducing tempera- ture are very remarkable, and it does not cause any of the disagreeable symptoms of cinchonism ; often no other effects than the reduction of temperature are observed. Sometimes it causes rigors and commonly profuse sweating. The pulse usually falls in frequency with the tempe- rature. In some cases cyanosis and symptoms of collapse have been induced. These appear to depend in great measure on the mode of preparation and the purity of the drug, which probably undergoes changes by keeping, and should therefore be used freshly prepared. By doses sufficiently large and sufficiently often repeated the tempera- ture may be readily brought down from a high febrile heat to normal or subnormal. The effect of the drug is, however, very transient, and the temperature rises rapidly again, often to a greater height than before its administration. Hence, to produce a permanent effect repeated doses are necessary. At first, Dr. Filehne recommended doses of from 7 to •15 grains, repeated every hour till the temperature fell ; usually two or three doses were necessary to cause a sufficient reduction. To keep down the temperature in a severe case it may be necessary to give as many as from 15 to 20 doses in the twenty-four hours. More recently Dr. L. Eiess ^ has found that with the improved method of preparing the drug much larger doses may be given with safety — 30 to 37 grains. In one case he gave as much as 3^ grammes, about 53 grains. The tem- perature fell from 104° to 96 -4° Fahr., the pulse to 36, and the patient became cyanosed and sank into a state of apathy. With the use of stimulants this condition passed off, and in five hours the pulse rose to Barthez and Eilliet, 1853. ' Filehne, 1883. ■ ' L. KiEss, 1883. 666 ENTEEIC OR PYTHOGEXIC FETER. 76, and in ten hours the temperature to 102-5'', Given in these large quantities, usually three to six doses in the twenty-four hours are suffi- cient to keep the temperature below 102°. The drug is extremely nauseous, and is best given in wafer papers. I have myself only tried it in the manner first recommended by Dr. Filehne, viz., m frequently repeated doses of 10 to 15 grams, and in some cases it has appeared to me to exercise a most beneficial effect. With the fall of temperature the patient's general condition has shown a marked improvement. In other cases where there has been great prostration, though the temperature has fallen the general condition has not been beneficially affected, and in one the prostration appeared to be increased. I should not now be inchned to administer it where the heart seemed to be failing, or where there was any serious pulmonary complications, and unless it can be given with safety in the larger doses at longer intervals, its use, except as a temporary expedient, would not be practicable. In Germany patients have been kept under its influence for many weeks without any injurious consequences. DigitaHs in large doses has a powerful action in reducing temperature, and is strongly recommended by Liebermeister.^ He gives it in powder or pills, fi'om 12 to 24 grains in divided doses in 24 to 36 hours, but only in cases where there is no great degree of cardiac weakness. Its use in these large doses can hardly be regarded as quite free from danger. (See note i., p. 585.) By the employment of these drugs in obstinate cases the number of baths may be much diminished, and the temperature may be more or less kept under control when circumstances render bathing inapphcable. Case LXXXVIII. — Enteric Fever treated by Cold Baths and Kairin. Edward L., a fishmonger, aged 19, was admitted into the Middle- sex Hospital Oct. 22, 1883. Previous health good. He was taken ill on the evening of Oct. 18 with rigors, headache, and general malaise. On the 20th he had to give up work and take to his bed. State on admission. — A muscular young man suffering from febrile oppression, headache, thirst, great muscular weakiaess. Tongue dry and red, coated posteriorly, lips cracked, belly distended, spleen en- larged, bronchitic rales audible over the back of the chest, urine free from albumen, no eruption ; in the evenmg, temperature 104°. He was ordered a bath at 70° of 15 minutes duration, whenever the temperature exceeded 102*5° ii^ ^^^ axilla. During the first five days of treatment nmeteen baths were admin- istered, and after the first one 20 grains of quinine. I then determined to try the effects of kairin, and 10 grains were ordered every hour when the temperature amounted to 100°. The " LlEBEKMEISTEK, 1876. TREATMENT. 667 first dose was 15 grains, and 5 grain doses were occasionally given when the temperature was below 100". The accompanying Table LXIII. shows the range of temperature. From this it will be seen that it was kept permanently below 102-5°, but in order to effect this 12 doses daily were usually requisite, and on one occasion 15 doses. The great rise of temperature on Oct. 31 was Caused by mental shock due to the death of another patient in the same ward. A few doses were given on Nov. 5 , but after this the drug was no longer required ; convalescence was not, however, completed till Nov. 14, it being delayed by an attack of cystitis, which, supervened on Nov. 7, and was accompanied by severe pain above the pubes and on micturition, and the urine became purulent. While taking the drug it continued free from albumen, but became of the usual greenish- M'own colour. The attack was a very severe one ; the belly became much swollen and there was profuse diarrhoea, six or seven motions daily, and much bronchitis. He vomited occasionally, but this did not seem to be due to the kairin, which appeared to produce no other symptoms than sweating and slight rigors, and except from its frequent administration was not disagreeable to the patient, who slept well between the doses. On the 27th before commencing it he was slightly delirious. Cold compresses were applied to the abdomen, and opium given to check the diarrhoea. He was also stimulated with brandy. The pulse ^varied from 100 to 120. The respirations were much accelerated, durmg part of the attack as many as 44, but there was no cyanosis. He was discharged on Dec. 3. During his illness his weight fell from 1741b. lo 1 10 lb.] TABLE LXin. B. signifies a hath at 70°. K. a dose of 10 grains of kairin. The temperature loas taken half an hour after each hath. Date and day of disease Hour Tempe •ature Date and day of Uicease Hour Temperature Oct. 22 6 p.Ji. 104 B. I Oct. 24 2 P.M. 104-2 B. 9 (fifth day) 102 (seventh day) 102 10 ,, 103-8 102 B. 2 6 „ 103-6 B. 10 99-2 Oct. 23 2 A.M. 103-2 B.3 10 „ I02-8 B. II (sixth day) 99 102 6 „ 102 Oct. 25 2 A,M. 104 B. 12 10 ,, 102-4 (eighth day) 100-4 2 P.M. I02-8 101-2 B.4 ; 6 „ 103-6 B. 13 99-6 6 „ 104-4 102-2 B.5 10 ,, 2 P.M. 102-4 103-4 B. 14 10 ,, 103-4 99-8 B. 6 6 „ 102-4 103-6 B. 15 Oct. 24 2 A.M. I02-8 B..7 10 ,, 103-4 B. 16 (seventh day) 99-8 99-8 6 „ 102 Oct. 26 2 A.M. 101-8 B. 17 10 ,, 103-6 lOI B. 8 (ninth day) 6 „ 100-4 102-4 66d> ENTERIC OR PYTHOGENIC FEVER. TABLE LXIII. {continued). Date and day of disease Hour Temperature Date and day of disease Hour Temperature Oct. 26 10 A.M. IOI-8 Oct. 30 6 P.M. 103 K. (ninth clay) 2 P.M. 103-4 B. 18 (thirteenth 8 „ 101-8 IOI-2 day) 10 „ 100-8 6 „ lOI II !» 100-4 K. 10 ,, 103 B. 19 12 „ 99-8 Oct. 27 2 A.M. 101-4 Oct. 31 3 A.M. 102 K. (tenth day) 6 „ 102-2 (fourteenth 6 „ IOI-6 K. 10 „ 103 K. gr. XV. day) 9 ,. 101-6 K. 2 P.M. 98-4 10 ,, IOI-2 K. 3 .. 103-8 K. II „ IOI-6 K. 4 ., 102 K. 12 „ loi K. 5 >, 97-8 I P.M. ICX) 7 n 99 2 ,, loi K. 8 „ io3'2 K. 1 1 )> 102-4 K. 9 n 103-8 K. 4 „ 101-8 K. 10 ,, 103 K. 5 » 100 II ,> 100-6 K. 6 „ IOI-8 K. 12 ,, 98-4 7 „ 104-6 K. Oct. 28 I A.M. 100 K. 8 „ 104-2 K. (eleventh clay) 2 ,, 100 K. 9 n 100-6 3 n 100-2 K. 10 ,, 98-8 6 „ IOO-8 K. II ,, 98-8 10 ,, 103-6 12 „ 98 12 „ I02-6 K. Nov. I 2 A.M. 102-4 K. I P.M. 102-4 K. (fifteenth day) 4 „ 102 K. 2 „ 100-6 K. 6 „ 102-6 K. 3 ,. 99 K. 8 „ 100 4 „ 101-8 K. 9 „ 99-2 5 ,> 101-6 K. II ,. IOO-6 K. 6 „ 102-4 K. 12 „ 100 7 „ I02-8 K. 2 P.M. I02-2 K. 8 „ 101-8 K. 3 .. 101-2 K. 9 „ IOO-6 K. 4 „ 100 10 ,, 99-2 K.gr.5 5 ,. 102-2 K. II ,, 1 00 -2 K. 6 „ 102-4 K. 12 ,, ior4 K. 7 „ lOI Oct. 29 I A.M. 100-4 K. 8 „ IOO-8 (twelfth day) 2 ,, 99-6 K.gr.s 9 .. 101-8 K. 3 „ 102-4 K. 10 „ 101-4 K. 4 ,. 103-2 K. II ,. 100 K. 5 .. IOO-2 K. 12 ,, 102 K. 6 „ 97"4 Nov. 2 2 A.M. 101-8 K. 8 „ 100 K. (sixteenth 4 „ 100 K. 9 „ 99-6 K.gr.5 day) 6 „ 101-8 K. 10 ,, 100-6 K. 8 „ 101 K. II „ TOI-2 K. 9 ,- 100 K. 12 „ lOI 10 „ 100-2 K. 2 P.M. IOO-6 II ,. 99-4 10 ,, lOI 12 „ loi K. Oct. 30 2 A.M. 102 K. I P.M. 99 (thirteenth 3 .. 99-8 2 ,, 100 K. day) 4 „ IOI-6 K. 3 It 100-4 K. 5 " 102 K. 4 n 97-8 6 „ IOO-6 K. 5 M 98-6 8 „ 98-6 6 „ 102 K. 10 ,, 98-2 7 M 102 K. 2 P.M. I02-2 K. 8 „ 99 3 >, IOI-6 K. 10 „ 98-8 4 „ 100-4 K. 1 TKEATMENT. 669 TABLE LXIII. {continued). Date and day of disease Hour Temperature Date and da}' of disease Hour Temperature Nov. 3 (seventeenth day) 2 A.M. 6 „ 8 „ 9 „ 98-8 98-6 IOO-2 K. 98-6 Nov. 4 (eighteenth day) 4 A.M. 10 ,, 1 P.M. 2 ,, 98-2 100 loi K. 101-6 K. II 1, IOI-2 K. 3 .. ior-2 K. 12 ,, 100-4 K. 4 „ 100-4 K. I P.M. 102-2 K. 5 M 99-8 2 ,, I02-6 K. 6 „ 100-2 K. 3 ,. IOO-6 K. 7 „ 102-2 K. 4 M 6 „ 7 „ 99 102-6 K. 100-4 K. 8 „ 9 ,. 12 ,, 100-4 K. 99 I02-8 K. 8 „ 9 n 12 „ 99-8 K. 99 99 Nov. 5 (nineteenth day) 4 A.M. 8 „ 99 99 4. Cardiac Sedatives. (See p. 287.) 5. Hygienic Measures. (See p. 288.) IV. Sustain the Vital Poivers hy ajjpropriate Food and Stimidants, hut in doing so avoid exciting congestion, or increasing the work of the already overtasked glandular organs. 1 . Diet. As long as the fever lasts the diet must be similar to what has been recommended in the case of typhus (see p. 288), the existence of the intestinal lesions being an additional reason for caution. Beef-tea appears sometimes to increase the diarrhoea, and may then be advantageously thickened by the addition of a little gelatine or arrowroot. 2. Alcoholic Stimidants. The remarks already made on the use of stimulants in typhus (p. 289) apply also to enteric fever, except that in the latter disease stimulants are oftener called for in patients under twenty years of age, but a smaller quantity usually suf&ces in patients more advanced in life. 3. Medicinal Stimidants. (See p. 293.) Large doses of car- bonate of ammonia are even more objectionable than in typhus, from their tendency to irritate the bowels and increase the diarrhoea. 4. Conserve Muscular Power. (See p. 294.) 670 ENTERIC OR PYTHOGENIC FEVER. V. Relieve Distressing Symptoms. Many of the symptoms of enteric fever, such as headache (p. 294), sleeplessness and delirium (p. 296), drowsiness a,nd stujjor (p. 301), convulsions (p. 303), hiccup (p. 304), albuminuria (p. 301), &c., require the same treatment as in typhus, except that strong purgatives must always be avoided. Certain symptoms, how- ever, pecuhar to enteric fever also call for treatment. The chief of these is : — I. Diarrhoea. It is usually well to have recourse to astrin- gents when there are more than two motions in the twenty- four hours ; and if the patient be very prostrate, even this amount of action may be injurious. The milder forms of diarrhoea are usually checked by a starch enema, containing from ten to twenty drops of laudanum, or by temporarily adding two or three minims of laudanum, or of Battley's liquor opii sedativus to each dose of the ordinary acid mixture (p. 274) ; or sulphuric acid, which is more astringent than the other mineral acids, may be prescribed as follows : — ■R Acid. Snlph. Aromat. n^xx., Liq. Op. Sed. ntiij., Tinct. Catechu 5ss., Aq. Mentli. pip. |j. M. Fiat liaust. 3a vel 6ta qq. liora sum. When these remedies fail, or when the acids are not tolerated by the stomach, recourse may be had to the subnitrate of bis- muth in a mucilaginous mixture, lime-water, vegetable charcoal (a tea- spoonful every four hours), which is j^articularl}^ useful when there is much tympanites along with diarrhoea, powders composed of equal parts of Dover's powder and hydrargyrum cum creta, or the acetate of lead. The last has long been a favourite remedy at the London Fever Hospital ; it may be given in solution in doses of two or three grains every four or six hours, with or without the twelfth of a grain of acetate of morphia. The ordinary vegetable astringents are less efficacious than the remedies now mentioned. When from any cause opiates even in small doses are contra- indicated, the chief reliance must be placed upon the acetate of lead, bismuth, and charcoal ; or drachm doses of the tincture of catechu may be given every three or four hours. In addition to these remedies much benefit will be derived in every case of enteric fever where there is diarrhoea, abdominal pain, or tympanites, from constant fomentation of the abdomen with poultices, or with wet flannel covered with oiled silk or gutta- TEEATJIENT. 6/ 1 percha. Stupes moistened with turpentine or with the compound camphor hniment may also be apphed at intervals. Other plans of treatment for the diarrhoea have been proposed, a knowledge of which may be useful. Huss strongly recommends small doses of ipecacuanha in combination with phosphoric or sulphuric acid and fomentation of the abdomen, and assisted, if need be, by starch and opium enemata.'^ Some years ago Professor Fouquier of Paris wrote very strongly in favour of alum dissolved in gum. He commenced with twenty- four grains in the day and gradually increased the quantity up to a drachm.'' Alum may also be used in the form of ' alum- whey,' which is prepared by adding one drachm of alum to a pint of boiling milk, and then straining ; two ounces may be given after each motion of the bowels. Nitrate of silver has been recommended by many practitioners, both by the mouth and also in the form of enema.'' In the latter form it is difficult to understand how it can act beneficially, seeing that the ileum is the chief seat of disease. In severe diarrhoea, after the fourteenth day, the late Dr. Joseph Bell found advantage from nitrate of silver, in doses of from one to three grains made into a pill, and taken every six or eight hours. ^ Sulphate of copper is a favourite remedy with some physicians ; a quarter of a grain may be given in pill with a like quantity of opium, or in solution with sulphuric acid, quinine and a few drops of laudanum, every four or six hours. Both the sulphate of copper and the nitrate of silver have appeared to me to be most serviceable for the diarrhoea due to 'atonic-ulcers,' after the primary fever has ceased. The treatment of the late Professor Trousseau consisted in giving first laxative doses of sulphate of soda or Seidlitz powders, which were believed to check the diarrhoea by altermg the secre- tions, and to be particularly useful when there was much meteor- ism as well as diarrhoea. If this did not succeed, he then ordered the English mistura cretse or equal parts (7 grains of each) of prepared chalk and of the subnitrate of bismuth to be taken from three to eight times in the twenty-four hours. These remedies failing, he had recourse to pills containing about a tenth of a grain of nitrate of silver.^ Lastly, Dr. G. Johnson advocates that the diarrhoea be let ^ Huss, 1855. " Brit, and For. Med. Eev. 1836, i. 568. » Yates, 1853 ; also Boudin, Journ. des Con. Med. Prat. Mai 1839, J Bell, i860, viii. 385. ^ Teousseau, 1S61, p. 182. 6/2 ENTEEIC OR PYTHOGENIC FEVER. alone ; but ^Yllen there is much meteorism, that a tablespoonful of castor oil by the mouth, or a laxative enema, be administered.* 2. Hcemorrhage from the Boicels, during the first ten days of the disease, is usually slight, and is readily checked by the acetate of lead and morphia, and the starch and opium enemata already recommended for diarrhoea. When intestinal haemorrhage co- exists with hsemorrhages elsewhere, large doses of the perchloride or pernitrate of iron will be found useful. But when profuse hgemorrhage from the bowel occurs by itself at an advanced stage of the disease, the patient is in great danger (see p. 527), and my experience is enthely opposed to the advice recently offered by Sir W. Gull, that ' it is best to trust to the hgemorrhage to cure itself.' ^ The remedies mainly to be relied on are tannic acid, turpentine, rhatanj^ opium and ergot. During many years I have found the following mixture almost invariably successful for arresting the bleeding. The doses are for an adult — R Acid. Tannic, gr. x., Tinct. Op. irtx.. Spirit. Terebinth. Tn.xv., Mucilag. 5ij., Tinct. Chloroform. Co. nixx., Aq. Menth. pip. ad ^j. M. Ft. haust. 2a qq. hora sum. Latterly I have found ergot a most efficacious styptic, even in the most profuse hgemorrhage. Mr. J. B. Eussell of Glasgow gives the tincture of ergot in drachm doses every hour, and has never known it fail.*^ Ergot also possesses this advantage, that it may be administered subcutaneously. From 3 to 5 grains of ergotine dissolved in 10 minims of distilled water, or in equal parts of glycerine and rectified spirit, may be injected beneath the skin. "With these internal remedies perfect rest is to be en- joined; a bladder containing broken pieces of ice is to be applied over the right side of the abdomen, and ice may be given to suck. Stimulants are to be administered according to the state of the pulse. 3. Vomiting occurring during the first ten days of the disease is often relieved by an emetic. If emetics fail, or if they be contra-indicated, as they always are after the tenth day (p. 653), a sinapism or a turpentine-stupe is to be applied to the epigas- trium, while ice is given to suck. If the vomiting continue, which rarely happens, the acid treatment must be suspended, and lime-water or bismuth and hydrocyanic acid are to be substituted. Equal parts of lime-water and milk I have often found an excel- lent rem.edy in such cases. The practitioner should bear in mind Brit. Med. Joiirn. 1867, i. 279. •> Lancet, June 29, 1872. " Glasgow Med. ■Joiirn. May 1869. TREATMENT. 673 that vomiting coming on after the fourteenth day is often the first symptom of peritonitis. 4. Tympanites is sometimes so excessive as to impede the breathing, and cause great distress to the patient, while the dis- tended state of the bowel increases the risk of perforation. Much may be done to prevent tympanites by turpentine-stupes and constant fomentation of the abdomen, but very often other measures must be resorted to. The gas is mainly in the colon, and, accordingly, enemata are the most effectual remedies. The best enemata are those containing carbolic acid (glycerin, acid, carb. 5SS., decoct, hordei Ojss.), creasote (creasot. vivj., glycer. 5ss., decoct, hord. Ojss.), vegetable charcoal (carb. lig. |j., mucilag. |ij., decoct, hord. Ojss.), turpentine (sp. tei'eb. 5ij., ol. oliv. 5ij., decoct, hord. Ojss.), assafoetida and rue (tinct. assaf. 5ij., olei rutse nix., decoct, hord. Ojss.). When with tympanites there is protracted constipation, one or two teaspoonfuls of castor-oil in peppermint water may be given by the mouth ; but more com- monly there is diarrhoea, and then the proper remedies are tur- pentine (as prescribed at pp. 305, 651),"^ charcoal, acetate of lead, or one of the antiseptic remedies already referred to (p. 651). Dr. Peter of Paris has found ice-poultices, made by scattering small fragments of ice over a thick layer of linseed meal, most effectual for subduing the tjrmpanitic distension.^ Failing these measures, the gas may be drawn off in large quantity by a long- tube passed into the colon. It must not be forgotten in the treat- ment of tympanites that it is often a symptom of peritonitis, and that in the typhoid state it may be a sign of debility, requiring stimulants and the remedies recommended under the head of typhus. [The application of ice to the surface of the abdomen is in my opinion by far the best way of treating great distension. It may be con- veniently applied by putting small pieces between two folds of flannel. It is especially indicated in haemorrhage. By this means a considerable reduction of the general temperature may be effected.] 5. Abdominal Pain is usually relieved by assiduous fomenta- tion, or poulticing of the abdomen ; and when these measures fail, a dessert-spoonful of laudanum may be added to the poultice, * Dr. Wood of America recommends turpentine in all cases of enteric fever where there is tympanites and a dry tongue. In certain cases, where the tongue, after cleaning, becomes dry, red, and smooth (a symptom which, he thinks, indi- cates great danger, and at all events slow cicatrisation of the intestinal ulcers and a protracted convalescence), he regards turpentine almost in the light of a specific. He gives it in doses of from 5 to 20 minims every hour, or every second hour. (Pract. of Med. 2nd ed. 1849, i. 328.) « Brit. Med. Journ. 1869, ii. 450. X X 674 ENTERIC OR PYTHOGENIC FEVER. or turpentine-stupes may be applied to the abdomen at intervals. When the pain is severe, an opiate may be given by the mouth or rectum ; or, if the patient be young and robust and in an early stage of the fever, from 2 to 6 leeches applied over the right iliac region, or round the anus, often give great and immediate relief. 6. Epistaxis is usually slight, and requires no treatment ; but when profuse, it must be checked without delay (p. 544). Gallic acid and turpentine, or tincture of ergot, may be given every hour, or ergotine may be injected subcutaneously in the manner recommended for intestinal hgemorrhage. At the same time a bladder containing ice is to be applied over the forehead and nose, while a solution of alum or tannin, or an infusion of matico or rhatany may be injected into the nostrils. If these measures fail, the nares must be plugged. VI. Obviate and Counteract Complications. Most of the complications of enteric fever demand the same treatment as the corresponding complications of typhus (p. 306), care being taken to abstain from all remedies calculated to irri- tate the bowels. Among the complications peculiar to enteric fever, the most important is — I, Peritonitis. Although the cause of the peritonitis cannot always be determined with certainty (p. 567), in the great majority of instances it is perforation of the bowel. The case, though desperate, is not altogether hopeless (p. 571). Opium is the only remedy to be relied on in such cases ; but, to be of ser- vice, it must be given immediately and boldly. To an adult, 2 grains of solid opium may be given at once, followed by i grain every second or third hour, till slight stupor is induced. When the stomach is irritable, the subcutaneous injection of morphia is preferable to opium by the mouth. The doses will vary with the age and other conditions of the patient, but the amount of opium tolerated is often extraordinary : as much as 60 grains have been taken in three days with benefit. The opium is to be given alone, and not in combination with calomel, which brings down more bile into the lower bowel, and so excites peristaltic action. The object is, not to produce absorption of lymph (even if mercury had the power to do this), but to paralyse the movements of the bowels, so as to prevent the escape of their contents into the peritoneum, and favour the formation of adhesions. Many writers have recommended the application of leeches to the abdomen on TREATMENT. 675 the supervention of peritonitis, but the extreme prostration and the circumstance that the tendency is to death by asthenia, contra-indicate such a practice. The pain and tension of the abdomen will also be relieved by warm fomentations, bran- poultices, and turpentine- stupes ; but a much more certain method of subduing the inflammation is covering the abdomen with a bladder of ice, or with the ice-poultice referred to under the treatment for tympanites. At the same time the patient must be kept in a state of absolute rest, and on no account raised in bed, and the ingesta ought to be liquid, and given in such small quantities at a time that they can be absorbed by the stomach. A tablespoonful of milk or of iced brandy and water may be given every hour, or every half-hour. The large quantities of food and stimulants sometimes given cannot fail, in my opinion, to be in- jurious. Dr. Joseph Bell, indeed, treated several cases to a suc- cessful termination with opium and absolute starvation ; for the first two or three days he allowed nothing in the way of nourish- ment except a table-spoonful of water, or of toast-water, every quarter of an hour.^ If the case does well, we must beware of interfering with the constipation induced by the opium : cases are recorded where the incautious administration of a purge appeared to break up the adhesions and produce a fresh and fatal attack of peritonitis. When the symptoms of perforation are followed by great abdominal distension, E. Friedrich^ and others '^ have recommended drawing off the intestinal gases by paracentesis. Notwithstanding the measures here recommended, peritonitis, as a rule, terminates in death ; and hence it is imperative to do all in our power to avert its occurrence. Bearing in mind that rupture of the denuded peritoneum is one of the ways in which perforation takes place, it is obviously of importance to prevent every movement which would favour such a laceration. Atten- tion to this point is particularly necessary in mild cases, in which the patient is able to get up without assistance and in which perforation is very apt to occur (see pp. 593, 627). It is a good rule not to allow the patient to get out of bed to the night-chair, after the fourteenth day of his illness, until convalescence is fairly established, and not even then, if there be reason to believe that the ulcers have become atonic instead of cicatrising. In the ad- vanced stages of the disease,^the physician ought also to be very *■ Bell, i860, viii. 386. « Prag. VierteljaJirs. f. prakt. Heilk. 1868, C. 11. ■> Stein, Dcutsch. Arch. f. klin. Med. l86q, vi. 4'>4. X X 2 6']6 ENTEEIC OR PYTHOGENIC FEVER. careful in the way in "which he manipulates the abdomen ; and throughout the disease all strong purgatives and solid food are to be avoided. 2. For Laru7igitis a small blister may be applied on either side below the angles of the jaw, while the whole neck is enveloped in a poultice, and the different measures recommended under the head of typhus for acute cedema of the glottis (p. 306) are re- sorted to. If these measures fail, and suffocation appears immi- nent, tracheotomy ought to be performed without delay, and it is satisfactory to know that in a large number of cases the operation has been successful.^ Treatment during Convalescence. Patients recovering from enteric fever require far more care and watching than those convalescing from typhus. While the intestinal ulcers are cicatrising, it is obvious that much mischief may be done by purgatives and improper diet. The bowels may be opened by aperients every second day, if necessary ; but for a month after the cessation of pyrexia, small doses of castor oil and simple enemata are the only means which should be resorted to for this purpose. Notwithstanding the cravings of the patient's appetite, the diet must be at first restricted to such articles as milk, eggs, farinacea, custards, light puddings, beef-tea, chicken- tea, or calf s-foot jelly. Meat ought not to be allowed for at least seven days after the cessation of pyrexia, and not even then if there be any signs of intestinal disturbance ; and before meat is given, it is well to try for a day or two a piece of boiled sole, smelt, or whiting. Malt liquors ought not to be given before meat, as they are apt to derange the bowels. When convales- cence is slow, quinine, the mineral acids, iron, cod-oil, and change of air are indicated. When diarrhoea persists during convalescence, the acetate of lead, sulphate of copper, or nitrate of silver must be given in the manner already prescribed (pp. 670-1), and the patient must be kept in bed. At the same time it is well to remember a remark ' Pachmayr has collected 46 cases in which tracheotomy was performed for ' perichondritis laryngea ' in enteric fever. Of the 46, 26 died, 6 during the operation, 6 within a few hours, and the remainder between the third and forty- seventh days. The causes of death were asphyxia (13), hfemorrhage (3), pyasmia (3), pneumonia (3), gangrene of lung (3), and pericarditis (i). {Verhancll. cler 2)hys. vied. Gesellscliaft in Wurzhurcj, 1868, Bd. I.) For successful cases, see also Teousseau, 1861, p. 197, and Schmidt's Jahrb. vol. cxix. p. 334; vol. cxxxiv. J). 114 ; vol. cxxxv. p. 241 ; vol. cxxxvii. p. 263. TEEATMENT. 6'JJ of Trousseau, that when there is great emaciation, especially in cases which have been treated on too lowering principles, vomit- ing and purging during convalescence may be of a purely nervous character, and at once relieved by solid food.J The liability to perforation, hgemorrhage, or a relapse, when convalescence appears to be progressing favourably, must always be borne in mind, and in every case it is important to continue taking the temjDerature once every evening for at least two weeks after the commencement of convalescence. J Trousseau, i86i, p. i^ 6y8 CHAPTEE V. ON THE SPECIFIC DISTINCTIONS OF TYPHUS AND ENTERIC FEVER. In this chapter Dr. Murchison considered in the previous editions the chief arguments in support of the specific distinctness of typhus and enteric fever, derived, in the first place, from their symptoms and j^ost-mortem appearances, and, in the second, from their etiology. But as this point may be now regarded as defi- nitely settled, it has not been thought necessary again to insert these arguments at length. The two diseases dift'er A. In their SymiJtoms and Post-Mortem Ai^jpearances, and the following propositions may be laid down : — 1. When lenticular rose-spots, as described at ^j. 510, api^car 171 successive crops in the course of continued fever, the abdominal lesions of enteric fever are invariably present. 2. When the eru])tion of typhus, described at pp. it,o aiid 513, shows itself in the course of continued fever, the abdominal lesions of enteric fever are absent. The clinical features, moreover, of the two diseases are very different. B. In their Etiology. Still more conclusive arguments in favour of the specific dis- tinctness of typhus and enteric fever are derived from a study of their etiology (see Introduction, p. 5). 1. The two, fever shave no community of origin. One fever does not give rise to another. 2. An attack of one fever confers an immunity from a suhscquent attack of itself, hut not of the other. While it is extremely rare for the same individual to have two attacks of typhus, although second attacks of enteric fever are more common (see pp. 94 and 469), there are numerous examples of persons contracting both of these fevers under favourable circumstances. It has repeatedly happened at the London Fever Hospital, that patients, after SPECIFIC DISTINCTIONS OF TYPHUS AND ENTEEIC FEVEE. 6/9 having convalesced from an attack of enteric fever, have con- tracted typhus while still in hospital, or have been re-admitted with it within a week or ten days of their discharge ; while, in rarer cases, an attack of typhus has been succeeded by enteric fever. I have notes of 23 patients who contracted typhus at an interval of from a few days to three years after enteric fever, of whom 3 died ; and of 7 patients who contracted enteric fever at an interval of from a few days to seven years after typhus, of whom I died. In fatal cases of enteric fever following typhus, the recent abdominal lesions of enteric fever are found in the dead body ; but when the sequence of the fevers is reversed, we find only the cicatrices of the old intestinal ulcers. The two diseases, moreover, may co-exist in the same patient (see p. 589). 3. The two diseases differ in their contagious properties, and in their mode of propagation (see pp. 80 and 458 and pp. 87 and 465). 4. The tivo diseases differ in their mode of prevalence. Typhus prevails in the epidemic form ; enteric fever is an endemic disease, or its epidemics are circumscribed (see pp. 55 and 441, and Diagram I.). Moreover, it is found that epidemics of typhus always com- mence among the poorest and most crowded of the population, and do not spread among the rich, whereas enteric fever attacks rich and poor alike, and often commences in the best and most ventilated localities. 5. The increased prevalence of enteric fever after a long con- tinuance of hot iveather does not hold good icith regard to typhus (see pp. 66 and 448). 6. While the poison of typhus appears to he generated and pro- pagated by over-croivding of human beings with deficient ventilation^ that of cjiteric fever appears to be developed during the fermentation of organic , for the most part f(2cal, matter (see pp. 119 and 499). 68o CHAPTEE VI. SIMPLE CONTINUED FEVER OR FEBRICTJLA. Sect. I. Definition. A SPORADIC, non-contagious disease, arising from exposure to the sun, fatigue, sui-feit, inebriety, etc. Its symptoms are fre- quent, full, and often firm pulse ; white tongue ; thirst ; constipa- tion ; high-coloured urine ; hot and dry skin ; no eruption ; severe headache, and sometimes acute delirium ; the fever subsiding in from one to ten days, with copious perspirations, herpetic eruj)- tions, etc. ; rarely fatal in Britain, except from complications ; but when death occurs, no specific lesion. Sect. II. Nomenclature. I. — Names derived from its Continued Character. Stjj'oxos? {Greeks) ; Syuocha vel Synoclms simplex {Biverius, 1623 ; Hoffmann, 1700 ; Juncher, 1736 ; Burserius, 1785) ; Spiocha (/Saw- vages, 1760; Linnaus, 1763; Cullen, 1769); La Fievre Synoque {Davasse, 1847); Synocliische [Germ.); Febris continua simplex {Lieutaud, 1776) ; Simple Continued Fever {Modern Woiters). 2. — From its suiyiwsed InflamviatorTj or Ardent Character. Suvex"*?? 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Stickstoffhalt- Substanz, etc. : Yirclww- Archiv, vol. ^4, p. 485, 1883. SoHiEE, D'une Cause possible et proba- ble de Mort subite dans la Fievre typhoide : Archiv. viid. Belg., Jan., 1880. Sutton (J. B.), The Diseases of Mon- keys, Lancet, Aug. 18, 1883. Tambereau, De la Pathogenie de la Mort subite dans la Fievre typhoide : th^se, Paris, 1877. TizzoNi (G.), Stud, di Patolog. speri- mentale sulla genes, e sulla nat. del tifo addominal : Ann. Univers. di Med. e Chir., Feb., 1880. ToMKiNS (H.), On the antipyretic treat- ment of Typhoid Fever by means of the Sodium Salicylate : Lancet, March 12, 1881. Waeeen (F.W.), Carbolic Acid : its local and internal uses and its poisonous effects : Med. Press, and Circular, Jan. II, 18S2. WiNTEENiTZ, Bemerkungen, &c. (results of cold bathing at Vienna) : Wicn. med. Prcsse, 1874, No. 3. WoiciECHOwsKi (Hfemorrhage from stomach and bowels in Tyjjhus) : T'w-- choiu undHirsch, Jahresbericht, 1879, vol. ii., p. 34. Woodwaed (J. J.), Typho-Malarial Fever : Trans. Internat. Med. Cong. Philadelphia, 1876, p. 305. 719 INDEX. Throughout the Index, T. indicates Typhus ; R. Eelapsing Pever ; E. Enteric Fever ; and S. simple Continued Fever. ABD Abdominal fever, 591 — pain, T. 148; E. 358, 413 ; E. 524, 611, 673 — typhus, 416, 418, 428 Abortion in T. 212 ; E. 388 ; E. 581, 612 Abortive attacks of T. 97, 187 ; E. 682; E. 549, 592 Access of T. 179 ; E. 372 ; E. 545, 61 1 Acids, use of in T. 274 ; E. 408 ; E. 651 Aconite in fevers, 287 Acute variety of E. 594 Adynamic fever, 24, 46, 227, 685 Africa, T. in, 59, 62 ; E. 324 ; E. 436 Age as predisposing to T. 64 ; E. 324 ; E. 437; S. 683 — in reference to mortality of fevers, T. 236; E. 305 ; E. 605 Ague, diminution of in England, 8 — Irish, 25 — relation to E. 4-5 1 — resemblance to E. 546, 597 Air expired in fevers, 15 ; T. 143 ; E. 355 ; E. 522 — in treatment of fevers, 275 Albuminuria in T. 154, 169, 182 ; E. 365; E.533 Alcohol in T. 289; E. 412; E. 669; action of in fevers, 290 ; rules for, 291 Alum in E. 671 Amaurosis in T. 207 ; E. 383 ; E. 564 America, T. in, 48, 59 ; E. 322 ; E. 436 Ammonia in blood of T. 118, 145, 259 expired air of T. 145 treatment of T. 293 ; E. 669 Ammoniacal nature of Typhus-poison, 118, 259 Ammoniaco-magnesian phosphate in stools of T. 150; E. 526 Anaemia in E. 382, 414; E. 612 Anaesthesia in T. 178, 206; E. 544, 563 Anasarca in T. 201, 213, 309; E. 386, 414; E. 583 AUT Anatomical lesions of T. 248 ; E. 400 ; E. 613; S. 683 Animals, T. in, 9§ ; E. 497 ; E, 401 Anthrax microbes in, 12 Antimony in fevers, 288 — and opium in fevers, 297 Antiquity of T. 26 ; E. 312 ; E. 419 Antiseptics in T. 275 ; E. 651, 673 Aphasia in T. 205 ; E. 563 Appendix vermiformis perforated in E, 578, 628 Appetite in T. 146; E. 341, 356; E. 523 Apyretic temperatures in E. 519 — treatment in E. 656 Arachnoid haemorrhage in T. 194, 262 ; E. 640 Ardent continued fever, 681, 684 Ari^ge, E. at, 480 Armentyphus, 312, 341 Army fever, 25, 112 Arsenic in E. 409 Arteries in E. 636. See Einholism and Thrombosis Arthritic pains. See Joints Artificial famine a cause of T. 54, 80 Ascaris lumbricoides in E. 616 Asphyxia from overcrowding, 118 Assafoetida enemata in E. 673 Assizes. See Black Assizes Asthenia in T. 248 ; E. 612 ; S. 685 Asthenic simple fever, 685 Astringents in T. 307 ; E. 414, 670, 672, 676 Ataxic fever, 24, 227, 417 Ataxo-adynamic fever, 24, 227 Atmospheric influence in T. 78 ; E. 344 ; E. 448, 491 Atonic ulcers, 626 Australia, T. in, 59 ; E. 437 Autumn prevalence of E. 446 Autumnal fever, 417, 447 — diarrhoea, relation to E. 497, 546 720 INDEX. BAG Bacilli in E. 645 Back, pain in, T. 158; E. 345 ; E. 535 Bacteria in blood of fevers, 10 ; in R. 400; in E. 498, 645 Bedford, E. at, 483 Beds for fever, 288 Bed-sores in T. 213; E. 386; E. 583; treatment, 307 Belladonna in fevers, 287, 299 Bibliography, 698 Bile in T. 256 ; E. 405 ; E. 635 — acids in urine of E. 367 Biliary fever, 312 — remittent fever, 312 Bilious fever, 418, 593 — headache, diagnosis from E. 393 ; from E. 563 — relapsing fever, 312 . — typhoid, 312, 361, 389, 393, 401,405 Birthplace of fever patients, T. 58 ; E. 322; E. 435 — influence on mortality of T. 242 ; E. 398; E. 610 Bismuth in T. 304; E. 670, 672 Black Assizes, 104 ; Cambridge, 104 ; Oxford, 104, 161 ; Exeter, 105 ; Taunton, 105 ; Launeeston, 105 ; Old Bailey, 106 — Hole of Calcutta, 118 — vomit in E. 357 Bladder in T. 212, 266, 302 ; E. 582, 641 Blisters in T. 295, 298, 301 ; bad effects of, 305, 584 Blood in fevers, 16; T. 182, 193, 258; in E. 365, 406 ; E. 636 Bloodletting in fevers, 7, 42 ; T. 279 ; E. 410; E. 655, 674 Blue spots in T. 135 ; E. 516 ; S. 684 Boils in T. 216 ; E. 387 ; E. 546 Bones in T. 216 ; E. 403 ; E. 512, 584 Brain, atrophy of in fevers, 16. See Cerebrum — fever, 24, 15S, 227, 591 — inflammation of, resemblance to T. 230; E. 599 Brazil, T. in, 59, 286 Brest, T. at, no Bromide of potassium in fevers, 297, 300 Bronchial glands in E. 639 Bronchitis in T. 191, 260, 306 ; E. 378, 406, 414 ; E. 556, 638 ; treat- ment, 306 Bronzing in E. 349 Broulhac, T. at, 100 Buboes in T. 175, 216 ; E. 387 ; E. 584 ; "treatment, 309 Bullae in T. 216 ; E. 387 ; E. 584 Butchers, exemption from T. 69 Cabs, not for fever patients, 91, 270 Cadaveric rigidity in T. 248 ; E. 613 Caffeine, use of in fevers, 277 Calcutta, Black Hole of, 118 CHL Cambridge Black Assize, 104 Camp Fever, 24, 112 Camphor in fevers, 294, 298, 300 Cancrum Oris. See Noma Cannabis indica in fevers, 300 Carbolic acid in fevers, T. 275 ; E. 651, 673 Carbonic acid in expired air of fevers, 15; T. 143 Carbuncles in T. 217 Carditis in T. 201, 257 Carlisle, T. at, 37, 100 Carphology in T. 168, 246 ; E. 370 ; E. 540 ; treatment, 300 Cases of T. 124, 172, 182, 188, 195, 198, 201, 204., 206, 208, 211, 223 T. and variola, 226 T. and enteric fever, 589 E. 347, 366, 371, 380, 381, 389 E. 503, 514, 529,537, 544, 549, 556, 559, 561,567,573,596,664, 672 E. and scarlatina, 587 E. and diphtheria, 588 E. and variola, 588 Catalepsy in T. 168 ; E. 541 Catamenia. See Menstruation Catarrhal T. 191, 228 Cattle, E. in, 467 Cattle plague distinct from E. 498 Causes of fevers, 3, 8 ; importance in distinguishing fevers, 8 ; of T. 62; E. 324; E. 437; S. 681 Causus, 680 Cellular tissue, inflammation of in T. 216, 309 Cerebellum in T. 264 ; E. 407 ; E. 640 Cerebral membranes in T. 203, 261 ; E. 406 ; E. 639 — respiration in T. 142, 245 — serosity in T. 262 ; E. 406 ; E. 640 — softening in T. 264 ; in E. 381 ; E. 640; pathology of , 17, 20, 182; E. 344 ; E. 500 Cerebrum in T. 203, 264 ; E. 3S1, 407 ; E. 640 Cesspool fever, 418 Chalk, use of in E. 671 Change of practice in fevers, 43, 47, 49, 56, 279, 411, 655 Change of residence a cause of T. 70 ; E. 328; E. 454 type in fevers, 7, 43, 46, 56, 279, 411 Charcoal in E. 670, 673 Chicken-cholera microbes in, 12 Children, E. in, 439, 594 — Beyer's patches in, 630 Chloral hydrate in fevers, 298 Chlorates in fevers, 275 Chloride of lime as a disinfectant, 271, 649 sodium in fevers, 277 INDEX. 721 CHL DIG Chlorides in urine of fevers, 16 ; T. 153 ; E. 366; E. 533 Chlorine in fevers, T. 275 ; E. 652 Chloroform in fevers, 300 Cholera, Payer's patches in, 630 Chorea in T. 167 ; E. 540, 564 Chronic ulcer. See Atonic Cicatrization of intestinal ulcers in E. 625 Circulation, organs of in T. 138, 193, 257; R- 353. 379- 4051 E. 525, 560, 635 Circumscribed epidemics of E. 445 — flush of E. 510 Clapham, E. at, 473 Classification of continued fevers, 3 Clergy, liability to T. 84 Clifton, E. at, 480 Clinical description of T. 120; E. 344; E. 500; S. 683 Clothes, propagation of fever by, T. 89 ; E. 333 ; E. 468 Club-foot after T. 206 ; E. 563 Coexistence of specific poisons, 225, 586 ; of T. and E. 589 Coffee in fevers, 152, 277, 301 Cold a cause of fever, 68, 326, 447, 681 — in treatment of T. 280, 288, 294, 302 ; E. 410 ; E. 655 ; S. 687 Collapse in T. 200 ; E. 379, 399, 413 ; E. 595, 611, 612; S. 685 Colon in T. 254 ; E. 404 ; E. 631 Colour of clothes predisposes to infec- tion, 89 Coma in T. 164, 248, 301 ; E. 369 ; E. 538, 612 Coma vigil in T. 164, 246 ; E. 538 Common continued fever, 417, 680 Communication of fevers. See Propa- gation Complications of fevers, T. 190, 247, 306; E. 378, 399, 414; E. 556, 674; S. 685 Concentration of fever -poison, 693 Condy's fluid in fevers, 274 ; as a dis- infectant, 275, 648-50 Congestive typhus, 227 ; E. 389 Conjunctivae in T. 129, 176; E. 361, 370; E. 542 Constipation in T. 148 ; E. 359 ; E. 525, 577. 655 Contagia, independent origin of, 8 ; T. 98, 114, 118; E. 335; E. 477, 499. See Poisons Contagion of T. 81 ; E. 329 ; E. 458 Continued fevers, their importance i ; plurality, 2 ; mortality, i Convalescence in T. 184, 310 ; E. 378 ; E. 547, 612, 676 Conveyance of fever patients, 91, 245. 270 Convulsions in T. 168, 246 ; E. 364, 370," 399 ; E. 541 ; treatment, 303 Copper, sulphate of in E. 415 ; E. 671, 676 3 Cornese, sloughing of in T. 167, 214, 308 ; E. 560 Craigentinny meadows, 494 Creasote in T. 275 ; E. 651, 673 Crimea, fever in, 51, 80, 112, 244 Crisis. See Defervescence Critical days in T. 187 ; E. 373-4 ; E. 548 — discharges in fevers, 17 ; T. 184; E. 346, 353 ; E. 547 ; S. 684 Crowding. See Overcroioding Croydon, E. at, 340; E. 482 Cutaneous sensibility in T. 178, 206, 303; E. 371; E. 543 Cuticulse, 23 Dantztc, T. at, 39, 219, 246 Darmtyphus, 416 Dead body, communication of T. by, 95 ; of E. 470 Deafness in T. 177, 207, 246; E. 377 ; E. 543. 564 Death, mode of in T. 248 ; E. 400 ; E. 612 — rate, T. 234 ; E. 394 ; E. 604 Debility, a cause of T. 70 ; E. 450 ; its effect on mortality, T. 244 ; E. 610 — in fevers. See Prostration Decomposing vegetable matter a cause of E. 499 Decomposition, a cause of E. 472, 487, 498 Decubitus in T. 166 ; E. 539 Defervescence in T. 183 ; E. 377 ; E. 547 Definition of T. 23; E. 311; E. 416; S. 680 Delirium in T. 158, 296; E. 368, 399, 413; E. 535 ; S. 685; treatment, 293 — ferox in T. 160, 231, 296; E. 369; E. 536 — tremens in T. 160, 231, 296 ^ potu, diagnosis from T. 231 Delusions in T. 161 ; E. 369 ; E. 536, 562 Depressing emotions a cause of fevers,- 70, 329, 450 ; a cause of increased mortality, 243, 399 Desquamation in T. 135 ; E. 354 ; E. 517 Destitution a cause of T. 75 ; E. 328, 336 ; not of E. 456 — a cause of mortality in T. 244; E. 399 Diagnosis of T. 22S ; E. 390 ; E. 596 ; S. 686 Diaphoretics in T. 278 ; E. 653 Diarrhosa in T. 149, 208 ; E. 354, 378, 385; E. 524, 565, 61 1; treat- ment, 307, 414, 670, 676 — autumnal, relation to E. 495, 546 Diet in T. 2S8 ; E. 412 ; E. 669, 676 Digestive organs in T. 145, 207, 250 ; E. 356, 385 ; E. 522, 564, 614 A ♦ 722 INDEX. DIG EPI Digitalis in fevers, 287, 297 Diluents in fevers, 276 Diphtheria in T. 259; E. 558, 588 Disinfectants, 270, 650, 651 Disinfecting power of dry heat, 98, 271 Distinctness of T. and E. 342; of T. and E. 596, 678 ; of E. and E. 597 Diuretics in T. 276 ; E. 410; E. 653^ Dothienenteritis, 418, 426 ; derivation of term, 426 Drainage, a cause of E. 473, 486 Drains. See Sewers Drinking water, poison of E. in, 466, 480, 483, 648 Drinks in fevers, 276 Drowsiness. See Somnolence Dublin milk epidemic of E. in 467 Duodenum in T. 251 ; E. 616 Duration of T. 185 ; E. 372 ; E. 548 ; S. 684-5 Dynamic fever, 312 Dysentery, its relation to T. 36 ; a com- plication of T. 175, 209, 307; E. 385, 414 ; E. 565 ; independent origin, 484 Dysphagia in T. 146, 167 ; E. 523 Ears. See Hearing Edinburgh, T. at, 52, 55 ; R- 3^5 ; E. 443 Egyptian plague, 219 Elimination in fevers, 22 ; T. 275 ; E. 409; E. 653 Emaciation in fever, 16 ; T. 248 ; E. 403 ; E. 545> 584, 613 Embolism, a cause of typhoid state, 21 — in T. 199; E. 381 ; E. 560 Emetics in T. 278, 305; E. 409; E. 653 Emphysema m T. 192 ; E. 559 — of liver in T. 256 Empyema. See Pleurisy Encephalitis, diagnosis from T. 230; E. 599 Endemic character of E. 441 — fever, 417 Endocarditis in T. 200, 212, 258 Endocardium in T. 258 ; E. 405 ; E. 636 Enemata in T. 279, 280 ; in E. 655, 670, 676 Enteric fever, 416; objection to term, 419; relation to T. 596, 678; mode of prevalence, 441 Ent6rite folliculeuse, 418 — septic6mique, 417, 532 Enteritis erysipelatosa, 418 Entero-mesenteric fever, 418, 425, 427 Ephemera, 681, 684 Epidemic character of T. 55 ; E. 320 — fever, 24, 312 Epidemics of T. and E. in Britain and Ireland in the years : 1665 . . 30 1685 . . 31 Epidemics of T. and E. in Britain and Ireland in the years : 1708 . . 31 1718 . . 32 1728 . . 32, 312 1740 . . 34, 78, 313 1771 . . 36, 78 1800 . . 38, 313 1S17 . . 40, 70, 313 1826 . . 44, 78, 314 1836 . . 47,78 1843 • • 48, 315, 338 1846 . . 49, 78, 316 1856 . . 52, 58 1862 , . 54, 58, lOI 1868 . . 319, 339 Epidemics of T. in Africa, 59, 62 America, 48, 59 ■ — . — • Australia, 59 Brest, no Broulhac, 100 Carlisle, 37, 100 Crimea, 112, 244 Dantzic, 39, 219, 244 France, 28, 29, 56, 82, 108, 109, 254 Germany, 29, 31, 36, 56 Grottingen, 423 Holland, 29, 56 Hungary, 28, 112 — Iceland, 56 India, 59 Italy, 27, 37, 39, 56 Mayence, 187, 219, 244 Philadelphia, 48, 100, 252, 429 Plymouth, no Poland, 39 Preston, loi Eheims, 108 Eussia, 39, 56, 319 Saragossa, 39, 112, 219 ■ Silesia, 50, 317, 319 Spain, 27, 56 Strasbourg, 109 — Sweden, 56 Torgau, 39, 112, 187, 219, 244 Toulon, 56, no, 253 Vienna, 36, 39, 112 Wilna, 39 Winchester, 37, 218 Epidemics, circumscribed of E. : in 1846, 447 at Ari^ge, 480 — Balletheron, 465, 478 Bedford, 483 — Charmouth, 478 Chatham, 476 Clapham, 473 Clifton, 480 Colchester, 476 a convent, 480 Cowbridge, 483 INDEX. 723 EPI Epidemics, circumscribed of E. : at Croydon, 456, 483 Donaldson's Hospital, 479 Guermange, 451 Gruildford, 482 Homburg, 479 Kloten, 467 La Fl^che, 464 ■ Lausen, 492 Limerick, 478 Munich, 450, 482 Newcastle, 427 — ■ North Boston, 465 North Tawton, 464, 489 Nottingham, 456 Nunney, 491 Over Darwen, 492 Paisley, 427 Peckham Police Station, 475 Peebles, 474 Penicuik, 477 Preston, 477 Eatho, 478 Simla, 479 Stuttgart, 449 Washington, 481 Westminster, 474 Windsor, 481 Epiglottis in E. 637 Epistaxis in T. 178; E. 371, 378; E. 544, 612 ; treatment, 674 Ergot in fevers, 287 ; in hemorrhages, 672 Eruption of T. 121, 130,246, 249; its nature, 131 ; varieties, 131 ; im- portance in diagnosis, 133, 228, 678 — in E. 349 — of E. 510, 611, 613; compared with that of T. 513; its importance in diagnosis, 514, 678 Eruptions, accidental in T. 216 ; E. 387 ; E. 584 ; S. 684 Erysipelas, diagnosis from T. 233 — in T. 207, 213, 308; E. 386; E. 582 — Peyer's patches in, 630 Esquimaux, alleged exemption from T. 56, 118 Essential Fevers, 13 Ether in fevers, 294 Etiology of T. 62, 119, 678; E. 324; E. 437, 499, 678 ; S. 681 Exanthematic Typhus, 23, 39, 428 Exanthematous nature of T. 23, 39, 47, 131 Exciting cause of T. 78 ; E. 329 ; E. 458 ; S. 682 Exeter Black Assize, 105 Expired air in T. 143 ; E. 355 Eyes. See Vision FEV FA.CIES typhosa, 129, 510 Pascal Fermentation, a cause of E. 486, 499 Fffices. See Stools Fall -fever, 417, 448 Famine a cause of T. 75, 269 ; E. 328, 336 ; not of E. 456 • — fever, 312, 341 Fatigue a cause of T. 70; E. 329; E. 450 ;^ S. 682 — increases* mortality of T. 244 ; E. 399 Fatuity. See Imbecility Faulheber, 25 Fear of T. 70 Febricula, 417, 422, 680 Febris acuta, 680 — ardens, 680 — asthenica, 23, 681 — atacta, 24, 417 — biliosa, 418, 593 — cacoethes, 25 — carcerum, 25, 35, 104, 424 ■ — castrensis, 25, 112 — continua simplex, 3, 18, 419^ 549, 593- 680 — diaria, 68 1 — ephemera, 681 — epidemioa, 24, 312 — exanthematica, 25, 131, 428 — gastrica, 417, 428, 593 — hectiea, 417 — infiammatoria, 227, 312, 680 — intestinalis, 418, 423 — lenta, 417, 421, 422 — maligna, 22, 23, 27, 33, 423 — mesenterica, 418, 421, 425, 427, 631 — militaris, 25, 112 — mucosa, 418 — nautica, 25, 36, 109 — nervosa, 417, 422, 424, 428 — non-pestilens, 417, 421 — non-putrida, 681 — nosocomialis, 25, 35, 114 — perniciosa, 25 — pestilens, 24, 27, 30, 420 — petechialis, 24, 31, 34, 229, 421 — petechizans, 417, 421 — peticularis, 24, 28, 29 — pituitosa, 418, 423 — purpurea, 24, 28 — putrida, 24, 33, 417, 424 — semitertiana, 417, 420 — septimanaria, 681 — stigmatica, 24, 33 — stomachica, 417 — tymiDanica, 418 — verminosa, 418, 421, 616 Fever, definition of, 13 ; theories of, 12 ; modern views of, 13 — hospitals, their origin, 38, 688 ; com- pared with General Hospitals, 693 ; objections to considered. 693 ; their necessity, 694 3 A 2 724 INDEX. FEV Fever patients, their allocation, 271, 688 ; classification, 697 Fi^vre typhoicle, 416, 426 Five clays' fever, 311 Flea-bites, distinct from tj'iDlius-erup- tion, 27, 133 ; from petechia of E. 350 Fleckfieber, 24, 29 Floccitatio. See Carpliology Flush of T. 129 ; E. 348 ; E. 510 Foetus in E. 388 ; E. 440 Fomentation of abdomen in E. 670, 673 head in T. 299 Fomites in T. 89 ; E. 333 ; E. 468 Food. See Diet France, T. in, 28, 29, 56, 108, no; E. 428, 435 Fungoid theory of fevers, 9, 259 Fungus of T. 9, 259 ; E. 645 Gall-bladder in T. 256 ; E. 405 ; E. 566, 634 — — ulceration and perforation of, 566, 634 Gangrene in T. 199, 213, 308 ; E. 381, 386; E. 560, 583 — of lung in T. 192, 306 ; E. 379, 406 ; E. 557 Gaol. See Jail Gastric fever, 417, 428, 593 Gastro-enterite, 418, 425, 615 ; diagnosis from E. 603 Gastro-hepatic fever, 312 General hospitals. See Fever Hospitals Geographical range of T. 56 ; E. 321 ; E. 434 Germany. See Epidemics Giddiness. See Vertigo Glanders, diagnosis from T. 233 Glands, changes of in fevers, i5, 266, 642 Glandular enlargement, stage of in E. 546, 617 Glandular T. 218 Glasgow Infirmary, admissions of T. 52 ; E. 318; E. 441 Glossitis in T. 207 Gottingen, fever at, 423 Gout, a comjDlication of T. 243 ; E. 605 Guermange, E. at, 451 Gurgling in T. 147 ; E. 358 ; E. 524 H.5i;MATE]UESis in T. 194, 207 ; E. 357, 399; E. 523 Hematuria in T. 156, 194, 212 ; E. 366 ; E. 534, 560 Haemoptysis in T. 193 Haemorrhage from bowels in T. 194, 209 ; R- 359. 399 ; E. 526, 573, 578, 61 r ; its danger, 528 ; treatment, 672 ears in E. 380 nose. See Epistaxis IMP Hemorrhage from uterus. See Menor- rhagia — into abscess, T. 224 arachnoid in T. 194, 262 ; E. 640 musclesinT. 194, 249; E. 559, 613 skin. See Petechice, Purpura, and Vitiees Hemorrhages in T. 193; E. 380, 399 ; E. 560 Hasmorrhagic fever, 560, 591 Headache in T. 157, 294 ; E. 367, 413 ; E. 534; S. 684-5 Hearing in T. 177, 207 ; E. 371, 380, 385 ; E. 543, 564 Heart's action in T. 140, 245 ; E. 354 ; E. 521 Heart disease in T. 141, 200, 257 ; E. 380, 405 ; E. 560, 635 Heat, a cause of Pyrexia, 19 ; of E. 448 — a disinfectant of T. 97, 271 ; E. 650 — in fevers. See Teinperctture HemijDlegia in T. 205 ; E. 563 Hemitritaeus, 417, 420 Henbane in T. 299 Herpes in T. 216, 686 ; E. 387 ; E. 584 ; S. 684, 686 Herpetic fever, 684, 686 Hiccup in T. 168, 246, 304; E. 540 History of T. 26; E. 312; E. 419; S. 681 - — of distinction between T. and E. 342 ; between T. and E. 420, 423, 429, 433 Hog, typhoid microbes in, 12 Holland, T. in, 29, 56 Horses, E. in, 498 Hospital fever, 25, 35, 114 — gangrene in T. 215 Hospitals for fever. See Fever Hospitals Hungerpest, 312, 341 Hyperemia of skin in T. 135 ; E. 350 ; E. 516 Hyperesthesia of skin in T. 178, 206, 303 ; E. 377 ; E. 543, 564 Hypostatic congestion of lungs in T. 142, 191, 260, 304; E. 355, 406; E. 556, 612, 638 Hysteric coma in E. 538 — fever, 417, 422, 538 Ice in fevers, 294, 672, 674 — poultices in E. 672, 673, 675 Iceland, T. in, 56 ; E. 435 Idiopathic fevers, 12 Idiosyncrasy a cause of T. 69, 95 ; E. 453 Ileo-tyijhus, 417 Ileuni in T. 251 ; E. 404 ; E. 616 Imbecility after T. 204, 307 ; E. 505, 560 Immunity from second attacks of T. 84, 96 ; E. 335 ; E. 470 Importation into healthy localities of T. 58,84; E. 332; E. 464 INDEX. 725 INC LYS Incontinence of urine in T. 166, 246, 307 ; K. 370 ; E. 539 Incubation period of T. 91; E. 334; E. 468 Independent origin of continued fevers, 10; of T. 99, 114, 119; E. 335; E. 471 ; objections considered, 9, 115,484 India, T. in, 59 ; E. 323 ; E. 435 ; S. 682, 6S4 Infantile hectic fever, 417 — remittent fever, 417, 594 Infecting distance of T. 88 ; E. 332 ; E. 467 Infectious fever, 24 — ship fever, 25, 109 Inflammatory fever, 227, 312, 680, 684 — . swellings. See Buboes — theory of fever, 42, 261, 263, 279, 410 — T. 227 Influenza, diagnosis from E. 598 Inoculation of T. 95 ; E. 401 ; E. 95 Insidious variety of E. 592, 611 Intemperance a cause of T. 70 ; E. 329 ; E. 450 mortality in T. 234 ; E. 394 ; E. 604 Intermission of E. 374 Intermittent fever. See Agtie Intestinal fever, 418, 423 in cattle, 498 horses, 498 pigs, 498 — hasmorrhage. See Hcsmorrlutge Intestines in T. 251 ; E. 404; E. 616 Invaginations of bowel inT.25i;E.6i6 Invasion stage in T. 179; E. 372; E. 545.611 Involuntary motions in T. 166 ; E. 370 ; E. 539 Iodine in E. 652 Ipecacuanha in diarrhoea of T. 307 ; E. 415; E. 671 Irish ague, 25, 31 — epidemics. See Epidemics — importation of fever by, 32 — liability to T. 57 ; E. 321 ; E. 435 — mortality from fevers, T. 243 ; E. 398 ; E. 610 Iron in T. 275; E. 408, 415; E. 672, 676 Isolation of fever patients, 688 Italy, T. in. See Epideviics Itchiness in E. 371 Jabokandi in E. 402 Jail fever, 25, 35, 104, 424 Jaundice in T. 194, 198, 210; E. 359, 362, 399 ; E. 565 ; treatment, 413 Jejunum in T. 251 ; E. 616 Joints, pains in, T. 158; E. 367, 383, 413, 414; E. 535 Joints, pus in, T. 194 ; E. 560 — serous effusion in, E. 387 Kaiein in E. 655 Kidneys in T. 170, 212, 243,265; E. 364, 380, 407 ; E. 582, 641 — disease of, diagnosis from T. 232 Kloten, E. at, 467 Kreatinine in urine of E. 534 Kriegspest, 25, 112 Laplanders, alleged exemption from T. 56, 118 Laryngitis in T. 193, 259, 306; E. 379 ; E. 558, 637, 676 — typhosa, 558 Latent enteric fever, 592, 611 — period. See Incubation Launceston Black Assize, 105 Laundry-women, liability to T. 8^, 90; E. 333; E. 468 Laxatives. See Purgatives Lead, acetate of in diarrhcea, 415, 670, 676 hemorrhage, 672 pneumonia, 306 tympanites, 673 Leeches in T. 295, 297 ; E. 674 Lenticulse, 27 Lenticular rose spots, 510, 678 Lesions of T. 248 ; E. 403 ; E. 612 ; S. 686 — specific of E. 617 Leucine in T. 156, 21T, 256; E. 367, 405 ; E. 534, 634 Leukemia in fevers, 16 ; T. 259 ; E. 406 ; E. 637 Lichen in E. 387 Limbs, pains in, T. 157 ; E. 367, 383 ; E. 535 Lime-water in T. 304 ; E. 672 Lips in T. 146 ; E. 356 ; E. 522 Lithic acid. See Uric Acid Liver in T. 148, 256 ; E. 359, 404 ; E. 634 Liverpool, T. in 1847,49; T. introduced by crew of Egyptian vessel, 90, III London, fevers in each district of, 74, 328, 454 — Fever Hospital, admissions of con- tinued fevers ; T. 52, 67 ; E. 318 ; E. 441 ; mortality from fevers, T. 234 ; E. 394 ; E. 604 Low fever, 417 — nervous fever, 419 Lungs, diseases of in T. 142, 190, 260 ; E. 378, 406 ; E. 556, 638 ; treat- ment, 304 Lymphatic glands in T. 255 ; E. 404; E. 566, 631, 639, 642 — vessels obstructed in T. 197 Lysis in E. 547 726 INDEX. MAH M.iHA3IUEEEE, 6 1 Malaria not a cause of E. 337, 344 Malarious fevers, relation to E. 451 Malignant feYsr, 24, 25, 422, 423 — stage of T. 180, 227 ; E. 3S9 ; E. 594 Mania in T. 204, 307 ; E. 369 ; E. 537, 562 ; diagnosis from E. 602 Marasmus after E. 584 Mayence, T. at, 187, 219, 244 Measles, coexistence -with E. 588 ; dia- gnosis fi'om T. 230 ; resemblance to T. 28, 230. See Variola Measly eruption of T. 28, 47, 121 Meat, diseased, a cause of E. 467, 499 Medical men, liability to T. 76, 82 ; E. 330-2 ; E. 461 Melffina. See UcemorrJmge Membranes of brain in T. 203, 261 ; E. 406 ; E. 639 Meningitis, complication of T. 203, 207, 231, 261 ; E. 561 — diagnosis from T. 230 ; E. 394; E. 599 Menorrhagia in T. 194, 212 ; E. 38S ; E. 582 Menstruation in T. 212 ; E. 388 ; E. 582 Mental state in T. 161, 204 ; E. 368 ; E. 535. 562 Mercury in fever, 279, 413 Mesenteric fever, 418,421,425,427, 631 — glands in T. 255; E. 404; E. 631, 642 ; rupture of in E. 566, 632 Meteorism in T. 147, 246 ; E. 358 ; E. 523, 611 ; treatment, 304, 673 Microbes in fever, 12 Mild form of T. 228 ; E. 592 Miliary fever, 312, 351, 418, 423 Military fever, 25, 112 Milk in treatment of fevers, 289 — propagation of E. by, 466 Miscarriage. See Abortion Moisture, atmospheric, a cause of T. 68 ; E. 4.48 — of skin in T. 137 ; E. 353 ; E. 519 Monkeys, E. in, 401 ; E. in, 498 Months in reference to prevalence of T. 66; E. 326; E. 445 mortahty of T. 240 ; E. 397 ; E. 608 Morbus Hungaricus, 25, 26 — mucosus, 25, 418, 423 • — pulicaris, 25 Morphia. See Opiimi Mortahty of continued fevers, i ; T. 234 ; E. 394 ; E. 604 ; S. 686 ; circum- stances influencing it in T. 236 ; E. 395 ; E. 605 Muco-enteritis, 418 Mulberry rash of T. 121 Munich, fever at, 449, 466, 484 Muriate of ammonia in T. 295 Muscles, hemorrhage into in T. 194, 249; E. 559, 566, 613 Muscles in fevers, 16, 19; T. 249; E. 403 ; E. 613 OPI Muscular agitation in T. 167, 246 ; E. 370 ; E. 539, 564 — pains in T. 158, 206, 303 ; E. 367, 383,413,414; E. 535 — paralysis in T. 166 ; E. 370, 382 ; E. 539. 563 — rigidity in T. 168, 246; E. 370; E. 540 — symptoms in T. 157, 246; E. 367; E. 535 Musk in fevers, 300 NiiL-iiiEKS after T. 136 ; E. 351 ; E. Xausea. See Vomiting Xecrosis of bones in T. 199, 216 ; E. 561, 584 Nephritis, acute in T. 174; R. 367; E. 534, 641 Nervous fever, 417, 422, 424, 430 — stage of T. 180, 295 ; E. 368, 389 ; E. 535 — symptoms in T. 157, 180, 203, 295 ; E. 367; E. 534 — system, diseases of in T. 203, 261 ; E. 382, 406 ; E. 561, 639 — ■ — influence of on phenomena of fever, 17 Neuralgia in E. 383 ; E. 564 Newcastle, E. at, 427 Nightmen, health of, 456, 491 Night-soil fever, 418 Nitre in fevers, T. 276 ; E. 410 Noma in T. 214, 308 ; E. 5S3 ; treat- ment, 308 Nomenclature of T. 23 ; E. 311 ; E.416; S. 680 Non-identity of T. and E. 342 ; T. and E. 596, 678 ; E. and E. 597 Nose, bleeding from. See Epistaxis — feeding by, 289 — gangrene of in T. 214; E. 381 Nosological relations of continued fevers, 2 Nurse in fever, 273 Nurses, liabihty to T. 82 ; E. 330, 331 ; E. 461 Occupation a cause of T. 69 ; E. 328 ; E. 456 Ochlotic fever, 25 Odour of T. 138 ; E. 353 ; E. 519 (Edema glottidis in T. 193, 259, 306 ; E. 379 ; E. 558, 676 — of lungs in T. 192, 260; E. 639 — See Anasarca (Esophagus in T. 250 ; E. 403 ; E. 614 Old Bailey Assize, 106 Ophthalmia postfebrilis, 383, 415 Opiate enemata in T. 299 ; E. 415 ; E. 670 Opisthotonos in T. 168, 203 ; E. 540 INDEX. 727 OPI Opium in T. 296 ; R. 413, 415 ; E. 670, 672 ; in peritonitis, 674 ; contra- indications, 299 Organisms in fever, 12 ; E. 400 ; E. 645 ; in water, 498 Origin of fevers. See Causes and Inde- pendent Otorrhoeain T. 178, 207 ; R. 385 ; E. 564 Overcrowding, a cause of T. 72, 119, 267 ; R. 328, 340 ; E. 453 Oxalate of lime in urine of R. 366 Oxford Black Assize, 104, 161 Oxygen in treatment of T. 275 Pacchionian bodies in T. 262 Pain in T. 148, 157, 206 ; 303 ; E. 358, 367, 383; E. 535 Pali disease, 61 Palpitations in R. 380 Pancreas in T. 256 ; R. 405 ; E. 635 Paralysis in T. 166, 201, 205, 225, 307; R. 370, 382 ; E. 539, 563 Parish infection, 24 Parotid swellings. See Buboes Pathological anatomy of T. 2d8 ; R. 400 ; E. 612; S. 686 Pathology of convulsions, 169, 370, 541 jaundice, 210, 362, 565 pyrexia, 12 typhoid state, 16, 19, 180, 203, 364, 532 ursemia, 16 Penis, sloughing of in T. 214 ; E. 560 Perforation of appendix vermiformis, 578, 627 colon, 579, 628 gall-bladder, 566, 635 • ileum, 567, 626 ; cases of, 573 ; causes, 569, 627; dangers, 571 ; frequency, 567 ; number, 629 ; prevention, 675 ; situation, 627 ; symptoms, 570; treatment, 674 Pericarclitis in T. 200 ; R. 380 ; E. 635 Pericardium in T. 257 ; E. 635 Periostitis in E. 584 Peritoneal abscesses in E. 572 Peritoneum in T. 257 ; R. 405 ; E. 635 Peritonitis in T. 212, 257 ; R. 386, 415 ; E. 565, 611 ; causes, 565 ; treat- ment, 674 ; diagnosis from E. 600 Peroxide of Hydrogen in fevers, 275 Perspiration. See Sweating Pertussis, coexistence with E. 588 Pestilential fever, 24, 27, 30, 420 Pestis bellica, 25 Petechia in T. 131 ; R. 350, 399, 403 ; E. 516 ; definition, 131 ; misuse of term, 5, 132 Petechial fever, 5, 23, 30, 33, 131 -^ Peyer's glands, structure of, 643 ; func- tion, 643 ; in T. 252 ; R. 404 ; E. 617 ; morbid conditions in other PEG diseases than E. 630 ; tubercle in, 630 ; nature of disease in E. 644 Pharyngitis in T. 207, 250 ; R. 385 ; E. 564, 614 Philadelphia, T. at, 48, 100, 252, 430 Phlebitis in T. 195, 309; R. 381 ; E. 560 Phosphates in urine of T. 154 ; R. 366 ; E. 534 Phosphoric acid in T. 274 Phosphorus in T. 302 Photophobia in T. 177 Phthisis in T. 69, 192; E. 452, 558; diagnosis from E. 600 ; relation to E. 452 Physiognomy in T. 129 ; R. 348 ; E. 510 Pig fed on stools of enteric fever, 498 — intestinal fever in, 498 Pipercoorn, 24, 29 Pituitary membrane in T. 259 Pituitous fever, 418, 425 Plague of Athens, 27 Egypt, 220 Ley den, 30 London, 30, 220 — its etiology, 220 ; relation to T. 219 symptoms, 219 Plaques dures, 618, 619, 620 — gauffr6es, 618 — moUes, 618, 619, 620 — reticulees, 618 Pleurae in T. 261 ; R. 406 ; E. 639 Pleurisy in T. 192, 261, 306; R. 379, 406; E. 557,639 Plurality of continued fevers, 2 Plymouth, T. at, no Pneumogastric nerve in fever. See Vagzis Pneumonia in T. 191, 261, 306; R. 379, 406, 414 ; E. 557, 639 ; diagnosis from T. 232 ; from E. 602 Pneumothorax in E. 559 Poison of T. destructibiUty, 98, 270, 273 ; nature, 97, 118; how produced, 98, 119 R. 329 ; how produced, 335 ; proofs of existence, 329 E. 458 ; destructibility, 495, 649 ; how produced, 471, 499 Poisoning, E. mistaken for, 465, 469, 473. 481 Poisons of fevers, 8. See Independent Poland, T. in, 39 Predisposing causes of T. 62 ; R. 324 ; E. 437 Pregnancy in T. 212, 243 ; R. 388 ; E. 582, 612 Presentiment of death in fevers, 245 Prevalence of continued fevers, i ; T. 52; R. 318 ; E. 441 Prevention of fevers, 8 ; T. 86, 267 ; R. 407 ; E. 495, 648 Prognosis in T. 234 ; R. 394 ; E. 604 ; S. 686 Propagation of T. 86 ; R. 332 ; E. 465 728 INDEX. PEO Propagation, prevention of, T. 270 ; E. 407 ; E. 650 Prophylactic treatment of T. 267 ; E. 407 ; E. 495, 648 Prostration in T. 165, 246 ; E. 370 ; E. 537 ; S. 685 Psyclirolutie treatment in E. 656 Pudenda, gangrene of in T. 214 Puerperal fever, diagnosis from E. 598 Pulse in T. 138, 201, 245 ; E. 353, 399 ; E. 520, 611 — a guide to use of stimulants in fever, 290, 292 Puncticula, 24, 27 Puntos, 29 Pupils in T. 177, 246 ; E. 370 ; E. 542, 599 Purgatives in T. 278; E. 410; E. 653, 671 Purpura, 229 — febrilis, 230 — spots in T. 135, 194 ; E. 350, 399, 403; E. 516 Pustular appearance of lesions of E. 420, 425, 620 Putrefaction after death in T. 249 ; E. 613 Putrid emanations a cause of fever, 472, 498 experiments with, 497 — fever, 24, 25, 180, 417 — stage of T. iSo Pyemia in T. 194, 309 ; E. 559 ; dia- gnosis from T. 233 ; E. 598 ; Peyer's patches in, 630 Pyrexia, pathology of, 12 Pythogenie fever, 418 ; derivation of term, 419 QuAKTEES of year, prevalence in each: — of T. 66; E. 326; E. 446 Quinine, use of, in T. 285, 295 ; E. 409 ; E. 664 Eace, mortality of fevers according to —of T. 242; E. 398; E. 610; prevalence according to — of T. 57; R-3I9; E. 435 Babbits, E. in, 498 Eain-fall, influence of on E. 448 Eeabsorption of contents of diseased glands in E. 592, 621 Eecent residence, a cause of T. 71, 242 ; E. 328 ; E. 454 ; influence on mortality of T. 242 ; E. 609 Eecrudescences in E. 547, 552 Eelapses in T. 18S ; E. 375 ; prevention of, 409 ; E. 552 Eelapsing fever, 311; complete disap- pearance of, 47, 314, 318; relation to T. 341, 390; followed by T. 320 ; relation to S. 682, 686 SEX Eemedies for T. 272 ; E. 408 ; E. 650 ; S. 686 Eemissions in E. 374; E. 517, 611, 612 Eemittent fever, diagnosis from T. 229 ; E. 323, 391 ; E. 597 of children, 594 mistaken for E. 320 ; E. 592 relation to E. 323, 391 ; E. 450 Eespiration in T. 142, 190, 245 ; E. 355 ; E. 521 Eespiratory organs, diseases of in T. 190, 259, 306 ; E. 378, 406 ; E. 556, 637 — symptoms in T. 142 ; E. 355 ; E. 521 Eestraint in T. 294 Eetention of urine in T. 166, 246 ; E. 370; E. 539 Eheims, fever at, 108 Eheumatie pains. See Joints Eigidity of muscles in T. 168, 246; E. 370; E. 540. See Cadaveric Eose-spots of E. 510, 678 Eubeola. See Measles Eubeoloid rash. See Measly Eupture of mesenteric glands. See Mesenteric spleen. See Spleen Eussia, T. in, 39, 56, 319 ; E. 319, 322, 340; E. 435 Saiictlate of soda inE. 402 ; in E. 464 Salines in T. 277 Sanitary science, triumphs of, 8 Saragossa, T. at, 39, 112, 219 Scarlatina, coexistence with T. 226 ; E. 586 — diagnosis from E. 516, 597 — Peyer's patches in, 630 — relation to E. 452 Scarlet rash in E. 516 Scavengers, health of, 456, 491 Scheah Gehaad, T. imported by, 90, 1 1 1 Scorbutic T. 71, 193 Scur-s'y in T. 71, 193 Seasons of year, prevalence of T. ac- cording to, 65 ; E. 326 ; E. 445 ■ mortality according to, of T. 240 ; E. 397 ; E. 60S Second attacks of T. 84, 96 ; E. 335 ; E. 470 Semitertian Fever, 417, 420 Senega in fevers, 305 Septicfemia in E. 532 Sequelaa of T. 190 ; E. 37S ; E. 556 Seven days' fever, 311 Sewage, decomposing, a cause of E. 472, 499 Sewers, a channel for transmission of E. 466, 484, 487, 491 ■ — workers in, their liability to E. 456, 491 Sex as i^redisposing to T. 62 ; E. 324 ; E. 437; S. 6S3 INDEX. 729 SEX THA 238; K- Sex as regards mortality of T. 2'- 396 ; E. 607 Ship fever, 25, 36, 109 Short fever, 311 Sickness. See Vomiting Silesia, fevers in, 50, 311, 317, 319 Silver, nitrate of in E. 611 Simple continued fever, 3, 18, 419, 549, 593. 680 Skin in T. 130, 178, 212, 249; R. 349, 371; E. 510, 543 Sleep, a predisiDOsing cause of T. 70 Sleeplessness. See Wakeftclness Sloughing stage in E. 546, 621 Slow fever, 417, 421 Small pox. See Variola Smell, organs of in T. 178 ; E. 371 ; E. 544. See Epistaxis and Odour Soil, a cause of E. 448 Softening of heart in T. 141, 257 ; E. 406 ; E. 635 Solitary glands, disease of in E. 617, 620 Somnolence in T. 164, 301 ; E. 369 ; E. 537 Sordes in T. 146 ; E. 356 ; E. 522 Spain, T. in, 27, 39, 56 ; E. 435 Spasms. See Subsultus and Convul- sions Species of continued fevers, 3 ; import- ance of distinguishing them, 6 ; reasons for non-recognition, 4 ; to be kept in view in study of causes, 7 Specific distinctions of T. and E. 596, 678 ; history of their discovery, 420-33 T. and E. 341 — gravity of poison of T. 98 Spinal cord in T. 265 ; E. 641 — symptoms. See Nervous Spirillum fever, 3 1 2 ; in E. 400 Spirochsete in E. 400 Spleen in T. 148, 256 ; E. 359, 381, 382, 405, 415; E. 524, 566, 633, 638 — rupture of in T. 212, 256; E. 379, 382, 386, 405 ; E. 633 Sponging in fevers, 283 Spontaneous origin of fevers. See Lule- pendent Sporadic cases of T. 100 ; E. 486 Spots in T. 130, 678; E. 349; E. 510, 678 Spotted Fever, 24, 34 Spring, increased prevalence of T.in,' 68, 103 ; as compared with that of E. 447 Squalor, a cause of T. 117 Stage, most infectious of T. 93 ; E. 470 Stages of T. 179 ; E. 371 ; E. 545 — of intestinal disease of E. 546, 617 Starvation, physiological effects of, 1 17, 342 — a cause of T. 75, 117 ; E. 328, 333, 345 ; not of E. 457 Station in life, a cause of T. 74 ; E. 336 ; E. 456 influence on mortality of T. 242 ; R. 398; E. 609 Stimulants in T. 289 ; E. 412 ; E. 669 — rules for in fevers, 291 — See Alcohol Stools in T. 149 ; E. 359 ; E. 526 ; con- tagious, 484 ; destruction of, 649 Strabismus in T. 167 ; E. 540, 542, 563 Strasbourg, T. at, 109 Stupor. See Somnolence and Comet Subcutaneous injection of stimulants in fevers, 294 Submaxillary glands in T. 217 Subsultus in T. 167, 246 ; E. 370, 399 ; E. 540; treatment, 300 Sudaminain T. 135; E. 351 ; E. 516, 613 Sudden death in T. 200 ; E. 379, 399, 414; E. 585, 612; S. 685 Sugar in urine of T. 157 ; E. 367 ; E. 534 Suicide in T. 160 Sulphates in urine of T. 154 ; R. 366 Sulphites in T. 275 ; E. 651 Sun, exposure to a cause of fever, 681, 685 — fever, 681 Suppression of urine in T. 150, 170; E. 365; E. 532 Sweating in T. 137, 184, 247 ; R. 353, 399; E. 519, 611 Sweden, T. in, 56 ; E. 435 Sympathetic nerves in fevers, T. 265, E. 641 Symptomatic fever, 12 Symptoms of T. 119, 245, 294 ; E. 344, 399, 413; E. 500, 611, 651 ; S. 670 Syncope in T. 200; E. 379, 399; E. 611, 612; S. 685 Synocha, 312, 374, 680, 684 Synochus, 418, 680 Synonyms of T. 23 ; E. 311 ; E. 416 : S. 680 Tabaediglio in Spain, 24, 27, 28 Taches bleuatres in T. 135 ; E. 516 ; S. 684 — lenticulaires, 510 Taste in T. 178 Taunton Black Assize, 105 Tea, use of in fevers, 277 Teeth. See Sordes Temperature, high, a cause of cerebral symptoms, 19 — a cause of T. 68, 118; E.448; S. 6S1, 685 — preternatural in fevers, 14 ; T. 136, 247; E. 352; E. 517, 611 ; S. 685 ; reduction of in T. 279 ; E. 410; E. 655 Thames, state of in 1858, 494 730 INDEX. THE Theine in fevers, 277 Thirst in T. 146 ; K. 357 ; E. 523 ; S. 684 ; its relief, 304 Thoracic variety of T. 191, 228 ; E. 591 Thrombosis, arterial in T. 199 ; E. 381 ; E. 560 — venous in T. 195, 309 ; E. 381 ; E. 560 Tinnitus auriumin T. 177, 207 ; E. 371 ; E. 543 Tongue in T. 145, 207, 246 ; E. 356 ; E. 522, 611 ; S. 684 Torgau, T. at, 39, 112, 187, 219, 244 Toulon, T. at, 56, no, 253 Trachea in T. 259 ; E. 406 ; E. 638 Tracheotomy in T. 193, 306; E. 379; E. 558, 676 Treatment of fevers, 22 ; of T. 267 ; E. 407 ; E. 648 ; S. 687 ; neglect of increases mortality of T. 244 Tremors in T. 160, 167, 246 ; E. 370 ; E. .539, 564. 611 Trichiniasis, diagnosis from E. 603 Triple phosphates in stools of T. 150; E. 526 Tube-casts in urine of T. 156 ; E. 367 ; E. 534 Tubercle in T. 71, 192 ; E. 452, 558, 639 Tubercular meningitis, a complication of T. 203 ; E. 561 ; diagnosis from .^- 599 . — peritonitis in T. 212 ; diagnosis from E. 600 — ulceration of intestine distinct from lesions of E. 631 Tuberculosis, diagnosis from E. 599 — latent, 601 Turpentine, use of in bronchitis, 305 ; in intestinal htemorrhage, 672 ; in tympanites, 304, 673 Twitchings. See Subsultus Tympanites. See Meteorism Type, change of in fevers, 7, 43, 46, 55, 279,411,655 Typhia, 417 Typhinia, 312 Typhlitis, diagnosis from E. 603 Typhoid fever, 417 ; objections to desig- nation, 418 — pneumonia, 232, 597, 602 — stage of T. 180 ; E. 369 ; E. 532, 547 — state common to many diseases, 5, 19, 181, 369, 532 — ulcer, characters of, 624 Typhomania in T. 160 ; E. 536 Typho-malarial fever, 452 Typho-rubeoloid, 24, 47 Typhous cell, 642 • — deposit or matter, 642 — odour, 138, 519 Typhus fever, 23 ; derivation of term, 25 ; mode of prevalence, 52, 53, 54, 55 ; relation to E. 342 ; to E. 596, 678 ; to S. 6S2, 686 ; to yel- low fever, 61 ; poison. SieeFoison VEI Typhus abdominalis, 416, 428 — bellicus, 25 — carcerum, 25, 35, 104 — castrensis, 25, 112 — comatosus, 24, 227. See Brain-Fever — entericus, 417 — exanthematicus, 24, 39, 131, 428 — gangliaris, 417, 428 — mitior, 416 — nervosus, 416 — recurrens, 311 — siderans, 187, 219, 220, 228 Tyrosine in T. 156, 211, 256; E. 367, 405 ; E. 534, 634 Ulcee, typhoid, characters of, 624 Ulcerative stage of E. 546, 621 Ulcers of colon in T. 255 ; E. 404 ; E. 631 duodenum, T. 251 ; E. 616 gall-bladder, T. 257 ; E. 566 ; 634 ileum, T. 252 ; E. 404 ; E. 621 larynx, T. 259 ; E. 637 Payer's patches, E. 621 pharynx, T. 250; E. 614 solitary glands in E. 630 stomach, T. 251 ; E. 615 Uraemia, resemblance to T. 5, 17, 181 ; pathology of , 16; in T. 152, 170, 181 ; in E. 364; in E. 531 ; in yellow fever, 181 Urea, increased formation of in fevers, 15; T. 151 ; E. 364;E. 531 Uric acid, increased in fevers, 15; T. IS3;E- 366 ;E. 533 Urine in T. 150, 247 ; E. 363, 399, 413 ; E. 530. See Incontinence, Beien- • Hon, and S^ippression Urticaria in E. 387 Uterus. See Menstriiation and Preg- nancy Vaccination, a supposed preventive of E. 450 Vaccinia, coexistence with E. 588 Vagus, influence on phenomena of fever, 18 Valerian in fevers, 302 Varieties of T. 227 ; E. 391 ; E. 591 ; S. 683 Variola, measles, and scarlatina, for- merly regarded as one disease, 3 ; their coexistence, 225, 586 — Peyer's patches in, 630 ; coexistence with T. 226; with E. 588; dia- gnosis from E. 393 ; from E. 598 ; its relation to E. 450 ; its eruption compared to intestinal lesions of E. 420, 425, 466, 4S7, 620 Veins. See Tliromhosis INDEX. 731 VEN Ventilation, a preventive of T. 88, 268, 270 ; defective a cause of T. 72, 88, 117, 119; of E. 340; of E. 453 ; in treatment of T. 275 Veratrum viride in fevers, 287 Vertigo in T. 157 ; R. 367 ; E. 535 Vibices in T. 135, 194 ; R. 350 ; E. 516 Vibriones in blood of fevers, 9 Vienna, T. at, 36, 39, 112 Vision, organs of in T. 176, 207 ; E. 370, 383 ; E. 542. See Cornece, Piopils, and Strabismus Vomiting in T. 146, 304 ; R. 357, 413 ; E. 523, 565,611, 672; S. 685 Voracious appetite in E. 341, 356 Wakefulness in T. 164, 245; E. 369, 413; E. 537 ; its treatment, 295 YETi Warburg's tincture in continued fevers, 286 Washington National Hotel, E. at, 48 1 Water, poison of E. in, 466, 480, 483, 648 — organisms in, 498 Weather, a cause of T. 68, 79 ; E. 326 ; E. 448 ; S. 685 Westminster fever, 474 White leg in fevers, T. 195, 309; E. 381 ; E. 560 Windsor, E. at, 481 Wine. See Alcohol Worm fever, 418, 421, 616 Yellow fever, its etiology, 61 ; diagnosis from E. 392 ; mistaken for E. 312, 392; urffimia in, i8i LONDON : PRINTED BT SPOTTISWOOUE A2^l> CO., XKW-STUEET SQUAEIJ ASH PAELIAiiENT STliEKT