A system of practical medicine. By American authors. Vol. 1 (part 3 of 8)

A system of practical medicine. By American authors. Vol. 1 (part 3 of 8)

VIII. INTEMPERANCE.--Every one knows that alcoholic drinks are the cause of a vast amount of disease, crime, and misery in all civilized countries. No one knows how this is to be prevented, for no one knows how to make the great mass of the people wise and contented. The effects produced by excessive use of alcohol are well known to all physicians, and the remedy is self-evident. I see no use in adding to the heap of useless rubbish which exists in the shape of the great mass of existing {198} popular literature on this subject, and therefore leave the subject to the reader, who is quite sure to know all that is really important on this subject.

IX. CLOTHING.--The hygiene of clothing is also a subject which may be treated summarily in this paper. People wear what they can afford, made according to the prevailing style. Diseases due to insufficient, excessive, or badly-fitting clothing occur most frequently in women and children, and the use of such clothing is for the most part due to poverty or fashion, either of which is beyond the power of the physician to successfully cope with. Here and there, in individual and exceptional cases, he may be able to do a little good by advising against tight lacing, high-heeled shoes, insufficient covering for the chest or legs, etc., and he will find that a knowledge of the peculiarities of the various styles of modern under-clothing will sometimes be very useful. Men are, as a rule, comfortably and sensibly dressed to suit their business and surroundings, and require no advice on this subject.

X. EXERCISE.--The ease and completeness with which the functions of an organ or of an organism are performed depend to a great extent upon the frequency and regularity with which such functions are exercised. Hence comes the importance of bodily exercise for the preservation of health, and every physician meets cases of disease due largely to want of work.

The term "exercise," or "bodily exercise," is commonly used as if it referred only to the muscles, and the amount of exercise which a man should take in a day is stated as equal to a certain number of foot-pounds. The mere giving work to muscles is not, however, exercise in the sanitary sense. A better definition is that of Du Bois Reymond--viz. that "exercise is the frequent repetition of a more or less complicated action of the body with the co-operation of the mind, or of an action of the mind alone, for the purpose of being able to perform such actions better." From this point of view it will be seen that exercise relates quite as much to the nervous system as to the muscles. When, for example, a student takes a walk over ground with which he is familiar, and is at the same time so deeply engaged in thought as to be practically unconscious of what he is doing, only being recalled to himself, it may be, by arriving at his own door, the exercise which he has had is but partial and insufficient. Going to the extreme, we can, as Du Bois Reymond remarks, conceive of a man with muscles individually exercised until they were like those of the Farnese Hercules, and yet who would be unable to walk, much less execute more complicated movements; for the proper co-operation of the muscles, which is effected through the nervous system, is quite as necessary as the force of their contraction.

The amount of exercise which is necessary for health varies with the individual and with age, season, etc., so that it is difficult to state any general rule upon this subject; but if stated in terms of muscular force only, the estimate of Dr. Parkes seems a fair approximation--viz. that every healthy man ought to take daily an amount of exercise equivalent to 150 tons lifted 1 foot, or a walk of about nine miles. The majority of trades and bodily occupations demand at least this amount of work, but in some of them the greater part of the exertion is made only by certain groups of muscles, and they are carried on in crowded and {199} ill-ventilated shops. Such workmen, as well as all who are engaged in sedentary pursuits, require exercise in the open air--exercise which will bring into play the unused muscles and will break the train of thought of the professional man.

One of the most important questions with regard to physical exercise is the extent to, and manner in, which it should be provided for in a proper system of education. One of the latest and most instructive articles on this subject is that by Du Bois Reymond in the "Physiology of Exercise," a translation of which is given in the Popular Science Monthly for July and August, 1882. He divides the physical training which is more and more becoming a part of modern systematic education into three classes: The first, the turning, or gymnastics of the Germans; the second, the Swedish system, in which the exercises are limited to very simple though varied movements; and the English system, or rather want of system, consisting largely of athletic games and contests of various kinds. His objection to the Swedish system is that, while it strengthens the muscles, it does not increase the power over composite movements; in other words, it does not exercise the nervous system. Naturally, he prefers the German system to any other, although admitting that the English meets better the demands arising from our structure. "Were the end masterhood in running, jumping, climbing, in dancing, fencing, riding, in swimming, rowing, or skating, then nothing could be more advisable than to practise equally the necessary concatenations in the actions of the ganglion cells, without pausing at the not practically applicable preliminary and intermediate steps of the German turning."

From a sanitary point of view, the gymnasium, as usually located and managed, is by no means equivalent to out-of-door sports and contests, although it is often the best substitute for them. The form of exercise most used by men whose occupation does not involve bodily labor is walking, and next to this riding. Whatever mode be selected, it is very desirable that it should be taken for some other object than that of the mere making muscular exertion, or otherwise it will soon come to be looked upon as an unpleasant task, the time spent upon which is given grudgingly; and it will be partially or wholly abandoned as soon as the immediate discomfort which induced its use has ceased.

It is not an uncommon error among men engaged in mental work to suppose that they can, and ought to, take the same amount of exercise which gives good results in those whose occupations involve physical rather than mental effort, or to think that the more exercise they take the more study or writing they are equal to. This is a grave mistake. Expenditure of brain-tissue is not to be repaired by muscular exertion, but by sleep and food, and exercise in the fresh air sufficient to produce appetite and sufficient weariness to ensure restful sleep is all that is necessary. For a time it is true that the student or writer who has a well-developed body can continue to burn the candle at both ends, and win literary honors while also standing high as an athlete; but this surely leads to physiological bankruptcy in the end.

It is to be remembered that good muscular development is not necessarily synonymous with health, and that strength is not a guarantee against disease. And, while it is true that in this, as in most other matters of individual hygiene, each man must to a great extent be a law to {200} himself, and learn by experience what kind of exercise and how much of it he requires, yet the physician can often supply the motive which was wanting, or check undue effort. Exercise for the sake of health and comfort is not an end, but a means; yet if this means can be made to secure to the patient an end agreeable and pleasant in itself, so much the better.

XI. CONTAGION AND DISINFECTION.--By "contagion" we mean the communication of disease from one person to another, either by direct contact or through some medium, such as air, water, etc. It therefore includes "infection," which is now generally used as a synonym for it. The so-called infective diseases of modern German writers (Infections-Krankheiten) include, besides what are commonly termed in English, contagious diseases, the so-called miasmatic diseases.

The characteristic of a contagious disease is its specificity; that is, the disease transmitted is always the same in its essential characteristics. It does not, however, follow that all cases of the disease are equally liable or have the same power to transmit it; in other words, the degree of virulence of the contagiousness is not an essential characteristic. That the same disease sometimes spreads rapidly and is very fatal, and at other times seems hardly to have any contagious properties and is very mild, has long been noticed, and has been attributed to an unknown something called the medical constitution of the place--the constitution médicale of French writers. The true cause is probably very complex, but in some cases, at all events, it seems to be due to difference in the contagion itself. If we suppose this contagion to be a minute organism, it is easy to form a theory as to the cause of these differences, but there is much careful experimental work to be done before we shall have positive knowledge on this point. The results obtained by Pasteur in attenuating the virus of chicken cholera and splenic fever indicate one line which these experiments will take, and the researches of Koch point out another.

The diseases which spread by contagion until they form epidemics are those which have from the earliest times attracted the most general attention, and which have given rise to organized efforts for prevention--i.e. to public hygiene.

They are also the diseases which have given rise to the most bitter controversies among medical men as to the means of their propagation and the best methods of prevention. Plague, cholera, yellow fever, and typhus are those with regard to which this difference of opinion has chiefly occurred--one party considering their chief cause to be contagion, or specific germs derived directly or indirectly from the bodies of the sick; the second party declaring that they are due to filth plus an unknown something, which is variously termed epidemic constitution, pandemic wave, Providence, or x. The great majority of opinions at present is in favor of the view that they are all contagious, but not all, or always, contagious from person to person--that they spread from infected localities, which localities receive their infection from cases of the disease. The best means of dealing with them under ordinary circumstances are now tolerably well understood, and where these means can be commanded--as, for instance, among troops in time of peace--epidemics of these diseases can be stopped with great precision and promptness by isolation and disinfection.

{201} By "isolation" is meant not only the separation of the sick from the well, but the isolation of the infected locality or water-supply until it has been rendered harmless.

By "disinfection" is meant the destruction of the specific causes of disease, and more especially of the infectious or spreading diseases. A disinfectant is not necessarily an antiseptic or a deodorant, nor are these last necessarily disinfectants. The best practical antiseptic for sanitary purposes is cleanliness; the best disinfectants are heat, bichloride of mercury, sulphate of iron, chloride of zinc, sulphurous acid, chlorine, sunlight, and pure air, and, for yellow fever, cold. With our present very imperfect knowledge of the nature of specific causes of disease which we wish to destroy, we have no means of determining the presence of these causes in or on an article of clothing or of furniture, or in a room or other locality, except by the production of their specific effects on man or by inductive reasoning; in other words, we can only say that it is more or less probable that such causes are present. This makes it necessary, or at least expedient, to employ disinfectants in many cases where the presence of such causes is doubtful. The practical difficulties are, first, to bring the disinfecting agent into such relation with the causes of disease that it can act upon them, and act upon all of them; second, to avoid unnecessary destruction or injury of things which should be preserved. The majority of the causes of disease upon which we wish to act by disinfectants are probably minute particles of solid or semi-solid matter which are living, and may be conveniently designated by the word "germs." In the presence of moisture the destruction of the vitality of these germs can be effected with comparative ease and rapidity, but when they have become dried, or, as in the case of the bacilli, are in the form of spores, it is a more difficult matter.

To illustrate the methods to be pursued and the precautions to be taken, let us suppose the physician to be called on for directions as to the management of a case of scarlatina, the object being to prevent its spread. The first thing to be done is to get the patient in a room by himself, and to leave nothing in this room which is not necessary. Remove the carpet, curtains, and all stuffed or upholstered furniture. Let the nursing be done, as far as possible, by one person only, and do not allow others, and especially children, to enter the room, no matter if they have had the disease. The danger of contagion depends upon particles coming from the skin and mucous membranes. All excreta, and more especially the sputa or discharges from the mouth or nose, are to be treated as dangerous. The excreta should be received in vessels containing a solution of sulphate of iron, one and a half pounds to the gallon. All clothing, towels, bed-linen, handkerchiefs, napkins, etc. should be placed in a solution composed of four ounces of sulphate of zinc and two ounces of common salt to the gallon of water as soon as they are not needed for further use. Especial care should be taken that none of these articles are removed from the room while dry, and while they are in the room, and before they have been moistened, they should not be shaken or disturbed more than is absolutely necessary. If for any reason the zinc solution above referred to is not at hand--which should very rarely be the case--the clothing, etc. should be placed in a bucket, tub, or boiler containing enough scalding water to entirely cover them, and be removed {202} from the room in this vessel. All such articles should be boiled at least one hour.

No sweeping or dusting in the ordinary way is to be done in the room; dust and dirt are to be removed by damp cloths, which are to be treated like the bedding and clothing. The great object is to prevent as far as possible the production of dust in the atmosphere of the room. The entire body of the patient, including head, face, and limbs, should be kept thoroughly anointed with camphorated oil, vaseline, or some similar substance, and especial care should be taken in this respect during the period of convalescence so long as any roughness or desquamation of the skin continues. No toys or books which it is desired to preserve should be allowed to remain in the room, and under no circumstances should books or toys be borrowed to amuse the child if they are to be returned. The best way to disinfect such articles is to burn them in the room.

When the patient is fully convalescent and all desquamation has ceased, cleanse him thoroughly with a warm bath and soap for four successive days. If at the end of that time no roughness of the skin remains, he may be dressed in clean clothes and taken from the room, for he is no longer a source of danger. The room itself and the furniture are then to be thoroughly cleansed and disinfected. The ceiling and walls, if of ordinary hard finish, are to be scraped and whitewashed. All woodwork should be rubbed with damp cloths and the floor well scrubbed. Care should be taken to remove all dust from the ledges over windows and doors. All the cloths used in this cleansing process are to be burned.

If these directions have been carefully carried out, there is no need for further disinfection. But if upholstered furniture has been allowed to remain in the room, or other articles which cannot be burned or scrubbed or soaked in the zinc solution, it may be desirable to attempt to disinfect the whole room and its contents by means of chlorine or sulphurous acid gases. Of these, sulphurous acid gas is the cheapest, and upon the whole the best, but it must be used in large quantity, and for a longer time than is customary, if it is to be relied upon. For this purpose all openings into the room should be closed, and pillows, mattrasses, upholstered furniture, and articles which cannot be treated with the zinc solution should be opened, so that they may be exposed throughout to the fumes. The sulphur should be burned in an iron pan or pot, placed in a tub containing water or upon a large surface of sand. About 18 ounces of roll sulphur should be used to each 1000 cubic feet of space, and after twenty-four hours 12 ounces more should be burned and the room be then closed for twenty-four hours longer, after which it may be opened and aired. In case of death the body should at once be wrapped in a sheet thoroughly soaked with the chloride of zinc solution, and either be placed in an air-tight coffin at once or be buried without delay. The funeral should be strictly private, and the sheet referred to should not be disturbed or the body exposed to view.

The cases most liable to spread the disease are those in which the attack is very light and the child is not confined to its bed. It is desirable that children in a house in which there are cases of scarlet fever should not be allowed to attend school or mingle with other children who have not had the disease.

With regard to disinfectants, it may be well to note that none of the {203} various patent disinfectants are superior to bichloride of mercury, chloride of zinc, sulphate of iron, chlorine, and sulphurous acid; very few are equal to them, and none cost so little. As a gaseous disinfectant for rooms, etc. chlorine is superior to sulphurous acid, but it has the disadvantage of injuring metals, is not so easily applied, and is more costly. It will destroy the vitality of the spores of the bacilli more rapidly and certainly than sulphurous acid, which last, to make sure work, must be exhibited for a much longer period than is customary. I should not feel confident as to the thorough disinfection by sulphurous acid of the hold of an infected ship unless the fumes had been applied for sixty hours. Carbolic acid as ordinarily used is an antiseptic rather than a disinfectant. Its vapor in a sick room is absolutely useless. When applied in strong solution it is effective, for a time at least, but as thus used it is expensive, its odor is unpleasant to many, and masks the odors from putrefying substances and excreta, etc., thus preventing the warning which these odors would give. Its use is in many cases very much like removing the rattle from the rattlesnake.

The suggestions made above for limiting the spread of scarlatina from a case to be treated in the residence of the patient apply--with certain modifications for each form of disease, which will readily suggest themselves to the physician--to all the affections due to portable contagia.

Among the poorer classes, however, it will often be found impossible to obtain the separate room and service and the constant intelligent care which are necessary to ensure the desired result; and in such a case the patient should be removed to a hospital, for his own sake as well as for that of the community. The utility of small hospitals for infectious diseases is by no means generally understood, and very few of our small cities and towns are provided with anything of the sort. If the subject is urged on the authorities of a place, the reply will be that it is an unnecessary expense, that the people would not go to it, and that such an institution is in itself a source of danger. The facts are, that such a hospital costs very little, and is the cheapest insurance against epidemics which a town can have; if it is kept clean and comfortable, the people will use it freely, and if properly managed it does not offer the slightest danger to the vicinity. This question will be further discussed in the last section of this paper.

The principles of isolation as applied to a single case as indicated above may also be applied to infected localities in case of epidemics. When taken in time, all diseases which depend upon particulate contagia for their origin can be stamped out by isolation and disinfection. Unfortunately, to effect this promptly and successfully requires money, labor, and the co-operation of the well in the vicinity; which last it is usually impossible to obtain voluntarily or to compel sufficiently to secure the desired results. A question which sometimes arises in case of epidemics, and with regard to the necessity for which physicians will be consulted, relates to the closure of the public schools. It is certain that the assemblage of children in schools exerts a powerful influence on the spread of such diseases as scarlet fever, diphtheria, and whooping cough. On the other hand, the closure of the schools infringes upon the rights of a large number of the community, and if long continued, as it sometimes must be to be really efficacious, inflicts upon them {204} a permanent loss. It is, moreover, a confession on the part of the authorities of inability to induce or compel what must always be a comparatively small part of the community to take the proper precautions. It is never justifiable to close schools on account of small-pox, and where there is a competent health authority supported by the influence of the medical profession, it must be a very exceptional set of circumstances which justifies their closure for diphtheria or scarlatina.

It is not deemed expedient here to discuss the vexed question of quarantine. It is more important against yellow fever than any other disease, because every day of delay of the entrance of the disease which it secures lessens largely the subsequent mortality, since the duration of the disease is limited by frost. This is not the case with cholera, and the mere keeping this disease out of a place for a few weeks does not diminish its ravages when it has once gained an entrance. To rely altogether on quarantine, either maritime or inland, to keep yellow fever, cholera, or any other disease out of this country is a far greater mistake than to neglect it altogether. The practical way to isolate and quarantine is to get as close to the affected spot as possible. Precautions at Havana for yellow fever, or at Hamburg for cholera, are far more useful to the United States than the same amount of work at our own ports can possibly be; really good work in this direction must be not only national, but international.

XII. MENTAL CAUSES OF DISEASE.--A man may give too much attention to his health and the means for its preservation, and the doing so is both a sign and a cause of disease--probably oftener the former than the latter, except in cases of psychological epidemics. The power of expectant attention, especially if accompanied by belief or fear, to produce derangement of function in the nervous system, and through this to affect the circulatory and digestive systems, is well known to medical men. The effects of an undue amount of brain-work, and especially of the anxiety and worry which often accompany this when it is specially directed to the acquiring of wealth, fame, or power, are also familiar to physicians in our large cities. The analogies between mental and physical exertion are close in some respects, and especially as to the effects of over-exertion in a limited time under the influence of excitement.

The danger from simple mental work, such as study, when there is no excitement from a contest, is small, and depends mainly on lack of physical exercise and consequent disorder of the digestive organs. The risk of producing what Fothergill calls "physiological bankruptcy" is greatest in the youth studying for a prize, the speculator, the man who feels responsibility which he knows he probably cannot meet. The danger of injury from overwork under excitement is a very real one in many of our schools, and, while the evil results are most apparent in girls of the middle and upper classes, the boys and the young men also suffer. The system of pass examinations, in which the standing of the pupil is to be determined, not from the average results of his daily recitations, but from a single examination at the end of the year, produces the greatest risks to health; and this is especially the case where the ambition and pride of the children are stimulated by competition for prizes, medals, etc. Such systems of grading by a single final examination should not be used in ordinary schools, and for some pupils there will always be a risk to health connected with them even when they are of age. No doubt the stimulus of {205} competition is useful with the majority of children as well as of adults, but with some of them it is pretty sure to go too far.

The symptoms produced by undue mental strain are familiar to all physicians, and there is usually little difficulty in tracing the effect to the cause when attention has been directed to the matter; in fact, the patient himself usually knows very well the cause of his troubles. The remedy is, of course, rest--but that does not mean idleness. In speaking of occupation, allusion has been made to the fact that the physician must at times advise his patient as to the adoption of some pursuit, and in cases of this kind such advice is also useful.

The effects of mental strain are often mingled with, and aggravated by, those of stimulants which have been used to spur the flagging energies. Alcohol, tobacco, opium, or coffee used in this way finally increase the very discomforts which at first they relieved.

II. Personal Hygiene in its Relations to the Practice of Medicine.

In the preceding section have been indicated briefly some of the principal causes of disease and the methods for their investigation or removal. We have now to consider some of the practical applications which may be made of the laws of etiology and prevention of disease in the treatment of the sick. While the removal of the cause of illness by no means always effects a cure, yet the importance of a knowledge of this cause as an aid to diagnosis, prognosis, and therapeutics is so evident as to require no proof.

To discuss with anything like completeness the practical applications of what would be commonly considered as hygienic rules in the treatment of disease would be to write a treatise on nursing, and would also include a large part of the practice of medicine, for regimen is the more important half of practical therapeutics. The hygienic requirements peculiar to each disease will be pointed out by the writers upon special subjects, and I shall only venture upon one or two general remarks in addition to the hints already given in speaking of the several causes.

In the acute stages of disease the sensations--or, if the term be preferred, the instincts--of the patient are usually the best guide to his regimen so far as they go. In most cases he desires quiet, shade, but not absolute darkness, and little or no food, although there is often a craving for drinks, especially of a cooling character. In the specific fevers which have a tolerably definite period and course it is important to keep up the nourishment even during the period of anorexia, in order to provide against the debility which is to follow. This nourishment is best given in the form of drink, and very frequently fresh milk is the type of what is required. The old notion that whatever a sick man desired must be hurtful, and therefore that the fever patient must be kept hot and refused cool water, has now almost entirely passed away.

In convalescence from acute disease and in many chronic cases, the sensations of the patient are not to be trusted as a guide in the choice of food. In such diseases as yellow fever and typhoid fever to allow the convalescent to follow the dictates of his appetite is to run great risk of a fatal result. In other cases the patient really has no wish in the matter, but it {206} will often be found that one who can think of nothing which he desires to eat, and who will even refuse a dish which he has requested and been thinking about, will eat with enjoyment some unexpected dainty when presented at the right moment and properly served as a skilled nurse knows how to do. The manner of serving the food, independent of its cooking, is not a matter of such small importance that the physician can afford to overlook it, and he will succeed best as a practitioner who best appreciates the influence which cracked goblet, a chipped saucer, a soiled napkin, or, on the other hand, a hot plate or a touch of color in the shape of a leaf or flower, may have upon the capricious appetite of the sick. In ordering diet for convalescence it is not an uncommon error to select only those articles which are agreeable to the physician himself, forgetting the old proverb, that what is one man's meat may be another man's poison, and also that it is above all things desirable to avoid monotony. One doctor always orders chicken, another eggs, a third a mutton-chop, etc. The practice in this respect has probably been unduly influenced by the reports of Beaumont of the results of his observations on Alexis St. Martin, and we still find that the relative digestibility of various articles of food is estimated according to the scale laid down in these reports, with no allowance for individual peculiarities, previous habits, mode of cooking, etc. The secret of success in the diet of convalescence lies mainly in the simplicity of the individual dishes, in varying the different meals, in the manner of serving, and in carefully observing the effects on the sick person, and being guided by the results.

To promote appetite and digestion, and to secure refreshing sleep, one of the most important things is fresh air, but in many houses a sick person will obtain but a very limited allowance of this if the physician does not give special attention to the matter. Except in cases of contagious disease, the rules for managing which have been given in a previous section (p. 201), as soon as a patient is sufficiently recovered to be moved for a short time into another room his bedroom should be thoroughly aired and cleansed, and this should be done morning and evening thereafter.

In treating cases of contagious disease the question often arises as to means of individual prophylaxis to be used by those who must be exposed to the effects of the infected locality or of the presence of the sick. The attempts which have been made to secure this individual protection in the midst of an epidemic have been numerous and varied, ranging from the use of the "vinegar of the four thieves" of the Middle Ages to the employment of the sulphites and chlorates to make the blood unsuited to the growth and multiplication of the supposed germs, or of cotton-wool respirators to strain the infected air, or of supposed specifics for particular diseases, as belladonna for scarlet fever and vaccination against small-pox. As yet, there is little or no satisfactory evidence as to the value of individual precautions against those diseases whose contagion is conveyed through the air, small-pox alone excepted, but in case of diphtheria in one member of a family of children it might be well to try the use of chlorate of potash internally, combined with the local application of the tincture of the chloride of iron, as suggested by E. M. Hunt. The question is one to be investigated by careful observation and experiment; and, though it is improbable that any definite results will be obtained except in those diseases which are communicable to animals, and therefore {207} susceptible of direct experiment, still, it is possible that some advance may be made. In rare and exceptional cases--as, for instance, in exploring a crowded, filthy, and intensely infected typhus-fever nest, as a tenement-house, or an infected yellow-fever ship--it may be worth while for the physician or inspector who is unprotected by a previous attack of these diseases to make use of a cotton-wool respirator, which is readily extemporized, and belongs to that exceedingly valuable and popular class of remedies which, "if they do no good, can do no harm." In epidemics of typhus, cholera, or yellow fever one of the most valuable prophylactics is to have a mind so occupied with other matters that it pays little or no attention to the danger, while in case of small-pox fear of the disease is indirectly the best prophylactic, since it leads to careful vaccination.

This branch of the subject is closed with the remark that it would be well if physicians, and especially the younger ones, gave more attention to the preservation of their own health than many of them do. The possession of a medical diploma does not prevent the evil effects of irregular and hurried meals, insufficient sleep, exposure to inclement weather, and lack of systematic and sufficient exercise; and too much tobacco, sometimes too much alcohol, and in exceptional cases too much study and literary work, so often combine with anxiety about individual patients or with pecuniary worries to damage the digestion and nervous system of the young practitioner that the wonder is that so many survive the ordeal. And, in fact, the mortality among physicians under the age of thirty is higher than that of any other profession during the same period of life.

III. Public Hygiene in its Relations to Physicians.

An important difference between man and animals is found in the extent to which he will sacrifice a present pleasure or convenience to secure a future good or to avoid a future evil. The savage will do this to only a very limited extent--little more, in fact, than the beaver or the squirrel--and the lesson is learned but slowly and by sad experience. This is especially the case as regards matters affecting health. When a man begins to take special precautions as to his diet or exercise, having in view rather his future health than his present comfort and tastes, he has in most cases already begun to suffer from the effects of his imprudence, and does not commence a hygienic course of life as a perfectly sound and healthy person. The same is true for a community. It will not usually submit to the burden of taxation necessary to secure drains and sewers or a proper registration of vital statistics, nor to the cost and inconvenience of the machinery necessary to limit the spread of contagious diseases, until the neglect of these things has resulted in such an amount of disease and death as to forcibly call attention to the matter. The result is, that the burden is far heavier than it would have been had the work been undertaken in proper season, and individuals may find it to their interest to leave the place and settle elsewhere rather than remain and meet their proportion of the expense.

When a state or municipality has so far advanced in civilization as to consider it desirable to take measures to protect the public health by preventing individuals from polluting the air or water liable to be used by {208} their neighbors, etc., the services of the medical profession are always called upon. The foundation of public hygiene is information as to the occurrence of certain forms of disease, the cause of which can be referred with more or less precision to a certain limited locality. This information may be very imperfect, consisting of little more than rumor and opinions as to the existence of an undue amount of sickness or mortality in a certain place, or it may consist of precise reports setting forth the number of deaths from each cause, the proportion of each of these to the population by age, sex, occupation, etc., and of the whole to births--constituting what is commonly called the "vital statistics of a place"--and also of reports of the occurrence of certain preventable diseases; and between these two the information may be of various degrees of completeness, but, whatever there be, it is for the most part obtained either directly or indirectly from medical men. The reliability and completeness of the information thus obtained by the state determines to a great extent the direction and character of the work done in destroying or preventing the causes of disease, and it is also an important means of increasing our knowledge with regard to the nature of these causes.

The character of this information depends largely upon the character of the physicians who furnish it. In a large part of the country medicine is legally in the position of any common occupation; that is, the term "physician" is defined as applied to "any one who publicly announces himself to be a practitioner of this art, and undertakes to treat the sick either for or without reward." Under such circumstances there can be no guarantee that all who call themselves physicians are properly qualified or competent to furnish reliable information for registration purposes, and, as a matter of fact, a large number are not so qualified. It is for this reason that there is such a close connection between public health authorities, registration of vital statistics, and the registration of those physicians whose certificates as to causes of deaths, etc. will be accepted by the state; and hence the nature of the public health organization of a state and the personnel of its officials are matters of great importance to physicians. On the other hand, the efficiency of a public health service depends very largely upon the relations which it holds with, and the light in which it is regarded by, the medical profession. A health officer who is distrusted and disliked by the physicians of his district cannot effect much unless he can overcome this feeling, and his tenure of office must always be very insecure.

The official relations of the practitioner with the health authorities are usually confined to the subjects of registration of vital statistics and of checking the spread of contagious diseases. The most marked exception to this rule is furnished by the States of Alabama and North and South Carolina, in which the State Medical Society is the State Board of Health, having been given legislative powers and the right of selecting the health officers. The most complete organization of this kind is that of the State of Alabama, where by the act of 1875 the Medical Association of the State was constituted the State Board of Health, and the county medical societies in affiliation with the State Society were made county boards of health, to be under the general direction of the State Board. These county boards at first had advisory powers only, and were to be conducted without expense to the State or the county, except that the competent legal {209} authorities of any county might invest the county board with such powers and duties for the promotion of the public health as might be mutually agreed on; but in such case the right to elect or appoint those employed in sanitary administration is reserved to the board of health, while all questions relating to salaries, appropriations, and expenditures shall be reserved to the legal authorities. It was further provided "that no board of health, or advisory or executive medical body of any name or kind for the exercise of public health functions, shall be established by authority of law in any county-town or city of this State except such as are contemplated by the provisions of this act, the object of this prohibition being to secure a uniform system of sanitary supervision throughout the State." By an act of 1881 the county board is directed to elect a health officer, who is to keep a register of the births, deaths, and cases of pestilential or infectious diseases occurring in the county, and furnish to physicians, free of charge, reliable vaccine--to obtain information as to the sanitary condition of his county, etc. etc. It will be seen that this plan of organization is an attempt to overcome the practical difficulties in the way of obtaining from physicians the information necessary for the registration of vital statistics and the work of preventing the spread of infectious diseases.

While the great majority of physicians are willing to furnish the information as to the cause of death, etc. which is necessary for a useful registration, there are always some who either neglect or refuse to do so; and if the law be made compulsory, it provokes hostility unless compensation is furnished, while as regards the requiring physicians to furnish information as to the existence of contagious diseases, this always rouses opposition on the part of a certain number of medical men, even if payment for such notification is provided. And while this opposition is no doubt in many cases due to improper motives, such as personal hostility to the existing authorities, party politics, or a desire for notoriety, its strength nevertheless rests upon the fact that it is unjust for the state to compel the services of any man or class of men without furnishing compensation. The advocates of health and registration laws are thus placed between Scylla and Charybdis: if they propose compensation, which involves appropriations from the public treasury, the law cannot be passed; if there is no compensation allowed, complete results cannot be obtained.

The Alabama law makes compulsory the furnishing by physicians of information relating to births, deaths, and infectious diseases, and gives compensation--not in money, but by allowing the medical profession to have the sole management of the matter and to choose the health officers to whom they are to report; in other words, they are allowed to tax themselves. The result in Alabama is yet doubtful. If competent and faithful health officers and registrars can be obtained without paying them a fair compensation, it will be contrary to experience; and if these officers receive a salary, it will be strange if the positions do not become the reward of partisan political work.

It should be noted that the requiring a physician to report the births occurring in his practice stands on a very different basis from the requiring him to report the cause of death, since there is no special necessity for the former. It requires no expert knowledge to report a birth, and the duty should obviously devolve on the householder.

{210} In those States in which by law only properly qualified medical men, as determined by examination, have the right to practice, to hold medical office, or to furnish medical certificates, the State certainly is entitled to require of all physicians thus registered and authoritatively recommended to the people as competent, that they shall furnish, free of charge, certificates of the cause of death in those cases where they are cognizant of such cause.

States and municipalities often demand much more than this; as, for instance, that the medical man shall fill out the whole certificate, including age, nativity, nativity of parents, etc., and that he shall furnish the information to the registrar. In some cases it is provided that any physician having attended a person during his last illness shall furnish the certificate: this would apply to cases where the physician may not have seen the case for weeks before death.

While it is most convenient to have the certificate of cause of death upon the same form which contains the data necessary to identify the individual, the certificate should be distinct from the latter, and the duty of making the return to the registrar should devolve on the householder or undertaker, and not on the physician. On the other hand, it is easy for the physician to be hypercritical in these matters: his certificate is to be considered rather as a statement of opinion than as a statement of facts within his personal knowledge, precisely as he would certify as to his own age and birthplace.

The compulsory notification of infectious diseases to the health authorities is a matter presenting much greater difficulties than that of certificates as to causes of death. The state has no right to require such notification from the physician without giving some quid pro quo, and it is not expedient to make it compulsory, even with payment, except from physicians employed by the state or municipality, to furnish gratuitous medical attendance to the poor. The state has the right to require such information from the parent or householder, and it has also the right to require the physician to notify the parent or householder as soon as he recognizes the existence of such infectious disease. It is extremely desirable that the health authorities of a city should receive promptly, and direct from physicians, notification of the occurrence of such diseases, and there will usually be no difficulty in obtaining this if the health officer has tact and discretion and the city is prepared to do its duty. This duty is not confined to registering the information or placarding the house, nor will it be properly performed by merely removing the sick person to a hospital and disinfecting the premises. If the case occur in a family which can secure its proper isolation, and the attending physician certifies that it is so isolated and makes himself responsible for its management (for which responsibility he should be paid by the patient or his friends), the health officer should not interfere nor do more than furnish a competent person to secure disinfection if required. The employment of a trained nurse known by the health authorities to be competent and reliable would do away with most of the difficulties connected with such cases in the upper and middle classes of society; and such nurses should be registered just as physicians and midwives are.

Where the case cannot be thus isolated and properly cared for, it should be removed to a proper hospital. This presupposes that the city has such a hospital, and if it has not, and is not prepared for such cases, notification {211} is useless. When the city places a house in quarantine so as to interfere with business, it should be for the shortest possible time consistent with securing thorough disinfection of the premises, and the city should bear not only the cost of such disinfection, but the cost of caring for the persons in the house in an isolated place until no further danger is to be apprehended for them. When the city undertakes to pay all expenses for isolation and disinfection of such cases, it has the right to require that all such cases shall be so treated, leaving it to private parties to meet the cost in case they prefer not to use the buildings and apparatus provided by the city for that purpose. And when the city does its duty in this respect, it will be found that physicians and the people will do theirs, with rare exceptions.

When a city becomes very unhealthy the usual policy is to conceal the fact as much as possible, and to attribute the mortality to some other than the real cause. The influence of the mercantile part of the community is in such a case strongly exerted on the daily press and on the health authorities to produce such representations of the condition of things as will tend to allay apprehensions on the part of their customers. The healthfulness of a place is usually estimated from its mortality reports, but the reliability of these is by no means always what it should be. Yellow fever is called typho-malarial or pernicious fever, typhoid is reported as diarrhoea or malarial fever, etc. etc., and great stress is laid upon what is called the sanitary condition of the place, which is declared to be excellent.

Unfortunately, this phrase, "sanitary condition," means different things at different times. When the mortality is low, sanitary condition means the healthfulness of a place; when it is high, it means the cleanliness of a place. To a certain extent physicians are responsible for the truth of the statistical returns, not so much in relation to the number as to the causes of deaths; but none save those who have practised in a city liable to epidemics can realize the enormous pressure which is brought to bear on medical men to induce them to aid in or wink at concealing the true state of the case. Of course, this ostrich-like policy is in the long run an exceedingly unwise one, but neither the average householder nor community can be expected at present to pursue any other, except under pressure.

There are many questions as to the best form of public health organization, and the powers and duties which should be conferred upon it, which can only be properly answered by taking into consideration the circumstances in each case. In a large city the health officers must have great powers if they are to be really efficient. They have to contend with ignorance, custom, and self-interest, and their action must in many cases be prompt and unrestricted if it is to be efficacious. They must sometimes be in conflict with wealthy and powerful corporations, whose interests are opposed to the reforms which they urge, and although their business is to protect the most important interest of the community at large--i.e. its health--against the interests of individuals, yet these last are much more immediately concerned, and are, naturally, so active that they are often, although few in number, able to defeat any attempt to interfere with their occupations.

It not unfrequently happens that a health board may have all the power {212} necessary, so far as the laws are concerned, and yet may be able to accomplish little for want of funds to pay the inspectors and other officials whose services are necessary. For a city, a health officer usually does better work than a board of health: his responsibility is more direct, and he has stronger motives to do good work, than a board. Of course, a poor health officer is less efficient than a good board of health, but the general rule is as above stated. The problems of hygiene require special knowledge, and the man who is to deal with them requires special training. The folly of treating diseases by their names with popular or patent remedies is not greater than that of the attempt to make a healthy house or city by men who are not architects or engineers or physicians, or who have only the information possessed by the average architect or engineer or physician. And, of all professional or educated men, the physician especially should recognize his own ignorance. When he is asked what one should take for dyspepsia or pneumonia his answer is, "Take the advice of a physician;" and so when he is asked how the plumbing of a house should be arranged, how a hospital should be ventilated, how a city should be sewered, how a marsh should be dealt with or a water-supply provided, he should reply, "Get expert advice and supervision, and be prepared to pay the amount necessary to secure it." It is the special duty of the physician to exert his influence to secure properly constituted sanitary authorities for his own locality, his State, and for the nation, and to support these against the hostility which they must inevitably arouse if they are efficient. And he should do this, not blindly and as a partisan, but intelligently and with due consideration of all the important interests involved.

The body of educated physicians in a community forms the tribunal by which the work of sanitary officials is to be judged, and they cannot judge wisely unless they appreciate the difficulties with which health officials have to contend. If a city has an incompetent or dishonest board of health, the medical profession of that city are to a certain extent responsible for it; if a competent, energetic, and faithful sanitary officer is crippled and harassed or forced out of office because he is on the wrong side of politics, or because in the legitimate and proper exercise of his functions he has come in conflict with the interests of powerful and wealthy individuals or corporations, it is the duty of medical men to support him, and to do this actively and promptly. And I take great pleasure in being able to say, as the result of somewhat extended observation, that, as a rule, the physicians of this country do cheerfully and promptly co-operate with the sanitary authorities where such exist, and are the first to try to have them properly organized and given the necessary means and powers to do effective work.

{213}

DRAINAGE AND SEWERAGE IN THEIR HYGIENIC RELATIONS.

BY GEO. E. WARING, JR.

For reasons, sometimes sound and sometimes fanciful, the drainage question often presents itself to the medical practitioner as an annoying if not as a serious one. It is not necessary for the physician to make himself an adept in the art of sanitary drainage, but he can properly meet neither the demands of nervous patients nor the exigencies of sometimes serious situations without having an intelligent general idea concerning it. Not only to prescribe improvement, but frequently to allay ill-grounded apprehension, he should be able to address himself, intelligently and promptly, at least to the few simple problems presented in connection with ordinary houses. I use the expression "ill-grounded apprehension," not because the drainage in and about houses is generally tolerably good, for it is not, but because the race seems to have so inured itself to certain grave defects in plumbing-work that one may reasonably hesitate, and look elsewhere for the occasion of diseases before accusing the imperfect sanitary appliances of an average house.

Anything like a treatise on the technical details of house-drainage would be quite out of place here. There are note-books easily accessible to such physicians as care to make a thorough study of the subject. It does seem worth while, however, to pass in careful review, in a work of this character, the various conditions of interior and exterior drainage upon which a physician is frequently called to pass judgment.

The perfect drainage of a house, like the perfect drainage of a town, implies the immediate and complete removal, to a point well beyond its limits, of all waste matters which are a proper subject of water-carriage; such a thorough ventilation of the channel which these matters have traversed as to reduce to a minimum the production of deleterious gases arising from the decomposition of the film with which they may have soiled the walls of their conduit; and adequate provision for the absolute and permanent exclusion from the atmosphere within the house of the air of the pipe or sewer. This is a brief and simple statement of the fundamental and absolute requirements of all good drainage. It is founded on the one grand object which governs all improvement of this character: the prevention of decomposition of refuse matters anywhere in house or town.

Practically, it is safe to say that these conditions are never complete, and that instances of perfect work are so exceptional as to need no {214} consideration here. We have to assume, substantially in every case that is presented, that we are dealing with defective work, ordinarily with work that is very seriously defective. Most houses have been built by contractors, and the plumbing is perhaps the item of the whole structure that it is considered easiest and safest to scamp or to neglect. Even where the motive of economy has had no controlling influence, the drainage has almost invariably been planned by a plumber who has learned his trade and conceived his ideas in the performance of work which was done at a time when no one realized the serious consequences of its being improperly done. The absence of interior ventilation, leaky joints, ill-arranged connections between the various plumbing appliances and the main outlet from the house, pipes and traps so large that an ordinary current is powerless to keep them clean, defects of form, defects of material, and defects of construction, are met with on every hand. This general statement is of itself sufficient to show how hopeless it is for the average physician to prescribe the manner in which the drainage of a house should be constructed or remodelled.

If we view the question solely with reference to its bearing on the causation of disease, we enter a field where neither the sanitarian nor the physician is ever sure of his footing. The precise relation between bad drainage and ill-health no man knows. Certain diseases are undoubtedly traceable to conditions of air or of drinking-water due to the improper disposal of organic wastes, but the extent and exact bearing of these influences are still greatly a matter of conjecture. It is, however, undoubtedly safe to assume--and the assumption is supported by ample general observation, if not by precisely ascertained facts--that whether we are considering serious diseases or the slighter ailments, every argument leads to the enforcement of the most strenuous requirements of cleanliness. Through all the ages no one has disputed, and no one has improved upon, the simple sanitary formula, "Pure air, pure water, and a pure soil." We may safely wait until the enthusiastic investigators now engaged with the subject shall have adduced the testimony of positive facts, if we will in the mean time adhere strictly to the requirements of Hippocrates' prescription. The physician will surely not go wrong if he treats all obvious defects of drainage as positive evils, and insists upon their complete reformation.

Not to confine ourselves to houses which are provided with the ordinary modern plumbing-works, but to include all collateral branches of the subject, we have to consider the following conditions:

I. THE REMOVAL OF HUMAN EXCREMENT: (a) By water-carriage in houses provided with modern plumbing; (b) By some form of dry conservancy; (c) By the fiendish privy-vault which prevails so generally, save in the larger cities. II. THE REMOVAL OF LIQUID HOUSEHOLD WASTES: (a) By delivery to public sewers; (b) By irrigation disposal; (c) By delivery into cesspools.

Incidentally to the above there must be considered the influences of the ultimate disposal of all household waste, whether by the public sewer or the private house-drain.

{215} I. THE REMOVAL OF HUMAN EXCREMENT.--We are too apt to judge of the power for mischief of any waste matter by its original offensiveness, and the world at large regards the solid and liquid exuviæ of the human body as the most dangerous material with which it has to deal. Doubtless it is so under certain exceptional circumstances. If impregnated with the infective principle of cholera or of typhoid fever, for example, its influence for evil may be widespread and active, but in the absence of such infection these substances offer a less serious problem, and, as their offensiveness causes them to be more carefully avoided, their evil influence is less, and is less widely disseminated, than is that of the comparatively inoffensive wastes of the kitchen-sink. This is a consideration important to be borne in mind. Nothing is more common than the expression of the opinion that the wastes of a population are offensive and dangerous in proportion to the degree to which excrementitious matter is allowed to flow away with its general drainage. The fact is, that the drainage from a house or from a town, if reasonably diluted with water, is very slightly offensive until it has passed through a considerable degree of decomposition. The outflow of a perfectly sewered town, where the whole community uses water-closets, is less offensive than the neglected back-yard drain of an average New England farm-house. The trouble begins with the condition of putridity. Fecal matter and urine are somewhat quicker than the other wastes of the house to enter into putrefaction, but the difference is only one of degree, and the latter rapidly overtakes the former in the foulness of its condition; so that where a house is provided with two cesspools, one for water-closet matter and the other for kitchen waste, it is quite impossible to determine from the character of their contents which is which; therefore examinations of the drainage of a house should by no means be confined to the manner in which its excrementitious matters are disposed of. Setting aside, in this connection, the peculiar liability of these matters to become the seat of specific infections, it is fair to assume that equally complete and cleanly arrangements are needed for all else that flows to waste, as for the discharges of the water-closet. The purpose of these remarks is of course not to belittle the importance of proper care in the disposal of human excreta, but to prevent the giving of an undue importance to this branch of the subject, with too light treatment of the very serious difficulties presented by the others.

(a) Modern conveniences may fairly be said to be the bane of modern society, or at least of such of its members as have the questionable good fortune to be housed within the same four walls with every device that a misguided talent for invention has led the American mechanic to provide for the comfort and convenience of the occupant. Properly regulated, there is no element of modern house-building more conducive to health than such a system of plumbing as brings within reasonable limits the labor of supplying abundant water at every point in the house, and obviates the need for exposure and removes the temptation to neglect and postponement attending the use of out-of-door houses of convenience. The spigot and the water-closet are the two essential sanitary agents which the plumber offers to us. The bath may be replaced by the sponge, the stationary wash-basin may be, and generally should be, replaced by the bowl and pitcher of our fathers, but there is no sufficient {216} substitute for an ample supply of water on each floor of the house and for a cleanly water-closet placed within doors. The evil that the plumber has inflicted upon the race is due very largely to his not having held his hand when he had fairly provided for our reasonable requirements. When he fills our bedrooms with stationary basins, connects our refrigerators with the sewer, provides twenty outlets for water which had better reach the drain through less than half that number, and incidentally underlays all our floors with pipes, every foot of which is a possible source of danger, he turns what ought to be a blessing into what is too often an unmitigated curse.

It will not be easy to convert persons who have become accustomed to the universal diffusion of plumbing-works throughout the house to a belief that their best sanitary interest, and, perhaps hardly less, the best requirements of refinement, point to the abandonment of what is practically superfluous in the way of wash-bowls, bidets, foot-baths, sitz-baths, urinals, etc.; but one who has given careful attention to the subject cannot hesitate to recommend that in a house which is "strictly first class" it would be the part of wisdom to reduce by at least three-fourths the openings which lead to the soil-pipe and drain and sewer, and to concentrate upon the remaining fourth the flushing effect of wastes which are now so widely distributed. Strenuous effort is being made, not only by those who write and talk in the interest of the plumber and manufacturer, but by many who honestly believe that the good the plumber has to give us cannot be given with too free a hand, to prove that so long as they are properly constructed and properly arranged we may use plumbing appliances at every point in the house with the utmost freedom and with a minimum of danger. The minimum of danger, and often more than the minimum, does, however, exist. It exists, perhaps, in a constantly increasing degree with every extension of the work, and it can only be the part of wisdom to insist, so far as advice can have influence, on the reduction of all these appliances to the least requirements of reasonable comfort and economy of labor. My own advice would be, in all cases, to permit the use of no wash-bowl or bath or other vessel at a greater distance than a few feet from a vertical soil-pipe, and not to permit their use in any case in bedrooms or in closets opening only into bedrooms.

At the risk of seeming extravagant, I would say that the stationary wash-bowl as ordinarily used is one of the most uncleanly of modern household appliances. Long experience in the inspection of houses and in the examination of waste- and drain-pipes has led me to the belief that servants, by no means rarely, use these vessels as the most convenient means of voiding and cleansing chamber utensils. Their overflow-pipes are coated with soap and with the exuviæ of the skin to a degree which makes them usually the seat of an offensive decomposition. Their plugs and chains are almost invariably foul, and those devices which provide for closing the outlets by valves or plugs, somewhat removed from the strainers at the bottom of the bowl, bring the water in which the face is washed into an interchanging communication with a considerable length of foul and uncleanable waste-pipe--a communication that is made active by the bubbling of the contained air as the pipe fills with water. The labor of filling pitchers from a spigot on the same {217} floor, and the labor of emptying chamber-slops into a water-closet on the same floor, are not to be considered as compared with the greater cleanliness and the greater sanitary security that such an arrangement ensures. There is no serious objection to the placing of wash-basins and baths in the same apartment with the water-closet, or elsewhere immediately adjoining the soil-pipe; but it certainly cannot be disputed that the extension of the drainage system by horizontal lead pipes to remote points is altogether and wholly to be condemned.

However, the question more immediately at hand is that of the disposal of human excreta by the use of water-closets; and it is the water-closet that first attracts the attention of one who is called upon to examine the sanitary condition of the work. There are several radical defects in water-closets, which are so widespread and which have become so familiar to the world at large as to attract less attention than they deserve. For example, it is a radical defect of a water-closet to be tightly encased in carpentry. Nearly all the water-closets now in use have a somewhat complicated mechanism about their bowls. They consist in part of earthenware and in part of iron, generally with an unstable connection between the two. More often than not they overflow or drip or leak, and whatever may escape from them, whether foul air or foul water, is confined within an unventilated space, but a space which is still not absolutely excluded from the atmosphere of the house. The removal of the "riser" or vertical board under the front of the seat will usually disclose at once a condition that suggests at least the need for thorough ventilation. It also discloses in some cases a complication of machinery and pipes and levers and chains which makes a thorough dusting and cleansing of the space difficult, even were it accessible. There are water-closets which are essentially good in their construction and working, which it is important to protect by a "riser," but this "riser" should never be of close work. It should at least be freely perforated with large holes, or, better still, be made with slats or blinds, so that there may be the freest possible circulation of air under the seat. If there is an entire absence of machinery, so that the whole space may be left open, being well finished with tiles or hard wood or other suitable material, it is better that it should be unenclosed and that the seat should be hung on hinges, so that it may be turned back, exposing the whole space to easy cleansing. It is better too, in all cases, that the ventilation should not even be interfered with by a cover over the seat, the freest possible exposure to the air being of great importance.

A very large majority of the water-closets in use throughout the world are either very imperfectly flushed "hoppers," which are generally foul and which are often defective in their traps, or that worst of all forms, known as the "pan" closet, where a slight depth of water is held in the bowl by a hinged pan closing over its outlet. This pan swings in an iron chamber under the bowl, which is entirely cut off from ventilation, which is generally foul with adhering fecal matter, and which as an abomination has no equal in the whole range of plumbing appliances. The closet of which it forms a part has everything to condemn it, and only its cheapness and its apparent cleanliness, and the habit of the world in its use, to commend it. If flushed, as it usually is, by a valve on the supply-pipe, it is rarely flushed adequately, and its use not seldom leads to an indraft {218} of foul air (or worse) into the main water-supply system of the house. Such closets may be easily inspected as to their condition by shutting off the water-supply, opening the pan, and lowering a candle into the container below. Such an inspection will almost invariably disclose an extremely and dangerously filthy condition. Yet the worst part of the container, that which never receives an adequate flush, is even then concealed from view by the pan being thrown back against it. The nose will here be a good adjunct to the eye, and the odor escaping from this filthy interior chamber will generally afford convincing testimony of the impropriety of allowing such a vessel to remain in use.

It is a rule almost without exception that closets, except perhaps on the first floor of the house, which are flushed by valves connected with the bowls, are to be condemned. However good or however bad the state of a closet thus supplied with water, its condition will always be improved by giving it a copious flush from an elevated cistern delivering never less than two and a half gallons of water at each use, and delivering it through a pipe so large and so direct as to secure a thorough cleansing at every discharge.

It would be out of place here to enter into a detailed description of the various closets which are and which are not to be recommended for use. So far as the physician's inspection is concerned, it is perhaps sufficient to say that wherever an odor, however slight, can be perceived, and wherever a fouling of the interior surfaces of the closets or of the spaces under the seat can be detected by the eye, radical reformation is necessary. The only safety with a water-closet, as with any other vessel connected with the drainage of the house, is to secure an immediate and complete washing away of all foul matter of every kind. Where this result is not attained, it should be insisted upon. This much lies within the province of the medical attendant; the manner in which it shall be secured is not necessarily for him to decide.

One other branch of this subject is worthy of attention. The cleanliness and freedom from offence of the water-closet or of a waste-pipe or drain is in proportion to the frequency with which it is used and to the abundance of the discharge of water through it. A dozen closets used by a dozen persons will be quite likely all to be offensive. If the dozen persons all used only one closet--not a pan closet--the frequency with which its trapping water is removed and the frequency with which its walls are washed would secure its tolerable condition, even if not of the best construction. In this case, as in all others, simplicity should be the controlling principle.

(b) Dry conservancy next after water-carriage is the best and safest system for the removal of human excreta. By dry conservancy is meant the admixture of dry earth, ashes, or similar material with the matters to be disinfected and absorbed. Theoretically, the effect of such admixture is entirely satisfactory; under very careful and intelligent regulation it is practically so. It has been proved, however, by much experience that under ordinary circumstances--that is, where no greater care is given than is ordinarily given to a water-closet or to a common privy--the dry conservancy system is open to serious objections, though always an improvement on the cruder privy-vault. The theory of the effect of a sufficient admixture of earth or ashes with urine and fecal matter is, that by the {219} admission of air thus secured to every part of the material there is a complete oxidation of their organic constituents, similar to, though slower in its operation than, actual combustion in an active fire. In isolated houses and in hospitals, factories, and other buildings not provided with sewerage facilities, there is no question that the earth-closet or the ash-closet affords the best available means for disposal, if we except a system, to be described hereafter, for the distribution of water-carried wastes over or under the surface of suitable ground.

Incidentally--and this is of special interest to the physician--the use of dry earth or of dry ashes in the close-stool of the sick chamber effects not only an immediate and complete deodorization, but without doubt a complete disinfection as well. A quart of dry earth at the bottom of the vessel to receive the deposits, and rather more than a quart with which immediately to cover them, constitutes a means of relief always available and always efficient.

Where the house is provided only with an old-fashioned out-of-door privy the greatest relief and the most complete security may be given at little cost by filling the vault, and placing under the seat a movable box to receive the mixture of fecal matter and of the absorbent material, which, if it is desired to avoid the simple patented appliances made for the purpose, may be kept in a box or barrel in the apartment and thrown down after each use of the closet with the hand-scoop. The objections to the common privy are so obvious, so universal, and so well understood that the practical value of such a means of relief should be appreciated without argument.

(c) Privy-vaults are the sole reliance for the disposal of fecal matter, and often of chamber-slops, of probably 95 per cent. of the population of this country, and of Europe as well. It is curious, in examining the recommendations of public health officers and the requirements of local boards of health, to observe the uniformity with which this most important subject is passed over with the prescription that the vault shall be tight, sometimes that it shall be vaulted over, and sometimes that it shall not be within a certain small number of feet of a boundary-line or of a drinking-water well. These prescriptions are most absurd. It is safe to say, that of the millions of privy-vaults in this country not more than hundreds are really tight; that a still smaller number are so vaulted over as to prevent the free exhalation of the gases of decomposition; that those which are so vaulted over are in all respects of worse sanitary effect than those which have freer communication with the air, and that their possibilities of evil reach many times farther than the limits of distance usually required to intervene between them and the well or the neighboring property. In view of the universality of their use and of the completeness with which modern communities are inured to their presence, it seems almost hopeless to attempt to secure a proper realization of their great defects. They are always the seat of the foulest, and even of the most dangerous, decomposition. They taint not only the air and the soil, but the water of the soil which goes so often to feed our sources of drinking-water, and their local stench is of itself sufficient to sicken all who have not by daily and lifelong habit become accustomed to it. Taking the country at large--farm houses and village houses as well as the dwellings of cities--it is not too much to say that the best sanitary service that {220} can be rendered by those interested in the removal of causes of ill-health would be in securing the abolition of these barbarous domestic appliances. In many ways the cesspool is as bad as the vault, but in some respects the vault is facile princeps as a public and private nuisance of the most annoying and dangerous character. Wherever a public or private sewer is available, wherever disposal by irrigation is possible, and wherever even the crudest attention can be secured for an automatic or simpler earth-closet, the strongest effort should be directed to the absolute inhibition of the common privy-vault.

II. THE REMOVAL OF LIQUID HOUSEHOLD WASTES.--As has been stated above, the liquid household wastes are of much more serious consequence from a sanitary point of view, as compared with excrementitious matters, than the public has been wont to suppose. These, owing to the large amount of water which they contain, are beyond the reach of any system of dry conservancy. They consist almost invariably of a flood of water containing but a small percentage of refuse food, urine, soap, filth of the laundry, grease--everything, in fact, except fecal matter and the coarser garbage and ashes--constituting the waste of the household. Where water-closets are used fecal matter is generally added to the flow, but its relative quantity is small, and its presence or absence does not seriously affect the problem of disposal.

In a house provided with abundant, generally superabundant, plumbing appliances, with a large consumption of water, the whole apparatus is constructed on the theory that all manner of filth is to be taken up by running water and carried well without the house. Where this theoretical end is completely attained there exists a condition of drainage rarely met with and little to be criticised. Unfortunately, the theoretical excellence is rarely secured. Running water confined within a narrow channel, and so compelled to move with force sufficient to give an energetic scouring to the walls of its conduit, may be trusted to carry with it or to drive before it pretty nearly all foreign matter that may have been contributed to it, but the moment this vigorous current is checked, that moment the tendency to excessive deposit begins. It is checked in practice in various ways:

First. By too great a diameter of the pipe: a volume of discharge requiring a velocity of 4 feet per second in a pipe 1 inch in diameter would have a velocity of only 1 foot per second in a channel 2 inches in diameter, and of less than 6 inches per second in a channel 3 inches in diameter. Ordinarily, except as the deposits are removed by decomposition (always objectionable), the deposited matters accumulate and reduce the original bore to the diameter which will secure a cleansing flow. It is the part of wisdom to provide only this bore at the outset or not greatly to exceed it, and it is one of the earliest recommendations of an experienced sanitary engineer to reduce the size of too large bores where they exist.

Second. By the use of traps larger than the pipes leading to them and from them, thus increasing the natural tendency of all traps to stagnation and deposit.

Third. By the use of vertical waste-pipes, which are almost universal, and which are very often necessary. The velocity of a current measured along the axis of the pipe is less if the direction is vertical than if it is laid on {221} a steep slope, because of the tendency of liquids flowing through vertical pipes, which they do not fill, to adhere to the walls and to travel with a rotary movement. I have seen vertical soil-pipes furred with excrement to a thickness of nearly three-eighths of an inch; I have never seen a corresponding deposit in a pipe of good slope where the current was direct. This latter point is rather one of curious interest than of practical value--certainly from the physician's point of view. Even in original construction it is rarely possible to give soil-pipes other than a practically vertical course as they pass from one story to the next. Indeed, the physician need not trouble himself to consider the question of the size or of the direction of this main channel. He will often find occasion to criticise the use of unduly large waste-pipes from single vessels; as, for example, two-inch pipes leading from bath-tubs; two and a half-inch pipes leading from laundry-tubs; and three-inch pipes leading from kitchen-sinks. Where reconstruction is to be undertaken, he may with advantage exert himself to secure in these lateral waste-pipes a diameter never exceeding one and a half inches, and from kitchen- and pantry-sinks, whose outflow is loaded with grease, preferably not exceeding the diameter of one and a half inches, with traps of even a little less size. Where several vessels lead into the same waste-pipe these small diameters may increase the tendency to the emptying of the traps by siphonage, but if proper mechanical traps are used for baths, wash-bowls, and laundry-tubs, and if ample flushing appliances are connected with kitchen- and pantry-sinks, the temporary removal of the trapping-water by siphonage may generally be disregarded. It will seldom happen that the removal of water will be so complete as to prevent the satisfactory closing of the mechanical valve by capillarity, even if it fails, in itself, to make a perfectly tight fit.

A favorite recent requirement of theoretical sanitarians, and one which has perhaps for business reasons been eagerly accepted by the plumbing trade, is what is called the "back" ventilation of traps; that is, the carrying of a vent-pipe from every trap in the house to a point above the roof. In my judgment, there is more to condemn than there is to commend this practice, for I believe that the more rapid emptying of traps by evaporation where they are not constantly supplied by frequent use, the dangers of accident to lead pipe, which is generally used for ventilating purposes, and the misapplication of a large outlay which might better be applied in other directions, constitute convincing arguments against this favorite new method of preserving the integrity of the water-seal. There are a number of traps which are closed by floating balls, or by balls bearing upon the outlet, which seem to be quite satisfactory and efficient. The worst waste-pipes, by far, are those of kitchen- and pantry-sinks which pass a large amount of hot grease. This soon cools sufficiently to congeal, and it attaches itself to the walls of the pipe, where it does congeal until the bore is reduced to what is barely sufficient to furnish the necessary limited water-way. Grease-traps of various forms have been invented with a view to retaining this obstructing material. After much experience with all of them that have been in general use, I have become convinced that the only satisfactory way to avoid the difficulty in question is to retain the outflow of the sink until a certain considerable quantity has accumulated, and until its grease has entirely {222} congealed, then to discharge the whole volume rapidly through a pipe of small calibre. This may be done with Carson's grease-trap by throwing in a pail of water to start a siphon action when the vessel has become filled to its overflow-point. It is more simply accomplished by a device of my own, wherein the whole outflow is retained by a plug at the bottom of a large vessel working after the manner of the plug of a wash-basin, until it is filled to the level of the sink, and then opening the outlet for its sudden discharge.

Good workmanship is as important as, if not indeed more important than, good arrangement. It seems a very simple proposition to say that all waste-pipes, whose office it is to carry foul liquids out of the house, should be made tight in material and in joint. It is a remarkable fact, however, that leaky joints in soil-pipes and in drains are by no means rare. Probably there are few houses, very few, in which they do not occur. The soil-pipe is put together by inserting the small end of each section into the bell at the top of the section below it, practically like putting the outlet of one funnel into the larger upper portion of another. There may be abundant space for leakage at every joint from the top to the bottom of the house, without there being the least show of the leakage of water. The foul air within the pipe may escape freely through a dozen openings, while the heavier liquid flow takes its easiest and most direct course downward from the point of one pipe through the bell of the one below. When we come to the horizontal run of the soil-pipe in the basement, if an imperfection of the joint occurs on the lower side there is an obvious drip, which continues at least until closed by rust. Similar imperfections in other parts of the joint would not be so manifested. It has recently been demonstrated that there is no safety in the construction of soil-pipes short of that absolute assurance which can be secured only by an efficient test. Plugging all the outlets of the soil-pipe and filling it with water, the slightest leak will be exposed.

However defective may be the condition of an iron soil-pipe, vertical or horizontal, it is perfection itself compared with the usual state of a drain laid under the cellar floor; and here is a point where the least experienced inspector of house drainage cannot be mistaken. Under all circumstances, at least in all work hitherto executed, he should demand as absolutely necessary that the drains under the cellar floor be removed, that the earth which has been fouled by the leakage of its joints and its breaks shall be taken out to the clean untainted soil below, and refilled with well-rammed pure earth or with concrete, the drainage being carried through a properly-jointed iron pipe above the pavement, and preferably with a fall from the ceiling of the cellar to near the floor at the point of outlet--in full sight for the whole distance. It sometimes happens that the necessity for using laundry-tubs or other vessels in the cellar makes the retention of an underground course imperative. When retained, the drain should be of heavy cast iron with most securely leaded joints tested under a head of several feet. When found to be tight and secure, it should not be, as ordinarily recommended, left in an open channel covered with boards or flags and surrounded by a vermin-breeding, unventilated and uninspected space, but closely and completely imbedded in the best hydraulic cement mortar. Its careful testing before this {223} enclosure is of course the only condition under which the work can be permitted.

Tightness of all waste-pipes being secured, the next point in order is their proper ventilation. A good deal has been said, and little has been proved, about the different effects on the human system of the gases of decomposition which have been produced in the absence of a sufficient circulation of air, and those produced where the ventilation and dilution are more complete. The probabilities of the case are, of course, entirely in favor of the latter condition, and it is accepted by all sanitarians as an axiom that all water-ways and all vessels in which organic decomposition, even the decomposition of adhering slime, takes place, should be ventilated as thoroughly as possible. Until about ten years ago nearly all waste-pipes were tightly closed at the top, and were shut from the sewer by a trap at the foot, allowing absolutely no communication between the outer air and the atmosphere of the pipe except as fresh air might be carried in through the water-seals of the traps at each end. At about that time it was becoming the general custom in the better class of work to carry a small vent-pipe, often only one inch in diameter, rarely more than two inches in diameter, through the roof of the house, closing it at the top and perforating it with a few inefficient holes. This had undoubtedly the effect of relieving the pressure on the atmosphere of the pipe caused by the filling of unventilated sewers with tide-water or storm-water, or by a sudden increase of temperature from the admission of hot water. Later, it was accepted as a universal rule, and it became a quite general practice, to carry the soil-pipe above the roof with its full diameter, providing its summit with some form of ventilating cowl. All this constituted not ventilation, but venting. Real ventilation was introduced only with the very recent improvement of admitting fresh air at the foot of the soil-pipe, so as to make a complete circulation from one end to the other--a circulation sufficient to produce, by the diffusion of gases, a very fair ventilation of lateral waste-pipes of moderate length. It is now coming to be understood that ventilating cowls, of whatever form, are an obstruction to the movement of air in the absence of wind, and that, as what is needed is never a vigorous current, but always a living one, these cowls had better be dispensed with. We have learned, too, that the most efficient means for increasing the flow of air through the top is to increase its diameter at the top, enlarging the highest length of a four-inch pipe, for example, to a diameter of six inches. With this arrangement, and with a foot-ventilation four inches in diameter opening at a point where it can never be obstructed by rubbish or by snow, there will be secured a condition perhaps more efficient in improving the condition of an imperfectly drained house than any other one thing that may be done.

I have sketched above, in a very hurried manner, the main outline of a system of house-drainage which may be accepted or which may be recommended by a physician with confidence of securing a good result. To go more into detail in technical matters would be out of place in a paper of this character. Before leaving this subject, however, it is important to call attention to the fact that what is recognized in our houses as sewer gas is in far greater degree the product of decomposition taking place within the house-drains themselves than the product {224} of decomposition in the distant sewer forced into the house through its connecting drain. It is emphatically a case of the beam in our own eye as compared with the mote in the eye of our neighbor. It is a rule which has exceptions, but they are few, that the contained air of the house-pipes is far worse than the contained air of the sewer; and the conviction is growing that the use of a trap to the main drain between the house and the public sewer is more often objectionable than advantageous. Such a trap always tends to check the flow of the drain and to induce deposits whose decomposition is objectionable. Wherever the abandonment of the trap is anything like universal the considerable ventilation of the sewer thereby secured brings its atmosphere to a condition which makes it not objectionable, and generally useful, as a source of movement in the air of the interior drain- and soil-pipe.

(a) Public sewers are more or less good or bad entirely according to their character and condition. As a rule, a well-flushed sewer which is used for no other purpose than the removal of foul waste, built on what is called the separate system, and automatically flushed at least daily, may be considered to be, if well laid and tightly jointed, absolutely safe. A public sewer of large size and of irregular construction, receiving not only household wastes, but the wash of streets as well, may be regarded at least as an object of grave suspicion. These general statements may be so far qualified by the character of the sewers of each class as to run very nearly together; that is to say, separate sewers, with leaky joints, irregular grades, defective alignment, insufficient flushing, and inadequate restriction as to the matters they are to receive, will be an intolerable and dangerous nuisance; on the other hand, a large brick sewer built in the best manner and of the best material, with sufficient fall and sufficient supply to maintain itself in a cleanly condition, is free from the serious drawbacks which usually attach to sewers of this class.

With sewerage as with house-drainage it is not worth while to attempt here to give anything like detailed directions for inspection and for reformation. It will suffice to call attention to this one broad and general rule: Every sewer or drain having for its object the removal of putrescible organic matters must be so arranged as to maintain itself in a condition of practically absolute cleanliness, without, as in the case of storm-water sewers, waiting for the flushing effect of storms, which often come only at long intervals, during which the worst condition of decomposition may be established. Whether the sewer be intended for drainage only or for both drainage- and storm-water, if it contains at any time deposits of any kind, it is defective--more or less so, of course, according to the extent and duration of the accumulation.

Although it should be rigidly insisted upon in every case that the sewer should maintain itself free from deposits, there will still be, unavoidably, a certain amount of foul gas produced by the decomposition of the matters coating its walls, and in order to dilute and to remove this, and perhaps in order to modify their original character, the most thorough ventilation is necessary.

Any sewer or other drain which at any time gives forth the odor of putrid decomposition is in bad condition and should be at once rendered inoffensive. So far as I know, there is no exception to this rule. I have met no conditions in towns of any size where absolute self-cleansing may {225} not be secured. It is worth while, however, to repeat here the statement made above, that sewer gas, in so far as it is a serious factor in connection with the drainage of houses, is the product of the interior pipes of the house much more frequently than of the public sewer in the street.

(b) The disposal of liquid wastes by irrigation, so far as this method is applied to the outflow of public sewers, is not of especial interest here, but an important modification has been made of the system of irrigation which is of the greatest consequence in considering the sanitary improvement of isolated country-houses, of hospitals, prisons, etc., and of houses in towns about which there is a small amount of available land. The process which has been found best suited to the purpose is the invention of the Rev. Henry Moule, the inventor of the earth-closet. He found it a serious drawback to the dry-earth system that it was incapable of taking care of the liquid wastes of the house. He devised a method of conducting the liquid into very shallow drains made with open-jointed agricultural drain-tiles, so porous in their character as to allow the liquid carried by them to escape at the joints into the soil, and thus get the benefit of its purifying qualities without the unsightly and often offensive process of allowing the liquid to flow over the surface. The first use made of this system was about 1866. Since that time its use has extended very considerably both here and in England, and many improvements have been made in its details, so that it may now be accepted as entirely satisfactory.

The process in its best development, as applied to the drainage of single houses, may be thus described, many of the appliances used being the subject of patents: The outflow from the house is delivered into a settling-basin or grease-trap of sufficient size to still the flow, to cause solids to settle to the bottom, and grease and other light matters to float at the top. The outlet from this basin is through a pipe having its inlet at some distance below its overflow-point; that is, at the level of the comparatively clarified liquid, below the grease and above the sediment. The outflow passes into another vessel known as a flush-tank, where it accumulates until it reaches the summit of a self-acting siphon. This height being reached, any considerable addition to the flow sets the siphon in action, and the whole contents of the flush-tank are discharged with rapidity into the drain beyond. The discharge completed, air is automatically admitted to the siphon, and no further flow can take place until the flush-tank has again been filled. The drain, of iron or vitrified pipes tightly joined, is continued to the edge of the ground prepared for purification. It here delivers into a series of open-jointed agricultural tiles, laid with their bottoms not more than ten inches below the surface of the ground. The total length of these tile-drains is regulated according to the discharging capacity of the flush-tank, with a view to their becoming entirely filled at each discharge. Within a short time after the flow has ceased the liquid has all left the pipes and entered the soil, its impurities being retained and its filtered water settling away into the porous or artificially drained ground below. During the interval between the discharges of the flush-tank, a day or more, the process of purification (oxidation) of the retained impurities goes on in the soil, and its thorough aëration prepares it to purify the next discharge. This method of {226} disposal is now employed in connection with hundreds of houses, and its use, which has in some cases continued for a dozen years, is constantly increasing. Its application implies a certain amount of fall, but this amount need not be great. The discharging height of the tank need not be more than twelve inches. The main outlet need not fall more rapidly than at the rate of 1 to 300, and the absorption-drains ought not to fall more rapidly than at the rate of 1 to 600. If the tank can be built on the top of the ground, an average surface fall of 1 to 400 can usually be made to meet all the requirements. Where waste matters are to be removed from cellars and basements below the level of the ground, a greater fall is necessary, or the wastes which are there collected must be thrown to the tank by pumping or otherwise.

Where there is a bit of grass-land a little removed from the house (and from sight), it answers a perfectly satisfactory purpose to dispense with the absorption-drains and to deliver the main outlet directly on to the surface of the ground. The effect in both cases is entirely different from what it would be were the flow of the drains not regulated by the use of the flush-tank. The moment we have a constant slight discharge, either on the surface of the ground or into the absorption-drains, we establish a condition of constant saturation which leads to the over-fouling of a small area, which is rarely if ever purified by aëration. For an intermittent discharge some form of flush-tank is an absolute necessity. It is often found in practice, where the flow from the house is considerable, that the discharge of the house-drains into the settling-basin produces such an agitation of its contents as to set in motion and to carry into the flush-tank bits of paper partly macerated, grease, etc. This has been met by a recent improvement, which consists in building a transverse wall in the settling-basin, which checks the current from the house-drain and causes the flow from the house side of the wall to pass over its top in a thin small current which does not materially agitate the contents of that part of the basin from which the outflow pipe is fed.

(c) The cesspool is still the chief reliance of the world at large. There is nothing to be said in its favor save what may be based on the old adage that "what is out of sight is out of mind." There is everything to be said in its condemnation, whether we regard its contents as a great mass of putrefying and infecting filth, as the source of oozings which travel through crevices of rocks, through layers of gravel, through seams in clay, or through lighter soils into and under cellars and into drinking-water wells and defectively constructed cisterns, or as an ever-active gas-retort supplying the pipes of the house with the foulest products of putrefaction. It is in all respects and under all circumstances a curse, unless placed far away from the possibility of tainting the air we breathe or the soil over which we live, or from which we or others take our drinking-water, and even then it had better be abandoned.

The simple drainage of the soil involves a question of the greatest importance. If the ground under the house or about it is at any time, unless perhaps immediately after heavy rains, saturated with moisture, we have to apprehend a condition of insalubrity more or less serious in proportion to the degree of saturation and the degree of foulness with which this is associated. The drainage requirements of land outside of the house are less easily determined, but it requires nothing more than a casual {227} examination of the cellar in ordinarily wet weather to determine whether or not an improvement of its soil-water drainage is necessary. If it is at such times wet, or even persistently damp, thorough drainage is demanded; and it is only necessary to say that this should be secured by some process which can under no circumstances bring the air of the cellar into communication with the air of a sewer or foul drain.

* * * * *

I have purposely abstained in the foregoing remarks from invading the province of the physician or the physiologist by discussing the influence of bad drainage on the health of those living subject to it. It may safely be assumed that physicians who care enough about the subject to interest themselves in investigating the condition of local or general drainage have convictions concerning it which could not be strengthened by the opinion of one belonging to another profession. The assumption is also confidently made that no intelligent medical man will hesitate for a moment to accept the dictum that the site of the house must be dry, and that it and its neighborhood must be entirely exempt from the influence of foul organic decomposition.

{229}

GENERAL DISEASES.

FROM SPECIAL MORBID AGENTS OPERATING FROM WITHOUT.

SIMPLE CONTINUED FEVER.

TYPHOID FEVER.

TYPHUS FEVER.

RELAPSING FEVER.

VARIOLA.

VACCINIA.

VARICELLA.

SCARLET FEVER.

RUBEOLA.

RÖTHELN.

MALARIAL FEVERS.

PAROTITIS.

ERYSIPELAS.

YELLOW FEVER.

DIPHTHERIA.

CHOLERA.

PLAGUE.

LEPROSY.

EPIDEMIC CEREBRO-SPINAL MENINGITIS.

PERTUSSIS.

INFLUENZA.

DENGUE.

RABIES AND HYDROPHOBIA.

GLANDERS AND FARCY.

MALIGNANT PUSTULE.

PYÆMIA AND SEPTICÆMIA.

PUERPERAL FEVER.

BERIBERI.

{231}

SIMPLE CONTINUED FEVER.

BY JAMES H. HUTCHINSON, M.D.

DEFINITION.--A continued, non-contagious fever, varying in duration from one to twelve days, and in temperate climates almost invariably ending in recovery. It may arise from any non-specific cause capable of producing a temporary derangement of one or more of the important functions of the body, is generally easily distinguished from the other continued fevers by the absence of the characteristic symptoms of these diseases, and presents in fatal cases no specific lesions.

SYNONYMS.--Synocha, vel Synochus Simplex, Febricula, Ephemera or Ephemeral Fever, Irritative Fever, Ardent Continued Fever, Sun Fever.

HISTORY.--Much difference of opinion continues to prevail, even at the present time, in regard to the existence of a simple continued fever, which, on the one hand, occurs independently of local inflammations or traumatic causes, and, on the other, is distinct from typhoid, typhus, and relapsing fevers; many observers contending that the condition to which this name is given is only a mild or modified form of one or other of the graver varieties of continued fever, from which the characteristic symptoms are absent. Prominently among modern writers, Dr. Tweedie[1] has taken this view of the subject, for, after reviewing the arguments for and against the recognition of simple continued fever as a distinct disease, he asserts that there is not sufficient evidence to justify us in encumbering our nosology with a doubtful novelty. If, however, there is room for doubt as to its right to a place in the list of diseases, there is certainly no good reason for characterizing it as a novelty, since it has been referred to, according to Murchison,[2] by many authors from the time of Hippocrates down to the present day, who not only separate it from the graver forms of fever, and give a very accurate description of its symptoms, but seem to have been perfectly familiar with the causes which give rise to it, and to have had very correct notions as to its proper management. Thus, Riverius[3] was aware of the existence of two forms of simple fever--the ephemeral, which lasts, as its name implies, only a single day, and the Synochus Simplex, arising from the same causes, but in which the fever continues for from four to seven days. Strother[4] and Ball[5] also allude to this fever in terms that leave no doubt upon the mind but that they distinguished it clearly from other forms of continued fever. {232} Among more recent writers who have made this distinction may be mentioned Lyons,[6] Jenner,[7] G. B. Wood,[8] Flint,[9] Murchison,[10] and J. C. Wilson.[11] Indeed, the weight of authority is decidedly on the side of those who claim for it a recognition as a distinct and separate disease.

[Footnote 1: Lectures on the Continued Fevers.]

[Footnote 2: A Treatise on the Continued Fevers of Great Britain, London, 1873.]

[Footnote 3: The Practice of Physick, being chiefly a Translation of the Works of Lazarus Riverius, London, 1678.]

[Footnote 4: A Critical Essay on Fever, 1718.]

[Footnote 5: A Treatise on Fevers, London, 1758.]

[Footnote 6: A Treatise on Fever, London, 1861.]

[Footnote 7: Medical Times, March 22, 1851.]

[Footnote 8: A Treatise on the Practice of Medicine, Philadelphia, 1855.]

[Footnote 9: A Treatise on the Principles and Practice of Medicine, Philadelphia, 1868.]

[Footnote 10: Ibid.]

[Footnote 11: A Treatise on the Continued Fevers, New York, 1881.]

Unquestionably, many cases which have been classed under the head of simple continued fever, are really mild or abortive cases of typhoid or typhus fever, in which, in consequence of partial protection on the part of the patient, the characteristic symptoms of these diseases have not been developed. Such cases are seen in numbers during epidemics of these diseases. But, making due allowance for this source of error, there yet remain many cases which cannot be thus explained. Moreover, the disease occurs at times when no such epidemics exist. It may, therefore, be safely assumed that there is such a fever, and that, consequently, it must be accorded full recognition.

CAUSES.--Any non-specific cause which is capable of producing a profound derangement of one or more of the important functions of the body may give rise to simple continued fever. It may follow, therefore, upon excesses of the table, extreme mental or bodily fatigue, exposure to the direct rays of the sun, or to great heat or cold, or upon the suppression of a secretion. One of its most frequent causes is over-exertion in warm weather. James C. Wilson has called attention to its frequent occurrence as a consequence of the combined influence of the excitement, the physical exhaustion, and the exposure to the direct rays of the mid-day sun which are attendant upon surf-bathing. It is often due in young children to the irritation involved in the process of teething or to that caused by the presence of worms in the alimentary canal. Wood taught that it might also sometimes occur during the prevalence of contagious diseases as an effect of the epidemic influence in those who were partially protected by a previous attack of the disease, or from some other cause, but it is more probable that cases arising under these circumstances are either mild cases of the prevalent disease or else are attributable to fatigue from nursing or to over-anxiety. The disease is more common in the young than in the old, and in children than in adults--probably from the greater impressionability of the nervous systems of the latter.

The causes of the ardent continued fever of the tropics, which is usually recognized as a form of simple continued fever, do not differ materially, except in degree, from those of the simpler forms of the disease; but exposure to the direct rays of the sun would seem to be especially prone to give rise to the disease in those who are unaccustomed to the heat of a tropical climate. Robust young Europeans lately arrived in a warm country are, it is said, peculiarly liable to suffer from it.[12] It is most common in those parts of India which do not experience much of the benefit of the monsoon rains, and whose hot season is not tempered by regular breezes from the sea. It is hence more frequently met with {233} in inland districts in which the temperature is high, but in which malaria-generating conditions are absent.

[Footnote 12: Morehead, Clinical Researches on Diseases in India, London, 1856; also Twining, Clinical Illustrations of the More Important Diseases of Bengal, Calcutta, 1835.]

SYMPTOMS AND COURSE.--Simple continued fever occurs in this country only as a sporadic disease, and almost invariably ends in recovery; in tropical climates, however, it may prevail epidemically, and sometimes presents symptoms of a very grave character. In its mildest form it not infrequently runs its course in a few hours, and is rarely prolonged much beyond twenty-four, and is hence called ephemera. It then usually begins somewhat abruptly with a chill, but in a few instances this is preceded by feelings of languor and weariness. Febrile reaction is soon established, and is generally well marked; the pulse is quick and full, the temperature rises rapidly, and the face is flushed. The tongue is coated with a whitish fur, the urine is scanty and high-colored, and the bowels are constipated. Other symptoms are excessive thirst, headache, restlessness, and sleeplessness, or, on the other hand, a tendency to somnolence. Vomiting is not common except in those cases which follow upon an error of diet, but there is generally some nausea and anorexia. Muscular pains are also occasionally present, and may give rise to a good deal of distress. The subsidence of these symptoms is often quite as abrupt as their onset, the crisis being frequently marked by a copious perspiration.

In other cases, however, the fever is more prolonged, and the symptoms, although not differing in kind, are apt to be more severe than those above detailed. The pulse is often full, hard, and bounding; the headache throbbing or darting in character; the tendency to somnolence increases, or gives place to delirium; and the pyrexia is more marked. Frequently an eruption of herpes is observed upon the lips and upon other parts of the face, from which circumstance the disease is sometimes called herpetic fever. Davasse[13] also observed in a few cases pale bluish spots, not elevated above the surface and not disappearing under pressure, which are identical with the tâches bleuâtres sometimes seen in typhoid fever and other diseases, and therefore have no diagnostic value. In this form the duration of the disease may be from four to ten or twelve days. The defervescence is usually less rapid than the rise in temperature, and is generally accompanied by a free perspiration, diarrhoea, a copious deposit of urates in the urine, or less frequently by hemorrhage from the uterus or rectum,[14] or from the nose, mouth, or urethra. This constitutes the synocha or inflammatory fever of the older writers. In children in whom there is no reason to suspect malarial poisoning the disease sometimes assumes a remittent form, and then constitutes a variety of the infantile remittent fever of authors--a name, however, which, it must be remembered, has been made to include a great many distinct diseases.[15]

[Footnote 13: Quoted by Murchison.]

[Footnote 14: Murchison.]

[Footnote 15: Lyons.]

When the disease occurs in individuals who are broken down in health from any cause[16]--as, for instance, previous illness, deficient food, long-continued anxiety, or great fatigue--it not infrequently presents symptoms of an asthenic character. The febrile reaction is then less intense, and the pulse feebler and more frequent, than in the variety just described. The duration of the disease in this form is also generally longer. Murchison has proposed for it the name of simple asthenic fever.

[Footnote 16: Wood.]

Under the name of ardent continued fever, Indian medical writers have described a variety of the disease which is frequently met with in tropical {234} countries, and which is usually much more severe than the varieties already referred to. In addition to the symptoms presented by these, Morehead[17] says that there is often intolerance of light and sound, contracted and subsequently dilated pupils, ringing noises in the ears, anxious respiration, pains in the limbs and loins, and a sense of oppression at the epigastrium. The bowels are sometimes confined; at others vitiated bilious discharges take place. The tongue is white, often with florid edges, and the urine scanty and high-colored. At the end of from forty-eight to sixty hours the febrile phenomena may subside, the skin become cold, and death take place from exhaustion and sudden collapse. In some cases the symptoms of cerebral disturbance are greater in degree, and in these coma may soon supervene upon delirium. Convulsions, epileptiform in character, with relaxation of the sphincters and suppression of urine, also frequently occur, and occasionally cerebral hemorrhage. In other cases the symptoms of gastritis are more prominent, or jaundice may appear and aggravate the disease.

[Footnote 17: Clinical Researches on Disease in India, London, 1856. See also "Croonian Lectures," by Sir Joseph Fayrer, _Brit. Med. Jour._, April 29, 1882.]

Symptoms closely resembling those just described are occasionally met with in this country in patients who have been exposed for some time to the direct rays of the summer sun, but who have escaped a sunstroke. Indeed, a few writers have been so much impressed with the general resemblance which this latter condition bears to the fevers that they have insisted upon including it in this group, and have given it the name of thermic or heat fever. This view of the pathology of sunstroke has, however, never been generally accepted.

One of the most characteristic symptoms of the disease in all its forms is the rapid rise of temperature, which may in ephemera be as great as from four to seven degrees in the course of a few hours, and which may be followed in a few hours more by an equally abrupt defervescence. When the fever is more prolonged, although the temperature rises rapidly, it may not attain its greatest elevation for from forty to sixty hours after the onset of the symptoms, and its fall will be more gradual than in the preceding variety. Unfortunately, there are no reliable thermometric records of ardent continued fever. The urine is usually scanty and high-colored during the height of the fever, especially in the severer forms of the disease. Its specific gravity is high, and it contains a large amount of solids, especially of urea. With the fall of the temperature it rapidly increases in quantity, and is very apt to let fall a copious lateritious sediment on cooling. According to Parkes,[18] who closely observed six cases with the view of determining this question, albuminuria does not occur at any stage of the disease. Convalescence is usually rapid, and is not liable to be interrupted by the occurrence of sequelæ.

[Footnote 18: The Composition of the Urine, by Edmund A. Parkes, M.D., London, 1860.]

DIAGNOSIS.--The diagnosis in those cases of simple continued fever in which the connection between the disease and some one of the conditions which have been referred to above as capable of exciting it has been distinctly made out, presents little difficulty. It is otherwise, however, when this relationship is not apparent. Indeed, the symptoms of the disease so closely resemble those of an abortive or mild attack of typhoid or typhus fever, in which the characteristic eruption is wanting, that the {235} physician may sometimes remain in doubt as to the nature of the disease he has been called upon to treat, even after the recovery of the patient. This difficulty will of course be especially likely to present itself during the epidemic prevalence of these diseases. Simple continued fever may, however, generally be distinguished from either of the latter by the much greater severity of its initial symptoms, and particularly by the rapid rise of temperature--a rise of from four to seven degrees in the course of a few hours--which does not take place in these fevers, but which, it must be remembered, may occur in erysipelas, measles, pneumonia, and some other diseases. The absence of a characteristic eruption, although it would not render it certain, would be in favor of the diagnosis of simple continued fever, as would also the absence of diarrhoea in cases in which there was difficulty in deciding between this disease and typhoid fever. On the other hand, Murchison regards the presence of an herpetic eruption on the lips as almost pathognomonic of simple continued fever; but in this country such an eruption is not an infrequent attendant upon fevers of malarial origin, and many observers attach great importance to it in the diagnosis of these diseases.

Simple continued fever is not likely to be mistaken for relapsing fever, except during epidemics of the latter disease. It may be discriminated from relapsing fever, the first paroxysm of which it closely resembles, by the absence of severe articular pains, of tenderness in the epigastric zone, of enlargement of the liver and spleen, and of jaundice. It may be mistaken for tubercular meningitis, especially in those cases in which the nervous symptoms are more than usually prominent, or in which a hereditary predisposition to tuberculosis exists; but its true nature may generally be recognized by its more abrupt commencement, and by the absence of the constant vomiting, screaming fits, strabismus, and paralysis so characteristic of the latter disease.

It is scarcely necessary to add that a local inflammation or a traumatic cause may give rise to symptoms simulating those of simple continued fever, and that the diagnosis of this disease must be uncertain until these conditions have been positively ascertained to be absent, or, if present, until they have been proved to be complications, and not the causes of the disease.

PROGNOSIS.--The prognosis of this disease, as it is met with in this country, is favorable. Indeed, when uncomplicated it may be said to end invariably in recovery, except in the aged and feeble, in whom, when it occurs during the great heat of the summer season, it is apt to assume the asthenic form, and to be accompanied by symptoms of a grave character. The ardent continued fever of the tropics, on the other hand, not infrequently terminates fatally, or may leave the sufferer from it a chronic invalid for life, which is frequently shortened by obscure cerebral or meningeal changes, which give rise to irritability, impaired memory, epilepsy, headache, mania, partial or complete paraplegia, or blindness.[19]

[Footnote 19: Sir Joseph Fayrer, K.C.S.I., M.D., F.R.S., Brit. Med. Jour., April 29, 1881, p. 607.]

ANATOMICAL LESIONS.--Death so rarely occurs in this latitude from simple continued fever that the opportunities for making post-mortem examinations do not often occur. There are, however, a sufficient number of such examinations on record to show that the disease gives {236} rise to no specific lesions. According to Murchison and Martin,[20] inspection in fatal cases of ardent continued fever usually reveals the presence of great congestion of all the internal organs and of the sinuses of the brain and pia mater, of an increased amount of intracranial fluid, and occasionally of an effusion into the abdominal cavity, and more rarely into the thoracic cavity.

[Footnote 20: The Influence of Tropical Climates on European Constitutions, by James Ranald Martin, F.R.S., London, 1856.]

TREATMENT.--In the milder forms of the disease little or no treatment is required--a fact which seems to have been recognized and acted upon long ago, since Strother remarks that the cure of it is so easy that physicians are seldom consulted about such patients. An emetic when the attack has been caused by excesses of the table, and there is reason to believe that there is undigested food in the stomach, a purgative when constipation exists, and cooling drinks, the effervescing draught or some other saline diaphoretic, are usually the only remedies that are called for. In cases in which the febrile action is more intense and prolonged, in addition to the use of these remedies an effort should be made to reduce the heat of the skin and the frequency of the pulse by sponging with cold water and by the administration of digitalis and aconite. The headache which is often a distressing symptom may usually be relieved by the application of evaporating lotions, and restlessness quieted by the bromides. Subsequently, quinia may be given with advantage. The patient should be restricted to liquid diet during the continuance of fever.

In the asthenic form quinia and the mineral acids, nutritious food, and very frequently alcoholic stimulants, must be given from the beginning. In the treatment of the ardent continued fever of the tropics the cold affusion or the cold bath, with quinia, would appear to be indicated, but Morehead and other Indian physicians advise the use of evacuants with copious and repeated venesections, cupping, and leeches, aided by tartar emetic, till all local determination and the chief urgent symptoms are removed; and Murchison expresses the belief, founded on his own observations, that life is often sacrificed by adopting less active measures.

{237}

TYPHOID FEVER.

BY JAMES H. HUTCHINSON, M.D.

DEFINITION.--An endemic infectious fever, usually lasting between three and four weeks, and associated with constant lesions of the solitary and agminate glands of the ileum, and with enlargement of the spleen and mesenteric glands. Its invasion is usually gradual and often insidious. Sometimes the only symptoms present in the beginning are a feeling of lassitude, some gastric derangement, and a slight elevation of temperature; at others there are slight rigors or chilly sensations, headache, epistaxis, diarrhoea, and pain in the abdomen. The principal symptoms of the fully-formed disease are a febrile movement possessing certain characters, headache passing into delirium and stupor, diarrhoea associated with ochrey-yellow stools, tympanites, pain and gurgling in the right iliac fossa, a red and furred tongue, which later often becomes dry, brown, and fissured; a frequent pulse; an eruption of rose-colored spots, occurring about the seventh or eighth day, slightly elevated above the surface, disappearing under pressure, and coming out in successive crops, each spot lasting about three days; prostration not marked in the beginning, but rapidly increasing; and occasionally deafness, sweats, and intestinal hemorrhages. When recovery takes place, the convalescence is usually tedious, and may sometimes be protracted by the occurrence of one or more relapses.

SYNONYMS.--The following are a few of the many names which have been given to the disease at different times. Most of them have ceased to be applied to it, and only three or four of them are at present in general use: Febris Mesenterica, 1696; Slow Nervous Fever, 1735; Febricula or Little Fever, 1740; Typhus Nervosus, 1760; Miliary Fever, 1760; Typhus Mitior, 1769; Synochus, 1769; Common Continued Fever, 1816; Gastro-Enterite, 1816; Entero-Mesenteric Fever, 1820; Abdominal and Darm Typhus, 1820; Typhus Fever of New England, 1824; Dothienterie, 1826; Enterite-folliculeuse, 1835; Infantile Remittent Fever, 1836; Enterite Septicémique, 1841; Mucous Fever, 1844; Enteric Fever, 1846; Intestinal Fever, 1856; Ileo-Typhus, 1857; Pythogenic Fever, 1858; Mountain Fever, 1870.

NAME.--It has been objected to the name "typhoid fever" as a designation for this disease that it tends to perpetuate among the laity the mistaken impression that typhoid fever is only a modified typhus fever, and also that the word typhoid has been generally applied to a condition of system which is common to a great many different diseases, {238} and which is not of necessity present in this. In spite of these objections, and although it must be admitted that they are not without force, I prefer to retain the name typhoid fever, and for the following reasons: 1st. It was the name given to the disease by Louis, to whom we owe the first full and accurate description of it. 2d. It is the name by which it is best known to the profession, not only in this country but abroad. 3d. No other name has been proposed for it which is not quite as much open to criticism. Thus the term enteric fever, originally suggested by the late George B. Wood, and adopted by the London College of Physicians in its Nomenclature of Diseases, is objectionable because it brings into undue prominence the intestinal lesions and implies that they are the cause of the fever. The same objection may be urged against the name "intestinal fever," proposed by Budd. The name "pythogenic fever" rests upon a theory of the disease which has never been proven, and is regarded by most observers as untenable. Under these circumstances even the influence of its distinguished proposer, the late Dr. Murchison, has been insufficient to secure its adoption by the profession at large.

HISTORY.--Certain passages in the writings of Hippocrates have been appealed to by Murchison and other physicians in support of the opinion that typhoid fever was a disease of at least occasional occurrence in ancient times; but, although from the nature of its causes it is probable that it has occurred in all ages and wherever men have congregated in towns and villages, the descriptions given by the Father of Medicine in the passages alluded to are not sufficiently full to render it at all certain that typhoid fever had ever come under his observation. Indeed, there is no author of an earlier date than Spigelius[1] whose writings furnish any positive evidence that he ever met with the disease. Spigelius, however, in spite of the doubt thrown upon his observation by Hirsch,[2] would seem to have had opportunities for examining the bodies of those who had died of it, since he gives an account of several autopsies, in which he says that the small intestine was inflamed and that that part of it next to the cæcum and colon was frequently sphacelated. Panarolus[3] also says that the intestines had the appearance of being cauterized ("apparebant tanquam exusta") in some cases observed by him in Rome a little later in the same century. Willis[4] would certainly appear to have been familiar with two forms of fever, which, from the description he gives of them, could have been nothing else but typhoid and typhus fevers. Sydenham[5] also described a fever in which the prominent symptoms were diarrhoea, vomiting, delirium, a tendency to coma, and epistaxis, and which was distinguishable from the febris pestilens by the absence of a petechial eruption. Baglivi[6] of Rome in the latter part of the seventeenth century described the hæmitritæus of previous writers {239} under the title of febris mesenterica, and maintained that it was always accompanied by and dependent on inflammation of the intestines and enlargement of the mesenteric glands. A similar observation was made soon after by Hoffmann,[7] and by Lancisi[8] in 1718. The latter seems to have fully recognized the characteristics of the eruption, for he says that it consisted of "elevated papules which disappeared completely on pressure." In 1759, Huxham described, under the title "slow, nervous fever," a disease which there can be no doubt was typhoid fever. He moreover pointed out very clearly the distinctions between this disease and another to which he gave the name of "putrid, malignant, petechial fever," and which was unquestionably typhus. Sir Richard Manningham[9] also described typhoid fever under the title of "febricula, or little fever." In the preface of his work he calls attention to its insidious origin, and to the fact that its gravity was often underrated at its commencement, "till, at length, more conspicuous and very terrible symptoms arise, and then the Physician is sent for in the greatest hurry, and happy for the Patient if the Symptoms, which are most obvious, do not, at this Time, mislead the Physician to the Neglect of the little latent Fever, the true Cause of these violent Symptoms." About the same time Morgagni[10] described certain post-mortem examinations in which the lesions of the intestines were evidently those of typhoid fever. Other authors, whose works bear evidence that they were familiar with the symptoms or lesions of typhoid fever, are Riedel, Roederer and Wagler, Stoll, Rutty, Sarcone, Pepe, Fasano, Mayer, Wrenholt, Sutton, Bateman, Muir, Edmonstone, Prost, Petit and Serres, Cruveilhier, Lerminier, and Andral.

[Footnote 1: De Febre Semitertiana, Frankf., 1624; Op. Om., Amsterdam, 1745. Quoted by Murchison.]

[Footnote 2: Handbuch der Historisch-Geographischen Pathologie, von Dr. August Hirsch, Stuttgart, 1881.]

[Footnote 3: Observat. Med. Pentecostæ; Romæ, 1652. Quoted by Murchison.]

[Footnote 4: Dr. Willis's Practice of Physick, translated by Samuel Pordage, London, 1684.]

[Footnote 5: The Works of Thomas Sydenham, M.D., on Acute and Chronic Diseases, with a Variety of Annotations by George Wallis, M.D., London, 1788.]

[Footnote 6: Opera Omnia Medico-practica et Anatomica, Paris, 1788.]

[Footnote 7: Opera Omnia Physico-Medico, 1699. Quoted by Murchison.]

[Footnote 8: Opera Omnia, Geneva, 1718.]

[Footnote 9: The Symptoms, Nature, etc. of the Febricula or Little Fever, London, 1746.]

[Footnote 10: Quoted by Hirsch.]

To Bretonneau[11] of Tours appears to belong the credit of having first distinctly pointed out the association between certain symptoms and the lesions of the solitary and agminated glands of the ileum. He regarded the disease of the intestinal glands as inflammatory, and therefore gave to it the name "dothienenterie" or "dothienenterite" (from [Greek: dothiên], a tumor, and [Greek: enteron], intestine), but, unlike Prost, fully recognized the fact that there was no necessary relation between the extent of the intestinal lesions and the gravity of the febrile symptoms. Hirsch, however, claims this honor for Pommer, whose little work on Sporadic Typhus he thinks has not received the consideration its merits deserve. Louis, to whom for his careful study of typhoid fever we owe a large debt of gratitude, was also fully aware of the lesions of the intestinal glands which occur in this disease.

[Footnote 11: Quoted by Trousseau, Archives Générales, 1826.]

The progress in pathology which observers were making was temporarily impeded about this time by the fact that while typhoid fever was of frequent occurrence in Paris, typhus fever was comparatively rarely met with and had not been epidemic there for several years. Bretonneau, Louis,[12] Chomel, and indeed the greater number of contemporary French physicians, therefore fell into the error of supposing that the fever which was then common in England was identical with that which they were describing, while the English physicians of the period, with but few {240} exceptions, contended with equal strenuousness that there was but one form of continued fever, and that this was very seldom associated with disease of the intestines. In the second edition of his work Louis abandoned his former opinion, and admitted that the typhus fever of the English was a very different disease from that which formed the subject of his treatise; but the confusion which existed in England in regard to this disease was not completely dispelled until the appearance in 1849 and the following two years of several papers on this subject by Sir William Jenner,[13] in which it was conclusively demonstrated that typhoid and typhus fevers were separate and distinct diseases. In Germany, however, the non-identity of these diseases was recognized as early as 1810. Murchison says that the names by which they are still generally known in that country, typhus exanthematicus and typhus abdominalis, were given to them not long after.

[Footnote 12: Researches Anatomiques, Pathologiques et Therapeutiques sur la Maladie connue sur les Noms de gastro-entente, etc., par P. C. A. Louis, Paris, 1829.]

[Footnote 13: Med. Chir. Trans., vol. xxxiii.; Edinburgh Monthly Jour. of Med. Sci., vols. ix. and x., 1849-50; and Med. Times, vols. xx., xxi., xxii., xxxiii., 1849-51.]

The contributions made by American physicians to the knowledge of typhoid fever have been both numerous and important. In 1824 it was described by Nathan Smith[14] under the name of typhus fever of New England, and in 1833, E. Hale, Jr.,[15] of Boston, published in the Medical Magazine for December an account of three dissections of persons considered by him to have died of the disease. In reference to these cases, Bartlett[16] says that if the diagnosis could be looked upon as certain and positive they would constitute the first published examples of intestinal lesion in New England. In February, 1835, William S. Gerhard of Philadelphia, who was then under the impression that the two diseases were identical, reported two cases under the name of typhus fever, the symptoms and post-mortem appearances of which he showed differed in no respect from those he had been accustomed to see in the cases of typhoid fever he had observed with Louis during his studies in Paris. The year after Gerhard had, however, the opportunity of observing an epidemic of true typhus fever, and was at once struck with the difference between the symptoms of the cases which then fell under his care and of those he had seen in Paris. In an admirable paper which appeared in the numbers of the American Journal of the Medical Sciences for February and August, 1837, he points out very clearly the differential diagnosis between the two diseases. He particularly insisted on the marked difference between the petechial eruption of typhus and the rose-colored eruption of typhoid fever. He showed that the latter disease was invariably associated with enlargement and ulceration of Peyer's patches and with enlargement of the mesenteric glands, and that these conditions were never presented in the former. He also fully recognized the fact that typhus fever was eminently contagious, while, on the other hand, he was fully aware that typhoid fever was not contagious under ordinary circumstances, "although in some epidemics," he says, "we have strong reason to believe it becomes so." The appearance of this paper marks an epoch in the history of typhoid fever. Murchison, when speaking of it, says that to Gerhard, and Pennock (who was associated with Gerhard in his observations) certainly {241} belongs the credit of first clearly establishing the most important points of distinction between this disease and typhus fever, and M. Valleix alludes to it in terms equally complimentary. It is undoubtedly owing to it, more than to any other cause, that the differential diagnosis of these two diseases was perfectly understood by the great body of the profession in this country long before the question of the relation which they bore to each other was definitely settled in Great Britain,[17] or even in France.

[Footnote 14: Medical and Surgical Memoirs, Baltimore, 1831.]

[Footnote 15: Observations on the Typhoid Fever of New England, Boston, 1839.]

[Footnote 16: The History, Diagnosis, and Treatment of the Fevers of the United States, 1842.]

[Footnote 17: The honor of having first clearly pointed out the distinguishing characters of typhoid and typhus fevers has been recently claimed for Sir William Jenner, but, as we have seen above, his papers on this subject were not published until thirteen years after that of Gerhard.]

Bartlett gave in the Medical Magazine, June, 1835, a short account of the entero-mesenteric alterations in five cases of unequivocal typhoid fever, which alterations, he said, corresponded exactly to those described by Louis. In the same year, James Jackson, Jr., of Boston, published an account of the intestinal lesions observed by him in cases during the years 1830, 1833, and 1834; and again in a Report of Typhoid Fever, communicated to the Massachusetts Medical Society in June, 1838, says that the alterations of Peyer's patches had been noticed at the Massachusetts General Hospital previous to 1833 in cases which were carefully examined. In 1840, Shattuck of Boston published in the American Medical Examiner an account of some cases of typhoid and typhus fever which he had observed at the London Fever Hospital during the previous year. In this paper, which had been already communicated to the Medical Society of Observation of Paris, and which had unquestionably exerted a marked influence upon medical thought there, he pointed out very fully the distinguishing characteristics of each disease. In 1842, Dr. Bartlett issued the first edition of his work on The History, Diagnosis, and Treatment of the Fevers of the United States, which contains very full descriptions of both of these diseases, and of the means by which they may be distinguished from each other. Since then there have been numerous additions in this country to the literature of typhoid fever, among the most important of which may be mentioned the chapter on the disease in the respective works on The Practice of Medicine by Professors Wood and Flint, the article on typho-malarial fever in the Transactions of the International Medical Congress of 1876, and the article in the work on The Continued Fevers, by James C. Wilson. Abroad, the medical press has been no less active. Within the last twenty or thirty years Jaccoud and Trousseau in France, Liebermeister and Hirsch in Germany, and Tweedie and Cayley in England, have all made important additions to our knowledge of the disease. To the late Dr. Murchison[18] of London, however, is justly due the honor of having produced the best treatise on typhoid fever in any language, and the writer cheerfully acknowledges that he has drawn largely upon it for the material of the present article.

[Footnote 18: A Treatise on Continued Fevers, London, 1873.]

GEOGRAPHICAL DISTRIBUTION.--Although it will be generally admitted that the conditions of civilization favor the occurrence and extension of typhoid fever, yet there is abundant evidence that they are not absolutely necessary to its production, as there is no country, whether civilized or not, of the diseases of which we have any knowledge, in which it has not occasionally made its appearance, being met with in every variety of climate. It is endemic in North America, attacking alike the inhabitants {242} of Greenland and British America and those of Mexico. In our own country it prevails from time to time in every State of the Union, committing its ravages as well among the rocks and hills of New England as in the more fertile valleys of the West and South. In many of the newly-settled portions of our country malarial fevers are, as is well known, exceedingly rife. In proportion, however, as towns and cities spring up, and as the land is properly drained, they diminish in frequency, and are gradually replaced, to a certain extent at least, by typhoid fever; but the influences which produced them retain for a long time enough of power to stamp their impress upon all other diseases. In large portions of the Western and Southern States typhoid fever is therefore rarely uncomplicated, and is much more likely to assume the form which will be fully described later as typho-malarial fever.

Typhoid fever has also occurred frequently in Central America and the West India Islands. It has prevailed from time to time in the states of South America, and occasionally assumed in some of them--as, for instance, Brazil and Chili--an epidemic form.

Typhoid fever is endemic in the British Isles, but, according to Murchison, is most common in England, more common in Ireland than in Scotland, and in Scotland more common on the west than on the east coast. It also exists as an endemic disease in every country of the continent of Europe, from Sweden and Norway on the north to Turkey on the south, and in some of them--as, for instance, France and Germany--would seem to be of much more frequent occurrence than in this country, or even in England. Medical literature is also not deficient in evidence that it has prevailed at various times in all the different countries of Asia and Africa and in Australia. Morehead asserted in the first edition of his Clinical Researches on Diseases in India that India enjoyed an absolute immunity from typhoid fever, but in the second edition of this work he acknowledged that a larger experience had led him to change his opinion on this point. Moreover, the writings of Annesley, Twining, and other Indian authors furnish convincing proof that the disease is by no means unknown in that country. Indeed, even the relative immunity from it which it has been claimed that tropical and subtropical countries possess has been found, upon a fuller study of the diseases of these countries, not to exist to anything like the degree that was formerly supposed.

The occasional occurrence of typhoid fever in islands separated from the main land by a considerable distance--as, for instance, the island of Norfolk,[19] which is situated in the Pacific Ocean four hundred miles west of South America--is an interesting fact, and one which, with the present limits to our knowledge on the subject, it is impossible to explain satisfactorily.

[Footnote 19: Metcalfe, Brit. Med. Jour., Nov., 1880.]

The ETIOLOGY of typhoid fever may be considered under the heads of--1, predisposing, 2, exciting causes.

1. PREDISPOSING CAUSES.--All observers agree that the predisposition to typhoid fever is greater in childhood and early adult life than after thirty years of age. Thus, Murchison states that during twenty-three years nearly one-half the admissions to the London Fever Hospital were of patients between fifteen and twenty-five years of age, and that in more than a fourth, the patients were under fifteen years. On the other hand, {243} in less than a seventh were they over thirty, and in only one in seventy-one did their ages exceed fifty. Taking these facts in connection with the circumstance that the entire population of England and Wales in 1861 was 12,481,323 persons under thirty years of age and 7,584,901 above thirty, it follows, he says, that persons under thirty are more than four times as liable to enteric fever as persons over thirty. Jackson found that the average age of the patients in two hundred and ninety-one cases observed at the Massachusetts General Hospital was a little over twenty-two years, the average age in the fatal cases being somewhat greater than in those in which recovery took place. Liebermeister, from an analysis of a large number of cases treated at the hospital in Basle, has arrived at the same conclusion. No age, however, enjoys a complete immunity from the disease. Manzini[20] has recorded a case in which lesions of Peyer's patches similar to those of typhoid fever were found in a seventh-month foetus which died within half an hour after its birth. Cases are also on record in which death has occurred from this disease in the first few weeks of life. I have myself observed several cases in young children at the Children's Hospital in Philadelphia. The probability is, that it is of even more frequent occurrence in children than is generally supposed, as this class of patients is not often admitted into general hospitals, and as from the absence of some of its characteristic symptoms when it occurs in the very young the nature of the disease is often unrecognized.

[Footnote 20: Quoted by Murchison.]

On the other hand, the disease occurs not infrequently in advanced life: 83 cases out of 5911 were observed at the London Fever Hospital in persons over fifty, 27 in persons over sixty, and in 2 the age was seventy-five. In a case recorded by D'Arcy the age of the patient was eighty-six, and in one reported by Hamernyk it was ninety.[21] Bartlett long ago contended that the disease was not so rare as was generally supposed among people over forty years of age; and there is really no good reason to believe that the susceptibility to the causes of the disease in an unprotected person diminishes with advancing years, the immunity from this disease which elderly people appear to enjoy being probably due to the fact that, as the disease is not uncommon in early life, they are in many instances protected by having already passed through an attack.

[Footnote 21: Quoted by Murchison.]

The mean age of the male patients treated at the London Fever Hospital was slightly in excess of that of the female, but in the cases analyzed by Jackson the reverse of this was observed.

The statistics of all general hospitals, with very few exceptions, show a greater or less preponderance of males over females among the typhoid fever patients treated in them. According to Murchison, of 5988 cases admitted into the London Fever Hospital during twenty-three years, 3001 were males and 2987 were females. Of 891 cases admitted into the Glasgow Infirmary during twelve years, 527 were males and 364 females. Liebermeister states that 1297 male typhoid patients and 751 female were treated in the hospital at Basle from 1865 to 1870. Occasionally, the difference is even greater than is indicated by these figures. Thus, of 138 cases observed by Louis, all but 32 occurred in males. When, however, we consider that the proportion of men who apply for admission to hospitals when sick is much larger than that of women, we should hesitate before accepting these statistics as proof that the former {244} are more liable to be attacked by typhoid fever than the latter. Indeed, the opinion which Murchison expresses is generally accepted as correct by authors, that neither sex is more likely than the other to contract the disease. Liebermeister asserts that pregnant and puerperal women and those who are nursing infants enjoy a relative immunity. On the other hand, Nathan Smith says that while the sexes are equally liable to it, more women are cut off by it than men, in consequence of its appearance during pregnancy or soon after parturition.

It was long ago pointed out by certain French observers that newcomers are much more liable to be attacked by typhoid fever than persons who have lived for some time in an infected locality. In 129 cases examined with reference to this point by Louis, the patients in 73 had not resided in Paris more than ten months, and in 102 not more than twenty months. Bartlett noticed that during an epidemic in Lowell which he had the opportunity of observing the disease attacked the recent residents in much larger proportion than the old. Liebermeister also calls attention to this peculiarity of the disease. Murchison's experience in reference to this point has been somewhat similar, for he found upon examination of the records of the London Fever Hospital that 21.84 per cent. of the patients admitted there for typhoid fever had been residents of London for less than two years. Almost all of these patients came, he says, 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. Moreover, a large proportion of them were first attacked within a few weeks after changing their residence from one part of London to another. He also refers to instances in which successive visitors at the same house at intervals of months, or even years, have been seized shortly after their arrival with typhoid fever or with diarrhoea, from which the ordinary occupants were exempt. These facts indicate with sufficient clearness that habitual exposure to the causes of the disease confers, to a certain extent at least, an immunity from their effects, just as it does in the various forms of disease arising from malaria. It is not unlikely, as has been suggested by Wilson,[22] that one of the causes of the frequency of typhoid fever in the early autumn in our American cities among well-to-do people is to be formed in the circumstance that during an absence of two months or more in the mountains or by the sea they have to some extent lost the immunity acquired by habitual exposure to sewer emanations, and return to the atmosphere of the city unprotected.

[Footnote 22: The occurrence of typhoid fever in the early fall among persons who have spent the summer out of town is, however, susceptible of another explanation. In many instances they have returned to houses which have been not only unoccupied, but closed, during several months, and which, in consequence of the more or less complete evaporation of the water in the traps of the drain-pipes, have been thoroughly permeated by sewer gas.]

There is no evidence that any particular occupation acts as a predisposing cause of typhoid fever. Among the 621 patients treated at the Pennsylvania Hospital during the last ten years, were representatives of every branch of industry, and the same fact has been observed at every general hospital, not only in this country, but abroad. There is also no reason to believe that the station in life of itself exerts much influence in predisposing to the disease. The rich suffer equally with the poor. It would appear, indeed, that since the recent general introduction of ill-ventilated water-closets and stationary washstands into the houses of the {245} better classes the liability of the former to suffer from the disease is greater than that of the latter.

Persons recovering from an illness or in an infirm condition of health do not appear to be more liable than others to be attacked by typhoid fever. Among the many patients who have fallen under my care only a very few were in ill-health at the time of their seizure. The same fact has been noticed by Murchison and other observers. Indeed, Liebermeister goes so far as to say that typhoid fever attacks by preference strong and healthy persons, while it avoids those suffering with chronic ailments. That this latter class of patients enjoys no immunity from the disease when exposed to its causes is shown by a fact which he himself records. During his service at the hospital at Basle from 1865 to 1871 several of the patients in the medical and surgical wards were attacked by typhoid fever, the cases being especially numerous in two rooms which were situated one directly over the other. Upon investigation it was found that a wooden pipe which extended from the sewer to the roof ran by both of these rooms. The sewer at the point where this pipe ran into it was of faulty construction, and was turned at a right angle, so that the refuse matter collected there. Since this source of infection was made known repeated cleansings, washings, and disinfections have been followed by satisfactory improvement, and Liebermeister believes that if the sewer were entirely altered the infection would disappear.

It would seem only natural that intemperance, by diminishing the powers of resistance in the individual, would increase his liability to contract typhoid fever, but there is no proof that it does so. Few of the patients who have come under my care were intemperate, and still fewer were broken down by this cause. There is also no evidence that grief, fear, or any other depressing emotion is a predisposing cause of the disease, and the same may be said of bodily fatigue and overcrowding. On the other hand, much importance has been attached by writers to idiosyncrasy as a predisposing cause of typhoid fever. What the peculiarities of constitution are which increase the liability to the disease are not definitely known, but there can be no question that it occurs much more frequently, and is much more fatal, in some families than in others.

Typhoid fever occurs with the greatest frequency in this country, as it does with very few exceptions elsewhere, during the latter half of summer and the early part of autumn. Indeed, its greater prevalence at this season than at other times has given to it the name of "autumnal" and "fall fever," by which it is popularly known in many sections of this country as well as of England. On the other hand, the disease is usually at its minimum in May and June. The number of cases, however, does not usually immediately diminish upon the onset of cold weather. On the contrary, R. D. Cleemann,[23] from a comparison of the mortality returns of Philadelphia for a period of ten years, observed that after diminishing in November they not infrequently underwent a marked increase in December. Of 621 cases treated at the Pennsylvania Hospital during the last ten years, 89 were admitted during spring, 259 during summer, 182 during autumn, and 91 during winter. Of 5988 cases treated at the London Fever Hospital,[24] 759 were admitted in the {246} spring, 1490 in summer, 2461 in autumn, and 1278 in winter. Of the whole number, 27.7 per cent. were admitted in the two months of October and November, and in April and May only 7.3 per cent. Hirsch[25] has published statistics which do not differ materially from these. He also mentions the interesting fact that in Rio Janeiro the maximum of the disease occurs in the months from March to June, or, in other words, in the season which in that latitude corresponds to our autumn. There are, however, some exceptions to the general rule of the greater prevalence of the disease during the autumn. Bartlett, who was aware of its greater frequency at that time, refers to an extensive and fatal epidemic which occurred in the city of Lowell in Massachusetts during the winter and early spring; and similar visitations have been observed in other places.

[Footnote 23: Transactions of the College of Physicians of Philadelphia, 3d S. vol. iii.]

[Footnote 24: Murchison.]

[Footnote 25: Handbuch der Historisch-Geographischen Pathologie, Stuttgart, 1881.]

Most authors agree with the statement made by Murchison, that typhoid fever is unusually prevalent after summers remarkable for their dryness and high temperature, and that it is unusually rare in summers and autumns which are wet and cold. Certainly, the severest epidemic of the disease which has been observed in Philadelphia in several years occurred in the year 1876, during and after a summer of exceptionally high temperature, and one characterized by a decidedly diminished rainfall. Still, there can be no question that the increased prevalence of the disease at this time was due, in part at least, to the crowded condition of the city consequent upon the Centennial Exhibition. In 1872, although the mean of the summer temperature was slightly higher than that of 1876, the disease did not prevail in an epidemic form. This may be explained by the fact that the rainfall of the summer months of this year was decidedly greater than the average. Hirsch, however, attaches much less importance to temperature as a factor in the production of typhoid fever than most other authors. He says that he has found, from a comparison of a large number of epidemics, that the disease occurs almost as often in cool as in hot summers, in cold as in warm autumns, and in mild as in severe winters. Murchison, moreover, admits that mere dryness of the atmosphere is not conducive to an increase of typhoid fever. On the contrary, he says, warm, damp weather, when drains are most offensive, is often followed by an outbreak of the disease.

The relation which temperature and moisture bear to the causation of typhoid fever is therefore not definitely ascertained. It is certain, however, that the largest number of cases does not occur at the period of the greatest heat, but is usually not observed until from six weeks to two months afterward, and the minimum is not reached until about the same length of time after that of the most intense cold. This difference in time Murchison explains by the hypothesis that the cause of the disease is exaggerated or only called into action by the protracted heat of summer and autumn, and that it requires the protracted cold of winter and spring to impair its activity or to destroy it. On the other hand, Liebermeister, who believes that the breeding-places of typhoid fever lie deep in the earth, holds that the time is consumed in the penetration of the changes of temperature to the place where the typhoid poison is elaborated, in the development of the poison without the human body, and in the period of incubation. In some places the maximum of the disease is observed earlier in the year than in others. In Berlin, for {247} instance, the largest number of fatal cases occurs in October, while in Munich it does not occur until February. This depends, he thinks, upon the difference in the distance beneath the earth's surface of these breeding-places in different localities, and the deeper they are the longer, he says, will it be before they are affected by the heat of summer or the cold of winter, since the changes of the temperature of the air are followed by corresponding changes in the temperature of the earth more and more slowly the deeper we go beneath the surface.

Buhl and Pettenkofer have, as the result of a series of observations carried on in Munich over a number of years, reached the conclusion that an intimate relation exists between the variations in the degree of prevalence of typhoid fever and the rise and fall of water in the soil. When the springs were low they found that there was a marked increase in the number of cases; when, on the other hand, they were high, there was just as decided a diminution. Out of this fact they have evolved the theory that the cause of typhoid fever lies deep in the soil, and has the power of multiplying itself there, and that this property is very much increased when the water-level sinks, and the upper layers of the earth are consequently exposed to the air. It is, on the contrary, diminished when the water-level rises and the earth is again saturated with moisture. It is unquestionably true, as has already been stated, that it is principally after hot and dry weather, when the springs are of course low, that typhoid fever is most prevalent, and that it very frequently subsides after the occurrence of very heavy rains; but it is not necessary to adopt the theory of Buhl and Pettenkofer to explain these facts. It seems quite as probable that the increased prevalence of the disease after dry weather is due, as suggested by Buchanan and Liebermeister, to the greater amount of solid matter which is then suspended in the water of the springs. A larger proportion of the germs of the disease, if there should be any present in the soil, will therefore be contained in any given quantity of the drinking-water. The theory fails to account, as pointed out by Murchison, for the connection which is frequently observed between defective house-drainage and outbreaks of typhoid fever, occurring irrespectively of any variations in the subsoil water. And, moreover, outbreaks of the disease have occurred under precisely opposite circumstances, as the outbreak at Terling in 1867, recorded by Thorne,[26] which was coincident with a rise in the subsoil water after drought.

[Footnote 26: Quoted by Murchison.]

It is believed in many parts of our country that there is an antagonism between typhoid fever and the various forms of malarial fever, and it is unquestionably true that in many districts in which the latter were formerly prevalent they have ceased to be frequent, and have been replaced apparently by the former. In the cultivation of the soil the causes of malarial fever disappear, or at least become less potent. On the other hand, the increase of population and the neglect of all sanitary laws in the building of towns, and the construction of sewers with their house connections, seem to favor the occurrence of typhoid fever. But there is no real antagonism between the diseases. During the recent Civil War typhoid fever was not infrequently developed in soldiers suffering from malarial disease. Indeed, so frequent was it to have the manifestations of the two diseases in the same individual that many observers at that {248} time supposed they had a new disease to deal with, to which they gave the name of typho-malarial fever.

2. EXCITING CAUSES.--Much diversity of opinion has existed in times past and to a certain extent continues to exist, in regard to the contagiousness of typhoid fever. In the early part of this century there was quite a number of good observers, including Nathan Smith in this country, and Bretonneau and Gendron of Château du Loir in France, who held the opinion it was an eminently contagious disease. Indeed, Smith went so far as to say that its contagiousness was as fully demonstrated as that of measles, small-pox, or any other disease universally admitted to be contagious. This was also the opinion of William Budd, who maintained that the contagious nature of typhoid fever was the master truth in its history. The late Sir Thomas Watson was also a warm supporter of the same view. At the present time, however, the large majority of physicians, whose opportunities for observation give weight to their opinions, do not regard the disease as contagious in the strict sense of the word. During the past twenty-four years I have been almost uninterruptedly connected with large general hospitals, and during that time have had a large number of cases of typhoid fever under my care, and a still larger number more or less under my observation. During all this time I have never known but one case to originate within a hospital, and that occurred in a servant whose duties did not bring her in immediate contact with the sick. Murchison's experience with a much larger number of cases has been very similar. In twenty-three years, in which 5988 cases were treated in the London Fever Hospital, only 17 residents contracted the disease, and most of these had no personal contact with the sick. Liebermeister asserts that he has never known a case to originate in a hospital from direct contagion. When such cases appeared to have occurred, they could generally be traced, he says, to some defective sanitary condition of the hospital.

There are, nevertheless, many facts on record which, unless duly weighed, appear to lend a good deal of support to the theory of the contagiousness of typhoid fever. Among the most important of these are (1) the occurrence in rapid succession of several cases in the same house, and (2) the limited epidemics which occasionally follow the arrival of an infected person into a previously healthy locality. These facts are, however, susceptible of an entirely different explanation.

1. In those instances in which several cases of the disease have occurred in the same house, it not infrequently happens that some defect in its sanitary conditions is detected, or that the drinking-water is found to be impure. The same cause which produced the first case may, therefore, also have produced those which succeeded it. Indeed, the interval between the cases is sometimes so short that for this reason alone, if there were no other, they could scarcely be attributed to contagion. It not infrequently happens that the seizure of one member of a large family is followed on the next day by that of another, and on the third or fourth by that of still another. Now, while it is undoubtedly true that the period of incubation has appeared in some cases to be very short, we know that under ordinary circumstances it is usually about two weeks.

2. The explanation of the second fact is not more difficult, but in order that it may be clear to the reader it will be well to give in detail a few {249} of the instances on record in which the arrival of an individual sick with typhoid fever in a previously healthy locality has been followed by an outbreak of the disease. Nathan Smith refers to two cases of this character. In both of these the disease appeared to be communicated to several individuals by patients who had contracted the disease elsewhere. So little is said in the reports of these cases of the water-supply of the localities in which they occurred, or of the manner of disposing of the discharges of the patients, that they would scarcely now be used as arguments in favor of the contagiousness of the disease. The report of a local epidemic by Austin Flint, Sr., is more satisfactory in this respect, and is as follows: A stranger was detained in a small village near Buffalo by an illness which proved fatal in the course of a few days, and which was recognized as typhoid fever by his attending physicians. Up to this time, it is stated, typhoid fever had never been known in the neighborhood. In the course of a month more than one-half of the population, numbering forty-three, was attacked by the disease, and ten had died. The family of the tavern-keeper at whose house the stranger lodged was the first to suffer, and of the families immediately surrounding the tavern but one wholly escaped, that of a man named Stearns. Upon investigation, it was ascertained that this family alone, of all these families, did not use the well belonging to the tavern, but had its own water-supply. The occurrence of the disease naturally produced great excitement, and Stearns, between whom and the tavern-keeper a quarrel existed, was suspected of having poisoned the well; but an examination of the water showed this suspicion to be unfounded. There can, however, be little doubt that the water of the well, which was in all probability contaminated by the discharges of the stranger, was the means of propagating the disease; for although it is said that the family of Stearns was cut off by the quarrel from all intercourse with that of the tavern-keeper--a fact upon which some stress is laid by Flint--it does not appear that a similar isolation existed as regards the other families affected.[27]

[Footnote 27: A Treatise on the Principles and Practice of Medicine, by Austin Flint, M.D., Philadelphia, 1868.]

The manner in which the arrival of a sick person may cause the dissemination of the disease in a previously healthy community is even better shown by the following histories of local outbreaks:[28]

"The water-supply pipes of the town of Over Darwen were leaky, and the soil through which they passed was soaked at one spot by the sewage of a particular house. No harm resulted till a young lady suffering from typhoid fever was brought to this house from a distant place. Within three weeks of her arrival the disease broke out and 1500 persons were attacked. At Nunney a number of houses received their water-supply from a foul brook contaminated by the leakage of a cesspool of one of the houses, but no fever showed itself till a man ill with typhoid came from a distance to this house. In about fourteen days an outbreak of fever took place in all the houses."

[Footnote 28: Wm. Cayley, M.D., Brit. Med. Jour., March 15, 1880.]

There are many other observations which seem to render it certain that the alvine dejections are a most important medium by which typhoid fever is communicated to others; and yet there is no evidence that they possess this power in a fresh condition. They have been repeatedly examined, and even handled, with impunity, and, as has already been stated, it {250} is rare for the disease to be imparted to the immediate attendants upon the sick, or in a well-ventilated hospital to the other patients in the same ward, provided that the discharges are disinfected and removed immediately after being passed, and the bed-linen and clothes of the patient changed whenever they are soiled. The feces must therefore undergo some changes before they become possessed of virulent properties. This appears to be shown conclusively by the following facts: (1) laundresses who wash the soiled clothes of typhoid fever patients not infrequently contract the disease; (2) the occupants of houses connected by ill-trapped drains with sewers into which the discharges of such patients have found their way often suffer severely from the disease; and (3) the use of water polluted by such discharges is, as has already been shown, almost certain to induce the disease in persons not protected by a previous attack.

The following histories of outbreaks of typhoid fever will show clearly how the dejections of patients may be the means of propagating the disease to others:

ILLUSTRATIVE CASES--Lausen[29] is a village lying on the railway between Basle and Olten shortly before coming to the great Hauenstein Tunnel. It is situated in the Jura, in the valley of the Ergolz, and consists of 103 houses with 819 inhabitants. It was remarkably healthy, and resorted to on that account as a place of summer residence. With the exception of six houses it is supplied with water by a spring with two heads which rises above the village at the southern foot of a mountain called the Stockhalder, composed of oolite. The water is received into a well built covered reservoir, and is distributed by wooden pipes to four public fountains, whence it was drawn by the inhabitants. Six houses had an independent supply--five from wells, one from the mill-dam of a paper-factory. On August 7, 1872, ten inhabitants of Lausen, living in different houses, were seized by typhoid fever, and during the next nine days fifty-seven cases occurred, the only houses escaping being those six which were not supplied by the public fountains. The disease continued to spread, and in all 130 persons were attacked, and several children who had been sent to Lausen for the benefit of the fresh air fell ill after their return home. A careful investigation was made into the causes of this epidemic, and a complete explanation was given. Separated from the valley of the Ergolz, in which Lausen lies, by the Stockhalder, the mountain at the foot of which the spring supplying Lausen rises, is a side valley called the Furjust, traversed by a stream, the Furlenbach, which joins the Ergolz just below Lausen, the Stockhalder occupying the fork of the valley. The Furlenthal contains six farm-houses, which were supplied with drinking-water, not from the Furlenbach, but by a spring rising on the opposite side of the valley to the Stockhalder. Now, there was reason to believe that under certain circumstances water from the Furlenbach found its way under the Stockhalder into one of the heads of the fountain supplying Lausen. It was noticed that when the meadows on one side of the Furlenbach were irrigated, which was done periodically, the flow of water into the Lausen spring was increased, rendering it probable that the irrigation water percolated through the superficial strata and found its way under the Stockhalder by subterranean channels in the limestone rock. Moreover, some years before a {251} hole on one occasion formed close to the Furlenbach by the sinking in of the superficial strata, and the stream became diverted into it and disappeared, while shortly afterward the spring of Lausen began to flow much more abundantly. The hole was filled up, and the Furlenbach resumed its usual course. The Furlenbach was unquestionably contaminated by the privies of the adjacent farm-houses; the soil-pits communicated with it. Thus, from time immemorial, whenever the meadows of the Furlenthal were irrigated the contaminated water of the Furlenbach, after percolation through the superficial strata and a long underground course, helped to feed one of the two heads of the fountain supplying Lausen. The natural filtration, however, which it underwent rendered it perfectly bright and clear, and chemical examination showed it to be remarkably free from organic impurities, and Lausen was extremely healthy and free from fever. On June 10th one of the peasants of the Furlenthal fell ill with typhoid fever, the source of which was not clearly made out, and passed through a severe attack with relapses, so that he remained ill all summer; and on July 10th a girl in the same house, and in August a boy, were attacked. Their dejections were certainly, in part, thrown into the Furlenbach; and, moreover, the soil-pit of the privy communicated with the brook. In the middle of July the meadows of the Furlenthal were irrigated as usual for the hay crop, and within three weeks this was followed by the outbreak at Lausen.

[Footnote 29: William Cayley, M.D., British Medical Journal, Mar. 15, 1880.]

In order to demonstrate the connection between the water-supply of Lausen and the Furlenbach, the following experiments were performed. The hole mentioned above as having on one occasion diverted the Furlenbach into the presumed subterranean channels under the Stockhalder was cleared out, and 18 cwt. of salt were dissolved in water and poured in, and the stream again diverted into it. The next day salt was found in the spring at Lausen. Fifty pounds of wheat flour were then poured into the hole, and the Furlenbach again diverted into it, but the spring at Lausen remained clear, and no reaction of starch could be obtained, showing that the water must have found its way under the Stockhalder, in part by percolation through the porous strata, and not by distinct channels.

Volz[30] refers to an epidemic which occurred at Gerlachsheim, a village of Germany, some years ago, in which, in the course of three weeks, 52 persons residing on one of the principal streets were attacked by the disease. It was found, upon investigation, that they all got their water from a well which was polluted by the stools of the first patient. A. Pasteur[31] reports an epidemic caused by the contamination of a well by typhoid dejections, and which ceased when the use of the water was discontinued. Niericker[32] also reports an outbreak which was found to be due to a similar pollution of the drinking-water, and which likewise ceased when the water-supply was derived from another source.

[Footnote 30: Schmidt's Jahrbuch.]

[Footnote 31: Revue méd. de la Suisse, Mars 15, 1881.]

[Footnote 32: Schweiz. Corr. Bl., ix. 1, 1879.]

An outbreak of the disease which occurred in a farm-house situated about eight miles from the city of Philadelphia came under my own observation. The first case occurred in a young girl of sixteen, who, with the exception of an occasional visit to the city, had not been away from her own home for several months before she was {252} taken ill. The disease ran in her a severe course, and eventually terminated fatally. About three weeks afterward four other members of the family were attacked, one of whom died. Two other persons, living in a house on the opposite side of the road, but who were in the habit of drinking water from the same well, also took the disease. There was no other case of typhoid fever in the immediate vicinity, nor had there been for some time. The farm-house is situated in a cup-shaped depression, so that water flowed toward it from all directions. The cellar was constantly filled with water during the winter, and just before the outbreak had contained not only an unusually large quantity, but also a large amount of decaying vegetable matter. The well from which the family drew their drinking-water is situated within a few feet of the kitchen door, and at some distance from the cesspool used by the family, so that there was no reason to believe that there was any communication between the two. The wall of the well was found to be very much loosened by the roots of two trees growing in the immediate vicinity. As the ground was also very much cut up by the burrows of rats, the water used for the various household purposes, and which was habitually thrown into a gutter which ran past the well, found a ready access to it. There would seem to be but little doubt that the first patient contracted the disease in some way during her visits to the city, and that the disease in the other patients arose from their drinking the water of the well which had been polluted by that used in washing her soiled linen.

Ballard[33] has shown very clearly that milk may also be a medium of communication of the disease. He found that an epidemic which occurred in the parish of Islington, London, in 1871 was (1) almost entirely confined to a district comprised within a circle having a radius of not more than a quarter of a mile; (2) that out of 62 families living within this district, who were known to have suffered from typhoid fever, 54 were constantly supplied with milk from a particular dairy, and it was satisfactorily proved that at least three of the remaining eight had occasionally partaken from the same source; and (3) that out of 142 families, comprising all the customers of this dairy, and living not only within the district above specified, but in other parts of the parish, 70, or very nearly one-half, were invaded by typhoid fever within the ten weeks during which the outbreak lasted. Upon a visit to the farm from which the milk came it was ascertained that a member of the dairyman's family had been ill with typhoid fever, and that the water of the well which supplied the family with drinking-water had been polluted by his discharges. Although the dairyman denied that this water had ever been mixed with the milk, he admitted that it had been used to wash the milk-pans. Murchison was also able, in an outbreak which occurred in another district of London, to trace the disease to the same source.

[Footnote 33: On a Localized Outbreak of Typhoid Fever in Islington, London, 1871.]

Typhoid fever may be likewise propagated in consequence of the contamination of the atmosphere by the typhoid poison. This may be the result of allowing the undisinfected stools, or linen soiled by them, to remain for some time exposed to the air, or may arise from pollution {253} of the soil from the same cause or from defective sewage. Hermann Schmidt[34] refers to several epidemics breaking out in garrisons which he believed to be due to pollution of the soil. In the citadel of Wurzburg typhoid fever occurred through several years, and persisted in spite of the cutting off of the water-supply, which was believed to be impure. It was finally found that the ground upon which it was built was saturated with all kinds of impurities. Volz refers to outbreaks of the disease from the same cause.

[Footnote 34: Die Typhus Epidemie in Fusillier Bat. zu Tübingen in Winter 1876-77, enstanden durch einathmung, giftiger Grundluft, Tubingen, 1880.]

But perhaps the most striking example of this mode of propagation of the disease is that recorded by Budd,[35] and is as follows: Two adjacent cottages, which for the sake of convenience may be designated as Nos. 1 and 2, had a privy in common, which was in the form of a lean-to against the gable end of No. 2. Through this privy there flowed with very feeble current a small stream which formed the natural drain for it. Having already performed this office for some twenty or thirty other houses higher up its course, the stream had acquired all the character of a common sewer before reaching the cottages in question. About a quarter of a mile farther on it acted as a drain for a privy, common as before, for two other cottages, Nos. 3 and 4. Notwithstanding the condition of the stream, which was so foul that it was said that the stink from it was often enough "to knock a man down," no evil result appeared to have occurred until a man living in No. 1 contracted typhoid fever--elsewhere, it was believed. As a matter of course, all his discharges were thrown into the common privy. In this way for more than a fortnight the stream which passed through it was daily fed with the specific excreta from the diseased intestines of the patient. No further cases occurred until the latter end of the third week or the beginning of the fourth week, when several persons were simultaneously attacked by the same fever in all four cottages. From first to last, the outbreak was confined to these four cottages, and there was no other case of typhoid fever at this time in the neighborhood.

[Footnote 35: Typhoid Fever: Its Nature, Mode of Spreading, and Prevention, by William Budd, M.D., F.R.S., London, 1873.]

The mattrass used by typhoid-fever patients, their bed-linen and clothes, have each been the medium by which the disease has been communicated to others. This is, as has already been pointed out, unquestionably due to the fact that these articles are generally soiled by their discharges, and that time has been allowed for the latter to acquire infective properties. It seems not improbable that the few cases in which the disease appears to have been contracted from the dead body may be explained in the same way. The statistics of the London Fever Hospital show that laundresses are more liable to contract typhoid fever than the immediate attendants upon the sick. This liability is greatest in those cases in which the bed-linen and clothes of patients are not immediately disinfected after use. According to Budd, the sputa in cases of typhoid fever where bronchitis is excessive may sometimes contain the germs of the disease, and mentioned a case in which he believed they were the means by which the disease was propagated.

The question naturally arises here, whether this is the only way in {254} which the disease can originate. This is a subject which has given rise to a good deal of controversy, and therefore demands some consideration at our hands. On the one hand, it is argued that typhoid fever never occurs in the absence of the specific poison or germ of the disease, and that this is contained principally, if not wholly, in the alvine dejections. On the other hand, it is contended that it may, and often does, originate spontaneously, and that all that is necessary to produce it is the presence of decomposing fecal or other organic matter, and the consequent contamination of the food, drink, or atmosphere. Both of these views have found able advocates. Among the upholders of the latter view is Murchison, who cites the histories of several outbreaks of typhoid fever which occurred in localities which had not been visited by it for many years, and which, after a careful investigation of all the circumstances attending them, he was forced to conclude had no connection with any previous case of the disease, and could only be explained by admitting that it might occasionally have an independent origin. Among the more remarkable of these outbreaks is the following, which we give in Murchison's own words:

"In August, 1829, 20 out of 22 boys at a school at Clapham within three hours were seized with fever, vomiting, purging, and excessive prostration. One other boy, aged three, had been attacked with similar symptoms two days before, and had died comatose in twenty-three hours; another boy, aged five, died in twenty-five hours; all the rest recovered. Suspicions were entertained that they had been poisoned, and a rigorous investigation ensued. The only cause which could be discovered was, that a drain at the back of the house, which had been choked up for many years, had been opened two days before the first case of illness, cleared out, and its contents spread over a garden adjoining the boys' playground. A most offensive effluvium escaped from the drain, and the boys had watched the workmen cleaning it out. This was considered to be the cause of the disease by Latham and Chambers, and by others who investigated the matter, and also by Sir Thomas Watson. The morbid appearances in the two fatal cases were described as like those of the common fevers of this country. Peyer's patches and the solitary glands of the small and large intestines were enlarged like 'condylomatous elevations,' and in one case the mucous membrane over them was slightly ulcerated. The mesenteric glands were enlarged and congested."

"A remarkable instance of a circumscribed outbreak of fever was recorded by Sir R. Christison in 1846. It occurred in an isolated farm-house in the thinly-peopled county of Peebles, N.B. Every one of the fifteen residents was seized with fever, and three died. Many of the servants who worked during the day at the farm were also affected, but none communicated the disease to their families who did not visit the farm. There was no evidence that the disease was imported from without, and the only explanation of the outbreak was, that the drains and sewers were found all closed and obstructed with the accumulated filth proceeding from the privies and farm-yard, the effluvia from which was very offensive."

"About Easter, 1848, a formidable outbreak of fever occurred in the Westminster School and the Abbey Cloisters, and for some days there {255} was a panic in the neighborhood respecting the 'Westminster fever.' No case of fever had occurred in the Abbey Cloisters for three years, and there was no evidence of its having been imported. Within little more than eleven days it affected thirty-six persons, all of the better class, and in three instances it proved fatal. Shortly before its first appearance there occurred two or three days of peculiarly hot weather, and a disagreeable stench, so powerful as to induce nausea, was complained of in the houses in question. It was found that the disease followed very exactly in its course the line of a foul and neglected private sewer or immense cesspool, in which fecal matter had been accumulating for years without any exit, and into which the contents of several small cesspools had been pumped immediately before the outbreak of fever. This elongated cesspool communicated by direct openings with the drains of all the houses in which it occurred; the only exception was that of several boys, who lived in a house at a little distance, but who were in the habit of playing every day in a yard in which there were several gully-holes opening into the foul drain."

The following cases would seem, however, to furnish stronger evidence in favor of the occasional spontaneous origin of typhoid fever than any of those referred to by Murchison. The first is recorded by P. Herbert Metcalfe,[36] and occurred in Norfolk Island in the Pacific Ocean, 400 miles from the nearest inhabited land. The patient was a gentleman who had come from England four months previously. To Metcalfe's certain knowledge, there had been no typhoid fever on the island for fifteen months. Three years previously a man is reported to have died of it, and in 1868 there had been an epidemic of fever, but he could not ascertain of what kind. Upon inquiry, he found that his patient had been drinking water from a well which had the reputation of being unclean, and that he was the only person who had done so. He also found that at a distance of seven feet there was an open sewer, and that just opposite to the well much of the sewage-water became so stagnant as to form an offensive cesspool. The well was cleaned out, and at the bottom of it were found four feet of stinking sewage mud, the skeleton of a duck, a pig's jaw, etc. The well was so situated that had there been any typhoid fever previously to this case the water could not have been contaminated by the specific poison, as the above-named sewer only conveyed water from the kitchen, which is a building detached from the dwelling-houses of the mission, and is far from and on a higher level than the open closets in use.

[Footnote 36: British Medical Journal, Nov. 6, 1880.]

In the second case, which is reported by R. Bruce Low,[37] Medical Officer of Health, Helmsley, Yorkshire, occurred in a lad who had not been away from his home for months. No stranger had visited his house, and there was no fever in the district, the last case having occurred eight months previously in a sequestered valley eight miles away. The patient's habits and those of his family were revoltingly dirty. The garden privy was in bad repair, the filth level with the seat, and the smell from it very offensive. Thirty years before there had been five cases of slow typhus in the house. In his remarks on this case Low says: "This case did not owe its origin to direct infection, and the question naturally arises, was this a case originating de novo, or had the poison {256} been due to infection in some way or another from the cases which occurred thirty years previously?"

[Footnote 37: Brit. Med. Jour., 1880.]

There can be but little doubt that in many of the cases cited by Murchison as instances of the spontaneous origin of typhoid fever there was an introduction of the germs of the disease from without. At all events, the evidence to the contrary is by no means convincing. For example, in the account of the outbreak at the Westminster School it is expressly stated that "the contents of several small cesspools had been pumped before the outbreak of the fever" into the large cesspool, the emanations from which it was believed had caused the fever. It does not seem that it was positively ascertained that none of these small cesspools had been used by a typhoid-fever patient, or that typhoid stools had not found their way into them in some other way. Moreover, in diseases generally admitted to be contagious it is not always possible to ascertain positively the source of infection in a particular instance. But after the elimination of all doubtful cases there yet remains a certain number in which it is reasonably certain that there has been no recent importation of the typhoid-fever germs, as in the case which is reported by Metcalfe and which occurred on Norfolk Island, and in that recorded by Low. The assumption does not seem an unwarranted one that in these cases the poison of the disease, which had been present before in a latent condition, had been suddenly called into activity by favoring influences. The following observation of Von Gietl[38] shows the length of time typhoid-fever stools may retain their infective properties: "To a village free from typhoid an inhabitant returned suffering from the disease, which he had acquired at a distant place. His evacuations were buried in a dunghill. Some weeks later five persons, who were employed in removing dung from this heap, were attacked by typhoid fever; their alvine discharges were again buried deeply in the same heap, and nine months later one of two men who were employed in the complete removal of the dung was attacked and died." If we assume--and there is no reason to doubt that this point was fully investigated by Von Gietl--that the patient in the latter case had not been otherwise exposed to the causes of the disease, the observation shows that the stools in typhoid fever retain their virulence for nine months. If for nine months, why may they not do so for a much longer period--for as many years, for example? No probability is violated by this hypothesis. On the contrary, it is in full accordance with what we know of some of the lower forms of life, and will serve to explain many outbreaks of the disease which would otherwise be inexplicable--for example, the outbreak at Clapham referred to by Murchison. Admitting that the disease in this instance was really typhoid fever--and this has been denied by some observers, among whom is Sir Thomas Watson--the assumption does not seem an unwarrantable one that the germs of typhoid fever had been present in this choked-up drain long before it was cleared, but that in consequence of their exclusion from the air their infecting power was at a minimum. It was, on the contrary, much increased when the contents of the drain were exposed to the vivifying influence of the atmosphere.

[Footnote 38: Quoted by Cayley, Brit. Med. Jour., Mar. 15, 1880.]

On the other hand, it is alleged that an individual may be exposed to the direct emanations of sewers or of foul privies, or even drink water {257} contaminated by leakage from them, without contracting typhoid fever, so long as they do not contain the specific germ of the disease. Every physician in large practice, either in the city or country, can call to mind instances in which the air of houses or the water-supply has been polluted in this way, and yet no typhoid fever has occurred. Let, however, the specific cause of the disease be introduced from without, and this immunity almost invariably disappears. There is no reason to believe that the contamination of the water used by the family which suffered in the outbreak of the disease which has been already referred to as having come under my own observation last year was of recent origin. On the contrary, there was evidence to the contrary, and yet no disease occurred until it was imported by a member of the family who was in the habit of making frequent visits to the city. Even more strongly corroborative of this view is the history of the epidemic reported by Ballard, in which milk was the medium of communication. The water which had been used with impunity to wash the milk-pans, or perhaps to dilute the milk, became a source of danger only after the occurrence of the disease in the family of the dairyman.

Several epidemics of typhoid fever have been recently reported in which the disease appears to have been caused by the use of the flesh of diseased animals or of meat in a condition of putrefaction. In some of these the symptoms were rather those of irritant poisoning than of typhoid fever, and consisted principally in violent vomiting and purging coming on very shortly after the ingestion of the unwholesome food. There yet remains a certain number in which the symptoms cannot be thus explained.[39] One of the most remarkable of these occurred in 1878 at a festival which was held at Kloten, a place about seven miles north of Zurich, of which the following is a condensed description: Out of 690 persons who sat down to the collation, 290 were taken ill; 378 other persons, who did not attend the festival, but who partook of the meat provided for it, were also affected. In addition these, 49 secondary cases occurred--i.e. of persons who subsequently became affected without having eaten of the meat. All other sources of infection could be certainly excluded, as Kloten was quite free from typhoid fever at the time, and as it was clearly shown that the water was not the cause of the outbreak. All the visitors at the festival who ate no meat escaped, as did also several persons who drank wine to excess and subsequently vomited. The period of incubation was short, as in other epidemics arising from the same cause. Some of the people were ill on the second day, with loss of appetite, nausea, headache, pain and swelling of the belly, and slight fever. These cases were slight, and generally ended in recovery. The greater number were affected between the fifth and ninth days. The symptoms in these cases, which usually ran a rapid course, and generally ended in recovery, were chills, fever, diarrhoea, great prostration, frequently violent delirium, and also profuse intestinal hemorrhage. The rose-colored eruption was present in almost all of them, and in a few the tâches bleuâtres were detected. On post-mortem {258} examination the characteristic appearances of typhoid fever were found. With regard to the meat supplied, the following facts were ascertained: Forty-two pounds of veal were furnished by a butcher at Seebach, taken from a calf which appears to have been at the point of death when it received the coup de grace from the hands of the butcher. All the flesh of the animal was sent to supply the festival at Kloten, but the liver was eaten by an inhabitant of Seebach, and he was attacked by typhoid fever. The brain was sent to the parsonage at Seebach, and all the household became affected by the same disease. It was also ascertained that another of the calves was diseased. The veal from this calf had been kept fourteen days, and was in a decomposed state. All the meat was placed together in the meat-receptacle of the inn at which the festival was held. This receptacle was in a horribly filthy state, and Cayley thinks there can be no doubt that the putrefying flesh of this last calf, together with the state of the receptacle, would rapidly excite decomposition in the whole supply.

[Footnote 39: On Some Points in the Pathology and Treatment of Typhoid Fever, by William Cayley, London, 1880; also Prof. Huguenin, Schmidt's Jahrbuch, from Schweiz. Corr. Bl., viii. 15, 1878; Carl Walder, Schmidt's Jahrbuch, from Berl. klin. Wochenschr., xv. 39, 40, 1878; George R. Shattuck, M.D., Supplement to Ziemssen's Cyclopædia, New York, 1881.]

Geissler, it is true, doubts whether the epidemic above described was really typhoid fever, and points out that the symptoms occurred too soon after the ingestion of the diseased meat, and reached their full development too rapidly. The cases were also accompanied by more pain in the abdomen than is generally met with in typhoid fever. The proportion of recoveries also appears to have been unusually large. Unquestionably, the patients in the Kloten epidemic were in a large number of instances simply suffering from the action of an irritant poison; but the presence of the characteristic lesions of typhoid fever in some of the fatal cases renders it certain that this disease also existed in the village at the same time.

In the report of this epidemic it is not stated that either of the calves which furnished a part of the meat for the entertainment were suffering from typhoid fever at the time they were slaughtered. It is now known positively that this animal is liable to be attacked by this disease, and a certain number of cases are on record in which the eating of the flesh of such animals has been followed by typhoid fever.[40] That it does not oftener occur from this cause is probably due to the fact that a certain time must elapse before the flesh of such an animal acquires infective properties, and that it is usually used as food before this has been allowed to pass.

[Footnote 40: Medical Times and Gazette, Feb. 8, 1879, p. 149, from Berl. klin. Wochenschrift, No. 39, 1878.]

Ludwig Letzench[41] asserts that he has produced some of the intestinal appearances of typhoid fever, as well as a high degree of pyrexia, in rabbits by the subcutaneous injection of the sputa and stools of typhoid fever patients.

[Footnote 41: Arch. f. exper. Pathol. u. Pharmak., 1878 and 1881.]

THE BACILLUS TYPHOSUS.--From what has preceded, it will be seen that the writer is disposed to range himself with those who hold that the exciting cause of typhoid fever is an organized germ, or, in other words, a contagium vivum. Although this view cannot be regarded as positively proven as yet, it has recently received some support through the investigations of Klebs, Eberth of Zurich, and others,[42] who believe that they {259} have found in the bodies of those who have died of typhoid fever a micro-organism peculiar to that disease.

[Footnote 42: Klebs (Philadelphia Medical Times, Dec. 3, 1881, from Archiv für experimentelle Pathologie und Pharmakologie, Bd. xiii. H. 5 and 6) claims that he has proved "that there exists in typhoid fever a separate and distinct bacillus--the Bacillus typhosus; that it undergoes certain transformations, consisting at first of little rods and small fine threads, containing a spore in the centre and often at the end, which spores divide off and form new bacilli. It later assumes a larger thread-like form, twisted at the end, and frequently taking a beautiful spiral shape; that the bacilli are observed first in the masses of epithelial cells which accumulate in the alimentary tract or in the air-passages; that they later penetrate the tissues, and are carried along by the blood-vessels and the lymphatics, and form a large network among the tissues they invade; that under a certain procedure, which never causes this same staining in any other living organism or tissue, they appear of a blue color; that they are found only in enteric fever, in which disease every part of the human body is the seat of masses of these bacilli, their quantity corresponding exactly with the severity of the symptoms; and that they produce, when carried into the system of animals, exactly the same disease with the same morbid alterations as in men." He says, further, that "the Bacillus typhosus enters the system by the respiratory passages and by the alimentary canal. This is the cause that in some cases of typhoid fever almost no abdominal symptoms are present, but a low form of pneumonia, developing from the very beginning, so that the lung seems alone to bear the brunt of the disease." He has found these bacilli in greatest numbers in Peyer's patches.

Eberth (British Medical Journal, Nov. 26, 1881, from Virchow's Archiv, Bd. lxxxi. and lxxxiii.) has shown that in typhoid fever the intestinal mucous membrane, the mesenteric glands, and the spleen contain rod bacteria, differing, as he believes, from organisms found in the body in other conditions (among others in phthisis with extensive ulceration of the intestinal mucous membrane). In seventeen cases of typhoid these bacilli were found in six and wanting in eleven. In the six cases the number of bacilli were in inverse proportion to the duration of the disease. They were not found in the spleen in the cases of the longest duration, and only scantily in the mesenteric glands. These bacilli appear not to differ in shape and size from the ordinary rod bacteria, but Eberth believes that they differ from them in their small capacity for taking on the staining of hæmatoxylon, methyl-violet, and Bismarck brown.

Wernich's views (Vjhrschr. f. Off. Geshpfl., xiii. 4, p. 513, 1881) in regard to the nature of the Bacillus typhosus differ from those held by the two authors just quoted. He regards the specific Bacillus typhosus as nothing but the ordinary Bacillus subtilis of the large intestines, which under certain circumstances acquires the power to accommodate itself to the small intestines, to undergo a higher development and to become the exciting cause of disease.]

PERIOD OF INCUBATION.--The conditions under which typhoid fever occurs in large cities render it difficult, if not impossible, to arrive at a definite conclusion as to its period of incubation. Occasionally, however, the time which has intervened between the exposure to the cause and the invasion of the disease may be ascertained with precision in the outbreaks which occur in small towns or in isolated country-houses. Under these circumstances it has been found to vary within very wide limits. In the three cases related by Griesinger the attack began the day after exposure to the infection, and in the outbreak at the school at Clapham, referred to by Murchison, twenty out of twenty-two boys were seized with the disease within four days of exposure to the causes. Other instances of a similar character are on record. In cases like the above the rapidity with which the attack follows upon exposure to the cause is no doubt due to the intensity of the poison--a view which is to a certain extent at least supported by the fact that the invasion of the disease under these circumstances is very apt to be abrupt; the attack being often ushered in with vomiting and purging or with grave cerebral symptoms. Sometimes, indeed, the gastro-intestinal symptoms have been so violent as to have given rise to suspicions of criminal or accidental poisoning. In the majority of cases, however, the period of incubation is probably very much longer than in those above referred to. In the outbreak which recently occurred in a farm-house about seven miles distant from {260} Philadelphia, the history of which has already been given in detail, the second case began three weeks after the first, the other six following in rapid succession. In the celebrated epidemic which occurred at Lausen in Switzerland in 1872, and which is referred to by Cayley,[43] the first ten patients were attacked within three weeks of the time when the contamination of the spring which supplied the village must have taken place, and these ten cases were followed in the course of nine days by fifty-seven others. In the town of Over Darwen 1500 persons were seized with typhoid fever within three weeks after a patient suffering from this disease was brought to a particular house, the sewage of which was allowed to soak into the ground through which the water-supply pipes of the town passed, and at a point at which they were leaky. Lothholz observed in an epidemic which occurred in the neighborhood of Jena that the average period of incubation was three weeks, the shortest period eighteen days, the longest twenty-eight days. Haegler found in three cases produced by contaminated water a period of at least three weeks.[44] There are, however, epidemics on record in which the period of incubation was under two weeks, as, for instance, that of Basle, referred to by Liebermeister, in which a few persons were attacked who had only been in the city from seven to fourteen days. Cayley also refers to localized outbreaks of the disease, as those of Calne and Nunney, in which persons were attacked within fourteen days of their exposure to the cause. C. J. C. Muller of Posen[45] says that the average period of incubation of the disease is fourteen days; that it may be not more than ten days, or, on the other hand, as long as from three to four weeks; and that he has known a case in which it was thirty-four days. Murchison believed that it was most commonly about two weeks, and William Budd arrived at the conclusion, from the observation of a large number of cases, that it varied from ten to fourteen days.

[Footnote 43: Brit. Med. Jour., Mar. 15, 1880.]

[Footnote 44: Ziemssen's Cyclopædia, vol. i.]

[Footnote 45: Neue Beiträge zur Aetologie des Unterleibs-Typhus, Posen, 1878.]

From this review of the opinions of various authors the conclusion would seem to be justifiable that the period of incubation in typhoid fever is usually between two and three weeks, but that in many cases it does not exceed ten days, and in rare instances has unquestionably been very much less. On the other hand, there are authentic cases on record in which it is said to have reached, or even exceeded, twenty-eight days. Unfortunately, we do not possess any reliable data with which to decide the question whether it is shorter or longer when the poison is imbibed with the ingesta than when it is inhaled. It would seem, however, that there is a difference in the susceptibility of different individuals to the poison of this disease, in many persons a single exposure to the cause being sufficient to induce an attack, while in others the disease is contracted only after repeated exposure.

MORBID ANATOMY.--As a thorough knowledge of the morbid anatomy of typhoid fever is absolutely necessary to a correct understanding of its pathology, it seems to me better to deviate from the order usually observed in systematic treatises and to proceed at once to a description of the former, rather than to defer it, as it is usual to do, until after the symptomatology of the disease has been discussed.

Rigor mortis is generally more marked and more prolonged than after {261} typhus. Emaciation is often extreme in cases in which death has taken place after the third week, especially if they have been attended by much diarrhoea and fever. No traces of the characteristic rose-colored eruption are found after death, no matter how profuse it may have been during life. Sudamina, on the other hand, persist, and discolorations of the dependent portions from settling of blood are always present in the dead body.

The lesions of typhoid fever may be divided into two classes. The first class includes certain changes in the glands of Peyer, the solitary glands of the intestines, the spleen, and other lymphatic structures of the body. These changes, which consist essentially in a medullary infiltration of these glands, will be minutely described presently. They are peculiar to the disease, and are just as characteristic of it as the condition of the lungs and their membranes found in pneumonia and pleurisy are characteristic of those diseases. They are usually most developed in grave cases, but occasionally they are slight and but little marked in cases in which the general symptoms were severe. They therefore cannot be regarded as the sole cause of the latter. It is more probable that they are themselves the results of the local action of the typhoid poison, and bear somewhat of the same relation to typhoid fever that the eruption in small-pox does to that disease. The second class is made up of lesions which are met with not only in this disease, but in other diseases accompanied by high fever, and are therefore unquestionably the result of the general process. They consist essentially of parenchymatous degenerations of various organs and tissues, and are generally more marked in typhoid fever because the pyrexia is not only of high grade, but also of longer duration than in other diseases.

We shall first consider the lesions peculiar to typhoid fever. Among the most important of these are the changes which occur in the agminated and solitary glands of the intestines. These have been usually described as passing through four stages, as follows: (1) the stage of medullary infiltration; (2) the stage of softening or sloughing; (3) the stage of ulceration; (4) the stage of cicatrization. These stages are said to last almost a week, and correspond to certain definite periods of the disease, but it is not uncommon to find in the same intestine glands in two or more of these stages. Indeed, the same gland may sometimes be found ulcerating at one side while cicatrization is going on at the other.

In the first stage the agminated glands are enlarged, each patch preserving its oblong shape, and being flattened on the surface and elevated from half a line to two lines above the surrounding mucous membrane, from which it is separated by an abrupt border, and which it may in a few cases overhang like a fungous growth. The solitary follicles are also swollen, and may vary in size from a hempseed to a split pea. In very severe cases all the glands may be more or less involved, but in mild cases the changes may be limited to three or four of the patches of Peyer, although the solitary glands rarely wholly escape. It is uncommon also for the latter to be alone affected, but a few such cases have been reported. In these the mucous membrane appears to be studded with pustules, and hence Cruveilhier designated this variety as the forme pustuleuse. The mucous membrane covering the affected glands is reddish-green in color, and that in their immediate vicinity is {262} often injected. The changes above described occur early in the disease--Murchison has seen them in two cases in which death took place at the end of the first day--and they are often well marked at the end of the third or fourth day. They are usually limited to the glands in the lower part of the ileum, the agminated glands being often found perfectly healthy four feet above the ileo-cæcal valve. In mild cases, indeed, the lesions may be confined to those nearest to this valve. So, too, the changes in the solitary glands may be confined to the last twelve inches of the smaller intestine, but this is by no means universally the case, for these glands are not only often found enlarged higher up in the small intestine, but also occasionally in the cæcum. The agminated glands are sometimes found enlarged in the bodies of those who have died of measles and of some other diseases, but the degree of enlargement is rarely as great as in typhoid fever, and the further changes presently to be described are never found except in the latter disease.

Under the microscope the medullary infiltration upon which the enlargement of the glands depends is found to be due to proliferation of the cellular elements. In the case of the agminated glands this proliferation may be limited to the follicles or it may extend to the intercellular tissue, and even to the adjacent mucous membrane. In the former case the patches have a reticulated aspect; they are soft and but little elevated. These are the plaques molles of Louis and the plaques reticulées of Chomel. In the latter they are harder, smoother, and more elevated. To this variety Louis has given the name of plaques dures, Chomel that of plaques gauffrées. The morbid process is also very apt to extend from the solitary follicles to the surrounding mucous membrane.

In a large number of the glands in many cases, and probably in all of them in the abortive form of the disease, the changes never advance beyond the first stage, a restoration to their normal condition taking place by colliquative softening.[46] The morbid material upon which their enlargement depends breaks down into an oily débris which is gradually absorbed. This retrograde process takes place faster in the follicles than in the interfollicular tissue, and, as pigment is very apt to be deposited in the depressions thus formed, the patches acquire an appearance which has been compared to that of a recently shaven beard. This appearance is met with, however, in other diseases, and is therefore not peculiar to typhoid fever.

[Footnote 46: Rindfleisch, Pathological Histology, Sydenham Society Translation, vol. i. p. 441.]

The description of the changes in these glands in the subsequent stages of the disease which follows is taken mainly from Rindfleisch's work on Pathological Histology.

In the stage of necrosis small portions of single Peyerian patches, varying in size from that of a lentil to from three-quarters of an inch to an inch and a quarter in diameter, assume a yellowish-white, opaque tint instead of their former reddish and translucent aspect, gradually become separated from the surrounding tissue by a sharp line of demarcation, and then pass into a state of cheesy necrosis. Here and there the same changes are observed to have taken place in the solitary glands. When once this has occurred, recovery can only take place by expulsion of the necrosed parts and consequent ulceration. Necrosis of the glands {263} probably rarely occurs before the beginning of the second week, but it has occasionally been observed much earlier. Murchison reports cases in which he saw it as early as the first and second days. The process usually involves the mucous membrane only, but it may extend to the muscular and even to the peritoneal coats.

In the third stage the dead parts are gradually thrown off, the process of separation usually occupying several days. At first an increased degree of congestion, followed by suppuration, is observed at the edges of the sloughs, which before their complete detachment may often acquire a yellow, green, or brown color from the imbibition of bile. The ulcers which result correspond in size and form with the sloughs. They are, therefore, in the case of the agminated glands elliptical in shape, with their long diameter corresponding to the axis of the intestine. Their edges are swollen and overhanging, and their floor is generally formed by the deepest layer of the submucous connective tissue. They sometimes penetrate much more deeply, and may even extend to the peritoneal coat, and thus give rise to perforation of the bowel. The ulcers which result from sloughing of the solitary glands are, as a rule, small and round. Murchison says that ulceration may also be produced in the following way: The mucous membrane becomes 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 completed perforation, but Rindfleisch and other recent German writers do not allude to this process.

The fourth stage, or that of cicatrization, usually commences with the beginning of the fourth week. The swelling of the edges of the ulcers gradually diminishes, and they become adherent to the tissues beneath. The floor of the ulcers covers itself with delicate granulations, which in course of time are converted into connective tissue. This is ultimately coated with epithelium, but neither the villi nor the glands of the mucous membrane are ever reproduced. The resulting cicatrices may be recognized by the affected parts of the bowel being thin and more translucent than in health, and may retain these characters after the lapse of several years. They never give rise to contraction of the bowel. The time occupied in the cicatrization of each ulcer is said to be about two weeks. It occasionally happens that while cicatrization is taking place at one end of the ulcer the process of necrosis and ulceration is still going on at the other, so that two or more ulcers may occasionally run together. This form of ulcer may often retard recovery, and may sometimes end in perforation of the bowel, even after convalescence seems to have been established.

The color and consistence of the mucous membrane of the cæcum and colon are in a large proportion of cases normal. In a few the membrane is paler than in health, and in others it is of an ash-gray color. It is also sometimes injected and softened. The solitary glands are frequently enlarged and ulcerated, like those of the ileum. In the former case the mucous membranes of the large intestine throughout its whole extent, but especially that of the cæcum and of the part of the colon adjacent to it, is studded with minute elevations about a line in diameter. When ulceration has occurred the ulcers are generally round {264} and small, but they may occasionally be oval and of considerable size. In the latter case their long diameter will correspond in direction with that of the circular fibres of the intestine. Murchison has known them to measure fully an inch and a half in length. The colon is generally found much distended with flatus.

Enlargement of the mesenteric glands from cellular hyperplasia and hypertrophy of the connective tissue is constantly associated with the morbid changes of the intestines just described. This enlargement varies in different cases. In some the glands are not larger than a pea or bean; in others they are said to have reached the size of a hen's egg. It is always more marked in the glands which lie in the angle between the lower end of the ileum and the cæcum, and usually bears some proportion to the intensity of the local disease; but it is not to be regarded merely as a result of the local irritation, as it has been observed in parts of the mesentery corresponding to perfectly healthy portions of the intestine, and as the meso-colic glands have been involved in cases in which the colon was free from disease. It has, moreover, been observed in cases in which death has occurred very early in the disease, and there can therefore be little doubt that it is as much the result of the infective process as the infiltration of Peyer's patches. In addition to being enlarged, if death has taken place before the end of the second week the glands are hyperæmic and of a purplish color. Later than this, when the sloughs become detached from Peyer's patches, the swelling of the glands diminishes; they lose their color and become pale, and if convalescence ensues they return finally to their former healthy condition. Still, Murchison has seen them shrivelled and pale or bluish for some time after convalescence. In other cases the substance of the glands softens, with the formation of a puriform liquid. If the softening only involves a small part of the glandular structure, restoration to health may take place through the absorption of this liquid. If it is more extensive, the whole of the glands may break down into this puriform liquid, which, when the patient recovers, undergoes caseous and finally calcareous degeneration. Occasionally, a gland in this condition is the cause of death from rupture and extravasation of its contents into the cavity of the peritoneum.

The glands in the fissure of the liver, the gastric, lumbar, inguinal glands, and indeed all the lymphatic glands in the body, have occasionally been found swollen and congested, but their enlargement cannot be classed among the specific lesions of the disease, but is merely the result of a local irritation. Thus, Jenner says that in the case of extensive ulceration of the oesophagus which came under his observation there was marked enlargement of the oesophageal glands. Liebermeister says that the lymphatic follicles which surround the glands at the root of the tongue and in the tonsils are often affected in the same way as the glands. In most cases after a time the swelling disappears, but sometimes softening and rupture take place.

The spleen is almost invariably found to be increased in volume and to have undergone changes in consistence and color. The degree of enlargement and the other changes vary of course with the stage of the disease at which death has occurred. The enlargement occurs with less frequency in elderly than in young people, and is most marked at the height {265} of the disease, the organ being then often twice or three times its normal size, and in some cases, it is said, even larger. Later, and especially during convalescence, the enlargement has generally very much diminished. During the first ten days of the disease the spleen is generally tense and firm, engorged with blood, and dark red in color. Between the tenth and thirtieth days its appearance remains the same, but the organ is found to be soft and friable. During convalescence it becomes paler and firmer again, and is often so shrunken in size that its capsule is relaxed and wrinkled. Hemorrhagic infarctions are often met with. These sometimes soften and break down into a puriform liquid, which may sometimes cause peritonitis by rupture into the peritoneal cavity. Rupture of the spleen is also said to have occurred from mechanical violence. These changes are due in part to variations in the amount of blood, and in part to a medullary infiltration of Malpighian corpuscles similar to that which takes place in Peyer's patches and the glands of the mesentery.

LESIONS WHICH ARE NOT PECULIAR TO TYPHOID FEVER, BUT ARE OF MORE OR LESS FREQUENT OCCURRENCE.--The mucous membrane of the pharynx and oesophagus may present a perfectly healthy appearance, but occasionally it is congested and the seat of ulcerations which are for the most part superficial. Sometimes, however, they have been found to extend to the muscular coat, but they have never been known to penetrate all the coats of these organs. Jenner refers to one case in which there was extensive ulceration of the oesophagus, but usually the number of ulcers is not large. In a few cases the mucous membrane of the pharynx is coated with diphtheritic false membrane, and the submucous tissue is infiltrated with serum and pus (Murchison).

The stomach and the upper part of the intestinal tract present no lesions which are at all peculiar to typhoid fever. In a certain number of cases congestion, softening, and even superficial ulceration, of the mucous membrane of the stomach, and less frequently of that of the duodenum, have been found. The mucous membrane of the jejunum and of the upper part of the ileum is not usually much reddened, and may be even paler than in health. In cases which have been protracted it may be of an ashy-gray or slate color. The contents of this part of the intestinal tract, which is rarely much distended by flatus, do not differ materially in appearance or consistence from the matter which generally composes the typhoid stool. The bowels may, of course, be found filled with blood in cases in which a recent hemorrhage has taken place. Invaginations of the small intestines, unaccompanied by any evidences of inflammation, are occasionally met with in the bodies of those who have died of typhoid fever. They are produced, there is good reason to believe, during the death agony, but are not peculiar to this disease, as they occur in many other diseases.

Enlargement of the liver has been found in only a few cases after death from typhoid fever. Softening is more common, but even this is not a frequent result of the disease, for it was absent in 41 out of 73 cases examined with special reference to this point by Louis, Jenner, and Murchison. The organ is occasionally hyperæmic, and darker in color than in health, but it is oftener pale or normal in appearance. Even, however, where it appears to be perfectly healthy to the unassisted eye, {266} the microscope shows that its cells are very granular and filled with oil-globules which often render the nucleus indistinct or completely conceal it. When death has taken place at an advanced stage of the disease many of the cells are found to be completely broken down into a granular detritus. These changes are usually proportional to the degree of pyrexia which has been present during life. Rarer lesions of the liver are pyæmic deposits, embolism, abscess, and emphysema.

The mucous membrane of the gall-bladder has been found to be the seat of ulcers by Jenner and numerous other observers. It also occasionally presents the evidences of catarrhal or diphtheritic inflammation. The gall-bladder usually contains a pale watery liquid of a less density than bile. When, however, inflammation of its lining membrane has existed, its contents are mixed with pus and shreds of false membrane.

The mucous membrane of the larynx is sometimes found to have been the seat of catarrhal or diphtheritic inflammation, and sometimes also of ulceration. Jenner says that in typhoid fever laryngitis independent of pharyngitis is extremely rare, but the German writers express a different opinion. Griesinger estimated that laryngeal ulcers were present in one-fifth of the fatal cases. Hoffmann found them twenty-eight times in two hundred and fifty autopsies, and that the ulcers had extended to and involved the cartilages in twenty-two out of the twenty-eight cases. They are most commonly found in the posterior wall of the larynx, and may involve the vocal cords. These are often discovered after death in cases in which their existence was not suspected during life. They were formerly supposed to be the result of typhoid infiltration of the laryngeal glands, but careful investigation has shown that they are the consequence of diphtheritic inflammation of the mucous membranes. Inflammation and ulceration of the trachea are comparatively rare. Hypostatic congestion and infarction of the lungs are not uncommonly found after death from typhoid fever, and less frequently the lesions of pneumonia. Evidences of recent pleurisy are also discovered in a few cases. Acute miliary tuberculosis of the lungs is more often met with as a sequela than as a complication.

The changes in the brain and its membranes caused by typhoid fever are few and unimportant, even in cases attended by severe nervous symptoms. Those most frequently found are adhesions of the dura mater to the inner surface of the cranium, injection or oedema of the pia mater, congestive oedema, and sometimes softening of the brain and effusion at the base of the brain. The microscopic changes do not appear to have been carefully studied. Liebermeister says that the gray substance of the cortical portion of the brain and of the interior is sometimes of a rather yellowish-brown color, and that he noticed besides diffuse yellow and blackish-brown spots in different places, particularly in the corpus striatum and thalamus opticus. In such places, he says, the microscope shows a diffuse yellow coloration, a deposit of small brown pigment-granules, and also, especially in the optic thalamus and corpus striatum, the ganglion-cells thickly crowded with brownish or blackish pigment-granules in such numbers as to conceal the outlines of many of the cells. These changes Hoffmann,[47] who has specially studied them, is inclined to place by the side of the parenchymatous degeneration of other organs. {267} The ganglion-cells of the sympathetic ganglia are said by Virchow also to contain an unusual amount of pigment.

[Footnote 47: Quoted by Murchison.]

The muscles are frequently the seat of marked changes in typhoid fever. Their macroscopic appearances vary with the stage of the disease at which they are examined. When death takes place in the first or second week they are usually dark red or reddish-brown in color, and very dry. If it is delayed until later, they "present a peculiar fawn or yellow tint permeating the ordinary red in patches and veins not unlike the appearance of veined marble." Their consistence is also so much diminished that the finger may be readily passed through them. Occasionally, pseudo-abscesses and hemorrhages into the muscular sheath are found, and Dauvé and B. Ball[48] report cases in which, in addition to these changes, rupture of muscles had occurred. Zenker, who was the first to call attention to them, ranged the changes seen under the microscope under two heads: (1) granular or fatty degeneration; (2) waxy degeneration. In the first variety the transverse striæ disappear and the sarcolemma appears filled with finely granular matter. In the second variety the striated muscles become, as it were, pervaded by a coagulating material which sets, and in contracting breaks up the fibres into great numbers of short waxy-looking lumps, not unlike a certain variety of casts of the tubuli recti of the kidneys. When recovery takes place the affected fibre is believed to be regenerated by a cell-growth within the sarcolemma. These changes occur in most fevers, as typhus, small-pox, scarlet fever, and are attributed by authors generally to the hyperpyrexia which is a frequent accompaniment of these diseases. Hayem, however, asserts that he has found them well marked in cases not characterized by a high temperature, and that, on the other hand, they are sometimes absent in cases where this has been present. The waxy form of degeneration may affect all the striped muscles, but is oftenest seen in the muscles of the abdominal walls, the adductors of the thigh, the muscles of the diaphragm, and tongue.

[Footnote 48: L'Union Médicale, 1866, quoted by Biennial Retrospect of Medicine and Surgery and their Allied Sciences, for 1865-66.]

The heart, in common with the other muscles of the body, suffers from both the forms of degeneration above described, but the granular form appears to be more common than the waxy. In protracted cases it is usually much softened, and when thrown upon a plate no longer retains its form. It has usually lost its normal color and acquired the tint described by the French as feuille morte (faded leaf). Upon minute examination the degeneration is found to have taken place in patches, the diseased fibres being found alongside of others which have scarcely undergone any alteration. These patches are especially common in the papillary muscles of the mitral valve--a fact which explains the occasional presence of systolic murmurs in typhoid fever. In addition to the microscopic appearances of the muscles already described, Hayem[49] has observed in his examinations of the heart a cellular infiltration of the connective tissue and a proliferation of the muscle nuclei. These changes are sufficient in his opinion to establish the existence of myocarditis. The same observer thinks he has also found evidences of the frequent occurrence of endoarteritis in the multiplication of the cellular elements {268} of the internal coat of the small arteries, which he has discovered under the microscope.

[Footnote 49: Leçons cliniques sur les Manifestations cardiaques de la Fievre typhoide, Paris, 1875.]

Some discrepancy of opinion exists in regard to the condition of the blood in typhoid fever. Trousseau, for instance, speaks of it as being profoundly altered and in a state of dissolution; Liebermeister says that at the height of the disease the blood is very dark-colored, and that after coagulation it presents a small and soft clot; and Murchison, that a dark, liquid condition of the blood is rarer than in typhus, and that fine white coagula are more common. Harley too has frequently found firm colorless clots of fibrin in the heart and roots of the great vessels in subjects dead in the third week of the disease. Forget concludes from an examination "of one hundred and twenty-three specimens of blood derived from patients in all stages of the disease that an appreciable alteration of the blood in the several periods of enteric fever cannot be accepted as a general fact; that the blood is rarely altered in the first period; that the alteration is more marked in proportion as the disease is more advanced; that the alteration is not always in proportion to the gravity of the disease."[50] I have myself seen the disorganization of the blood as complete in severe cases of typhoid fever which have rapidly proved fatal as in cases of diphtheria or of other malignant diseases. On the other hand, in protracted cases and during convalescence the blood is often thin and watery.

[Footnote 50: Quoted by Harley, Reynolds's System of Medicine, vol. i.]

The kidneys are sometimes engorged with blood, sometimes pale and flabby. Under the microscope the appearances are similar to those just described as occurring in the liver, and it is therefore unnecessary to refer to them more fully here. As a rule, the epithelium becomes granular earlier and to a marked degree in the cortical than in the tubular portion. The absence of albuminuria must not always be accepted as proof of a healthy condition of the kidneys, as this symptom has been wholly wanting in cases in which the organs have been extensively diseased.

Analogous changes have also been observed in the salivary glands and pancreas, except that, according to Hoffmann, a cellular proliferation precedes the degenerative process.

CLINICAL DESCRIPTION.--The invasion of the disease is usually so gradual that it is often impossible to obtain from patients exact information as to the time of the beginning of their illness. Among those who present themselves for treatment at the Pennsylvania Hospital it is not uncommon to find that many have suffered for several days, it may be as long as a week, or even longer, before taking to their beds, from vague feelings of discomfort, from headache more or less intense, aching pains in the back or limbs, or from sensations of chilliness alternating with flashes of heat. In other cases derangements of the digestive system are more prominent, such as nausea, or even vomiting, diarrhoea, or irritability of the bowels. Notwithstanding these symptoms, and the indisposition to exertion engendered by them, they have frequently continued to follow their usual avocations up to the time of their application at the hospital for admission. There is generally, however, no difficulty in recognizing at once the nature of their disease. Upon examination the pulse is found to be frequent, the respiration accelerated, the tongue furred, the skin hot and dry, and the abdomen tympanitic.

{269} Among patients whose position in life enables them to pay greater attention to trifling symptoms than those who are compelled to seek hospital relief, opportunity is frequently afforded to the physician to study the disease at a period less remote from its commencement. The symptoms it presents when seen as early as the second day are generally of a very indefinite character. There may be a feeling of malaise, headache with a tendency to giddiness, pain in the back and limbs, a slightly coated tongue, thirst, and anorexia. The patient may complain of chilly sensations alternating with flashes of heat, but it will rarely be found that the attack has commenced with a decided chill. Diarrhoea may also be present at this time, or may not supervene until later. Even in cases in which it is absent the bowels will generally act inordinately after the administration of a gentle purgative. Occasionally, the attack begins with vomiting, but this is not, in my experience, a frequent mode of commencement. If the visit be made in the morning, the febrile symptoms will be little marked, the pulse being only slightly accelerated and the temperature being rarely more than from a half to a degree above the normal. In the evening, however, the thermometer usually indicates a greater elevation of temperature.

At subsequent visits the same symptoms are presented. It will be observed, however, that the fever is decidedly remittent in character, the evening temperature being always from a degree to a degree and a half higher than that of the morning, while the temperature of each succeeding day is a little higher than that of the day which preceded it. The patient is restless and wakeful at night, or sleep, when obtained, is unrefreshing and disturbed by dreams. He grows dull and slightly deaf, and although able to answer questions intelligently when roused, does so with an effort, and soon after lapses into his former condition. Although obviously growing weaker every day, it is sometimes difficult to get him to take to his bed. The diarrhoea continues and increases in severity; the stools become watery in character and ochrey-yellow in color; they may exceed six, or even twelve, in the twenty-four hours. Epistaxis either consisting of a few drops of blood only, or so profuse as to endanger life, may also occur during the first week. Examination of the abdomen toward the middle or close of the first week will almost always reveal the existence of tympany and of tenderness and gurgling in the right iliac fossa, and very frequently also of slight enlargement of the spleen. The urine at this stage of the disease is dense, scanty, and of high color. The tongue too will be observed to be more heavily coated than at first, and to be dryish, the fur being disposed on the middle of the dorsum of the organ, while the tip and edges are free from it and abnormally red in color. Usually, toward the close of the first week, the pulse will be found to be between 100 and 120 in frequency. It often, however, does not attain this frequency, and in some cases does not exceed 50 throughout the whole of the attack. At the same time, the thermometer generally indicates a temperature of from 102° to 104°, and in bad cases even one much higher than the latter.

These symptoms are not pathognomonic, but Murchison regards their existence in a young person as warranting the suspicion that he is suffering from this disease. About this time, however, or, to speak more accurately, usually from the seventh to the twelfth day, a new symptom occurs {270} which is more characteristic. This is an eruption of isolated rose-colored spots, the tâches roses lenticulaires of Louis, occurring principally upon the surface of the abdomen, but not infrequently seen also upon the chest, back, limbs, and even, according to some authors, upon the face. They are round in shape, with a well-defined margin, usually about a line in diameter, but sometimes considerably larger, slightly elevated above the surface, and disappearing upon pressure, but returning when the pressure is removed. They can almost always be found at this stage of the disease if diligently sought for.

If the disease tends to run a severe course, all the symptoms become aggravated toward the end of the second week. The tongue grows dry and brown, the pulse more frequent, feeble, and markedly reduplicated in character, the diarrhoea still more severe, and the fever higher than before, with little or no tendency to remit in the morning. The nervous symptoms also come into prominence. The headache may grow more violent or may be replaced by increased dulness, which may sometimes be so decided as to render it difficult to fully rouse the patient. At other times delirium is a prominent symptom. This may only occur at night, but not infrequently is observed during the daytime as well. It is usually more active in character than that which accompanies typhus. Trembling of the tongue and of the limbs is not uncommon at this time. The urine becomes more abundant, paler, and less dense than before. Even in cases characterized by symptoms as severe as those above detailed some improvement is, however, often observed to take place between the fourteenth and twenty-first days. The morning remission becomes more decided, the evening temperature less high than that of the preceding day; the stools lessen in number, and gradually assume a more healthy appearance; the pulse diminishes in frequency and gains in force; the tongue becomes moist, and shows a tendency to throw off its fur; the trembling grows less marked; the dulness and delirium lessen; and the patient falls into a refreshing sleep. In other cases, in many of which recovery eventually takes place, there is at this time, instead of an improvement, a still further aggravation of the symptoms. The pulse becomes more feeble and frequent; the tongue is not only excessively dry and brown, but shrivelled and fissured; the lips and teeth are encrusted with sordes; the stools contain shreds of membrane, and often blood; the subsultus tendinum increases; carphololgia, or picking at the bed-clothes, occurs. The prostration becomes so extreme that the patient frequently slips down in bed from sheer weakness. The active delirium of the previous stage is replaced by the low muttering form, or the patient lies upon his back with his eyes half closed in a semi-unconscious condition, from which he is with difficulty aroused, and which may deepen into coma. Occasionally, however, the active delirium continues, and is associated with an obstinate wakefulness; the urine and feces are passed involuntarily, or, with an apparent incontinence of the former, there may be retention, which is very apt to be overlooked. If these symptoms continue for any length of time, bed-sores may form not only over the sacrum, but on other parts subject to pressure, and the patient, worn out by long-continued suffering, dies from exhaustion.

Occasionally, in the midst of these symptoms, and sometimes even in cases in which the condition is not so alarming, prostration approaching {271} collapse, without obvious cause, suddenly supervenes. The pulse becomes a mere thread, the surface is bathed in a clammy sweat, and the temperature is found to have fallen from four to seven degrees, and in some cases even more. These symptoms almost always indicate that intestinal hemorrhage has taken place, and are followed by the discharge of blood either in the course of a few hours or not until a day or two subsequently. If the hemorrhage be moderate in amount, and does not recur, reaction usually takes place in a short time; but if, on the other hand, it is profuse or frequently repeated, death may occur, either immediately or later, as the result of the exhaustion it has induced. Very much the same set of symptoms attend the occurrence of perforation of the bowel, an accident which is also liable to happen in the course of typhoid fever, but which may generally be distinguished from intestinal hemorrhage by its being accompanied by a sharp pain in the abdomen, which is frequently so severe as to cause the patient to cry out, by its not being attended with the same reduction of temperature, and by the absence of blood in the discharges. In a day or two all doubt will be set at rest, if the case be one of perforation, by the occurrence of general peritonitis.

A fatal termination is by no means the usual result, even in cases in which the disease has assumed its worst features. Indeed, it may be said that there is no condition in typhoid fever so grave that recovery from it is impossible. Many authors would make perforation of the bowel an exception to this general rule, but there are observations on record which would seem to show that this accident is not invariably fatal. Even in cases in which the patient has lain helplessly on his back in a semi-unconscious or comatose condition, passing his discharges under him, the physician will often be gratified to find at one of his visits some evidence of improvement, trifling as it will probably be. It may be only a slight change of position, an inconsiderable fall of temperature, or a scarcely appreciable moistening of the tongue; but these changes, insignificant as they apparently are, are sufficient to indicate to the practised eye of the observant physician the approach of convalescence. Next day there will be a still further reduction of temperature, a more decided moistening of the tongue, a sensible diminution of the nervous symptoms, and a reduction in the frequency of pulse. In this condition, however, as may be readily imagined, convalescence may be retarded by numerous accidents, and life may hang trembling in the balance for several days, or even weeks, before it is fully established. It is not necessary to recount here the various steps by which a return to health is reached, as they are essentially the same as those which mark the convalescence of the less severe variety of the disease, and have already been fully referred to in the description of that form.

But even after the establishment of convalescence, and after the patient has been free from fever for several days, febrile attacks lasting for a day or two, or even longer, may occur as the consequence of very slight causes, such as undue excitement, or fatigue of any kind, or the immoderate indulgence of the appetite, which in this condition frequently needs to be restrained. These attacks are usually spoken of as recrudescences of fever, and do not differ materially from attacks of irritative fever occurring under other circumstances. They usually subside under appropriate treatment with the removal of their cause, but leave the patient somewhat {272} weaker than they found him. In other cases, it may be a week or ten days after the fall of the temperature to the normal, and frequently at a time when all danger seems to have been passed, a true relapse of the disease occurs. In this, of course, all the symptoms of the primary attack are reproduced, including even the eruption of rose-colored spots. The temperature usually, however, attains the maximum more rapidly, and the duration of the fever is generally shorter, than that of the original attack. A second relapse is also not very uncommon, and even a third may occur. Various complications and sequelæ also occur in the course of typhoid fever, which will be referred to fully hereafter.

Another form of the disease, which it may be well to allude to briefly here before closing the general description of the disease, is the abortive form. In this variety the attack begins and runs its course up to a certain point, including often even the occurrence of the eruption, as it does in the majority of cases; but at a period which varies between the seventh and fourteenth day the symptoms suddenly subside and the patient rapidly convalesces. In some cases it may be difficult to distinguish this form from an attack of simple continued fever, and, in fact, in cases in which the eruption is absent it will be impossible, unless other cases of typhoid fever have occurred in the same house or family, or unless the patient has been unmistakably exposed to the influences under which the disease arises.

In a few cases the disease begins abruptly with a chill, intense headache, or with gastro-intestinal symptoms, which have in rare instances been so violent as to have suggested to the mind of the attending physician the possibility of corrosive poisoning. This, according to Chomel, is the most frequent mode of commencement, but his experience on this point is opposed to that of the great majority of observers.

* * * * *

I shall now proceed to describe in detail some of the most important of the symptoms presented by the disease.

Even in the beginning of an attack of typhoid fever the face has a listless and languid expression, although the eyes are usually bright and the pupils dilated. In mild cases no further alteration of the physiognomy than this may be noticeable throughout the whole course of the disease, but in bad cases, when the typhoid condition is fully developed, the expression becomes dull and heavy. There is, however, never the general suffusion of the face seen in typhus. On the contrary, the face is often pallid, or there is at most a circumscribed flush on one or both cheeks, which is most marked during the exacerbations of fever or after the administration of food and stimulants. During convalescence the effects of the long illness are fully visible in the face.

Prostration, or loss of muscular strength, is present from the beginning in a large number of cases of typhoid fever, but is generally not so marked in the early stages as in typhus fever. It is usually most intense in grave cases, but to this rule there are numerous exceptions. It is not rare to find patients, in whom the other symptoms are severe, able to sit up in bed, and even to rise to stool, throughout the attack. Bartlett records a case in which the patient did not confine herself to bed until the occurrence of perforation, and I have had under my care a man who, supposing he was suffering only from a slight diarrhoea, performed the duties {273} of a nurse in a military hospital until two days before his death, although the autopsy showed very extensive ulceration of the intestine. Several cases have come under my care in the second week in which patients have walked a considerable distance to make application for admission to a hospital. Generally, however, the prostration becomes extreme in the third and fourth weeks of bad cases, the patient lying helplessly on his back, and frequently slipping down in bed from sheer weakness.

Epistaxis may occur at any stage of typhoid fever, but is most common in the forming stage. Observers differ in opinion in regard to its frequency. Murchison noted it in only 15 of 58 cases, and gives it as his belief that it is more common in France than in England or this country. Flint found that it had occurred in 21 only of 73 cases, and Jenner in 5 of 15 fatal cases. On the other hand, Bartlett says that it is quite a common symptom, and Wood and Gerhard, from the frequency with which they had met with it in the beginning of the disease, were accustomed to regard its presence as of importance in a diagnostic point of view. Part of this divergence of opinion is probably due to the fact that it is usually small in amount, and therefore very apt to be overlooked. I have in many cases, after having been told there had been no epistaxis, found the evidence of it upon the fingers or bed-clothes of the patient. It may, however, be so profuse as to endanger life and render necessary the use of the tampon. Except in the latter case it is without influence upon the course of the disease.

The skin may be almost constantly dry as well as warm throughout the whole course of the fever in a small proportion of severe cases. But, on the whole, perspiration occurs with greater frequency in typhoid fever than in any other acute disease, unless it be rheumatism. It takes place most commonly at night after the evening exacerbation, or in the morning when the patient awakes from sleep, but it is not very rare to find the skin clammy at other times. The sweating is usually general, but in a few cases it is local only. When colliquative, it is frequently exhausting, and is then a grave symptom. It is sometimes prolonged into convalescence, when it is not only annoying, but in consequence of the prostration it induces may sometimes retard the restoration to health.

I have never been able to satisfy myself that any peculiar odor is given off by the skin in typhoid fever, and most observers make a similar statement. Chomel, however, asserted that the perspiration has a strong acid odor, and Bartlett agreed with Nathan Smith in thinking that typhoid fever patients exhale a peculiar odor, not pungent and ammoniacal, like that of typhus, but "of a semi-cadaverous and musty character," which is especially noticeable during the later stages of severe and fatal cases.

The eruption is one of the most characteristic symptoms of the disease. Indeed, in many cases, without it the diagnosis would be impossible. It is rarely absent in a well-developed case. Murchison says that it was noted in 4606 cases only out of 5988 admitted into the London Fever Hospital in twenty-three years, but admits that it would probably have been found in some of the others if it had been properly looked for. Wood says that he has seldom met with cases in which it was absent. It is oftener absent in children than adults--a circumstance which makes the diagnosis of the disease in the former often a matter of great difficulty. It consists of isolated rose-colored spots, slightly elevated above {274} the surface, circular in form or nearly so, having well-defined margins, usually about a line in diameter, but sometimes varying from half a line to two and even three lines in diameter, and disappearing on pressure, to return when the pressure is removed. They are generally first observed some time between the seventh and fourteenth days, but cases are on record, especially in children, in which they are said to have appeared much earlier, and others in which they could not be discovered until the twentieth day. In the latter cases, however, it is not improbable they had really been present at an earlier period, but had escaped detection. The eruption occurs in crops at intervals of three or four days, each spot lasting from three to five days, and the whole duration of the eruption being usually from ten to twenty, and varying of course with the severity of the attack. It may continue to appear as late as the twentieth day, and in cases of relapses very much later. Spots are sometimes seen on the abdomen or elsewhere after the subsidence of fever, and whenever seen indicate that the diseased process is not at an end. They are usually scattered over the lower part of the front of the chest and the abdomen, but are also not infrequently met with upon the back, and if they are not found upon the abdomen, the patient should be gently turned upon his side and this part of his body carefully examined. When very abundant they are often also seen upon the extremities, and occasionally even upon the face. Wood has seen them abundant on the upper and inner part of the thigh, and confined to that place. When tardy in making their appearance, they may often be brought out by application of a mustard plaster or by that of heat in any form; and it is probably, therefore, owing in large measure to the warmth of the bed that they are often so fully developed upon the back. In number they may vary from two or three to several hundred. In one case Murchison counted one thousand, and in three cases which came under my care in the winter of 1881-82 the body was so thickly covered by spots of an unusually large size that when I first saw the patients I directed them to be isolated under the fear that the disease would prove to be typhus fever. When very numerous the edges of two or three of the spots may run together, giving the eruption an irregular character. No relation between the copiousness of the eruption and the severity of the disease has ever been proved to exist. While the prevailing impression, therefore, that cases in which the eruption is freely developed are apt to be of a mild character, is true in many instances, it is by no means so in all. The three cases above referred to all ran a severe course, and one of them proved fatal. The spots disappear after death, and are rarely converted into petechiæ, but in bad cases I have seen purpura spots, and even vibices, developed independently of them. Sometimes the appearance of the eruption is preceded for a day or two by a delicate scarlet rash, which Tweedie says resembles roseola and has been mistaken for scarlet fever.

Sudamina, so called from their resemblance to sweat-drops, also occur not infrequently in this disease. They are minute vesicles, often not larger than a pin's head, but sometimes two lines in diameter, and occasionally, in cases in which two or three have coalesced, much larger. They usually contain at first a clear serum, which may, however, subsequently become turbid, and when very minute must, in consequence of {275} their transparency, be viewed obliquely to be seen. Frequently, when they cannot be distinguished by the eye, they are readily detected by the touch. They rarely occur before the twelfth day, and often not before the close of the third week. Their most usual seat is the neck, the folds of the axillæ, and the groin, but there is no part of the body except the face in which they may not occur. They are most frequently seen in those cases attended by profuse sweating, and are by no means peculiar to typhoid fever, but are met with in other diseases--as, for instance, acute rheumatism--which are attended by this symptom. They are generally followed by branny desquamation of the cuticle in the position they have occupied.

Spots of a delicate blue tint--the "tâches bleuâtres" of French writers--are sometimes observed on the skin in cases of enteric fever. They must be of infrequent occurrence in this country, for, although I have looked carefully for them in every case that has come under my care, I have rarely been able to detect them. According to Murchison, "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 common on the abdomen, back, and thighs." They are said in some cases to be distributed along the course of the small cutaneous veins, and to occur most frequently in cases which are mild. They are met with in other diseases, and usually precede in appearance the characteristic eruption of typhoid fever.

The hair is very apt to fall out after an attack of typhoid fever. The nails suffer in their nutrition in common with other parts of the body--a fact which may be recognized by the peculiar markings which are found upon them after recovery, and to which attention has been particularly drawn by Morris Longstreth in a paper in the Transactions of the College of Physicians of Philadelphia, vol. iii., 3d Series.

The circulation is usually accelerated from the beginning of an attack of typhoid fever. The degree of acceleration is commonly proportioned to the severity of the other symptoms, and especially to the elevation of the temperature, and is generally more marked in the evening than in the morning. It is subject, however, to numerous variations, not only in different cases, but even in the same case from day to day, and even from hour to hour. Murchison refers to a case in which the pulse sank to 37, and never exceeded 56 during the fever, although it rose to 66 during the convalescence. I have never had the opportunity myself of observing such an infrequent pulse in the febrile period of the disease, but have had cases under my care in which the pulse often fell below 60, and in which it never exceeded 80 until after the commencement of convalescence. A comparatively infrequent pulse may coexist with a high temperature. Thus, for example, a pulse of 80 was noted in one of my cases at the same time that the thermometer showed that the temperature was 105°, and on another occasion in the same case the pulse was 82 and the temperature 104-1/2°. As a rule, the pulse is more frequent in cases which terminate fatally than in those which end in recovery; but to this rule there are numerous exceptions. In eight of Louis's cases it never {276} went above 90, and in some of my own it did not reach 100 on more than one or two occasions. On the other hand, in mild cases the pulse may be exceedingly frequent, reaching, and even exceeding in many cases, 120. When the disease is prolonged and the prostration is extreme, a pulse of from 140 to 150 is not uncommon. In the majority of cases which have come under my care the pulse has varied in frequency from 80 to 120. In some cases the range has been between these two figures, in others it has been very much less.

During convalescence the pulse usually gradually diminishes in frequency, and may sometimes fall below the normal standard. I have known it in a few instances to fall to 38, and have often met with pulses ranging between 40 and 60 at this period. In other cases, on the contrary, the pulse continues frequent during convalescence, or readily becomes so after a slight exertion or excitement of any kind. A slow pulse during convalescence has been in my experience most frequent in men whose health previous to the attack was good, and a frequent pulse in women and delicate men. If the convalescence is retarded by a complication, the pulse will maintain its frequency until this is removed.

The pulse will of course present other changes than those above referred to. It is in the beginning firm and full, but after the first week becomes small and compressible, and acquires the peculiarity known as reduplication. Sometimes, when this is not well developed, it will be rendered quite distinct by elevating the patient's arm. Irregularity or intermission of the pulse, although not commonly observed in this disease, occasionally occurs. The heart's action will also be observed to grow feeble in the course of severe cases, and its first sound indistinct, but neither of these changes is as marked in typhoid as in typhus fever. Hayem asserts that in a certain number of cases a systolic bellows murmur, with its point of greatest intensity at the apex, is heard during the course or at the close of the second week. This murmur is sometimes soft in the beginning, but becomes harsh and intense later, or may have these characters from the start to such a degree as to give the impression that endocarditis exists. During convalescence an anæmic murmur is not infrequently present.

The respiratory movements are accelerated in typhoid fever, as they are in all febrile conditions, independently of any disease of the lungs, and their frequency is generally proportional to that of the pulse. In looking over my records of cases I find that the former are less liable to fluctuate from day to day than the pulse, and that when the latter becomes abnormally infrequent they do not sink below the standard of health. In several cases of which I have notes the respiration was from 20 to 28, while the pulse was below 60, and in a case referred to by Murchison the pulse was 42 at the same time that the respirations, although no pulmonary lesion could be discovered, were 48. The respiration is often, as in the case just alluded to, very much accelerated when the most careful examination of the chest will not lead to the detection of any disease there. This is sometimes the consequence of very great tympanites, which, by interfering with the descent of the diaphragm, gives rise to dyspnoea, but it may also occur as a purely nervous phenomenon. The air expired by patients has been examined, and has {277} been found sometimes, in the later stages of the disease, to contain ammonia.

Bronchitis is so common an accompaniment of typhoid fever that auscultation rarely fails to reveal its presence in some form or other. In some cases there may be only slight harshness of the respiratory murmur at the base of the chest, but in a large number of cases the auscultatory signs will be sonorous, sibilant, and mucous râles. The last named may be so numerous that I have known the disease in the beginning mistaken for acute bronchitis, and even acute phthisis, by accomplished diagnosticians.

Headache is one of the most constant symptoms of typhoid fever. Bartlett says that it is rarely absent, Louis found it in all but 7 of 133 cases, and Jackson noted it in nearly all his cases. It is often the first symptom of which the patient complains, and, when not present at the beginning of the attack, makes its appearance soon after. It is almost as common, although less severe, in mild cases as in grave ones. It sometimes persists throughout the attack, but oftener subsides at the close of the first week or toward the middle of the second, or the patient may cease to complain of it in consequence of the dulness which is very apt to supervene. It is usually referred to the forehead and temples, but may extend over the whole head. It is usually dull and heavy, but in a few cases is throbbing. It is said by authors rarely to be severe, but I have known it so intense and acute as to cause the disease at its commencement to be mistaken for meningitis, and Jackson asserted that it is sometimes so severe that local bloodletting, and even venesection, had to be employed for its relief. It would appear to be as common in children as adults.

The headache is sometimes accompanied by vertigo and dizziness, and even by retraction of the head. Distressing pains in the back and limbs may also occur, and in rare cases even contraction of the hands and feet.

In the beginning of an attack of typhoid fever the patient usually suffers from wakefulness and restlessness at night, and it occasionally happens that the wakefulness becomes a distressing symptom. But in a great many cases, sooner or later in the course of the disease, drowsiness supervenes. In mild cases this symptom is late in making its appearance, and is generally slight and evanescent, but in grave cases it may come on as early as the eighth day, and when once present may gradually become more profound until it deepens at last into unconsciousness. It usually persists until the occurrence of death or of convalescence, but may alternate with periods of delirium, the delirium being more frequent at night and the somnolence by day. It is as frequent in children as in adults. Occasionally, the wakefulness of the earlier stage may reappear at the beginning of the third week, and coexist with muttering delirium, or occasionally with delirium of a more violent character. It then constitutes a most unfavorable symptom, the patient frequently passing several days and nights in incessant agitation, and sinking finally from exhaustion due to want of sleep.

Some degree of mental hebetude is rarely absent, even in the mildest cases of typhoid fever, and is usually among its earliest symptoms. It may, however, be absent occasionally in cases which run a severe course. It exhibits itself in the beginning in an indisposition to be disturbed, a slight inability to fix the thoughts, or a loss of memory. Generally, the {278} patient will be able at first, by an effort, to rouse himself from this apathy, but the moment he relaxes this effort will lapse into his former condition. As the disease progresses the hebetude becomes more profound and is overcome with greater difficulty. In mild cases it may continue until the occurrence of convalescence, but in grave cases it is soon lost in delirium. This is one of the commonest symptoms of the disease. If I should rely solely upon my own experience, I should say that it was rare for any but the mildest cases to run their course without its occurring at some time or other. Louis found, however, that it was absent in 32 cases, 8 of which were fatal, out of 134 cases, and Murchison in 33 cases, 3 of which ended in death, out of 100 cases. In 8 of these fatal cases death was due to perforation--a fact which would seem to show, as suggested by James C. Wilson, that this symptom is not dependent upon the intensity of the local disease alone. The delirium of course varies with the severity of the other symptoms, and especially with the intensity of the fever. In its mildest form it consists of a slight confusion of ideas, which is readily dissipated by fixing the patient's attention, and is most apt to occur in the night or when he first wakes up from sleep. In other cases it is much more marked; occasionally it is violent and noisy; the patient may talk wildly and incoherently, he may break out into a paroxysm of screaming, or, possessed with a sudden terror, he may leave his bed and attempt to rush from the room or to jump from the window. Later in the course of the disease the active delirium subsides, and low muttering delirium takes its place. The latter may go on until convalescence occurs, or the patient may gradually fall into a comatose condition, which very often ends in death.

The delusions from which the patient suffers are various. I have known in two instances a perfectly pure young girl call loudly for her baby, which she accused her mother and sister of keeping from her. Very frequently patients insist that they are in a strange place, and beg piteously to be taken to their home and friends; occasionally, in grave cases, the patient declares that there is nothing the matter with him. This Louis was accustomed to regard as a bad symptom, having never known recovery to take place after it. Delirium generally first makes its appearance some time in the course of the second week, but occasionally the invasion of the disease is marked by maniacal excitement. I have known delirium to occur on the second or third day. Louis records two cases in which it was present during the first night, and Bristowe[51] one in which it was noted on the fourth night. It is sometimes so prominent a symptom in the beginning of an attack that the patient has at first been supposed to be affected with acute mania. M. Motet[52] indeed refers to a case in which a man was actually admitted into an insane asylum before the true nature of his disease became known. On the other hand, delirium may not occur until much later in the disease--sometimes not before the close of the third or even the fourth week, when it may suddenly make its appearance when least expected. I have known it to be present in a marked degree during a relapse when it had been wholly wanting in the primary attack.

[Footnote 51: Trans. Path. Soc. Lond., vol. xiii.]

[Footnote 52: Archiv. gén. de Méd., 1868, quoted by Murchison.]

During convalescence, especially in cases in which there has been much {279} mental disturbance during the febrile period, the intellect may be weak, and continues so in some cases even after recovery in other respects is complete; but it is rarely permanently impaired. Insanity may also occur during the convalescence or after recovery, but it is usually under these circumstances amenable to treatment. In some cases the moral sense appears to be weakened after an attack, as in the case reported by Nathan Smith, in which a young man of previously good habits developed thieving propensities after his recovery.

Hyperæsthesia of the skin exists, according to Murchison, in about 5 per cent. of the cases, and may occur at any stage of the disease. It is chiefly observed in the abdomen and lower extremities, and is more frequently met with in women and children than in adult males. In a case which was partially under my care during the past summer the slightest touch made the patient, a boy of fifteen years, cry out with pain, and the administration of an enema gave him excruciating agony. Occasionally, the tenderness over the abdomen is so great that it is sometimes difficult to distinguish it from that due to peritonitis, except by the coexistence of hyperæsthesia in other parts of the body. It is very often associated with spinal tenderness, and sometimes with other spinal symptoms. Murchison does not regard it as a formidable symptom.

Cutaneous anæsthesia may also occur, but it is certainly less common in the earlier stages than hyperæsthesia. Rilliet and Barthez look upon it as of grave diagnostic import when it occurs in children.

Muscular tremor is also a common symptom of typhoid fever. A little tremulousness of the tongue when protruded may often be detected before the close of the first week. A little later the hands will be observed to tremble when held up, and still later twitching of the tendons at the wrist may be appreciable while the pulse is being felt. When muttering delirium supervenes this subsultus tendinum becomes constant, and extends to other parts of the body. The hands of the patient are frequently then in constant motion, either picking at the bed-clothes--a very unfavorable symptom--or moving in an objectless manner through the air. This condition presents many points of resemblance to that often seen in delirium tremens, and is said to come on earlier and to be more marked in those who are addicted to the abuse of alcoholic liquors. Hiccough is occasionally observed toward the close of grave cases, and is justly regarded as a bad symptom.

Spasmodic contraction of various groups of muscles is occasionally observed in severe cases, but is less frequent than muscular tremor, and in my experience is generally met with in the earliest period of the disease. The muscles of the extremities, especially those of the legs, are oftenest affected, but I have known the head as rigidly retracted as in tubercular meningitis, and have seen cases in which strabismus has been an early symptom. Murchison has had patients under his care who have suffered from constriction of the pharynx to such an extent that they could not swallow. He also reports cases in which trismus and spasm of the glottis have been present. General convulsions are not common, but occasionally do occur. Although a very grave symptom, they are not invariably fatal. Recovery took place in one of two cases which came under my own observation, and in four of the six recorded by Murchison. They are not always associated with an albuminous {280} condition of the urine. In neither of my cases was there albuminuria, and in only one of the four of Murchison's cases in which the urine was examined was it present. In one of my cases--the fatal one--the convulsions seemed to have been induced by giving the patient improper food; in the other no cause could be discovered.

Ringing or buzzing noises in the ears are present in the early stage of the disease in a large proportion of the cases, and may sometimes persist until the disease is well advanced. Usually, however, after a few days they subside and give place to deafness. This is a very common symptom, and may either affect both ears or be limited to one. In the former case it is probably generally due to the blunted perceptions of the patient, although in a few instances it may be caused, as suggested by Trousseau, by inflammation of the Eustachian tube. When only one ear is affected the deafness is of more serious import, as it is then dependent upon the presence of local inflammation, which may possibly extend to the meninges. It is, as a rule, most marked in the severest cases. Unless there has been a local inflammation it is not followed by permanent impairment of the hearing. It has even been regarded by some observers as a favorable symptom, but this opinion does not appear to rest upon a more substantial basis than the observation of Louis, that the most profound deafness adds nothing to the gravity of the prognosis.

Imperfect or perverted vision occasionally occurs in the course of typhoid fever. In a case which was recently under my care, and which has already been referred to in another connection, there was double vision associated with strabismus. Sometimes haziness of vision, and sometimes even visual illusions, are observed. Bartlett and Murchison have often known intolerance of light present in cases characterized by active febrile excitement. As a general rule, the pupils are widely dilated and the conjunctiva pearly white--a condition which is in marked contrast with what is seen in typhus fever. When, however, stupor supervenes in bad cases, the pupils are frequently as much contracted and the conjunctivæ as much injected as in the latter disease. In a few cases unequal dilatation of the pupils has been noticed. Trousseau was accustomed in his clinical lectures to call attention to the frequency with which sloughing of the cornea occurred in the condition known as coma vigil, in which the patient lies with his eyes wide open. He attributed this accident to the fact that the eye in this condition is not kept constantly moist by the occasional closure of the eyelids, and hence, as its innervation is also impaired, is especially prone to take on ulcerative inflammation. In other cases there is a free secretion of viscid matter, which often glues the eyelids together.

The sense of taste is often lost or perverted. This is partly due to impaired innervation of the tongue and palate, and partly to the thick deposits which usually cover the mucous membrane of these organs.

Frequent observations of the temperature in typhoid fever not merely give most important information in a diagnostic and prognostic point of view, but also often furnish valuable indications for treatment. From a close study of a large number of cases, Wunderlich and other physicians have discovered that the pyrexia has certain characters which distinguish it from other fevers, and which, being present in a case in which the other symptoms are obscure or ill defined, will often enable us to recognize {281} its true nature. The pyrexia may be divided into three periods, each having its own peculiarities. It is usually said that each period lasts about a week, but in severe cases the second and third periods extend over a longer time than this, and the occurrence of a complication or of any other disturbing influence will have its effect in producing either a prolongation of any one or more of these periods, and especially of the last two, or an unwonted elevation or fall of temperature. During the first period there is a progressive rise of temperature, but the rise is never so abrupt as in typhus or in many of the phlegmasiæ. As there are morning remissions, ranging from a degree to two degrees in extent, corresponding to the morning fall in the daily variations of temperature, the tracing upon the temperature chart will be a zigzag line, each evening temperature being from a degree and a half to two degrees higher than that of the preceding evening, while the same difference will be observed in the morning temperature. The temperature ought, therefore, never in an uncomplicated case to be much over 100° on the first evening or 102° on the second. A temperature of 104° at any time during the first or second day will consequently exclude typhoid fever from the diagnosis. From six to eight days are usually occupied before the maximum is reached. I have seen it attained as early as the fourth day in mild cases, and, on the other hand, not until much later in severe ones. It is usually 104° or 105°, but will of course vary with the gravity of the other symptoms. The temperature rarely rises higher than 106° at this period. On the other hand, I have known cases in which it never exceeded 103° during their whole course. It would therefore be wrong to exclude typhoid fever from the diagnosis, as Wunderlich does, if this temperature is not reached by the sixth, or at latest the eighth, day.

In the next period the temperature usually ceases to rise, but has a tendency to oscillate about the maximum temperature of the previous period as a fixed point, occasionally not quite reaching it, at other times rising a little above it. The morning remissions, too, become less decided. In other words, the fever now becomes continuous. This period, although usually lasting about a week, may extend over more than two weeks, even in the absence of complications, in cases which run a severe course, and when it is prolonged from this cause the temperature may again show a tendency to rise, and may even attain an elevation considerably above that of the preceding period. The prognosis in all such cases in which the temperature rises after the middle of the second week is grave. Temperatures of 108°, and even of 110.3°, have been noted at this time. Death invariably follows such high temperatures as these, but before death actually occurs a considerable fall of temperature very often takes place. Wunderlich has also called attention to the fact that it is not uncommon for a sudden and temporary remission of temperature to take place at this stage, varying from one degree to two degrees and a half, which may last from ten to twelve hours, and which usually has occurred in his experience from the sixteenth to the eighteenth day. Toward the close of the second period the morning remissions will be observed to be more decided, while the evening temperature remains about the same as before. The beginning of the third period is indicated by a diminution of the evening exacerbation, while the morning remissions become still more marked. The diminution is progressive, but slow, the {282} temperature each evening falling short by from half a degree to a degree of the point it reached the preceding evening. The morning remissions, on the other hand, each day become greater, a fall of three and a half degrees being not uncommon. The lysis, therefore, occupies usually a longer time than was required by the pyrexia in reaching its maximum. Toward the close of this period the morning temperatures may be normal, as even subnormal, while an elevation of temperature may continue to take place in the evening. Occasionally, however, an abrupt defervescence takes place. The duration of this period will be very much prolonged if complications are present or if the intestinal ulcers are slow in healing. I have known it to last for more than three weeks. During convalescence the temperature is frequently subnormal even in the evening, but the slightest cause is often sufficient to produce a considerable though temporary elevation of temperature. I have known the temperature in one case to rise from 99° F. to 105.6° in a few hours in consequence of an indiscretion in diet, and in another from 100° to 104° from the suffering and excitement caused by a severe attack of toothache. Indiscretions in diet are a fruitful source of these recrudescences of fever. The fever of the third period has all the characters of an irritative fever, and is probably kept up by the irritation arising from the intestinal ulcers. On the other hand, that of the first two periods is due to the action of the specific poison upon the nervous system and the other tissues of the body, and corresponds exactly with the primary fever of the eruptive diseases.

{283} [Illustration: FIG. 13. Chart showing recrudescence of fever from indiscretion of diet.]

The febrile movement, however, rarely follows a perfectly typical course, and I consequently find, in looking over the temperature sheets of a large number of cases, very few which bear, except during the first period, anything more than a general resemblance to the chart which {284} Wunderlich has prepared as typical. A very slight cause will exercise, as has already been said, a disturbing influence upon the course of the fever, and serious complications or accidents will of course produce a still more marked effect. An intestinal hemorrhage, for example, will cause a rapid and decided fall of temperature. I have often known it to fall from 104° to the normal temperature, or even below it. This depression, unless the bleeding continues and the case ends fatally in the course of a few hours, is only temporary, the temperature rising within twenty-four hours to its former height, and sometimes even beyond it. A free epistaxis or a copious diarrhoea will in the same way cause a fall of the temperature, but it is rarely so marked as in the preceding case. The same effect is produced by the administration of large doses of quinia or by the application of cold water either in the form of the bath, the douche, or any other form, to the surface of the body. On the other hand, the occurrence of a complication will cause a rise of temperature, often considerably above the maximum of the first period.

The thermometer should be used at least twice daily. In this country it is generally introduced into the axilla, and less frequently into the mouth, for the purpose of making an observation. In other countries it is not infrequently inserted into the rectum, and even into the vagina. The best hours for making the thermometric observations are eight in the morning and eight in the evening, since it has been ascertained from {285} frequent observations that the daily remissions are more marked between the hours of 6 and 8 A.M., and that the temperature usually reaches its maximum some time between those of 7 and 12 P.M.

Loss of appetite is, except in mild cases, one of the earliest symptoms of the disease, and usually persists as long as the fever lasts. It is sometimes accompanied by positive loathing for food, but generally there is no great difficulty in persuading the patient to take the necessary amount of nourishment. During convalescence the appetite returns, and is occasionally immoderate, so that it is frequently necessary to curb it lest harm should be done by over indulgence.

Thirst, usually proportionate to the degree of fever, is also present in the beginning of the fever. Later, when the patient sinks into a semi-unconscious condition and becomes insensible to the wants of the system, he will cease to call for water, although it is still urgently needed.

Nausea and vomiting sometimes occur at the beginning of the disease, but they have not been such frequent symptoms in my experience as they would appear to have been in that of Murchison, who says that they are of such common occurrence that the patient is often supposed at first to be suffering merely from a bilious attack. He does not regard them, when occurring at this stage, as serious symptoms. Indeed, he expresses the belief that the subsequent course of the disease is sometimes favorably modified by them. They may also occur later in the disease, and are then of grave import, as they are not infrequently the consequence of peritonitis. Louis regarded vomiting as a grave symptom, but it is probable it occurred in the cases from which he makes his deductions late in the course of the disease. It may sometimes occur during convalescence, and may then interfere very materially with the proper nutrition of the patient. The matter vomited usually consists of a greenish bilious fluid, with the food last taken. In some cases blood has been thrown up.

The tongue at the beginning of an attack of typhoid fever is usually moist and coated with a thin white fur, and in mild cases may retain these characters until the close. Even in some cases which terminate fatally in the course of the second week, the tongue, with the exception of being less moist than in health, may present no marked deviation from this appearance. Generally, however, as the disease progresses, and sometimes as early as the tenth day, it becomes dry and brownish, and is protruded with a tremulous motion. Still later it tends to cover itself with a thick brown coating. This coating is disposed principally along the middle of the organ, leaving uncovered the edges and tip, which are very apt to be unnaturally red in color. The bare portion at the tip is often rudely triangular in shape--a point which is regarded as of some importance in the diagnosis of the disease by Da Costa. In bad cases, during the course of the third week the tongue is frequently crossed by cracks and fissures, which are the cause of much discomfort to the patient, and when deep may bleed and leave behind them scars which are recognizable during the remainder of his life. In other cases the tongue is dry, brown, and shrivelled, or covered with a tenacious, viscid secretion which renders it difficult to protrude it.

In favorable cases, as convalescence approaches the tongue regains by degrees its normal appearance. At first the only noticeable change may {286} be that the organ is a little less dry than before. In a few days it will be observed to have become moist and to be gradually throwing off its coating. The process is, however, a slow one, and one, moreover, subject to frequent interruption. Very often, when it seems nearly completed it will be suddenly arrested, and the tongue become dry and brown. Sometimes, instead of cleaning itself gradually, the tongue throws off its coating in large flakes, leaving the mucous membrane red and shining, as if deprived of its papillary structure. Wood was accustomed to teach that if the tongue when thus cleaned remained moist convalescence might be expected, but would always be tedious. This is an observation the correctness of which I have had abundant opportunity to confirm. If anything happens, however, to interfere with the progress of convalescence, it not infrequently becomes dry and coats itself over again. When the restoration to health is retarded by the continuance of diarrhoea or by the occurrence of any intercurrent affection, the tongue will often become pale and flabby and be the seat of superficial ulcerations or of aphthous exudations.

The mucous membrane of the posterior fauces is also often red and dry and covered with a glutinous secretion, which often materially interferes with swallowing. The lips and teeth are in bad cases encrusted with sordes, and the former are dry and cracked, and bleed readily when picked.

Meteorism or tympanites is observed in the greater number of cases of typhoid fever, having been noted by Murchison in 79 out of 100 cases, and by Hale in 130 out of 179 cases, and in only 43 of the remainder of his cases is it expressly stated to have been absent. My own experience leads me to believe that it is present in even a larger proportion of cases; in fact, that it is rarely absent. It is, as a rule, later in making its appearance than the other abdominal symptoms, showing itself usually about the end of the first or the beginning of the second week. It is generally most marked in grave cases, especially those attended by severe diarrhoea, but I have seen it highly developed in cases in which the symptom was not present at all or but little developed. It may vary, moreover, frequently in degree at different times in the same case, but when once present generally persists until convalescence is established or death occurs. When extreme, it may give rise to distressing dyspnoea by preventing the descent of the diaphragm.

The meteorism is usually preceded and accompanied by gurgling and tenderness on pressure in the right iliac fossa. The former of these symptoms is most marked in cases in which diarrhoea exists, and is caused by the presence of liquid and gas in the lower part of the ileum. The tenderness is unquestionably due to the presence of ulcers in the same part of the bowel. There is also occasionally pain in the region of the umbilicus, but this is a much less frequent symptom.

Enlargement of the spleen was noted by Hale as being present in some of the cases which he has described. It is a frequent symptom of the disease, and may be generally demonstrated by percussion in the course of the second week. It has not, however, often happened to me to be able to feel the organ enlarged through the abdominal walls, as Murchison asserts he has been able to do. Indeed, tympanites is usually present in a sufficient degree to render this difficult. The enlargement {287} occurs more frequently in persons under thirty years of age than in those over it.

Diarrhoea is one of the most frequent symptoms of the disease, especially in severe cases, and there are very few mild cases in which it does not occur at some period of their course. Louis noted it in all but three of his fatal cases, Murchison in 93 out of 100, and M. Barth in 96 out of 101. It varies in different cases in severity, in duration, and in the time at which it appears. It may be one of the earliest symptoms, presenting itself frequently on the first day, and often being the only one which occasions uneasiness to the patient or his physician. At other times its appearance may be postponed until the end of the first week, or even until the patient is apparently entering on convalescence. It may be mild in the beginning and become more severe as the disease progresses, or after having been at first acute may cease spontaneously in a few days to occasion any uneasiness. In degree it may vary from two stools to three or four, or even twenty, in the course of the twenty-four hours. It is absent in a few cases, but in many even of these cases the bowels will be found to act inordinately after a very moderate dose of purgative medicine. I have known, for instance, the administration of a single teaspoonful of castor oil to be followed by five or six stools in an adult. Constipation does, however, actually exist in a certain number of cases. Murchison has known the bowels in cases in which a relapse has occurred to be constipated in the primary attack and relaxed in the relapse. There is no relation between the severity of the diarrhoea and the extent of the local lesion. Although oftenest met with in mild cases, constipation has existed in cases in which perforation of the bowel or intestinal hemorrhage has occurred during life, or very extensive lesions been found after death.

The stools are fetid and ammoniacal, and are alkaline in reaction, instead of acid as in health. They are usually liquid and of the color of yellow ochre. Murchison says that they separate, on standing, into two layers--a supernatant fluid and a flaky sediment--but that, occasionally, instead of being watery they are pultaceous, frothy, and fermenting, and so light as to float in water. I have myself often seen the appearance which Bartlett compares to that of new cider. They may contain blood, and when they do, occasionally present the appearance of coffee-grounds. They are not infrequently, in grave cases, passed involuntarily.

Intestinal hemorrhage is fortunately not a frequent symptom of typhoid fever. It may occur as early as the fifth or sixth day, but is more common after the middle of the second week or in the third or fourth week. In 60 cases observed by Murchison in which the hemorrhage exceeded six ounces it began during the second week (mostly toward its close) in 8; during the third week in 28; during the fourth in 17; during the fifth in 1; during the sixth in 3; during the seventh in 1; and during the eighth week in 1; while in one case the date of its occurrence is not noted. In the cases observed by Liebermeister and Griesinger, 113 in all, the bleeding took place in a much larger proportion of cases at an early period of the disease, occurring in as many as 43 in the second week, and in only 27 during the third. In 7 cases in which I had the opportunity of observing it in patients under my own care it occurred on the seventeenth day in 1; on the twenty-third day in 1; during the {288} third week in 2; during the fifth week in 2; and on the fifth day of a relapse in 1. There may be a single hemorrhage, or the bleeding may be repeated one or more times. In 5 of my cases there was a second hemorrhage, and in 2 of them a third; and in several of Murchison's cases it recurred at varying intervals after its first appearance.

When the bleeding occurs early in the disease it is usually insignificant in amount, and is due either to extreme congestion of the mucous membrane of the intestine, giving rise to rupture of the capillaries, or to disintegration of the blood, allowing its ready passage through the walls of the vessels. In the latter case it usually coexists with petechiæ or a hemorrhage from some other part of the body, as, for instance, epistaxis or hematuria. After the middle of the second week the hemorrhage is generally the result of the laying open of a small artery, either by the detachment of a slough from one of the glands of Peyer or by the involvement of its walls in the ulcerative process. It is then often profuse, and may even reach several pints in quantity. Murchison has, however, seen profuse hemorrhage at such an early stage of the disease that it was impossible that ulceration could have taken place. The blood is not always voided immediately after a hemorrhage has taken place; it may be retained for some days. Indeed, if the amount be large the patient may die within a few hours of its occurrence without any appearance of blood externally. This is, however, rare; it is more usual for the hemorrhage to be repeated before death takes place, but the occurrence of the bleeding may be suspected in such cases by the abrupt fall of temperature, sometimes below the normal standard, and by the extreme prostration and pallor which come on suddenly without other assignable cause. The depression of the temperature does not continue long. It generally reaches its former elevation, or even exceeds it, in the course of twenty-four hours.

There would appear to be a slight difference in the frequency with which intestinal hemorrhage occurs in different times and at different places. Murchison noted it in 58 cases of 1564, or 3.77 per cent.; Louis in 8 cases of 134, or 5.9 per cent.; Liebermeister in 127 cases of 1743, or 7.3 per cent.; Griesinger in 32 cases of 600, or 5.3 per cent.; and I have noted it 7 times in 81 cases, or in about 8.5 per cent. Liebermeister makes it twice as frequent in women as in men. It seems to be much less common in children than in adults, for in 252 patients under fifteen years of age observed by Taupin, Rilliet, and Barthez it occurred in 1 only. There is considerable diversity of opinion among observers in regard to the importance of this symptom. Murchison lost 32 of his 60 cases. In 11 of the 32 fatal cases the immediate cause of death was peritonitis; in 14 of the remaining 21 cases the patients died within three days of the bleeding, and in 8 of the 14 within a few hours. Of Liebermeister's 127 cases 49, and of Griesinger's 32 cases 10, terminated fatally; 3 of my own cases ended in death, but none of them until several days had elapsed after the bleeding. In the face of facts such as these there have not been wanting authors to assert that the effect of the hemorrhage was sometimes beneficial. Chief among these are the celebrated Irish physician Graves and his devoted admirer Trousseau. There may occasionally be a slight subsidence of the nervous symptoms upon the occurrence of a hemorrhage, consequent upon the reduction of temperature {289} which usually accompanies it, but this relief is only temporary, and procured at too great expense to be really of service to the patient.

The bleeding is most frequently observed in bad cases. All the cases which were under my care in which it occurred were of great severity from the very start. In 18 of Murchison's 60 cases the antecedent symptoms were mild. In 3 of my cases there was severe diarrhoea. In 2 of the other cases, 1 of which was fatal, the bowels were constipated, and in another one, also fatal, they were slightly loose. In 8 of Murchison's cases, 6 of which were fatal, the bowels had been constipated up to the time of its occurrence. The blood, if voided immediately after its escape into the intestines, is generally fluid and bright red in color. When retained for a day or two it is passed in dark clots, and if retained longer than this it is usually mixed with fecal matter when discharged from the bowels, and gives the stools a tarry appearance and consistence, which is not always recognized by inexperienced attendants as due to blood.

It has been asserted that intestinal hemorrhage has become more frequent since the introduction of the cold-water treatment, but Liebermeister shows this to be an error, for he has found that of 861 cases treated before the introduction of this treatment, 72, or 8.4 per cent., had intestinal hemorrhage, but that of 882 cases treated since its introduction hemorrhage occurred in 55, or in 6.2 per cent. Other methods of treatment have also been charged with inducing a tendency to hemorrhage, but probably not upon more substantial grounds than the above.

The occurrence of perforation may be suspected when the patient is suddenly seized with acute pain in the abdomen, accompanied by symptoms of collapse and occasionally by rigors. The fall of temperature is often considerable. Liebermeister refers to one case in which it was as much as 5-1/2°, or from 104° to 98-1/2°. Very soon the abdomen becomes tender on pressure, and, if it were not so before, hard and tympanitic; the pulse grows frequent, small, and sometimes almost imperceptible; the breathing is thoracic; the physiognomy expresses great suffering; the features are contracted, and the face is bathed in profuse perspiration. Nausea and vomiting come on soon after inflammation has commenced, and rapidly exhaust the patient. The decubitus is dorsal, and the legs are generally drawn up so as to relax the abdominal muscles. Prostration rapidly increases until death puts an end to the patient's sufferings. Occasionally, the symptoms are more obscure. Pain and rigors may both be wanting, and nothing but the extreme prostration, the frequent and feeble pulse, and the distended condition of the abdomen will indicate the gravity of the danger. This is not infrequently the case in delirious patients. Death may take place during the collapse, but this is rare. It more frequently takes place on the second or third day; on the other hand, it may be postponed until much later. Liebermeister and Murchison refer to cases in which there was an interval of two or three weeks between the first symptom of perforation and the fatal result.

Perforation of the intestine was formerly regarded as an inevitably fatal accident, but this view is no longer entertained. I have had under my observation cases in which all the symptoms of this accident were present, and in which recovery took place. In some of these cases there {290} may have been an error of diagnosis, but all of them will not admit of this explanation. Moreover, cases of a similar character have been reported by physicians whose skill in diagnosis is universally recognized. Thus, Murchison reports six such cases, Tweedie two, and Wood one. Liebermeister and Bristowe[53] also both say that recovery is possible. This view is sustained by the results of certain autopsies. In one of these, reported by Buhl,[54] a perforation was found completely closed by adhesions to the mesentery, and in others reported by Murchison partial adhesion had taken place between the edges of the perforation and the abdominal walls or to an adjoining coil of intestine. Occasionally, the inflammation excited by the perforation may be circumscribed and terminate in an abscess, which may permit recovery by discharging itself into the bowel or externally. At other times, however, it ruptures into the peritoneal cavity, when death speedily ensues.

[Footnote 53: Transactions of the Pathological Society of London, vol. xi. p. 115.]

[Footnote 54: Cited by Murchison.]

Perforation is, fortunately, not a frequent accident in typhoid fever. It was the cause of death in 20 only of 250 fatal cases collected by Hoffmann. It occurred, according to Liebermeister, in only 26 cases, 3 of which ended in recovery, in more than 2000 cases observed at the hospital at Basle. Murchison observed it 48 times in 1580 cases, Griesinger 14 times in 118 cases, and Flint twice in 73 cases. Murchison found that in a total of 1721 autopsies, the details of which were collected from various sources, it was the cause of death in 196, or 11.38 per cent. It would appear to be rather more common on the continent of Europe than in England or in this country. Perforation is much more frequently met with in men than in women. The patients were men in 15 of 21 of Liebermeister's cases, in 51 of 73 of Murchison's, and in 72 of 106 cases collected by Näcke. It is rarer in children than in adults. Rilliet, Barthez, and Taupin met with it only three times in 232 children under treatment. Murchison has, however, had a fatal case in a child of five years of age. It is also not common after forty years of age, but does occasionally occur, although the contrary has been asserted.

Perforation is most likely to happen during or after the third week of the disease, but it has been met with as early as the eighth day, as in a case reported by Peacock. On the other hand, in three cases cited by Morin[55] it did not occur until the seventy-second, seventy-sixth, and one hundred and tenth day, respectively. Instances are on record in which it has taken place after the patient was supposed to be thoroughly convalescent and had returned to his occupation. When it occurs early it is due to the separation of a slough. After the middle or end of the third week it is probably always the result of the extension of the ulcerative process to the peritoneal coat. In a large proportion of cases the perforation has been preceded by symptoms of great gravity, such as severe diarrhoea, great tympany and tenderness of the abdomen, and intestinal hemorrhage, but in a certain number of instances the cases in which it has occurred have been of a mild character, the patient in many of them not considering himself sick enough to take to his bed or even to abstain from his daily labor. After death the perforating ulcer has been found to be the only one.

[Footnote 55: Quoted by Murchison.]

The most frequent causes of perforation are the irritation arising from {291} indigestible and unsuitable food, distension of the bowels by feces or gas, vomiting, and movements on the part of the patient. Liebermeister calls attention to the frequency with which ascarides are found in the intestines of those who die of perforation, and is inclined to think they may have something to do with causing it. Morin[56] reports a case in which the perforation appeared to be caused by the administration of an enema.

[Footnote 56: Quoted by Murchison.]

For our knowledge of the changes in the composition of the urine we are largely indebted to Parkes and certain German observers. As the disease generally begins insidiously, the condition of the urine before the attack and during the first two or three days has not been ascertained with certainty. During the latter part of the first week the amount of water is greatly diminished, occasionally falling to one-fourth or one-sixth of the usual quantity. In the second and third weeks it increases, and at the end of the fourth week may again be normal. The amount may, however, vary from day to day, but its variations do not stand in close relation to those of the febrile heat; that is, the thermometer may mark one day 104°, and the next day 100°, while the amount of urine remains the same. Still, when the temperature begins to fall permanently it increases at once, or, according to Thierfelder, two or three days after. The specific gravity is usually high in almost all cases in which the urine is scanty, and may be as high 1038. With the establishment of convalescence the specific gravity often diminishes before the water begins to increase. In other words, the lessening of the solids of the urine frequently takes place prior to the increase of the water.

The reaction of the urine is very acid in the beginning, but the acidity is not due to an increased secretion of acid, but simply to concentration. Later it may become alkaline, and even ammoniacal. The color of the urine is darker than in health during the early part of the febrile period. This is due partly to concentration, and partly to increased disintegration of the blood-corpuscles, which is a consequence of the fever.

The quantity of urea is augmented during the fever, and especially during the first week, when the water and chlorides of sodium are most diminished. As a general rule, the higher the temperature the greater the amount of urea. It may, however, be very much diminished during the presence of inflammatory complications. On the other hand, it is not affected by diarrhoea. Uric acid is uniformly increased, the amount of increase being relatively greater than that of the urea; it is often doubled, and sometimes the increase is even more than this. This increase takes place, according to Zimmer, up to the fourteenth day. It diminishes after this, and during convalescence may fall below the normal amount. Copious deposits of urates may occur at any time in the course of the disease. The chloride of sodium is usually diminished in amount. This diminution is partly due to a less amount of this salt being taken with the food, and partly to the fact that large quantities of it pass away with the stools. As the diminution cannot always be fully accounted for in this way, it would appear that it is also stored up in the body during the fever. In cases in which sweating and purging are absent the sulphuric acid is increased in amount. The phosphoric acid is at first slightly diminished, but later undergoes an increase. The hippuric acid is also diminished.

{292} Parkes found albumen in the urine in 7 out of 21 cases. In 5 of these it was temporary, and entirely disappeared before the patients left the hospital. Becquerel found it in 8 out of 38 cases, Andral in only 4 out of 34 cases. Griesinger found it commonly, though it was usually temporary. He met with only four or five cases in which it was never present. Kerchensteiner found albumen in a fourth part of the severe cases. Brattler noticed it in 9 out of 23 cases. I have very frequently found it myself, but it has always been in my cases a temporary phenomenon. Desquamative nephritis may occur occasionally in the course of typhoid fever, and give rise to the appearance of a large amount of albumen in the urine, and also occasionally of blood. Renal epithelia and casts are sometimes seen in cases in which there is albuminuria, but usually soon disappear. Zimmermann asserts that in all but very slight cases casts may be found even when no albumen can be detected. The statement is probably too general, but there is no doubt of the occasional presence of casts under these circumstances. Bladder epithelia and pus-cells are seen in a few cases in small quantities, but decided cystitis is rare, unless it has ensued upon retention of urine. Sugar has not been found except in the urine of diabetic patients, who may have happened to contract typhoid fever. In these patients the sugar diminishes, and is sometimes wholly absent during the continuance of the fever. Leucin and tyrosin have been found by Frerichs, but at present no observations have been made as to the frequency or import of their occurrence.

In many cases, when the prostration is extreme, the urine is passed involuntarily, but in some of these cases the incontinence of the urine is only apparent, and is really the result of over-distension of the bladder. This is a condition which is very apt to be overlooked, and I have known paralysis of the bladder to result in consequence of this neglect, and to continue sometimes after convalescence has been established.

COMPLICATIONS AND SEQUELÆ.--Although cerebral symptoms are among the commonest manifestations of the disturbing effects produced in the economy by the typhoid fever poison, they are almost always independent of inflammation of the brain and its membranes. In a few cases, however, the lesions of meningitis have been found after death. In some of these it has come on without assignable cause, in others it has been the consequence of pyæmia, of tubercles, or of the extension of inflammation from the petrous portion of the temporal bone. Occasionally, during convalescence, some impairment of the intellect is observed. This may consist in simply some loss of memory or childishness of manner. At other times delusions of a mild form are present, or else the patient is liable to attacks of acute mania, sometimes violent, coming on suddenly and without fever. In a few instances the moral sense seems to have been perverted, as in the case reported by Dr. Nathan Smith, already referred to, in which a young man of previously good character developed a propensity to steal after his attack. Recovery with the re-establishment of the physical health almost occurs in these cases. Murchison says he knows of no case in which this condition has been permanent. On the other hand, Dr. C. M. Campbell,[57] who had the opportunity of observing an attack of typhoid fever among some insane patients {293} at the Durham County Asylum, reports that the mental state was in no case injuriously affected by the disease, but, on the contrary, underwent a marked improvement in several of the cases. Indeed, in two of the cases, in which the prognosis had become very unfavorable, mental recovery began during the attack of fever.

[Footnote 57: The Journal of Mental Science, July, 1882.]

Paralysis, muscular tremors, and chorea are also occasionally observed after attacks of typhoid fever. According to Murchison, paralysis does not supervene until several weeks after the commencement of convalescence. It may last for several weeks or months, but recovery in the majority of instances eventually takes place. According to Nothnägel,[58] 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 anæsthesia. On the other hand, neuralgias and disturbances of sensation are not common sequelæ of typhoid fever.

[Footnote 58: Cited by Murchison. See also article by Paget, St. Bartholomew's Hospital Report, vol. xii.]

Degeneration of the muscular tissue of the heart is probably present in some degree in every case of typhoid fever, being, of course, most marked in the severest cases. There would seem, however, to be no special tendency to disease of its valves or membranes. Arterial thrombosis or embolism, giving rise to gangrene of the part supplied by the obstructed artery, is of occasional occurrence. Patry,[59] Hayem,[60] Trousseau,[61] and others report or refer to several cases in which gangrene of the leg, hand, or cheek was observed, and among others a case in which sphacelus depending upon obstruction of the carotid artery, the result, as Patry thought, of arteritis, commenced in the left ear, and extended from there to the forehead and cheek.[62] A. Martin[63] reports the case of a woman who expelled from the vagina a fetid-smelling structure of cylindrical form, which proved to be the cervix of the uterus, with the upper part of the vagina, and in whom menstruation was not re-established until after the performance of an operation. Spillmann[64] has also called attention to the occurrence of gangrene of the vagina and vulva in cases of typhoid fever. {294} This complication is generally met with toward the end of the febrile period.

[Footnote 59: Archives générales de Médicine, 1863, vol. i. pp. 129-549.]

[Footnote 60: Loc. cit.]

[Footnote 61: Clinique médicale.]

[Footnote 62: Since the above was written Barié has called attention in the Revue de Médicine, Jan. and Feb., 1884, to the frequency with which acute inflammation of the arteries occurs as a sequel of typhoid fever. The author, whose investigations were limited to the larger arteries, found that the vessels generally implicated are in the order of their frequency, the posterior tibial, the femoral, and the dorsal artery of the foot. The affection is usually unilateral, appears during convalescence or when the patient leaves his bed, and occurs just as often after light as after severe cases. He distinguishes two varieties: 1, acute obliterating arteritis, and, 2, acute parietal arteritis. The first variety is characterized by embryonal infiltration of all the tissues, by disappearance of the smoothness of the intima, which becomes uneven and granular, and by the formation of a secondary thrombus, and almost invariably terminates in dry gangrene. The second is merely an inflammation without such a clot, and always terminates in recovery without gangrene.

The symptoms of obliterating arteritis are--pain, more or less sudden in its onset, directly over the course of affected vessels, and increased by pressure, by the erect position, and by walking; diminution, and then absence, of pulsation; swelling of the limb, without oedema or redness; and, later, the appearance of bluish mottling of the surface, and, more rarely, of patches of purpura; lowering of the temperature, with or without troubles of sensibility, such as formication, anæsthesia, etc., and the appearance of a hard and painful cord, due to the formation of the thrombus. In the parietal form the diminution of the pulsations is sometimes preceded by a considerable exaggeration of their amplitude, and, while the temperature on the affected side is usually lowered, it may sometimes be increased.]

[Footnote 63: Centralblatt f. Gynakol, 1881.]

[Footnote 64: Archives générale, Mars, 1881.]

Venous thrombosis, the result of weakness of the heart's action, is more frequently observed. It occurs generally during the convalescence of cases which have run a severe course, and usually affects the veins of the lower extremities. I have seen both the femoral veins obstructed from this cause at the same time. All the cases which have come under my own observation have ended in recovery, and only 2 of 31 collected by Liebermeister terminated fatally. Death occurred in 3 of the 17 cases collected by Murchison, but in none of them was this result attributable to this complication alone. There is, however, always danger of a portion of the thrombus becoming detached and producing embolism of the pulmonary artery.

Pyæmia is said by Murchison and other authors to be an occasional complication, but it is certainly rare in this country. In the milder cases abscesses form during convalescence beneath the skin in different parts of the body. In the more severe cases pus is deposited in the joints or in the internal organs. Albert Robin[65] has reported two cases in which there was suppurative joint affection. In one of these the joints of the fingers and toes, with the sheaths of the corresponding extensor tendons and both knee-joints and one shoulder-joint, were affected. In the other the left knee was filled with pus. In both cases the fever soon assumed an adynamic character.

[Footnote 65: Gazette de Paris, 1881.]

Laryngitis may sometimes occur in the course of typhoid fever, and when it assumes the diphtheritic form and runs on to the formation of ulcers is a very serious complication of typhoid fever, as it is not infrequently accompanied by oedema of the glottis and gives rise to the necessity for tracheotomy. It is fortunately, at least in its worst forms, rare in this country. In Germany, judging from the number of cases collected by Hoffmann and Griesinger, it is of more common occurrence. The ulcers are oftener met with in some epidemics than in others. During the winter of 1860-61, which I passed in Vienna, the frequency with which they occurred was the subject of remark among those who were in attendance upon the various clinics.

I have already called attention to the frequency with which bronchitis in some form or other attends upon typhoid fever. When it invades the smaller bronchial tubes it occasionally gives rise to lobular pneumonia or to collapse of some of the lobules of the lung. Lobar pneumonia may also occur in the course of typhoid fever. It was observed 52 times in 1420 cases of typhoid fever under treatment at the Basle hospital from 1865-68. When it comes on late in the disease, especially if the patient is comatose, or even semi-conscious, it may be entirely overlooked, unless the lungs are carefully examined, as it often does not reveal itself to us by any of the ordinary symptoms. It may, however, occur early, and I have known it so prominent in the beginning of an attack that the existence of typhoid fever was not suspected. It sometimes terminates in abscess or gangrene, but is more usually followed by chronic pneumonia, which may eventually either end in recovery or lay the foundation for phthisis. Pleurisy with effusion is also not an uncommon complication. It was observed, according to Liebermeister, at the hospital at Basle 64 {295} times in 1743 cases of fever. It is also a serious complication, as 21 of the 64 cases terminated fatally. Murchison refers to three cases in which it was followed by empyema. Other morbid conditions of the respiratory organs which may occur as complications of typhoid fever are oedema, infarction, hypostatic congestion of the lungs, emphysema, and pneumothorax. Acute miliary tuberculosis is also an occasional complication, but is oftener met with as a sequel. According to Liebermeister, the tendency to pulmonary complications has diminished since the introduction of the cold-water treatment.

Catarrhal or diphtheritic inflammation of the fauces and pharynx occurs in a large number of cases, and frequently gives rise to a great deal of difficulty in swallowing. Indeed, it has been so frequently observed in some epidemics that a few writers have regarded it as a symptom rather than a complication of the disease. Either of the varieties of inflammation may extend through the Eustachian tube to the middle ear and be the cause of deafness, which usually passes off as the inflammation subsides. Occasionally, however, the affection of the middle ear gives rise to perforation of the tympanum or to caries of the petrous portion of the temporal bone.

Murchison says he has known the symptoms of and lesions of dysentery to coexist with those of typhoid fever in several cases, and Liebermeister asserts that diphtheria of the intestinal mucous membrane is an occasional sequel to severe cases, especially when other mucous membranes are the seat of diphtheritic inflammation. In a few instances which have come under his observation it had given rise to perforation of the bowel or to gangrene of the intestinal mucous membrane.

Jaundice occasionally occurs in the course of the disease. I have never happened to see this complication, and am inclined to think it is rare in this country. Liebermeister, however, met with it 6 times in 1420 cases, and Griesinger 10 times in 600 cases. Hoffmann found it in 10 of 250 fatal cases, and Murchison was able to collect 9 cases, all of which but one terminated in death. Several of Griesinger's cases, however, ended in recovery. In a few cases the jaundice may be attributed to catarrh of the biliary ducts, but this solution of the question will not explain those cases in which the feces remain colored throughout. In fatal cases marked degeneration of the liver has been found, which Liebermeister regards as of similar character to that which occurs in acute yellow atrophy. In two of Murchison's cases the liver was small and its secreting cells loaded with oil. In most cases it does not appear until late in the disease, but it has been observed as early as the fifth day.

Abscess of the liver and diphtheritic inflammation of the mucous membrane of the gall-bladder are among the rarer sequelæ of typhoid fever.

Peritonitis is the most serious of all the complications of typhoid fever. Its most common cause is perforation of the bowel, but it may also be due to the extension of inflammation to the peritoneal membrane without ulceration. Liebermeister believes that it is sometimes the result of the typhoid infiltration so frequent in various tissues of the body taking place in the serous membrane. In other cases it arises from the rupture of softened mesenteric glands, of softened {296} infarctions in the spleen, or of the abscesses which are sometimes the consequence of the circumscribed inflammation by which perforation is occasionally prevented from proving immediately fatal. Less frequent causes of it are rupture of the gall-bladder, with the escape of gall-stones into the cavity of the abdomen, abscesses of the ovary, and abscesses in the walls of the urinary bladder. It is said by Murchison to have been in one case the result of a pseudo-abscess in the sheath of the rectus muscle bursting inward.

Swelling of the parotid gland occasionally occurs in typhoid fever, but is much less common than in typhus. It is most frequently met with in bad cases about the end of the third week or later, and generally involves one side only. The swelling is hard and firm in the beginning, and may terminate in resolution or suppuration. I have seen it three times only, twice in my own practice, and once in that of a medical friend. One of my cases was fatal, the other ended in recovery, as did, I believe, the third case. Murchison saw it in only 6 cases, 5 of which were fatal. According to Hoffmann,[66] 16 cases of suppurative parotitis were found at Basle among about 1600 typhoid fever patients, 7 of the 16 ending fatally. Parotitis without suppuration occurred three times. In 15 cases the attack was confined to one side, 9 times to the right and 6 to the left; in 4 it was double. Trousseau[67] looks upon these swellings as a very grave accident, and says that he has scarcely ever seen a case recover in which it has occurred, either in the course of typhoid fever or any other disease. Chomel, on the other hand, is said to have regarded them as critical and auspicious.

[Footnote 66: Quoted by Liebermeister.]

[Footnote 67: Clinique médicale de l'Hôtel Dieu, t. i. 1861.]

Menstruation occasionally occurs during typhoid fever, and may be profuse. Bartels,[68] who has investigated the histories of 172 patients in reference to this point, says that the catamenia always appear if the menstrual period falls within the first five days of the fever, and that they do so in two-thirds of the cases if they are expected between the sixth and fourteenth days. On the other hand, menstruation does not occur if the time for it falls in the third week. He says also that the catamenia generally appears about the time they are expected, or later, and very seldom earlier. Liebermeister, on the contrary, says that they often occur prematurely. Other uterine hemorrhages seldom occur, and never in those who have ceased to menstruate or in whom the function has not been established.

[Footnote 68: Petersb. Med. Wochenschr., 1881.]

Suppuration of Bartholini's glands is said by Speilman to have taken place in one case.[69] In the fourth week the patient complained of violent pains in the right nympha, which, upon examination, was found to be swollen. A tumor as large as a nut, which was red and painful on pressure, could also be felt in the vagina.

[Footnote 69: Arch. générales, Mars, 1882.]

Pregnancy was formerly thought to confer an entire immunity from typhoid fever, but recent and accurate investigations have shown that if this immunity really exists, it is only relative, not absolute. Gusserow[70] says that the disease is more frequently met with in the first half than in the latter half of pregnancy. Abortion under these circumstances commonly occurs. Gusserow says that it takes place in from 60 {297} to 80 per cent. of the cases. He believes it to be due to the high temperature, which causes the death of the foetus, which is then expelled from the uterus. In a few cases, however, the child is born living. Of Murchison's 14 cases, 10 recovered, and two of the ten patients carried the child, at the fourth and eighth months respectively, throughout the attack. All the others miscarried or aborted, only one of them being delivered of a living child. Out of 18 pregnant women[71] treated in the hospital of Basle for typhoid fever, between the years 1865 and 1868, 15 miscarried or aborted. In the three years following the introduction of the anti-pyretic treatment only five cases of abortion occurred, and but one of these proved fatal. This accident generally happens during the second or third week of the fever. It is always a serious complication, and if it occurs in the first three months of pregnancy it generally gives rise to profuse hemorrhage, which is usually followed by a fall of temperature as marked as that observed in hemorrhage from the intestines. Just as in the latter case, the fall is only temporary, being soon succeeded by a rapid rise of the temperature to its former height, or even beyond it.

[Footnote 70: Schmidt's Jahrbuch, Bd. 193, No. 1, 1880, from Berl. klin. Wochenschr., 1880.]

[Footnote 71: Liebermeister, loc. cit.]

The danger of bed-sores occurring in typhoid fever is in consequence of the impaired nutrition of the tissues, the length of time the disease lasts, and the great emaciation which usually attends it--greater than in any other acute disease. They constitute a very serious and troublesome complication, and may occur on any part of the body subjected to pressure, but are most frequent over the sacrum and trochanters. Oedema of the lower extremities from feebleness of the circulation is occasionally observed in the convalescence from protracted attacks. Lendel has published a series of 7 cases observed at Rouen, in which the entire body became very oedematous in the second or third week of the attack or during convalescence. In none of the cases was the urine albuminous. All the patients recovered except one, who died of peritonitis. Similar cases have been reported by other observers. Barthez and Rilliet have seen several cases in children.

Periostitis is an occasional sequel. I have seen it in one case only. Sir James Paget,[72] who appears to have met with it in several cases, says that it never occurs in the continuity of the fever, but always when the patient is apparently convalescent, when his temperature is normal and constant, and he is beginning to move about and to grow stronger and stouter. Its most usual seat is the tibia, but it is also met with in the femur, ulna, and parietal bone. Except in one case, Sir James has never seen it in more than one bone in the same person. It is always circumscribed within a space of from one to three inches in extent, and usually subsides without necrosis or other abiding change of structure; but in some cases the patient has remained for some time subject to repeated attacks of pain and swelling of periosteum. In the few cases, he says, in which the periostitis is followed by necrosis the extent of dead bone has always been less than that of the inflammation over it. Murchison, however, refers to two cases of necrosis of the tibia, to one of the temporal bone, and to two in which extensive necrosis of the lower jaw occurred. Gay[73] also reports a case of extensive necrosis of the thigh-bone in a child three years old, following an attack of typhoid fever.

[Footnote 72: St. Bartholomew's Hospital Report, vol. xxi.]

[Footnote 73: Path. Trans. Lond., vol. xx., p. 290.]

{298} Very frequently after an attack of typhoid fever the patient evinces a tendency to grow stout, which is either continuous or else is gradually lost after he fully recovers his health. This increase in flesh is not always accompanied by a corresponding gain in physical strength, and he may remain for a long time after convalescence is apparently complete incapacitated for much bodily or mental exertion. Sometimes, on the other hand, the patient, instead of gaining flesh and strength, may continue weak and emaciated, even when he is taking a full amount of nourishment, which he is, however, unable to assimilate. Cases of this kind may terminate in phthisis, but they occasionally prove fatal, without any discoverable lesion after death except an abnormally smooth appearance of the mucous membrane of the ileum and a shrivelled condition of the mesenteric glands.[74]

[Footnote 74: Murchison.]

Patients suffering from typhoid fever may occasionally contract other specific diseases. Murchison has notes of eight cases in which the eruption of this disease coexisted with that of scarlatina, and says that it was not uncommon in the London Fever Hospital for a patient suffering from the former disease to contract the latter. Similar cases are recorded by other observers. Typhoid fever may also be complicated with rubeola, pertussis, diphtheria, variola, and vaccinia. I have repeatedly seen children convalescent from typhoid fever in the hospitals of Paris contract one or other of the eruptive fevers.

VARIETIES.--A great variety of forms of typhoid fever has been described by various authors, but as many of them present few points of difference from the usual form of the disease, it will not be necessary to discuss them at any length. They derive their names from some peculiarity of the mode of seizure, from the prominence of some one symptom or set of symptoms, or from the presence of complications. They are--(1) The adynamic form, in which prostration is marked in the beginning and throughout the attack. (2) The ataxic or nervous form, which is characterized by the predominance of delirium, subsultus tendinum, and other nervous symptoms. (3) The hemorrhagic form, in which there is a special tendency to hemorrhage from the different mucous membranes. (4) The abdominal form, in which the abdominal symptoms, such as diarrhoea and tympanites, are well developed. (5) The thoracic form, so called from the presence of some thoracic complication. (6) The gastric or bilious form, in which the disease is complicated at its commencement by gastro-intestinal catarrh. La forme muqueuse of French authors is probably identical with the above. (7) The acute form, in which the disease begins abruptly and with great violence, and runs a very rapid course, terminating usually in death before the end of the first week or early in the second, before ulceration can have taken place. Delirium is an early and prominent symptom in this form, so that it has sometimes been mistaken for meningitis.

Certain forms of the disease deserve a little fuller consideration. One of the most important of these is the abortive form, in which, as its names implies, the fever is cut short in its course, and in which there is every reason to believe that infiltration of Peyer's glands takes place as usual, but that the subsequent course of the disease is different, the glands undergoing resolution instead of advancing to ulceration. The majority {299} of observers agree that in the beginning there is nothing to distinguish such attacks from those which follow their usual course. Liebermeister and Jaccoud state, however, that their commencement is usually more abrupt than in the ordinary variety, the former asserting that the temperature generally reaches its maximum earlier, and the same opinion is expressed by other authors. They are occasionally characterized by severe symptoms, including a high temperature. In the few cases which have come under my own observation the symptoms have been mild, but they were sufficiently developed to leave no doubt on the mind as to the nature of the disease. In a case which aborted on the twelfth day there were hebetude, diarrhoea, tympany, and rose-colored spots persisting even after the subsidence of the fever. Constipation would appear, however, to be more frequent than diarrhoea in this class of cases. The subsidence of the fever may occur at any time between the seventh and fourteenth days; Griesinger has seen it occur as early as the fifth day. Sometimes the defervescence occurs abruptly, with copious perspiration; at others it is gradual and similar to that which takes place in ordinary attacks. Between the abortive form of typhoid fever and simple continued fever there are, of course, many points of resemblance, but cases of the former may generally be recognized by the presence of this rose-colored eruption and enlargement of the spleen, or, where these are absent, by their occurring in the same house or under the same circumstances as typical cases of the disease.

Liebermeister has called attention in his article on typhoid fever in Ziemssen's Cyclopædia to a class of cases which, he thinks, is also caused by the typhoid infection, and of which the prominent feature is the insignificance of the fever or the entire absence of it which characterizes them. Such cases appear to be of frequent occurrence in Basle. Many of them, he says, never show during their entire course any rise of the temperature, or occasionally a slight elevation only, but an enlargement of the spleen could generally be detected, and occasionally an unmistakable rose-colored eruption. The action of the bowels was usually irregular; sometimes there was diarrhoea, and sometimes, on the other hand, obstinate constipation. The other symptoms were prostration, pains throughout the body, often headache, persistent loss of appetite, with more or less swollen and furred tongue, and markedly diminished frequency of the pulse, which disappears with convalescence, while its quality is not appreciably altered. The long duration of an apparently trifling indisposition he considers as especially characteristic. Cayley also refers to cases, and even epidemics, of typhoid fever in which the temperature has been below the normal throughout the whole course of the attack. Strube[75] had the opportunity of observing such an outbreak during the siege of Paris by the Germans in 1870. "In many of the cases," he says, "the temperature throughout was subnormal, and in others never exceeded the normal point. The roseola was usually profuse; the nerve symptoms were of marked severity, and were in inverse ratio to the temperature, consisting of violent delirium alternating with stupor; the duration of the fever was very short, defervescence usually taking place at the end of a fortnight. Of the 23 fatal cases, in 20 death took place during the first fourteen days. The abdominal {300} symptoms were slight, but the characteristic lesions were found on post-mortem examination. All the cases were characterized by great prostration. These cases presented some features which were probably due to this peculiarity of the temperature; thus, the pulse was but little accelerated, seldom exceeding a hundred; the tongue did not become dry and brown; and the enlargement of the spleen was either absent or much less marked than usual. Strube attributed the peculiar features of this epidemic to the depressed condition of the troops; they had been exposed to great hardships on the way to Paris, over-fatigued by forced marches, and very insufficiently supplied with food."

[Footnote 75: Quoted by Dr. Cayley.]

A mild form of the disease has been described by certain authors, in which the symptoms, although not severe, are characteristic, and in which there is therefore, with due care, little danger of making a mistake in diagnosis. It therefore seems an unnecessary refinement to set apart such cases under a separate head.

The latent form, or the typhus ambulatorius of the Germans, is of more importance from the fact that the symptoms are so mild, or that so many of the ordinary symptoms are wanting or masked by those due to complications, that there is great danger of regarding the attack as of little moment. In many cases there is no symptom present but prostration and fever to indicate that the patient is ill, and these may be so slight that he may positively refuse to go to his bed, and may even insist upon pursuing his ordinary avocation, in the midst of which he is often suddenly seized with alarming symptoms, such as violent delirium, intestinal hemorrhage, or, what is more common, those due to perforation of the bowel. Still, even in these cases a careful examination will often disclose the presence of some symptom which had failed before to attract attention, and which will often reveal to us the true nature of the disease. I was myself the subject of such an attack nearly twenty years ago. Supposing that the excessive prostration from which I was suffering was due to overwork at a large army hospital in the neighborhood of Philadelphia, I determined to seek repose in travel and in change of scene. On the eve of doing so I fortunately sent for a medical friend, who, after a thorough investigation of my symptoms, succeeded in finding a few rose-colored spots upon my abdomen. The attack subsequently ran a mild but well-marked course. Occasionally, the symptoms due to a complication so predominate over those arising from the disease itself that they completely mask it. I have known bronchitis so severe as to divert in this way the attention of a skilful diagnostician from the primary disease. When vomiting, together with other symptoms of hepatic derangement, is especially prominent in the beginning of typhoid fever, the mistake is not infrequently made of attributing these symptoms to a "bilious attack."

TYPHO-MALARIAL FEVER.--Under this name, which was originally suggested by J. J. Woodward, Surgeon U.S.A., early in the summer of 1862, as a designation for a class of cases in which the symptoms of typhoid fever are associated with those of remittent, and which was especially common among the soldiers of the United States Army during the late Civil War, are probably included at least two distinct conditions: 1st, remittent fever, in which the disease, on account of the depressing circumstances surrounding the patient, assumes {301} a typhoid form; and, 2d, typhoid fever, occurring in a patient who has also been exposed to malarial influence. This association of diseases is of course not new, or even undescribed before this name was suggested for it. Woodward thinks that he has found enough in the description of Röderer and Wagler to justify him in concluding that the epidemic which occurred at Göttingen in 1762 was really of this character. There would seem also to be no doubt from the descriptions of Dawson[76] and Davis[77] that the fever which decimated the British army in the Walcheren expedition was typhoid fever, modified by the malarial influence to which the soldiers were subjected. The latter of these authors says that the ileum and jejunum in the bodies of those who died of this disease were frequently found interspersed with tubercles, inflamed and ulcerated in different parts.

[Footnote 76: Observations on the Walcheren Diseases, Ipswich, 1810, by G. P. Dawson.]

[Footnote 77: A Scientific and Popular View of the Fever of Walcheren, J. B. Davis, London, 1810.]

In our own country the occasional association of these two diseases has also long been recognized. Drake describes it under the name of remitto-typhoid, and Dickson seems to have been perfectly familiar with it, for he says that typhoid lesions will sometimes be found in the bodies of those dead of bilious remittent. Levick recognized the presence of the symptoms of both diseases in some patients who were under his care as early as the spring of 1862, and proposed the name of miasmatic typhoid fever for this class of cases in the following June.[78] Meredith Clymer has also frequently met with cases in which the symptoms of the two diseases were coexistent.[79]

[Footnote 78: Med. and Surg. Reporter, June 21, 1862.]

[Footnote 79: The Science and Practice of Medicine, by William Aitken, M.D., 3d Amer. ed.; with additions by Meredith Clymer, M.D., Philadelphia, 1872.]

As is indicated by the name given to it, the symptoms in this form of typhoid fever are modified by the presence of malarial poisoning. The cases always manifest a decided tendency to periodicity, the evening exacerbations are more decided than in the ordinary form, the remissions are often ushered in with a profuse sweating, gastric and hepatic derangements are more marked, and headache is more severe. There is frequently less mental hebetude or dulness than in ordinary typhoid fever. In some of the cases observed by Levick[80] the symptoms were those of pernicious congestive remittent fever, such as copious serous discharges, not unlike those of Asiatic cholera, colliquative sweats, and other symptoms of exhaustion.

[Footnote 80: Amer. Journal of the Med. Sci., April, 1864.]

TYPHOID FEVER IN CHILDREN.--It was formerly thought that infants and very young children were not often the subjects of typhoid fever, but, so far is this opinion from being correct, it is now known that they are especially liable to suffer from it. The rose-colored eruption is more often wanting in them than in adults, and the fever more apt to assume a distinctly remittent type; and hence, no doubt, the difficulty which is often experienced in diagnosticating this fever from other forms of fever in children. There is no doubt that many cases which have been described by authors under the head of infantile remittent fever are really examples of typhoid fever modified simply by the age of the patient. It may occur in infants not more than six months old, and is not infrequent in {302} children of two or three years of age. Henoch,[81] who has had the opportunity of observing a large number of cases, says that the rise of temperature is commonly more abrupt in children than in adults, and that the disease generally runs its course in a shorter time. The pulse is more frequent, and may be as high as 144 in cases in which the prognosis is not grave. Dicrotism is very rare. Slowness and irregularity of the pulse, like that observed in basillar meningitis, he has never seen. The nervous symptoms are not so pronounced even when the temperature is high, and they bear no relation in severity to the height of the temperature. Diarrhoea in the cases observed by Henoch was often absent during the whole course of the attack, and the stools were often brownish or greenish instead of yellow.

[Footnote 81: Charité Ann., 1875.]

TYPHOID FEVER OF AGED PERSONS.--The modifications which the disease undergoes when it occurs in patients advanced in life are precisely those to be expected from the diminished activity of the processes of life in them, as compared with those of younger persons. The febrile movement is generally prolonged, although of low grade, the temperature rarely rising high, and frequently during convalescence sinking below the normal. The diarrhoea is commonly not so severe, the delirium so violent, or the rose-colored eruption so often present. On the other hand, adynamic symptoms, such as excessive prostration, tremors, subsultus tendinum, and the like, are frequently prominent from the beginning of the attack.

Several authors, among whom may be mentioned Arnat,[82] Hornburger,[83] and Greenhow,[84] have described a renal form of typhoid fever. In this form the urine is blood red in color or like dark broth. It often contains albumen during the first week of this disease, usually hyaline or more or less granular casts, and occasionally red blood-discs, white cells, epithelia of kidneys and bladder, and epithelial detritus. The specific gravity is high, and the quantity is usually diminished. The prominent symptoms are pain in the region of the kidneys, oedema of face, tense and frequent pulse, great prostration, profuse epistaxis, violent delirium, and hyperpyrexia. The temperature may be 105.8°. On the other hand, the intestinal symptoms are less marked. In fatal cases the lesions of intestinal nephritis have been found at the autopsy.

[Footnote 82: Thesis, Sur la Fievre typhoide à forme renale.]

[Footnote 83: Berlin klin. Wochenschrift, 1881.]

[Footnote 84: Transactions of Clinical Society of London, 1880.]

RELAPSES.--Much difference of opinion will be found to exist among authors in regard to the frequency with which relapses occur in typhoid fever, and this difference does not appear to be due to any greater frequency of this accident in some countries than in others, since Liebermeister met with them in 8.6 per cent. of the cases treated at the hospital at Basle, while, according to other German observers quoted by him, they occur in 6.3 per cent. (Gerhardt), in 11 per cent. (Bäumler), and in 3.3 per cent. (Biermer). Murchison noted them in 80 of 2591 cases in the London Fever Hospital, or in 3 per cent., and Maclagan in 13 of 128 cases at Dundee, or in 10 per cent. about. Immermann[85] of Basle says that they occur in 15 per cent. of the cases, and that in very unfavorable years the proportion may be as high as 18 or 19 per cent. Prof. Henoch[86] observed relapses in 16 cases out of 96, or 16.6 per cent. In my own {303} practice they have not been very numerous. I find that in 80 cases of which I have full notes they are recorded five times, or in 6.25 per cent., and I believe this ratio correctly represents the frequency with which they have happened in all the other cases which have come under my care. Part of this difference of opinion is unquestionably attributable to the fact that under the term relapse are sometimes included two distinct conditions: (1) Mere recrudescences of fever, which occur during the stage of defervescence or that of convalescence, and which are provoked by errors of diet, mental or bodily fatigue, or some other irritating cause. They usually last a day or two, and are entirely distinct from (2), true relapses, in which all the characteristic symptoms of the primary attack are reproduced, and which commonly occur some time after the disease has apparently run its course. There is occasionally no distinct apyretic interval between the two attacks, but in by far the greater number of instances the relapse occurs in the second or third week, or even later, after the establishment of convalescence. In 20 cases reported by W. M. Ord and Seymour Taylor[87] the relapse occurred in the third week of the disease in 1; in the fourth week in 5; in the sixth week in 3; in the seventh week in 7; in the eighth week in 3; in the ninth week in 1. James Jackson refers to a case in which the date of the relapse is not given, but in which he was able to detect the rose-colored eruption in the sixty-sixth day[88] from the commencement of the disease. In my five cases the relapse occurred on the seventh, eighth, ninth, eleventh, and twentieth day after the apparent establishment of convalescence. In these cases the duration of the relapse was 11, 13, 17, 20, and 13 days respectively. The highest temperature noted in any of the relapses was 105°, which occurred in two cases. In both of these this temperature had also occurred in the original attacks. In one of the others, however, a temperature of over 104° F. was repeatedly observed in the relapse, while in the primary attack it had never risen above 102°.

[Footnote 85: Schweiz. Corr. Bl., viii. 1878.]

[Footnote 86: Charité Ann., ii. 1875.]

[Footnote 87: St. Thomas's Hospital Report, vol. ix., London, 1879.]

[Footnote 88: Since the above was written I have had under my care a case of typhoid fever in which a third relapse occurred nearly four months after the patient, a woman aged thirty years, was first taken ill. The following is a brief abstract of the history of this remarkable case: The original attack began about Sept. 20, 1883, was of moderate severity, and lasted between three and four weeks. Convalescence, which seems to have been nearly complete, as the patient had left her bed, was interrupted on Nov. 1st by a relapse, during which she was admitted into the Pennsylvania Hospital. This relapse was severe, and before it had entirely run its course was itself interrupted, on Nov. 17th, by an intercurrent relapse, which lasted two weeks. During these two relapses extensive bed-sores formed upon the nates, occasioning more or less irritation and consequent febrile reaction. On Jan. 11, 1884, a third relapse occurred. This relapse was accompanied by diarrhoea, rose-colored spots, tympany, dry and brown tongue, and other characteristic symptoms of typhoid fever, the diagnosis being fully concurred in by my colleague, Dr. Morris Longstreth, who saw the case with me. Convalescence was again interrupted on Feb. 13th by fever, which continued for two weeks, but which possessed none of the characters of typhoid fever, and was clearly due to imprudence on the part of the patient. The patient is now (April 25, 1884) entirely well, and will shortly be discharged from the hospital.]

The onset of a relapse is usually much more abrupt than that of the original attack. It is rarely preceded by prodromata. The temperature rises more rapidly and attains its maximum earlier, which may be much greater than in the original attack. In one case under my care it reached 105° on the evening of the first day, and temperatures of 103.5° and 104° on the evening of the second day are not infrequent.

{304} The rose-colored eruption appears earlier. In 38 cases investigated by Murchison with reference to this point, it appeared on the third 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. In the case the history of which is given below it was detected on the second day. The delirium also comes on sooner. The relapse is usually less severe, and is of shorter duration, than the primary attack. All my cases terminated in recovery. Occasionally, however, it is much more severe. In one case in which the primary attack was so mild that the patient could scarcely be persuaded to remain in bed, the relapse was so severe that for many days it was uncertain whether the patient would recover. In another intestinal hemorrhages to an alarming extent occurred on two occasions. Moreover, of Murchison's 53 cases, 7 were fatal; in 2 of the cases death was due to perforation; in 2 to peritonitis, induced by infarction of the spleen; and in 1 to abortion; and of Ebstein's 13 cases, 3 were also fatal. Occasionally, a second, and it is said even a third, relapse is noted. In one of Da Costa's cases hemorrhage from the bowels took place during a second relapse.

The following histories and temperature charts illustrate the prominent peculiarities of relapses occurring in typhoid fever:

TYPHOID FEVER (with a relapse).--G---- L----, æt. 20, single, seaman, Italian, admitted March 6, 1878; April 30, 1878, left in ward. Patient is unable to speak English. The following history is obtained through an interpreter: His family history is good, and he is naturally a healthy man, never having had any serious illness--no venereal disease, no cough or rheumatism, no intermittent fever, and he has not been in the habit of drinking to excess. His vessel has been lying off Gloucester Point, and two seamen have recently been similarly affected on another vessel anchored near by. For about two weeks he has had malaise, but not until three days ago was he so ill that he was obliged to give up work. He was then taken with cough, chills followed by fever, diarrhoea, headache, and pain in the abdomen. Has had no epistaxis or vomiting.

Upon admission patient has fever, his face is flushed, his tongue coated with a brown fur in the centre, dry, fissured, and red and glossy at the tip and edges. He has hebetude and some delirium, though not very active; he is deaf. His abdomen is somewhat tense and tympanitic, and covered with very numerous rose-colored spots, which disappear momentarily on pressure; they are also distributed over thighs and chest. There seems to be no tenderness on pressure over abdomen, and there is no gurgling felt. Has moderate diarrhoea, having about three stools daily, which are light yellow in color and are loose and fetid. Urine cloudy orange red, acid, 1021. No albumen.

{305} 3.7. Ord. Ol. Terebinth. gtt. x; Acid. Muriat. dil. gtt. v every two hours, with Quinine gr. viij daily, and restricted diet.

3.8. Tongue not so dry; is better. Whiskey fl. oz. ij.

3.9. Temperature elevated. Ord. to be sponged.

3.10. Has had four stools in the last twenty-four hours. Some sonorous râles over chest posteriorly. Sponging to be repeated when temperature rises.

3.11. There is some subsultus. There are more numerous râles heard over chest posteriorly.

Ord. whiskey fl. oz. v daily; turpentine stupes to chest. His diarrhoea is better; considerable hebetude.

3.12. Tongue is not so dry, and is cleaner. The spots over his body are beginning to assume more the appearance of petechiæ. They are found everywhere on his body. Has had but one stool within the last twenty-four hours.

3.13. He is brighter; skin feels better; tongue cleaner; pulse but 80. Fewer râles heard in chest. No change in his treatment.

3.14. Spots disappearing. Two stools in last twenty-four hours, not so loose in character. Pulse dicrotic.

3.15. There is no tympany. Had one natural stool yesterday. Sudaminæ over abdomen.

3.16. Doing well. Pulse very slow.

3.17. Tongue moist and clean; no diarrhoea.

3.18. No diarrhoea; spots are still to be seen, but are fading every day.

3.20. Takes a little lemon-juice, as the gums are disposed to be a little spongy.

Stop turpentine and muriatic acid.

3.25. Bowels somewhat constipated.

Ord. enema of castor oil.

3.26. Stop quinine; give whiskey fl. oz. iij only. Allowed chicken and two eggs daily.

Ord. Tr. Cinch. Co. fl. drachms ij s.t.d.

4.4. Slight chill, headache, and pain in side. Temp. 101°.

4.5. Temp. normal again; as well as before.

4.8. Has been up for a week, and steadily gaining in strength, except the slight attack on the 4th, when to-day, without his having taken any indigestible food, or indeed any reason to which it could be assigned, he was seized with a relapse, his temperature rising to 105°, but being reduced a half degree by sponging.

4.9. Spots have again appeared in great numbers, and they are very large. Last evening his temperature reached 104-3/4°, and was reduced to 101° by sponging.

4.10. Doing very well; spots are still making their appearance.

4.12. Diarrhoea not at all excessive.

4.15. Spots are very numerous.

4.20. Temperature nearly normal.

4.25. Doing perfectly well; up and about.

4.30. Left in ward, upon completion of my term of service.

{306} [Illustration: FIG. 16. Chart of temperature in typhoid fever with relapse.--Original attack.]

ABORTIVE ATTACK, FOLLOWED BY TYPICAL ATTACK.--Thomas Rogers, October 15, born in Philadelphia, assistant nurse. Admitted {307} January 25, 1883; discharged March 26, 1883, cured. Father died of hemorrhage from the lungs; mother living and healthy. Two years ago he sustained a compound fracture of the left leg from a bale of cotton falling on him; otherwise he has always enjoyed good health. For the past three months he has been assisting the nurse in the receiving ward of this hospital. Four days before admission, without unusual exposure, he had a slight chill, and felt cold for several hours. This was followed by fever and a feeling of weakness. He also had slight headache and the bowels were constipated; no epistaxis.

Upon admission patient has a good deal of hebetude, face flushed, temperature 102°, pulse 106, tongue slightly coated, moist. Has slight pain in right lumbar region, but no distension of abdomen. Urine negative.

Ord. quinine gr. viij. daily; liq. ammon. acet. fl. drachms ij. q.q.h.

Jan. 29th. More hebetude; tongue more coated with brownish fur, red at tip; bowels continue costive; opened by an enema.

31st. Is brighter and better. One doubtful rose-colored spot seen on abdomen.

Feb. 4th. The morning temperatures for the past two days have been subnormal and the evening rise is very slight. All the symptoms also indicate the approach of convalescence.

6th. More fever; pulse weaker; functional murmur heard over heart; sudamina out over abdomen. Ord. whiskey fl. oz. ij.

8th. Some fulness of abdomen; had three loose yellowish-colored stools in the last twelve hours.

9th. A few doubtful rose spots out over abdomen and back; sudamina still abundant.

10th. More tympany; numerous rose-colored spots out over abdomen and back; slight epistaxis and bronchitis.

11th. Pulse more feeble; still slight diarrhoea. Increase whiskey to fl. oz. iv.

15th. Has a good deal of hebetude, but no headache; fewer spots; pulse weaker; temperature lower. Increase whiskey to fl. oz. vj.

17th. Temperature high again; most of the spots have disappeared; slight epistaxis and subsultus; no delirium; bowels not open for two days.

20th. Temperature falling; spots disappearing; still fulness of abdomen.

25th. Temperature has been subnormal for several days, and he is doing well; tongue cleaning. Has emaciated a good deal, and is weak.

March 1st. Is convalescent; tongue has lost its redness.

8th. Continues to improve; allowed semi-solid food.

17th. Is now quite well; has gained a good deal in flesh, and is stronger.

{308} [Illustration: FIG. 18. Temperature chart of typhoid fever.--Abortive attack, followed by typical attack.]

The examination of the bodies of those who have died during a relapse reveals the presence of two sets of lesions in the cicatrizing ulcers of the primary attack and the recent ulcerations of the relapse. The latter are usually less extensive, and are found to be situated at a greater distance from the lower end of the small intestine, than the former, for the reason that the Peyer's patches most remote from the ileo-cæcal valve are least apt to be affected in the primary attack.

No satisfactory explanation of these relapses has as yet been discovered. {309} They occur in patients of both sexes and of all ages with about the same frequency. They have been attributed to errors of diet, mental and bodily fatigue, and the like, but, while we know that causes of this character often provoke recrudescences of fever, and can understand that they may act as exciting causes of a relapse in cases in which the predisposition exists, it does not seem possible that they should by themselves be able to bring back all the characteristic symptoms of a specific disease. It has been maintained by some authors that a relapse indicates that a new infection has taken place; but this hypothesis, even if we admit that it accounts for those cases in which the patient is allowed to remain in the place in which he has acquired the disease, does not explain those in which he is removed during the first attack to a hospital where all the sanitary arrangements are presumably perfect. Griesinger has endeavored to explain relapses occurring in hospitals by suggesting that they may possibly be due to a fresh contagion from other patients with typhoid fever in the same ward; but this explanation is rendered improbable by the fact that relapses have occurred when cases have been thoroughly isolated. As I have already said, during a long connection with the Pennsylvania Hospital I have only known a single case of typhoid fever to originate within its walls, although relapses probably occur in its wards with the same frequency as in other hospitals. To adopt Griesinger's explanation, it would therefore be necessary to assume that a patient just recovered from an attack of the disease is more susceptible to the action of its contagion than patients suffering from other disease; which seems improbable, to say the least. It has also been maintained that relapses are due to the inoculation of the previously healthy Peyer's patches by the typhoid poison which is thrown off with the sloughs from those first affected. Maclagan alleges that relapses are more frequently met with in cases in which constipation is present in the primary attack, a condition which he regards as favorable to absorption; but this is opposed to the experience of almost every one who has paid any attention to the subject. In the cases which have come under my own observation it certainly was not the case, diarrhoea having been present in all of them. It is more likely, as suggested by Liebermeister, that part of the poison remains latent somewhere in the body, not developed, destroyed, nor expelled during the first attack, but brought later into activity by some exciting cause. Da Costa adopts this view, and says that relapses of typhoid fever are not unlike the outbreaks of malarial fever which occur after worry or fatigue and when there has been no chance for a fresh infection. Different plans of treatment have at various times been charged with increasing the predisposition to relapses. This is especially true of the cold-water treatment, and the records at the hospital at Basle show that the proportion of relapses and the number of deaths from them are both increased under the use of cold water. Liebermeister thinks, however, that this does not necessarily prove that this treatment favors the occurrence of relapses, since before the introduction of this plan of treatment many more typhoid fever patients died in the first attack of the disease. Employing those cases only for statistical purposes in which the patients have survived the first attack, he finds that the difference at once disappears, there being 9 per cent. of relapses before the use of cold water, and 10.3 per cent. after its use.

{310} Gerhardt[89] asserts that in cases in which relapses occur the enlargement of the spleen does not diminish during the non-febrile period that intervenes between the original attack and the relapse.

[Footnote 89: Ziemssen's Cyclopædia, vol. i. p. 193.]

Da Costa[90] has shown that the appearance of the white line and furrow left by the primary attack, to which attention has already been drawn, may sometimes be of service to us in diagnosis when we see the patient for the first time during the relapse. In a case which was recently under my care their appearance certainly rendered the nature of the previous illness from which the patient had suffered much clearer than it would otherwise have been.

[Footnote 90: Transactions of the College of Physicians of Philadelphia, 3d S., vol. iii.]

DURATION.--The mode of invasion of typhoid fever is generally so insidious, and the first symptoms so little pronounced, that the patient, even if free from mental hebetude and confusion at the time when he first comes under the care of a physician, is usually unable to fix with certainty the time of the beginning of his illness. This inability is of course most marked in what are known as walking cases, in which, notwithstanding that the disease is far advanced, the patient continues to pursue his ordinary avocations or at least refuses to go to bed. In a few cases, however, either in consequence of the violence of the first symptoms or from some other cause, opportunity is afforded to the physician of observing the disease from its onset. In many others the date of commencement may be approximately ascertained. The average duration of such cases, if uncomplicated, has been found to be between three and four weeks. According to Bartlett, the average duration of 255 cases at the Massachusetts General Hospital between the years 1824 and 1835, inclusive, was twenty-two days. It was a little less than this in patients under twenty-one years of age, and a little more in those over. As these cases occurred before the introduction into use of the clinical thermometer, and as the commencement of convalescence is fixed in them at the time when the patients were able to take a little solid food, it is possible the fever may have continued in them some time after convalescence was supposed to have been established. Of 200 cases which ended in recovery, and in which Murchison was able to ascertain with precision the date of commencement, the duration was 10 to 14 days in 7 cases, 15 to 21 days in 49 cases, 22 to 28 days in 111 cases, and 29 to 35 days in 33 cases. The mean duration of these 200 cases was 24.3 days, while that of 112 fatal cases was 27.67 days. From the same author we learn that the average stay in hospital of 500 cases which recovered was 31.24 days, and of 100 fatal cases was 16.52 days, while the average duration of the illness before admission in the 600 cases was 10.78 days. During the twenty years from Jan. 1, 1862, to Dec. 31, 1881, 621 cases of typhoid fever, 121 of which were fatal, were admitted into the Pennsylvania Hospital. No notes of many of these cases were taken, and of some of the others the notes are incomplete or inaccessible, so that they cannot, unfortunately, be used for the purpose of determining the duration of the disease. The books of the hospital, however, show the length of time each patient remained in the wards. From these we learn that the average stay of the 500 patients who recovered was 43.5 days, while that of the 121 patients who died was only 8.75 days, and that of these a large number (28) died within {311} 48 hours after their admission to the hospital. As a rule, patients are retained at the Pennsylvania Hospital until they are fully able to return to work, while at the English and continental hospitals it is usual to discharge them when they cease to need active treatment. This circumstance probably explains the much greater average duration of the cases admitted to the Pennsylvania Hospital than that of the cases referred to by Murchison. In the abortive form the duration of the disease may not exceed ten days, and there are authors who contend that it may occasionally be very much less.

Death may occur at almost any time in the course of typhoid fever. I have never seen it myself take place before the seventh day. Murchison reports two cases in one of which the disease terminated fatally within twenty-seven hours of its commencement, and in the other on the second day. Instances are more numerous in which death has occurred on the fourth, fifth, or sixth day, but still they are comparatively infrequent, and, as a rule, the fatal termination takes place most frequently during the course of the third week. On the other hand, death may sometimes occur at a very much later period. This is, of course, the case when it occurs during a relapse, but if the fever continues after the third week the patient may sometimes die from exhaustion or from the intercurrence of a complication. Death may also be the result of a sequela long after the disease has run its course.

DIAGNOSIS.--The insidious invasion of typhoid fever, together with the absence of pathognomonic symptoms in the beginning, always renders the diagnosis difficult, and sometimes impossible, during the first week. Still, even at this time the existence of the disease may be suspected if the frequent use of the thermometer reveals from day to day a gradual increase of the fever and the existence of evening exacerbations followed by morning remissions, the temperature rising each evening from a degree to two degrees higher than it had done the preceding evening. If in addition to this character of the pyrexia there are diarrhoea with ochrey-yellow stools or an increased susceptibility to the action of cathartic medicines, epistaxis, enlargement of the spleen, slight fulness of the abdomen, with tenderness and gurgling in the right iliac region, slight hebetude and some confusion of ideas upon awakening, the diagnosis becomes more probable. During the next week the symptoms are usually much more characteristic. The presence of marked abdominal symptoms, together with the eruption of rose-colored spots, will generally render the recognition of the disease at this time an easy matter. There are, however, a few cases in which no rose-colored spots can be found, and in which the abdominal symptoms, if they exist at all, are so little marked that they do not arrest attention. Even in these cases the temperature record, when carefully studied, will often throw a good deal of light upon the nature of the disease. If the febrile movement resembles that usual in typhoid fever, if it has continued for more than a week, if the patient has not been recently exposed to malarial influences, and presents no symptoms of local disease, the diagnosis may still be made with at least an approach to certainty.

The following are the diseases which are most likely to be mistaken for typhoid fever:

Typhus fever has a course which is so essentially different from {312} that of typhoid that in well-marked cases it would scarcely be possible to mistake one for the other. Cases, however, do occur which, in consequence of a very profuse and dark-colored eruption in the latter, or of the existence of abdominal symptoms in the former, present at first a good deal of difficulty in diagnosis. The invasion of the former is more abrupt and its duration shorter than in typhoid fever. The eruption is usually also much more copious, and appears in the former as early as the fourth, fifth, or sixth day, while that of the latter is rarely observed before the seventh day. The fever in the former is much more nearly continued in type than that of the latter. Defervescence occurs in the former by crisis; in the latter, by lysis. The expression of the physiognomy is different in the two diseases. In typhus there is a uniform dusky hue of the face, with injection of the conjunctivæ and contraction of the pupils. In typhoid fever the pupils are often widely dilated, the conjunctivæ clear, and the face pallid, with the exception of a circumscribed flush on each cheek. Diarrhoea is much less frequent in the former than in the latter, and when it does occur is not accompanied by ochrey-yellow stools. Epistaxis, tympanites, pain, and gurgling in the right iliac region, and intestinal hemorrhage, common symptoms in the latter, are very infrequently met with in the former. On the other hand, petechiæ and vibices, which are of almost constant occurrence in the former, are rarely met with in the latter. The circumstances also under which the two diseases are contracted are different. Typhus originates from overcrowding or is due to direct contagion. The origin of typhoid fever is often involved in more obscurity, but it can generally be traced either to a polluted water-supply or to defective drainage.

Relapsing fever, with due care, is not likely to be confounded with typhoid fever. The abrupt commencement of the former, the high fever, lasting for from five to seven days only, and terminating by crisis with a profuse sweat, and the period of complete apyrexia of a week's duration, followed by the relapse in which the temperature rises even higher than in the primary paroxysm, and which also terminates by crisis, form a chain of symptoms which has no counterpart in the latter. The mind in relapsing fever is usually clear, there being none of the hebetude and mental confusion commonly observed in typhoid fever. The rose-colored eruption is, moreover, wanting, and diarrhoea and tympanites are absent. On the other hand, jaundice and tenderness in the epigastric zone are more common than in typhoid fever.

Influenza sometimes, Murchison says, when epidemic, closely simulates typhoid fever, but as the two diseases occur in this country the resemblance between them is not often sufficiently strong to lead the careful observer astray. In both there are fever, prostration, sleeplessness, delirium and sweating, and occasionally deafness, diarrhoea, epistaxis, and a dry red tongue; but the onset of the attack in the former is more abrupt, its duration shorter, and subsequent convalescence more rapid than in typhoid fever. The prostration, too, is more decided in proportion to the degree of fever present. Coryza and bronchial catarrh are much more marked symptoms in the former than in the latter, while hyperæsthesia of the surface, which is present in almost every case of influenza, is only rarely met with in typhoid fever.

Remittent and typhoid fevers often prevail together in the malarious {313} districts of this country, and, as they present many points of resemblance, they are sometimes with difficulty distinguished from each other. They both may begin with nausea and vomiting; abdominal and cerebral symptoms are common to both, and so is enlargement of the spleen. The typhoid state may supervene in either, and in both the febrile movement is remittent in character. In remittent fever, however, the remissions are more marked, and are usually accompanied with more profuse sweating, than in typhoid fever. Jaundice and other symptoms of hepatic derangement are also more common, and the pains in the back and limbs are more frequent and more severe. The effect, too, of quinine in producing a permanent reduction of the temperature, is generally more decided. On the other hand, the rose-colored eruption of typhoid fever is never present in pure remittent fever. Occasionally, in cases of the variety of typhoid fever known as typho-malarial fever, the symptoms of the latter may be so prominent as entirely to mask those of the former. In such cases the discovery of a few rose-colored spots somewhere on the surface will clearly reveal the true nature of the disease.

Epidemic cerebro-spinal meningitis differs from typhoid fever by its more abrupt invasion, by the retraction of the head which rapidly supervenes, and by the appearance a short time afterward upon different parts of the body of petechiæ, which are not likely, even at first, to be mistaken for the rose-colored spots of typhoid fever. The fever has, moreover, no constant character, but is remarkable, on the contrary, for its great irregularity. The duration of the disease is in fatal cases much shorter, death taking place not infrequently within the first week, and occasionally as early as the second or third day. On the other hand, the duration in cases which recover may be even longer than in typhoid fever.

Simple continued fever may readily be mistaken in the beginning for typhoid fever, especially in those cases complicated by diarrhoea, but, as a general rule, the different character of the febrile movement, its more abrupt commencement and termination, and its shorter duration, together with the absence of the rose-colored eruption, will usually serve to distinguish it.

The eruptive fevers are always readily distinguishable at the period of invasion from typhoid fever, and the mistake of confounding them with the latter disease may generally be avoided by a close study of the character of the pyrexia. In the eruptive fevers the temperature rises abruptly, frequently attaining its maximum in the course of twenty-four hours, and sometimes in very much less time. There are also in all of them early symptoms which indicate pretty clearly their true nature, as, for instance, the sore throat of scarlatina, the naso-pulmonary catarrh of measles, and the rachialgia of small-pox. The uncertainty, moreover, is of short duration, as the characteristic eruption appears in all of them before the fourth day.

Acute tuberculosis of the lungs is the condition which in my experience has been the most difficult to distinguish from typhoid fever. Indeed, in some cases which have come under my observation physicians of recognized skill as diagnosticians have been unable to make the discrimination until after the death of the patient. Muscular prostration, a dry brown tongue, delirium, stupor, bronchitic râles, dyspnoea, and even cyanosis, are symptoms frequently met with in both diseases, so that when the {314} rose-colored eruption and enlargement of the spleen happen to be wanting in typhoid fever, or diarrhoea and tympany present in acute tuberculosis, as they may be, the distinction is often impossible. The diagnosis may, however, even in these cases, be sometimes made after a careful study of the temperature range, which in acute tuberculosis is irregular and rarely presents any resemblance to that which is typical of typhoid fever.

Acute tubercular meningitis has also many symptoms in common with typhoid fever, such as high fever, headache, vomiting, delirium, and stupor, but in the former disease the rose-colored eruption, epistaxis, enlargement of the spleen, and intestinal hemorrhage do not occur. Diarrhoea is also rare, and the abdomen, instead of being tympanitic, is flat, and in many cases even scaphoid. The headache, too, is much more acute than in typhoid fever, and is very apt to be associated with retraction of the head. Here, again, the frequent use of the thermometer will yield very important results in diagnosis, as the temperature range in tubercular meningitis is always irregular and does not present any resemblance to that usually observed in typhoid fever.

Several of the inflammations, especially when associated with the typhoid state, have so many symptoms in common with typhoid fever that they may very readily be mistaken for one another by a careless observer. I have known, for instance, the general disease to be entirely overlooked in a case of typhoid fever complicated by pneumonia, and, on the other hand, it has sometimes been supposed to be present in a case of pure typhoid pneumonia. Gastro-enteritis is another disease which is also occasionally confounded with typhoid fever. The diagnosis in these cases will rest principally upon the presence or absence of epistaxis, enlargement of the spleen, tympanites, the rose-colored eruption, and of a temperature range presenting some similarity to that usual in typhoid fever.

Trichiniasis is not likely to give rise to much difficulty in diagnosis, for although vomiting, diarrhoea, and the typhoid state occur in it as well as in typhoid fever, the former disease may usually be recognized by the severe muscular pains and the local oedema which are constant accompaniments of it, and by the absence of the characteristic symptoms of the latter.

PROGNOSIS.--There is no other disease in which the physician should be more careful in making a positive prognosis than in typhoid fever. On the one hand, accidents of a fatal character frequently occur in cases which are apparently progressing favorably, and, on the other, recovery has often taken place after all hope of it had been abandoned. But, although it is impossible to foretell with absolute certainty the result in any particular case, there are certain symptoms which furnish very important indications for prognosis, and the proper appreciation of which will generally enable us to arrive at a correct conclusion as regards the gravity of the disease. Prominent among these is the character of the pyrexia. A fever characterized by high temperature should always give occasion for great anxiety. This is very fully shown by the statistics of the hospital at Basle. Thus of those patients in whom the temperature did not reach 104°, only 9.6 per cent. died; of those in which it reached or exceeded 104°, 29.1 per cent. died; and, finally, of those in whose axilla the temperature rose to or above 105.8°, more than half died. {315} Wunderlich has arrived at very nearly the same conclusions, for he says that the prognosis is very unfavorable when the temperature rises to 106.16°, that the deaths are almost twice as numerous as the recoveries when it rises to 107.06°, and that recoveries are rare when it rises to 107.24°. Murchison has, however, known recovery to follow a temperature of 108°. The highest temperature recorded in any of my cases was 106° F. In this case, which proved fatal, the temperature reached 105° F. five times. In three other cases, in all of which recovery took place, a temperature of 105.5° F. was observed. In twelve cases the temperature reached 105° F. on more than one occasion. Six of these ended fatally; in the others the patients recovered.

The prognosis is more unfavorable in a fever in which the temperature is continuously high, and in which the morning remissions are slight or wanting, than in one in which the daily fluctuations are greater, even though the temperature may reach a higher point during the evening exacerbations in the latter variety than is attained at any time in the former. Occasional remissions, even if produced by quinia or other remedies, are to be regarded as favorable omens, as they indicate that the fever tends to subside. A high morning temperature ought, therefore, to give rise to more alarm than a high evening temperature. The prognosis is grave when the morning temperature rises to 104° or is persistently above 103°. Murchison says that recovery is rare after a morning temperature of 105°. Fiedler[91] saw, with a single exception, all patients die whose temperature in the morning rose to or exceeded 106.25°, while of those whose temperature in the morning rose to 105.44°, if only on one day, more than half died. Any marked deviation from the usual temperature range in the course of the fever is unfavorable. A rapid rise of temperature indicates increased danger: it may be due to the occurrence of a complication or of some other cause acting unfavorably upon the patient. A sudden and decided fall should excite even more alarm, as it is generally the consequence of a free intestinal hemorrhage. A temporary abatement of the fever, with amelioration of the other symptoms, occurring between the tenth and twentieth days, and giving rise to the hope that convalescence is about to commence, but followed by a return of the symptoms in an aggravated form, is also unfavorable. Such cases, according to Chomel, Louis, Bartlett, and Murchison, almost invariably terminate fatally.

[Footnote 91: Quoted by Liebermeister.]

The prognosis is bad in cases in which coma or wild or violent delirium comes on early. A moderate amount of delirium, especially when it occurs only at night or upon wakening in the morning, and is readily dissipated by attracting the patient's attention, or stupor which disappears when he is thoroughly roused, is not unfavorable. Insomnia, subsultus tendinum, carphologia, slipping down in bed, incontinence of the urine or feces, and retention of urine, are all symptoms of bad omen. Rigidity of the limbs is also a bad symptom; Dr. Jackson reports six cases in which this symptom occurred, only one of which recovered. Excessive subsultus is especially unfavorable, as it is generally most marked in cases in which the ulcerations of the intestines are most extensive. Extreme deafness occurs in mild as well as severe cases; it is therefore without significance in prognosis.

{316} In estimating the importance, in a prognostic point of view, of these various nervous symptoms, it is important to bear in mind that a degree of fever which produces no disturbance of the mental functions in a phlegmatic person will give rise to active delirium and other marked cerebral symptoms in a person of an excitable temperament.

A change in the character of the pulse and of the action of the heart is often the earliest indication of the approach of danger in typhoid fever, and both pulse and heart should therefore be carefully examined at every visit. The first change is usually a diminution in the intensity of the first sound of the heart. This is significant, as it is frequently the earliest premonition of cardiac failure, to which a large proportion of the deaths in typhoid fever is due. A pulse of 120 and over, especially if it is at the same time feeble, is also unfavorable. The important part which the frequency of the pulse plays in the prognosis is shown by the following observations made by Liebermeister at the hospital in Basle: Of 63 cases in which the pulse rose to or above 120, 40 were fatal, or nearly two-thirds. Among these 63 were 37 in which it did not rise to 140; of these, 19 were fatal, or about one-half; in 26 it rose above 140; of these, 21, or about four-fifths, were fatal. In 12 patients it rose above 150; of these, 11 died. Of those in which the pulse rose to 160, the only case that ended in recovery was that of a girl twenty-one years old suffering from an imperfectly developed typhoid. Intermittence of the pulse is unfavorable, especially, according to Hayem,[92] when it occurs during the first week of the disease. In convalescence intermittence is not to be regarded as an unfavorable symptom. The prognosis is bad also in those cases in which, with excessive weakness of the pulse, there are other evidences of cardiac failure, as, for instance, congestion of the lungs, cyanosis of the surface, coldness of the extremities. A very frequent pulse is not so unfavorable in a child as in an adult, or in a person of a nervous temperament as in one of a different disposition.

[Footnote 92: Loc. cit.]

Other unfavorable symptoms are a dry, brown tongue, excessive tympanites with great abdominal tenderness, severe diarrhoea, vomiting when it occurs late in the disease, intestinal hemorrhage, and colliquative sweats. The delusion sometimes observed in very severe cases, in which the patient declares that he is not ill, is a very bad sign, many authors, and among them Louis, asserting that they have never known recovery to take place after it has been manifested. Peritonitis is a very serious complication, whether due to perforation or to some other cause. Still, it would appear not to be invariably fatal, since recovery has occurred in cases in which all the symptoms of this complication were present.

Favorable symptoms, on the other hand, are a gradual decrease of the temperature with increasing morning remissions, moistening and cleansing of the tongue, a lessening of the delirium, and other nervous symptoms, reappearance of an intelligent expression, recognition by the patient of friends and attendants, and a diminution of the diarrhoea. A copious eruption is also regarded by many as a favorable symptom. Cases in which constipation exists generally do well. Nathan Smith never knew a patient to die whose bowels were constipated throughout the attack.

The death-rate of typhoid fever is found to vary very considerably in different years and in the different seasons of the year, as will be seen {317} from the two following tables. Statistics as to the mortality of the disease to be reliable must therefore be based upon a large number of cases extending over a series of years.

The following table shows the number of cases admitted into the Pennsylvania Hospital during each of the twenty years ending Dec. 31, 1881, and the ratio of mortality among them:

TABLE NO. 1.

-------+------+------+------+------+--------+--------+-------+------- | | | | | | | |Percen- | | | | | | | |tage of | | | | | | | | deaths | | | | | | | | after | | | | | | | |deduct- | | | |Number| | | | ing | | | | of | | | | cases | | | |deaths| Average| | | fatal | | | |within| stay | | | within | | | | 48 |in cases| | | 48 | |Number|Number| hours| ending | Average| | hours |Number| of | of | of | in | stay |Percen-| of | of |recov-| dea- |admis-| recov- |in fatal|tage of| admis- YEAR. |cases.|eries.| ths. | sion.| ery. | cases. |deaths.| sion. -------+------+------+------+------+--------+--------+-------+------- 1862 | 89 | 68 | 21 | 7 | 54-1/3 | 8 | 23.6 | 17.7 1863 | 36 | 33 | 3 | 2 | 32-1/5 | 3-1/3 | 8.3 | 2.9 1864 | 43 | 35 | 8 | 1 | 38-1/2 | 8 | 18.6 | 16.3 1865 | 36 | 31 | 5 | 1 | 38-1/2 | 5-1/2 | 13.9 | 11.4 1866 | 23 | 17 | 6 | 0 | 45-2/3 | 9 | 26.0 | 1867 | 24 | 20 | 4 | 0 | 37-1/3 | 6-1/2 | 16.6 | 1868 | 27 | 23 | 4 | 0 | 44-3/4 | 10 | 14.8 | 1869 | 21 | 16 | 5 | 1 | 35-1/2 | 14 | 23.8 | 20.0 1870 | 24 | 19 | 5 | 1 | 47-1/2 | 11 | 20.8 | 17.4 1871 | 32 | 26 | 6 | 1 | 37-3/4 | 13-1/2 | 18.8 | 15.0 1872 | 21 | 16 | 5 | 3 | 37-1/2 | 4-1/2 | 23.8 | 11.1 1873 | 12 | 8 | 4 | 2 | 34 | 9 | 33.3 | 20.0 1874 | 16 | 12 | 4 | 0 | 54-1/2 | 9-3/4 | 25.0 | 1875 | 20 | 18 | 2 | 1 | 48 | 4-1/2 | 10.0 | 5.3 1876 | 30 | 21 | 9 | 2 | 45-1/2 | 11 | 30.0 | 25.0 1877 | 48 | 34 | 14 | 4 | 48-1/2 | 12-1/2 | 29.2 | 22.7 1878 | 8 | 5 | 3 | 0 | 49 | 5-2/3 | 37.5 | 1879 | 17 | 15 | 2 | 0 | 53-1/3 | 8 | 11.8 | 1880 | 40 | 35 | 5 | 2 | 47 | 10-1/2 | 12.5 | 8.0 1881 | 54 | 48 | 6 | 0 | 41-3/4 | 8 | 11.1 | -------+------+------+------+------+--------+--------+-------+------- Totals,| 621 | 500 | 121 | 28 | 43-1/2 | 8-3/4 | 19.5 | 15.7 -------+------+------+------+------+--------+--------+-------+-------

Out of the 621 cases admitted, 121 were fatal. This gives a death-rate of 19.5 per cent.; but if we deduct the 28 cases in which the patients died within forty-eight hours of their admission, it falls to 15.68 per cent., or about the same ratio as Murchison found to exist among the cases treated at the London Fever Hospital. Other observers have obtained slightly different results. Thus, the mortality was 11.16 per cent. in 197 cases analyzed by Dr. Hale, and 13.5 per cent. in 303 cases collected by Dr. James Jackson. Dr. Cayley[93] found the death-rate of the several hospitals in London to be 17.8 per cent., and Geissler[94] that it was in all the German hospitals 12.8 per cent. in 1877, and 13.5 per cent. in 1878. Flint had 18 deaths in 73 cases, or 24.4 per cent. According to Liebermeister, the ratio of mortality at the hospital at Basle during the twenty-two years from 1843 to 1864, or before the introduction of a {318} systematic anti-pyretic treatment, was 27.3 per cent., and only 8.2 per cent. during the six years immediately following its adoption. As the results obtained at the Pennsylvania Hospital are apparently not so favorable as those reported at some of the continental hospitals, it is only proper to state that a large proportion of the cases were severe, that many of them were far advanced in the disease when admitted, and that very few of the patients were under twenty-one years of age. These are all circumstances which influence very decidedly the prognosis in typhoid fever. In no other city are the laboring classes able to surround themselves with so many comforts as in Philadelphia. This fact, fortunate as it is in the main, often operates to the disadvantage of the patient by enabling his family to indulge for a time the reluctance which it naturally feels to part with a member when sick. In the case of the young this reluctance is so hard to overcome that children with acute affections are rarely brought to hospitals for treatment. There were also special causes for the large mortality in certain years. This was particularly the case in 1862, when a large number of soldiers fresh from the battlefields of Virginia, and suffering from the typho-malarial form of the disease, were admitted into the hospital. Many of them were moribund upon admission, and others, exhausted by the fatigue incident to transportation here and by previous hardships, soon succumbed to the disease.

[Footnote 93: Med. Times and Gaz., 1880.]

[Footnote 94: Schmidt's Jahrbuch.]

Table 2 gives the number of cases, with the number of deaths occurring in each season, at the Pennsylvania Hospital during the last twenty years:

TABLE NO. 2.

-------------------------+---------+---------+---------+--------- | Spring. | Summer. | Autumn. | Winter. -------------------------+---------+---------+---------+--------- Number of cases | 89 | 259 | 182 | 91 Recoveries | 73 | 191 | 163 | 73 Deaths | 16 | 68 | 19 | 18 Percentage of mortality | 18.0 | 26.2 | 10.4 | 19.8 -------------------------+---------+---------+---------+---------

It will be seen from this table that the highest death-rate occurred in the summer and the lowest in autumn, while there was only a slight difference between the death-rate of spring and that of winter. Murchison's experience, based on a much larger number of cases, has led him to conclude that while the disease is a little less fatal in autumn, the difference in the mortality at different seasons is very inconsiderable. Chomel believed that the percentage of deaths was highest in France during the winter months, and Bartlett held the same opinion as regards America. Epidemics of great severity have undoubtedly prevailed in winter, as the in Lowell, Mass., referred to by Bartlett, but there can be little doubt that the death-rate is highest in this country during the warm months of the year. Dr. Cleemann[95] found that the monthly average mortality in Philadelphia for the ten years from 1866 to 1875 was highest in August, and next highest in September, confessedly the two months of the year when the heat in this city is most exhausting. I feel very sure I have lost patients with typhoid fever in these months {319} and in July who would probably have recovered if the weather had been cooler. With a temperature often rising above 90° F. at midday, and sometimes for several days at a time never falling below 80°, all radiation of heat from the surface of the body is arrested, and death frequently occurs as the result of hyperpyrexia.

[Footnote 95: Transactions of the College of Physicians of Philadelphia, 3d S., vols. ii. and iii.]

The stage of the disease at which efficient treatment is begun has a manifest influence upon the result. This is strikingly shown by some observations of Jackson: 90 cases were admitted into the Massachusetts General Hospital during the first week--of these 7 died, or 1 in 12.85; 139 cases were admitted in the second week--of these 16 died, or 1 in 8.68; 46 cases were admitted in the third week--of these 10 died, or 1 in 4.60; and 21 cases were admitted in the fourth week, and of these 5 died, or 1 in 4.20. Convalescence also occurred much earlier in those who were admitted early.

Murchison found that in a large number of cases the death-rate varied at different ages as follows: Under ten years it was 11.36 per cent.; from ten to fourteen years it was 12.86 per cent.; from fifteen to nineteen years it was 15.48 per cent.; from twenty to twenty-nine years it was 20.46 per cent.; from thirty to thirty-nine years it was 25.90 per cent.; from forty to forty-nine years it was 25 per cent.; and above fifty years it was 34.94 per cent.

According to Liebermeister, among the 1743 patients treated for typhoid fever in the hospital at Basle from 1865 to 1870, inclusive, there were 130 who were more than forty years old; of these 39, or 30 per cent., died, while the mortality among the patients under forty amounted only to 11.8 per cent. Among the cases of typhoid fever in individuals over forty years of age collected by Uhle, more than half proved fatal. According to Friedrich,[96] there were, among 16,084 children treated in the Children's Hospital at Dresden, 275 cases of typhoid fever, of which 31, or not quite 11 per cent., proved fatal. Age, therefore, exercises a positive influence upon the mortality of typhoid fever. Its influence is less decided in this disease than in typhus, in which the death-rate does not reach 4 per cent. until after the age of twenty, when it rapidly rises from 12.34 per cent. until it reaches 57.03 per cent. in patients above fifty years of age. The comparatively slight mortality of typhoid fever among children is probably due to the fact that the temperature is less often continuously high in them than in adults, and that while hyperpyrexia is frequently present, it is generally better borne and less likely to produce paralysis of the heart. Liebermeister says that the only case which he has seen recover after the temperature had repeatedly risen to 107.5° F. was that of a girl fourteen years of age. It is also said that the intestinal lesions are not so severe, and the liability to complications and sequelæ less marked, in children.

[Footnote 96: Quoted by Liebermeister.]

Typhoid fever appears to be a slightly more fatal disease in women than in men, for while in some local epidemics the percentage of deaths is greater among the latter than among the former, the reverse is found to be the case when the records of a large hospital for a number of years are carefully examined. According to Murchison, the mortality at the London Fever Hospital was about 1 per cent. higher among the female than among the male patients, and about the same difference in the death-rate {320} of the two sexes has been reported by continental physicians. A greater disparity even than this has been observed by Liebermeister at the hospital at Basle, where the death-rate for women was 14.8 per cent., and only 12 per cent. for men. Murchison says that this excess of mortality among the former cannot be accounted for by the influence of child-bearing upon the course of the fever, since it is much more decided between the ages of five and fifteen than in the period of child-bearing.

The rich are not only as liable to contract typhoid fever as the poor, but the disease is also quite as fatal among them. Murchison found from the statistics of the London Fever Hospital that the mortality is not greater among the destitute than among the better class of patients, and expresses the opinion that in private practice enteric fever is probably more fatal among the upper classes than among the very poor. Chomel and Forget seem to have reached a similar conclusion.

All authors agree that the prognosis is unfavorable in corpulent persons, not only on account of the diminished power of resistance to disease generally which such persons exhibit, but also because the febrile movement is often intense in them, and the degenerative changes of the muscles and organs of the body which it induces are generally early developed and of high grade. Liebermeister goes so far as to say that even in the case of ill-nourished, anæmic, or chlorotic individuals the chances for life are better than in the corpulent. Murchison has also expressed the opinion that a large, muscular development is likewise an unfavorable element in prognosis, having seen the strong and robust succumb to the disease oftener than the feeble. The mortality from the disease appears to be greater in certain families than in others. This has been ascribed by some writers to peculiarities of constitution, but it may be due to other causes, as, for instance, difference in the intensity of the poison. The disease is also often very fatal among the intemperate, who usually bear the disease badly in consequence of the presence of various degenerations of one or more of the important organs of the body caused by the excessive indulgence in alcoholic stimulants; paralysis of the heart being not an infrequent cause of death among them.

Certain epidemics have been exceedingly fatal, while in others the percentage of deaths has been very small. There can be no doubt that in most of these cases there has been a difference in the virulence of the poison. Recent residence in an infected locality has been shown by Murchison and other writers to have a decided influence in increasing the fatality of the disease. Second attacks are, on the other hand, usually mild. Some diversity of opinion exists among authors in regard to the effect that pregnancy has upon the course of the disease. Murchison believes that it is a far less formidable complication than is usually thought, while Liebermeister, on the contrary, holds a directly opposite opinion. He also regards the prognosis as unfavorable when the disease occurs in childbed or a short time afterward. Individuals with disease of the heart, emphysema, or bronchial catarrh who contract typhoid fever are said to be more liable to paralysis of the heart than others, hence the existence of these diseases materially diminishes their chances of recovery.

TREATMENT.--Inasmuch as the spread and propagation of typhoid fever may be prevented to a great extent, if not entirely, by the {321} employment of judicious sanitary measures, it is proper, before entering upon the discussion of its curative treatment, to devote a few words to the prophylaxis of the disease.

Whether the physician accepts the theory so ably advocated by Murchison, that typhoid fever may arise from exposure to the products of the fermentation of healthy feces, or adopts the view now held by a large number of investigators, that the disease is never generated in the absence of the specific germ, he will admit the great importance of an efficient system of sewerage, with a thorough flushing of the sewers at regular and frequent intervals, for disposing of the fecal discharges of the population of all towns, no matter how inconsiderable in size. No less important is it that the drains of every dwelling should be well constructed and kept in good order. They should be trapped just before they empty into the sewer, and should be provided with the means of thorough ventilation between the trap and the walls of the house by a free communication with the outer air. The soil-pipe should be carried up three or four feet above the top of the house, and every water-closet, bath-tub, stationary washstand, and sink should have its own separate trap, and none of them should be placed in rooms unprovided with a window or with some other sufficient means of ventilation. Physicians should, as sanitarians, urge upon the authorities of all cities and towns the importance of deriving their water-supply from a source unpolluted by sewerage or by any other substances likely to be deleterious to health. They should also see that when water is stored in a tank inside of a house the overflow pipe does not communicate directly with the drain, since if this is allowed to occur the water may very soon become contaminated with sewer gas, and consequently unfit for internal use.

In the case of isolated country-houses and of small villages some other means of disposing of the fecal discharges of the inhabitants than by sewers has to be found. In the great majority of instances no better way presents itself than by the ordinary cesspool. Care should, however, be taken that this is so constructed and situated that there can be no filtration of its contents into wells from which water for drinking is obtained.

As the alvine dejections of the sick are beyond question the medium by which typhoid fever is most frequently communicated to others, the importance of thoroughly disinfecting them before they have acquired the power of imparting the disease cannot well be overestimated. Liebermeister recommends that the bottom of the bed-pan should be strewed, each time before being used, with a layer of sulphate of iron, and that immediately after a passage crude muriatic acid should be poured over the fecal mass, as much as one-third or one-half of the bulk of the latter being used. He also urges, whenever it is practicable, that the contents of the bed-pan should be emptied into trenches dug anew every two days and filled up when discarded, care being of course taken that they are not located anywhere in the vicinity of wells. Murchison seems to prefer carbolic acid to other chemical agents as a means of preventing fecal fermentation. For this purpose the liquid carbolic acid may be diluted with water in the proportion of 1 to 40 to 1 to 20, or it may be mixed with sand or sawdust. I have myself employed as a disinfectant with success the solution of the chlorides sold under the name of Platt's chlorides. As the discharges must in cities, in the great majority of instances, be emptied into {322} water-closets, these should be freely flushed with water after every time they are used; and it is well to impress upon the attendant on the sick the importance of doing this. The bed-linen of the patient and his clothes, if they are soiled by his discharges, should be removed as soon as possible, and subjected to a high degree of heat (248° F.) or soaked in a solution of the chlorides or of carbolic acid for several hours before being washed. If these precautions are observed, cases of typhoid fever may be treated in the wards of general hospitals without danger to the other patients.

In the doubt and obscurity which generally envelop the diagnosis of the disease when the physician is first called upon to treat it, it is impossible to lay down any positive rules for the management of typhoid fever at its commencement. But even in those cases which begin insidiously, if the patient is carefully examined enough of the early symptoms of typhoid fever will be detected to put the physician on his guard. The thermometer will show the existence of fever, which has a tendency to increase at night. There will generally be found to be a little diarrhoea, or at least an increased susceptibility to the action of purgative medicines; perhaps a little tympany and tenderness in the right iliac fossa, and moreover a prostration which is out of all proportion to the other symptoms.

These symptoms, it is true, are not infrequent concomitants of many diseases besides the one under consideration; but when their presence cannot be otherwise satisfactorily explained, especially if they have continued for several days, it is a safe rule in practice to regard the case as one of typhoid fever, and to regulate the treatment accordingly. The patient must be put to bed at once, and not allowed to leave it on any pretext, not even to empty his bladder, after the first week. This is a rule which should be rigidly enforced in every case, no matter how mild the symptoms may be. Its non-observance, either through the neglect of the physician or the ignorance or wilfulness of the patient, has been the cause of some disastrous results; in illustration of which it is only necessary to refer to the frequency with which perforation of the bowel occurs in walking cases of typhoid fever. Perfect quiet should be maintained in the sick room. Visitors should be excluded from it, and the attendants limited in number to those actually necessary to carry out the directions of the physician. All unnecessary talking is to be avoided, and especially conversation carried on in a low tone of voice, which is always annoying to the sick.

There is only one condition under which I should be disposed to break the rule of absolute quiet and rest laid down above, and that is when called upon to treat typhoid fever in the built-up portion of our large cities during the summer season. If the patient were still in the first week of the disease, if his circumstances were sufficiently affluent to enable him to surround himself with every comfort, and if it did not involve a journey of more than a few hours, I should unhesitatingly send him to the sea-coast. I have so often seen cases prove fatal in summer in consequence of the great heat of the city--a heat, too, which is sometimes almost as great at night as in the day-time--that I should feel that I was giving him an additional chance of life by sending him where the heat was, at least occasionally, tempered by cool breezes from the ocean. During the late war numbers of soldiers were frequently sent in the early stages of {323} typhoid fever from the camps in the South to their homes or hospitals in the North, and it is fair to say that they did at least as well as those who remained behind. But when the journey may be accomplished by means of Pullman cars and the other appliances of modern travel the risk, and even discomfort, it involves to the patient is reduced to the minimum.

As the disease is usually one of long duration, the patient being rarely able to leave his bed under four weeks, and more frequently being obliged to keep it for a much longer time, the sick room should, wherever practicable, be large, airy, and provided with an open fireplace, which is a much more efficient means of securing thorough ventilation than an open window, while it is not liable to the objection sometimes applicable to the latter of causing a direct draught upon the patient. It is well, however, for the physician to remember that the danger from this source is very much exaggerated by the laity, and that patients in the febrile stage of typhoid fever do not readily take cold. Still, the same end may generally be attained without the least risk to the patient by opening a window in an adjoining room. The temperature of the sick room should be steadily maintained at between 65° and 68° F.

The careful regulation of the diet is also a point of great importance in the management of typhoid fever; for in this disease there are not merely the high fever and other exhausting symptoms, speedily inducing excessive prostration, loss of strength, and emaciation, common to many fevers, but there is also the peculiar ulceration of the bowels, which gives rise to danger of its own and demands special consideration in treatment. The food must therefore be not only nourishing, but also readily digestible, and not likely to create irritation in its passage through the intestines. All solid food should therefore be excluded from the dietary of the patient as long as the fever lasts. Indeed, it is better to continue this prohibition even after the subsidence of the fever if rose-colored spots are still to be seen on the abdomen or elsewhere, or if there exists a tendency to diarrhoea or any other symptom indicating that the disease has not fully run its course. Having myself seen some rather disastrous results from a too early return to solid food, I have been accustomed in my own practice to interdict its use until at least two weeks after the beginning of convalescence. Jaccoud also lays much stress upon this point, saying that the early administration of meat always gives rise to fever, to which, from its cause, he gives the name of febris carnis. On the other hand, Flint[97] and Peabody have recently advocated the giving of solid food immediately after the cessation of fever, in the belief that recovery is thereby promoted. Milk as an article of diet is unquestionably to be preferred to all others in typhoid fever. It is open, it is true, to the objection of occasionally forming tough curds in the stomach, but this may generally be prevented by giving the milk in small quantities at a time, diluted with lime-water or barley-water or mixed with some farinaceous substance. No positive general rule can be laid down as to the amount to be given. This will be found to vary not only in different cases, but also in the same case at different times. Indeed, in those cases which begin abruptly with symptoms of gastro-intestinal irritation, if it is forced upon the patient in large quantities it is not only usually rejected, but also causes an aggravation of the symptoms, while after {324} this irritation is allayed it will be digested without difficulty. As a general rule, most adult patients will be able to take from a quart and a half to two quarts of milk daily, given in quantities of from four to six ounces every two or three hours. It should be remembered, however, that if more is taken than can be assimilated it will act as an irritant and increase the diarrhoea. If, therefore, the stools contain undigested milk, the quantity should be diminished. Patients are occasionally met with, but not in as great number as is often asserted, with whom milk habitually disagrees. In these cases it must of course be replaced in whole or in part by some other article of food. Under these circumstances some one of the liquid preparations of beef may be given with advantage, although it may be objected to them also that they sometimes occasion an increase of diarrhoea. Beef-tea or beef-essence, made from the fresh meat whenever this can be obtained, is to be preferred to all others; but when it cannot, that made from the preparations of Johnston or Brand is the best substitute. When the stomach is very irritable, Valentine's meat-juice, in consequence of the smaller bulk in which it is given, often answers an admirable purpose.

[Footnote 97: Medical News, Mch. 29 and Apl. 5, 1884.]

Various farinaceous substances, such as farina, corn-starch, and arrowroot, are also occasionally given in typhoid fever, and, although the last named would seem to be indicated in cases in which diarrhoea is a prominent symptom, their tendency to cause flatulence is so great that their use in the acute stage of the fever has not found favor among physicians generally. In convalescence, on the other hand, they are generally perfectly well borne.

The subject of the administration of alcoholic stimulants in typhoid fever may be conveniently considered in this connection. Some difference of opinion exists in regard to the quantity in which they should be given, and indeed in regard to the necessity for their use at all in many cases, as, for instance, in those of young persons whose health and habits had been good previously to the attack. I have myself treated several such cases without alcohol, and have not been able to perceive that their duration was longer and the result less favorable than in cases in which it was given in the usual amount. It is, moreover, not necessary to prescribe it always, even in very severe cases, at the beginning of an attack. When given at this time, it not infrequently does harm by increasing the fever. It should be reserved, therefore, until the action of the heart grows feeble and the first sound becomes indistinct. It is not possible to lay down any general rule as to the amount to be given, even in severe attacks. This will vary in different cases, and to a certain extent will be determined by the effects it produces. If the pulse grows stronger and the delirium diminishes under its use, it is doing good and should be continued; if, on the other hand, there is increase of delirium and restlessness, the quantity should be diminished.

In cases in which only a gentle stimulus is required wine in the form of wine-whey will often be found to meet the indication fully. Generally, however, it will be necessary to have recourse to whiskey or brandy. The choice between these may usually be left to the patient's fancy; brandy is, however, to be preferred in cases in which diarrhoea is a prominent symptom. These stimulants should be given in small quantities frequently repeated. In many cases a dessertspoonful every two or three hours, {325} either diluted with water or, when the stomach is irritable, with carbonic acid water or given in the form of milk punch, will be sufficient. In others a tablespoonful every two hours, or even at shorter intervals, will be required, but it will rarely be necessary to exceed eight ounces a day for more than a few days at a time.

Although the physician will not often be called upon at the present day to encounter and combat the prejudice so common formerly against the free administration of water in the febrile condition, he will frequently find nurses and others not sufficiently alive to the importance of supplying it when the patient, having fallen into the typhoid state, ceases to ask for it. The high temperature which is generally present in this condition, and the rapid combustion of tissue which it causes, make a full supply of liquid an urgent necessity which it is dangerous to disregard. Water is the best of all diuretics, and it is important in this disease, as indeed it is in many others, that the functions of the kidneys should be kept active, so that the products of the combustion of the tissues may be eliminated with their secretion. Care, however, should of course be taken, as pointed out by Da Costa,[98] that water is not given in such quantity that the desire for and capability of digesting food is destroyed by it.

[Footnote 98: Preface to Wilson's Treatise on the Continued Fevers.]

In the few cases which begin abruptly with symptoms simulating those of a so-called bilious attack the practitioner will usually content himself with the administration of medicines calculated to allay the irritability of the stomach and bowels. For this purpose I have found the bicarbonate of potassa in solution, to which lemon-juice is added at the moment it is taken, so as to produce an extemporaneous effervescing draught, often an admirable remedy. In other cases I have used with advantage small doses of calomel or blue mass, followed, if necessary, by a gentle saline purge. When the symptoms have occurred soon after a hearty meal, or when there is evidence that the stomach is overloaded, it will occasionally be necessary to have recourse to an emetic. Usually, the indications for treatment at the beginning of an attack are much less definite, and even in the class of cases just referred to they become so after the subsidence of the gastro-intestinal symptoms. Indeed, the treatment in the larger number of cases must be purely symptomatic until the nature of the disease has fully declared itself. The presence of fever will suggest the use of the neutral mixture, effervescing draught, or spirit of Mindererus, combined, if there is decided tendency to evening exacerbations, with sulphate of quinia in full doses. If there is much diarrhoea, Hope's camphor mixture or opium in some other form may be given; if delirium is a prominent symptom, ice or cloths wrung out of cold water should be kept constantly applied to the head.

But even after all doubt in regard to the diagnosis has been dispelled and the existence of typhoid fever has been recognized, the treatment most in favor with physicians is in large measure symptomatic in character. It is true that various specific treatments, to which fuller reference will be made hereafter, have been lately proposed, but the results obtained by them up to the present time where they have been fairly tested are not so favorable as to induce the body of the profession to adopt them to the exclusion of all other methods. It is certain that no remedy or plan of {326} treatment has yet been discovered which has the power of cutting the disease short, although this power has been claimed at different times for several. Thus, at one time quinia in very large doses was believed to possess it, at another venesection, and at another cold baths. But experience has shown that these and other perturbating remedies often do harm, and there is good reason to believe that the apparent good which has followed their use in a comparatively small number of instances may be better explained by supposing that an error of diagnosis has been made than by attributing to them the power of arresting the progress of the disease. Medicines are, however, by no means useless in the treatment of typhoid fever. There is no question that the disease is not only generally conducted to a favorable issue, but that its duration is often materially shortened, by their judicious use. It is evident, however, that the treatment must vary with the severity of the attack. In a few cases it is scarcely necessary to interfere with the course of the disease by the administration of medicines. In others, on the contrary, it is necessary to act promptly and energetically in order to save life.

When called upon to treat typhoid fever, if the case is a mild one with no bad symptoms, such as excessive diarrhoea, delirium, tremors, and the like, and especially if the temperature does not rise higher than 102° F., I am accustomed, after giving minute directions as to the diet and general care of the patient, to prescribe from two to three grains of sulphate of quinia four times daily. No great power in reducing the temperature of the body can, of course, be claimed for these doses, but experience has shown that the impression which they make is useful, and they do not interfere with the administration of the drug in larger quantities should this become necessary. Their action, too, is tonic, and, as they rarely produce cinchonism, the objection often made to the use of larger doses does not apply to them. I am also in the habit of adding to each dose of quinia from ten to fifteen drops of one of the mineral acids. These acids were originally prescribed in typhoid fever under the impression that they neutralized the cause of the disease, which was supposed to be an alkaline poison. Although the results of recent research, which tend to show that the cause of the disease is an organized germ, give no support to this theory, they continue to be used by a large number of physicians of experience. I do not know that any satisfactory explanation of their action in typhoid fever has ever been given. They are certainly tonics, and are therefore indicated, if not in the beginning of the disease, as soon as the strength begins to fail. If, as the disease progresses, the tongue becomes dry and fissured, and if there is much tympany, it will be well to give, in addition to the quinia, ten drops of the oil of turpentine in mucilage every two hours. This was a favorite remedy of the late George B. Wood, the distinguished professor of the Theory and Practice of Medicine in the University of Pennsylvania, who attributed the improvement in the symptoms which generally follows its use to a direct influence of this medicine upon the ulcers in the intestines. Although inclined to believe that the correct explanation of this improvement is its stimulating action upon the circulation and secretions, I fully agree with him in regard to its usefulness in many cases. Under its use I have often seen the dry, fissured, and shrivelled tongue {327} grow moist and throw off its coating much earlier than in all probability it would otherwise have done.

No other than this simple treatment is required in a large number of cases, but even in mild cases symptoms occasionally arise which render necessary some modification of it. It will, however, be more convenient to postpone the discussion of this part of the treatment of typhoid fever until after the treatment of the more serious forms of the disease has been considered.

When typhoid fever assumes a severe type, the success of the physician in the management of the disease will depend largely upon the readiness with which he detects indications for treatment and the promptness with which he meets them. Usually, one of the first symptoms to demand attention is the high temperature. This is not only an early symptom in many bad cases, but may continue throughout the attack; or it may suddenly supervene in cases in which the fever has previously been moderate in degree, and when excessive may be the direct or indirect cause of death. The reduction of the temperature is therefore an indication the importance of which cannot well be overestimated. Fortunately, there are several methods by which this end may be accomplished. It will, however, be necessary for our purpose to consider only two of them in detail: 1, the cold-water treatment; 2, sulphate of quinia in full doses.

The cold-water treatment is not new, since it was practised in the form of cold effusion in the treatment of fevers as long ago as 1787 by Currie of Liverpool, who may be said to have introduced it, and who asserted that it had the power not merely of moderating the symptoms of these diseases, but also, in many cases, of cutting them short. It enjoyed at first a high degree of popularity, which lasted for from twenty to thirty years, but finally fell into disuse, probably in consequence of the exaggerated character of the claims which were made for it by its advocates. Although resorted to from time to time in various parts of the world, the merit of having brought it again into notice seems to be due to Brand of Stettin, who published a work on The Hydrotherapy of Typhoid Fever in 1861. Still more recently, the recorded observations of Bartels, Jürgensen, Ziemssen, and Liebermeister in Germany, and of Wilson Fox and others in England, have so far restored the treatment to professional favor that there are few physicians either in this country or abroad who do not occasionally have recourse to it.

The cold-water treatment may be applied in several different ways: 1, the cold bath; 2, the graduated bath; 3, cold affusions; 4, the cold pack; 5, cold sponging; 6, cold compresses; and 7, frictions with ice. They all act in the same manner, and depend for their efficacy upon their power of abstracting heat from the body, and are useful just in proportion as they do this. There is no reason for believing that they have the power to modify the conditions upon which the production of heat depends, but there is, on the other hand, no doubt that under their use distressing and dangerous symptoms, such as coma, stupor, subsultus, and the like, are often much relieved. They probably act, therefore, by diminishing the metamorphosis of the tissues, and the consequent loading of the blood with excrementitious products which the hyperpyrexia has a tendency to promote.

The cold bath is the most effective of all the methods of applying the {328} cold-water treatment. Liebermeister recommends that the bath for an adult should be at the temperature of 68° F., and its duration should be about ten minutes; if, however, the patient shows signs of great weakness, it should not exceed seven. After the bath he should be wrapped up in a dry sheet or light blanket and put back in bed. If the pulse should then show signs of failing, or if there should be shivering or any other evidence of weakness, he should be given a glass of wine or brandy or a dose of some other diffusible stimulus, and bottles containing hot water should be applied to his feet. The process of cooling goes on for some time after the patient's removal from the bath, for while a thermometer placed in the axilla will show that the external temperature is immediately affected by it, the same instrument placed in the rectum will indicate a gradual fall, which will continue in many cases for at least half an hour. Shortly after this the temperature will be observed to rise, and in many cases it will not be more than two hours before it has attained its former height. Liebermeister therefore recommends that the thermometer should be frequently used, and that the baths should be repeated as often as the temperature rises to 103° F. or above it. He has himself given them as often as every two hours, or as many as two hundred during an entire illness, but usually finds that not more than six or eight a day are required. It often requires some persuasion to overcome the repugnance which most patients feel at first for these baths, and the shock of being suddenly immersed in cold water is agreeable to very few. Later, this repugnance, he says, entirely disappears. Intestinal hemorrhage, perforation of the bowel, and great weakness of the heart's action are all contraindications to the use of the cold bath. They are especially to be avoided, according to Liebermeister, when the force of the circulation is so far reduced that the surface of the body is cold while the interior is very hot. On the other hand, the advocates of this plan of treatment contend that the existence of pneumonia or of hypostatic congestion of the lungs is not a sufficient reason for abandoning it, the congestion often disappearing under its use.

The graduated bath possesses some advantages over the cold bath, as its use involves less of a shock to the system. It is therefore more suitable than the latter for nervous and excitable patients, for persons of advanced age or of general feebleness of constitution, or for very young children. In it the temperature of the water, which at the time of the immersion of the patient should be at or above 95° F., is cooled by the gradual addition of cold water until it is reduced to 72°, or below this point. These baths, to produce the same effect as the cold baths, must be of longer duration. They are contraindicated in the same conditions as the latter, but to a less degree.

Although fully willing to admit the good effects of the cold bath in many cases, having been, of course, myself a witness of them, I am indisposed to have recourse to it except in cases of hyperpyrexia of such intensity that death seems imminent and only to be averted by energetic treatment, or in cases in which other antipyretic remedies have failed to reduce the temperature; and for the following reasons: 1. In the first place, it is generally possible to produce a decided effect by the other methods of applying the cold-water treatment, with much less discomfort to the patient. 2. In a private house it is not always practicable to have {329} a bath brought to the bedside of the patient, and in a general hospital to do so often would occasion a good deal of annoyance to the other patients in the same ward, and I have seen ill result from carrying him some distance to the bathroom. But even where the bath is brought directly to his bedside, it involves so much movement, and is sometimes the cause of so much excitement, that its good effects are more than neutralized by its bad.

Cold affusions, while not nearly so efficacious in reducing the temperature of the body as the cold bath, are open to many of the objections which may be urged against the latter mode of treatment. They are, therefore, rarely employed at the present time. Liebermeister, however, thinks that they may sometimes be resorted to with good effect for their brisk stimulating effect on the psychical functions or the respiration.

The cold pack possesses the advantage over the cold bath and cold affusions of involving less movement on the part of the patient and of being less terrifying to children, and may therefore be resorted to in cases in which the latter method of applying the cold-water treatment is contraindicated, as, for instance, in persons of feeble circulation. It is, however, inferior to either of them in its cooling effects, and must be longer applied to produce the same effect. Liebermeister estimates that a course of four consecutive packs, of from ten to twenty minutes' duration apiece, is about equivalent in effect to a cold bath of ten minutes.

Cold sponging is assigned a very low place among the methods of abstracting heat from the body by many writers. It has, however, often been in my hands of much service, and its easy application and the comfort which patients derive from it are certainly strong recommendations in its favor. I have employed it frequently in cases of intestinal hemorrhage, and even in cases of great debility, and have never yet had any reason to repent my having done so. The addition of a little vinegar to the water has seemed to me to increase the effect of the sponging.

Cold compresses, either in the form of cloths wet with cold water or bladders filled with ice, can only produce a local fall of temperature, and therefore, except when applied to the head, can be of little service.

Frictions with ice are a powerful means of depressing the temperature of the body, and may therefore be resorted to in cases of intense hyperpyrexia when for some reason the cold bath cannot be obtained, and when there are no contraindications to the latter.

Liebermeister classes cold drinks, the internal administration of ice, and the injection of cold water among the means of cooling the body in fevers; but it is doubtful if any great reduction of temperature can be brought about by any of these remedies in the quantities in which it would be safe to use them. The first two, and to a less extent the last, meet a very important indication, that of supplying water to the system. Their free use, therefore, forms a very important part of the treatment of typhoid fever.

Luton of Rheims[99] extols the Diæta hydrica in the treatment of typhoid fever. The patient receives absolutely nothing else to drink but water, which is given in large quantities, for from four to six days. No nourishment is given until the beginning of the third week, and first of all milk. If fever returns, the water is given again. Medicines such as {330} quinia and eucalyptus are given in adynamic conditions, which Luton says are rare under this treatment. He believes that the increase of the typhoid germs is prevented by absolute diet and abundant supply of water.

[Footnote 99: Journal de thérapie, Oct., 1880.]

Quinia to produce a decided antipyretic effect must be given in large quantities. Murchison says that a dose of from fifteen to twenty grains causes within an hour or two a fall of the temperature, and, to a less extent, of the pulse, which may last from twelve to eighteen hours, and that he has never known any other disagreeable symptoms result from its use than noises in the ears, temporary acceleration and irregularity of the respiration, and occasional vomiting. This quantity will often, however, be found to be insufficient to produce a notable reduction of the fever, and it is therefore necessary occasionally to increase it. Liebermeister usually gives to adults from twenty-two to forty-five grains of the sulphate or the muriate of quinia, and this dose must positively be taken within the space of half an hour, or, at the most, an hour, as it is useless, he says, to expect the full benefit of this dose to appear if the dose is divided and its administration is extended over a longer time. He never repeats it in less than twenty-four hours, and, as a rule, does not give it again under two days. Jürgensen has exceeded the dose of forty-five grains without observing any bad effects from it. When these large doses are taken the fall of the temperature usually begins a few hours after the administration of the medicine, the minimum being reached in from six to twelve hours, and it is usually not until the second day that the temperature attains its former height. It is found in practice that the most decided results are obtained when the medicine is given in the evening, so that the time of its fullest antipyretic effects will coincide with that of the morning remission. When these large doses produce vomiting, as they occasionally will, the quinia must be given by the rectum or hypodermically.

Quinia possesses the great advantage over the cold bath that it may be given in conditions in which it would be dangerous to resort to the latter. The existence of great cardiac weakness, of perforation of the bowel, or of intestinal hemorrhage do not usually constitute contraindications to its use. In my own practice I have not often found it necessary to have recourse to much larger doses than those recommended by Murchison, preferring to repeat them if necessary rather than to give a single dose of even half a drachm.

It will be well, in this connection, to allude briefly to a few other remedies which have been given for their antipyretic effect. One of these is digitalis, which has been administered for this purpose in very large doses. Thus, Liebermeister recommends that from eleven to twenty-two grains should be given in the course of thirty-six hours. I have never used this drug in these doses, and therefore cannot speak of its effects from personal knowledge of them. I have frequently had recourse to it, however, in more moderate doses, and I think with advantage.

Another is sodium salicylate. This remedy has been used largely in England and Germany, and to a less extent in this country. It has been claimed for it that it has the power of destroying the germs of typhoid fever, but Stricker[100] finds it difficult to accord it this property in the face {331} of the fact that he has had three cases of typhoid fever under his observation which occurred in patients just recovered from rheumatism, which had been treated by this drug. My own experience with it in the treatment of this disease is small, but has been unsatisfactory. While it is undoubtedly an antipyretic, the pulse becomes weak and the inspiration less strong under its use. The brain symptoms do not diminish under its use. Indeed, it is said to produce narcotism in some cases. Dr. Jahn[101] and Dr. Jh. Platzer[102] speak more favorably of it, but admit that its administration is occasionally attended by the inconveniences above referred to. The verdict of the profession in regard to it, tersely expressed by one who had given it a fair trial, appears to be that it is a remedy that brings nothing but disappointment to the physician and disaster to the patient.

[Footnote 100: Deutsche Milit.-arztl Zeitsch., 1877.]

[Footnote 101: Deutsches Arch. f. klin. Med., 1877.]

[Footnote 102: Bayr. Arztl. Intell. Bl., 1877.]

Eucalyptus, in the form of the tincture, is also a favorite remedy with many practitioners. Dr. Benj. Bell[103] is in the habit of giving a teaspoonful every three or four hours in a wineglass of water, and asserts that it diminishes the tendency to diarrhoea and the duration of the illness.

[Footnote 103: Edin. Med. Jour., Aug., 1881.]

The different varieties of typhoid fever require slight modifications only of the treatment laid down above. In the typho-malarial form, especially in those cases in which the malarial element predominates, and in which there is a marked tendency to remission, the early administration of quinia in full antiperiodic doses is urgently called for. In some cases which he had the opportunity of observing in the army, A. L. Cox[104] found great advantage from the use of arsenious acid in rather large doses. When the disease attacks elderly people, an early resort to alcoholic stimulants is usually necessary, in consequence of the excessive prostration it induces in them. Henoch and Steffen[105] assert that cold baths are not so well borne in children as in adults. Their influence is transitory only, and their use has sometimes been followed by fatal collapse. In the renal form dry, and in some cases cut, cups should be applied externally and saline diuretics given internally.

[Footnote 104: Outlines of the Chief Camp Diseases of the United States Armies, by Joseph Janvier Woodward, M.D., Philada., 1863.]

[Footnote 105: Jahrb. f. Korhde, 1880.]

SYMPTOMS REQUIRING SPECIAL TREATMENT.--Vomiting, when it occurs early in the disease, is usually checked by the administration of an emetic and by the application of sinapisms to the epigastrium. The use of emetics is no longer advisable when it occurs after the first week. It is better then to trust to small doses of hydrocyanic or carbolic acid, aromatic spirit of ammonia, or bismuth. It will often be found that lime-water and milk will remain upon the stomach when every other article of food or medicine is rejected. In some severe cases which have been under my care the symptom was permanently relieved by the frequent administration of small quantities of brandy in iced soda-water. When vomiting is a consequence of peritonitis it usually resists every form of treatment.

Diarrhoea, if the number of the stools does not exceed two or three in the course of twenty-four hours, does not need special treatment. When, however, it is more severe, prompt measures should be taken to check it. Under these circumstances laudanum injections have seemed to me to be {332} by far the best remedy. It is not necessary that these injections should always contain a large amount of laudanum or that they should be repeated frequently. In many cases twenty drops once a day will be found to be sufficient, and it is rarely necessary to exceed forty drops twice daily. Opium given by the mouth or in suppository in equivalent quantity does not act with anything like the same efficacy. If the laudanum injections fail to restrain the diarrhoea, it will be well to have recourse, in combination with opium, to the subnitrate of bismuth or the acetate of lead. Nitrate of silver was at one time much employed in the treatment of typhoid fever, especially by the late J. K. Mitchell of this city, but was afterward suffered to fall into neglect. Its use has been recently, to a certain extent, revived in consequence of the recommendation of William Pepper,[106] who claims for it the power of modifying the course of the disease. I have given it in a number of cases, but have never been able to satisfy myself that it possessed this power. I have therefore ceased to prescribe it except in the later stages of the disease, when the symptoms indicate that the intestinal ulcers are in an atonic condition. Under these circumstances it has appeared to me to promote their cicatrization. It is important, however, to remember that diarrhoea is occasionally caused and kept up by more food being given to the patient than he can assimilate, and it is therefore a good rule to examine the stools from time to time to see whether they contain curds of milk or other undigested food. If such is found to be the case, the amount of nourishment should be diminished, and it will be well also to prescribe pepsin either in powder or in solution.

[Footnote 106: Philadelphia Medical Times, Feb. 12, 1881.]

Tympanites also occasionally requires treatment, for in addition to interference with the descent of the diaphragm and other discomfort it produces, the distended condition of the bowels directly increases the risk of perforation. It is usually sufficient to employ embrocations or stupes of equal parts of sweet oil and oil of turpentine, or of camphor liniment. If the tympanites coexist with constipation, enemata, either with or without a small quantity of oil of turpentine, may often be used with advantage. If it is extreme, an intestinal tube should be introduced very carefully into the rectum and the gas drawn off. Charcoal has occasionally been administered in this condition with a view of preventing decomposition of the intestinal contents. Tympanites occasionally rapidly supervenes upon the occurrence of perforation, and must then, of course, be treated with due reference to the latter condition.

Intestinal hemorrhage is a symptom which always demands prompt attention, no matter how slight it may seem to be, for it is to be remembered that not only is there a danger of its recurrence, but that the quantity of blood which appears in the stools is by no means a reliable measure of that actually lost, as more blood frequently remains in the intestines than appears externally. In estimating its severity, it is therefore proper to take into consideration the gravity of the other symptoms which attend it, such as the fall of temperature, feebleness of the pulse. In many cases the enforcement of absolute rest, with the administration of cold drink and a small amount of opium to diminish peristaltic action, is all that is needed. In cases in which the symptoms are graver it will be necessary to have recourse to more energetic {333} measures. Under these circumstances the hypodermic injection of from three to five grains of ergotin, repeated if necessary, has seldom in my experience failed to check the hemorrhage. Dilute sulphuric acid, oil of turpentine, and acetate of lead have also proved themselves useful remedies in my hands. The application of ice to the surface of the abdomen has also been said to be attended with good results, but the objections to the use of this remedy in the condition of collapse, which is so apt to accompany profuse intestinal hemorrhage, are so evident that it is unnecessary to discuss them here. Monsel's solution, tannic acid, and various other mineral and vegetable astringents have been recommended for their direct effect upon the bleeding surface, but, even admitting that they can, when administered by the mouth, reach this unaltered or in a sufficient state of concentration to be active, it is evident that they could only do so after the loss of valuable time.

When perforation occurs, it is obvious that the indications for treatment are to preclude the extravasation of the contents of the intestine into the cavity of the peritoneum, and to prevent the peritonitis which is a consequence of this accident from becoming general. Both of these indications are met by the administration of opium, which diminishes, and, if pushed, arrests, the peristaltic action of the intestines. By means of it the bowels may be kept as free from movement as if "placed in splints." A grain of solid opium may be given every hour until a decided effect is produced, or if it is found to disagree with the stomach an equivalent quantity may be given by the rectum, or it may be substituted by morphia administered by the mouth or hypodermically. With the same view, food is to be allowed in small quantities only at a time, and of a character capable of digestion by the stomach. A light poultice, or, if there is much evidence of inflammation, ice should be applied to the abdomen. It has been recommended also, in cases in which the peritonitis has become general, to apply leeches to the abdomen, but few patients in this condition will readily bear the loss of much blood. It is very important not to interfere with the constipation which results from the above treatment, and which it is one of its objects to promote, until all inflammatory symptoms have been absent for at least a week, when a simple enema may be administered. Peritonitis resulting from other causes than perforation of the intestine does not require any modification of the above treatment.

Severe abdominal pain, when it occurs independently of inflammation, is best treated by the application to the abdomen of light poultices, to which two or three teaspoonfuls of laudanum may be added.

Constipation is an occasional symptom, but it rarely calls for active interference. When it is present so early in the course of the disease that the diagnosis is still uncertain, and has continued for several days, it is best to prescribe a small dose of castor oil; a dessertspoonful is generally sufficient. The late Dr. Gerhard was in the habit of giving a tablespoonful of sweet oil in this condition. The inordinate action which frequently follows the administration of these mild purgatives will often dispel all uncertainty as to the nature of the disease we have to do with. When it occurs in a more advanced stage of the disease it is best met by the administration of enemata, which may contain, if there is much tympanites present, a small quantity of oil of turpentine. Under all {334} circumstances it will be well to remember the advice given by Baglivi two centuries ago, to avoid the use of active cathartics in this disease.[107]

[Footnote 107: "Fuge purgantia tanquam postem," Opera Omnia Medico-Practica et Anatomica, Georgii Baglivi, 1788.]

The headache which is sometimes a distressing symptom in the beginning of the disease is usually relieved by the application to the head of cloths constantly wet with ice-water or by that of a bladder filled with ice and lard. If it is very severe and does not yield to these remedies, a few leeches applied to the temples often have a very happy effect in moderating the pain. Murchison recommends that the cold affusion should be administered by simply placing the patient's head over a basin at the edge of the bed and pouring water on it from a height of two or three feet. He also says that warm fomentations are to be preferred to cold in aged and infirm persons of feeble circulation. Sleeplessness will often disappear under the use of remedies presented for the relief of the headache and other nervous symptoms. It is occasionally so persistent as to call for special treatment. If it occur early in the disease, it will generally be sufficient to prescribe at bedtime ten grains each of potassium bromide and chloral, repeated once or twice during the night. Later in the disease this combination ceases to produce any effect, besides which chloral cannot be administered with safety after the action of the heart becomes feeble. It is therefore necessary to have recourse to opium in some form or other. There are, it is true, theoretical objections to its use in typhoid fever, such as its interference with digestion and its tendency to lock up the secretions; but these will hardly weigh in the balance against the fact that the patient will die of exhaustion if the insomnia is allowed to continue, and that under certain circumstances opium is the only drug which will procure the needed sleep. The form in which it is given is not a matter of much importance. I prefer the deodorized tincture, twenty or thirty drops, repeated if necessary in an hour or two, but I have seen good results from the solid opium and from the hypodermic injection of morphia. When the insomnia is attended by much tremor and muttering delirium, camphor may be added to the opium, and given throughout the day as well as in the evening. Violent delirium is sometimes also relieved by administration of opium and alcoholic stimulants, and by the application of cold to the head. It is also much lessened by the cold-water treatment. When the delirium is so violent that restraint is necessary, it is better that this should be mechanical than that it should be left wholly in the hands of ignorant and untrained nurses. A folded sheet passed over the chest of the patient and fastened to the sides of the bed is frequently all that is needed. Stupor requires very much the same kind of treatment as that suitable for the other forms of nervous derangement. If it is extreme, counter-irritants should be applied to the nape of the neck and cold to the head. The late Dr. Wood was in the habit of shaving the hair and applying a blister to the scalp of a patient in this condition, and I have seen good in more than one instance result from this treatment. The urine should also be examined, and if the quantity be insufficient diuretics should be given. If it contain albumen or blood, counter-irritants and even cut cups should be applied to the loins. It is also important, if the patient be in this condition, that the physician should not rest satisfied with the nurse's {335} assurance that the urine is passed freely, but should from time to time examine the supra-pubic region himself. It is not infrequently found under these circumstances that there is really retention, and that the wetting of the bed upon which the nurse has based her assurances is really the consequence of the dribbling of urine from an over-distended bladder. I have known of serious results, such as cystitis, paralysis of the bladder, having followed the neglect of this very simple precaution. Convulsions when they occur are to be treated by the application of cold to the head and counter-irritants to other parts of the body.

Epistaxis is rarely so severe as not to yield to the use of simple remedies, such as the application of ice to the forehead or back of the neck, or of styptics locally. In a few cases, however, it is profuse, and it will then be necessary to have recourse to hypodermic injections of ergotin, as in the case of hemorrhage from the intestines, or to plug the nostrils.

TREATMENT OF COMPLICATIONS.--Hypostatic congestion of the lungs, as it is usually the consequence of feeble action of the heart, is best treated by frequently changing the position of the patient, and by remedies calculated to increase the power of the organ, such as alcoholic stimulants, ammonium carbonate, oil of turpentine, and digitalis. Recent German authors, however, regard digitalis as a dangerous remedy when the heart has undergone the granular degeneration peculiar to fevers. It had, therefore, better not be given if the congestion occurs late in the disease. I have myself always found advantage from the application of turpentine stupes to the chest, and occasionally from the application of dry cups. Pneumonia when it occurs as a complication does not render necessary a material modification of the above treatment. It may sometimes be well, if it occur early in a robust subject, to take blood locally, but it can rarely be justifiable to do so by venesection.

Bed-sores may generally be prevented by frequently changing the position of the patient, by scrupulous attention to cleanliness, and by bathing prominent parts of his body with whiskey and alum. These parts should also be protected from pressure by the judicious arrangement of pillows and cushions. When redness or abrasions appear the part should be covered with soap plaster smoothly spread upon kid. This application may be continued even after the formation of sloughs. As soon, however, as these show a tendency to suppurate poultices should be applied, and the resulting ulcer treated as if occurring under other circumstances.

Thrombosis of the femoral vein is best treated by elevating the affected leg and enveloping it with flannel cloths saturated with hot vinegar and water. Thrombosis of other veins is to be treated on the same general principles. When an artery becomes obliterated, whether from embolism or thrombosis, the part which it supplies should be surrounded with cotton wool and every effort made to favor the establishment of the collateral circulation. If sphacelus occurs, it should be treated on general surgical principles.

TREATMENT OF CONVALESCENCE.--The importance of a strict adherence to a liquid diet in the early part of the convalescence of typhoid fever has already been alluded to. The ulcers in the intestines often remain unhealed for some time after the subsidence of the fever, and errors in diet may therefore readily cause recrudescences of fever, if not true relapses. {336} These recrudescences are sometimes produced by very slight causes. I have seen them follow undue mental exercise or worry, or sitting up too early or too long. It is therefore important to guard our patients at this stage of the disease from undue fatigue or excitement of any kind. Medicines calculated to build up the strength and to improve the nutrition are clearly indicated at this time. If the diarrhoea should persist, nitrate or oxide of silver, sulphate of copper, and subnitrate of bismuth in appropriate doses, given with a little opium, will all be found to be useful remedies. When, on the contrary, constipation exists, it is still necessary to avoid the use of drastic cathartics; indeed, even mild laxatives should be given by the mouth only after enemata have failed to produce a movement of the bowel.

SPECIFIC TREATMENT.--The search for a specific remedy in typhoid fever is not new. It is as old as the theory that the disease is generated by a specific cause. The hypothesis that this is an alkaline poison led many years ago to the use of the mineral acids, and it was only after experience had shown that they were without power to cut the disease short, or even to control many of its symptoms, that they ceased in a measure to be prescribed. Calomel also, which was occasionally resorted to formerly for its antiphlogistic effects upon the intestinal lesions, has been lately recommended in Germany in the treatment of typhoid fever on account of its supposed antidotal properties. Seven and a half grains of the drug, and in some cases a much larger dose, are given four times daily on alternate days as soon as the nature of the disease is fully recognized. It is claimed for this treatment that when it is begun early the rate of mortality and the duration of the disease are much less under it than under any other. Its advocates admit, however, that the latter is not always the case--a variety in the action of the medicine which is attributed to a difference in the way in which the poison of the disease has been taken into the body. Salivation is rarely produced by the calomel. The diarrhoea, which is at first increased by it, subsequently diminishes, and the administration of each dose is followed by a decided although temporary reduction of temperature.

A diminution in the rate of mortality is also said to have been obtained by the administration of iodine in typhoid fever, although the results of its use are on the whole less favorable than those of calomel. Liebermeister recommends that three or four drops of a solution of one part of iodine, two parts of iodide of potassium, and ten parts of water should be given every two hours in a glass of water.

--------------------------+---------+--------+-------------- | Number | Number | Percentage of | treated.| died. | mortality. --------------------------+---------+--------+-------------- Non-specifically treated | 377 | 69 | 18.3 Treated with calomel | 223 | 26 | 11.7 Treated with iodine | 239 | 35 | 14.6 --------------------------+---------+--------+-------------- Total | 839 | 130 | 15.5 --------------------------+---------+--------+--------------

The preceding table, which is taken from Liebermeister's article on typhoid fever in Ziemssen's Cyclopædia, is based upon the results of {337} treatment in 839 cases, a part of which were treated with iodine, a part with calomel, and a part with neither, the rest of the treatment being exactly alike in all of them, and consisting in the employment of a partial antipyretic method.

James C. Wilson[108] has recently used with great success in the treatment of typhoid fever the following prescription, which was originally suggested by Roberts Bartholow: Rx. Tinct. Iodinii fl. drachm ij.; Acid. Carbolici liq. fl. drachm j.--M. Of this, one, two, or even three drops is given in a sherry-glassful of ice-water after food every two or three hours during the day and night. In addition to this prescription his patients were given a dose of calomel varying in amount from seven and a half to ten grains, which was repeated on every alternate night until three or four doses had been administered in the course of the first six or eight days. Of sixteen cases so treated, none proved fatal, although eight of them were severe, the temperature reaching or exceeding 104° F. Da Costa[109] has used carbolic acid in this disease, and has found it useful in controlling the diarrhoea and in lowering the temperature, but suggests the use of thymol in doses of from half a grain to one grain as a substitute, on account of its greater acceptability to the stomach. C. G. Rothe[110] recommends a mixture of carbolic acid, tincture of digitalis, tincture of aconite, brandy, and tincture of iodine. Its use causes a decided fall of temperature and diminution in the frequency of the pulse.

[Footnote 108: Transactions of the College of Physicians of Philadelphia, 3d Series, vol. vi., Philadelphia, 1883, p. 221.]

[Footnote 109: Ibid., p. 234.]

[Footnote 110: Deutsche Med. Wochenschr., 1880.]

My own experience does not enable me to speak with positiveness of the value of this plan of treatment. Indeed, it has been used in so few cases, to the exclusion of all other remedies, that it is difficult to decide how far the result attained in cases treated by them is due to them, and how far to the other therapeutic means employed. With the testimony of such competent observers as those above named it is only proper that the treatment by iodine and carbolic acid should have a further trial. More caution, it seems to me, is required in the use of calomel. While it is probable that in a few cases the intestinal lesions may be favorably modified by the purgation which it induces, the indiscriminate use of the drug is, I am sure, calculated to do more harm than good.

{338}

TYPHUS FEVER.

BY JAMES H. HUTCHINSON, M.D.

DEFINITION.--Typhus fever is an acute contagious disease, usually occurring epidemically, lasting from ten to twenty days, and characterized, among other symptoms, by an abrupt commencement, great prostration, profound derangement of the nervous system, and a peculiar eruption which appears between the third and eighth days, and which, disappearing at first under pressure, soon becomes persistent, and in severe cases may be converted into and be associated with true petechiæ. When it proves fatal, it generally does so at or near the end of the second week. The lesions found after death are not specific in character, and consist mainly of a marked alteration of the blood, congestions of internal organs, softening of the heart, and atrophy of the brain.

SYNONYMS.--Petechial Typhus, Putrid or Malignant Fever, Camp, Jail, Ship, or Hospital Fever, Spotted Fever, Irish Ague, Contagious Typhus, Brain Fever, Adynamic or Ataxic Fever, Ochlotic Fever, Catarrhal Typhus.

The term typhus was first applied by Sauvages in 1760, and afterward by Cullen, to certain forms of fever, characterized by marked prominence of the nervous symptoms, to distinguish them from another group of cases to which they gave the name synochus, and is derived from the Greek word [Greek: typhos], which literally means smoke, and which is employed in the treatise on internal affections attributed to Hippocrates for a similar purpose. According to Murchison,[1] Hippocrates used the word to define a "confused state of the intellect, with a tendency to stupor." The appellation typhus, therefore, as indicating a very prominent symptom of the disease about to be described, is perhaps the best that could be given to it. It has been generally adopted by the physicians in England and in this country to denote this disease, but on the Continent, and especially in Germany, it is applied also to typhoid fever, the two fevers being usually designated there as typhus petechialis and typhus abdominalis, respectively.

[Footnote 1: A Treatise on the Continued Fevers of Great Britain, by Charles Murchison, M.D., LL.D., F.R.S., etc., second edition, London, 1873.]

HISTORY.--As human want and misery and the evils which follow in the train of war have never been wholly absent from the world, and as these are the conditions which are now known to be favorable to the spread, if not to the generation, of typhus fever, it is highly probable that this disease was the cause of some of the epidemics to which allusion is made by the sacred and profane writers of antiquity. Yet their descriptions are too vague to justify us in assuming that such was positively the {339} case. The records of the first fifteen centuries of our own era are similarly wanting in details, for, with the exception of a brief notice of an outbreak of the disease in the monastery of La Cava, near Salerno, in the year 1083, by Corradi[2] it may be said to have been practically undescribed before the year 1546, when Fracastorius[3] published his work, De Contagionibus et Morbis Contagiosis. From the description which this distinguished physician gives there of the epidemics which prevailed in Verona in the years 1505 and 1508, there can be no doubt that the disease he had the opportunity of observing was really typhus fever. Not only are the principal symptoms succinctly described, but its contagiousness and tendency to early prostration fully recognized. We learn also, from the same work, that the disease, although previously unknown in Italy, was one with which the physicians of Cyprus and the neighboring islands were perfectly familiar. According to the same authority, it again made its appearance in 1528 in Italy, and from there extended to Germany.

[Footnote 2: In Chron. Cavense Annali, p. 1, 101, quoted in Handbuch der Historish-Geographischen Pathologie, von Dr. August Hirsch, Stuttgart, 1881.]

[Footnote 3: Quoted by Murchison.]

During the last half of the sixteenth century epidemics of typhus fever would seem to have been of more frequent occurrence than before it, since many of the medical authors of this period not only refer to it very fully, but also give accurate descriptions of the disease. There is also abundant evidence of the same kind that it frequently prevailed epidemically in almost every part of Europe during the seventeenth and eighteenth centuries, following generally in the wake of famine and of war, and often attaining a high degree of virulence in besieged towns. The histories of many of these epidemics are exceedingly interesting, especially those of the so-called Black Assizes which occurred at different times in several of the towns of England, and which derived their name from the fact that the disease was communicated from the prisoners on trial to the judges and other persons in attendance upon the court; but to give these in detail would be beyond the scope of this article. Although many of the authors of these two centuries boldly advocated copious venesection as the only rational method of treating the disease, there was a not inconsiderable number who recognized its essentially typhoid nature, its tendency to early prostration, and the fact that patients suffering from it bear bleeding badly, as fully as is done by physicians of the present day. They were also unquestionably quite aware of the circumstances under which typhus fever generally arises, for in 1735, Browne Langrish[4] wrote that it originated from "the effluvia of human live bodies," and that its principal cause was overcrowding with deficient ventilation, as a result of which "people were made to inhale their own steams;" and a similar opinion was expressed a few years later by Sir John Pringle,[5] J. Carmichael Smyth,[6] and others.

[Footnote 4: The Modern Theory and Practice of Physics, by Browne Langrish, p. 354, London, 1764.]

[Footnote 5: Observations in Diseases of the Army, London.]

[Footnote 6: Quoted by Murchison.]

Epidemics of typhus fever have frequently occurred in various parts of Europe during the present century, although they have, on the whole, shown a greater tendency than before to confine themselves to the place in which they first appeared. The most severe of these began in 1846, and after committing great ravages in Ireland extended to England, and {340} subsequently to the Continent. The disease proved much more fatal than the sword in the armies of Napoleon in the towns besieged by him in the early part of this century, and was the cause of an immense loss of life in the Russian and French armies in the Crimea after the fall of Sebastopol.

In our own country typhus fever has appeared several times during the present century, but the outbreaks have rarely attained the magnitude of epidemics, such as are seen in Europe, and have usually been distinctly traceable to importation from abroad. It was first met with, according to Wood,[7] in New England in 1807 and in Philadelphia in 1812, continuing to lurk, this author says, in the lanes and alleys of that city until the winter of 1820-21, when, as a student of medicine, he had an opportunity of studying it. Another outbreak of the disease occurred in the same city in 1836, and is the subject of an admirable paper by the late Wm. S. Gerhard.[8] Since then epidemics of moderate severity have repeatedly occurred at different times in several of the American cities, and have been described, among others, by Flint, Da Costa,[9] and Loomis. A large number of cases of typhus fever (1723), with 572 deaths, were reported to the Surgeon-General's office during the late Civil War, but doubt has been thrown upon the correctness of the diagnosis of many of these cases by Clymer[10] and Woodward,[11] and by other army surgeons, who, as the result of their investigations of this subject, have reached the conclusion that typhus did not prevail as an epidemic, however limited, among our soldiers at dépôts for returned prisoners of war. A like immunity from this scourge may be assumed to have been enjoyed by the Confederate forces, since Joseph Jones,[12] one of the most eminent of their medical officers, has stated positively that no case of true typhus fever came under his observation during the war in any army, in any field hospital, general hospital, or military prison, and that the experience of all of his associates whose opinions on this question he was able to obtain, either personally or by letter, was the same. It is therefore most probable that the cases entered upon the sick reports of both armies as typhus fever were in almost every case, if not in all, cases of typhoid fever occurring in scorbutic subjects.

[Footnote 7: A Treatise on the Practice of Medicine, by George B. Wood, M.D., etc., Philada., 1855.]

[Footnote 8: The American Journal of the Medical Sciences, February and August, 1837.]

[Footnote 9: Ibid., January, 1866.]

[Footnote 10: The Science and Practice of Medicine, by William Aitken, M.D., Edin.; 3d Amer. ed., p. 462, Philadelphia, 1872.]

[Footnote 11: Camp Diseases of the United States Armies, by Joseph Janvier Woodward, M.D., Philadelphia, 1863.]

[Footnote 12: United States Sanitary Commission's Memoirs--Medical, p. 600, New York, 1867.]

From the foregoing sketch of its history it is evident that typhus fever has prevailed from time to time in almost all the countries of Europe. Indeed, it is probable that no one of them has wholly escaped its ravages, while in others--as, for example, Ireland--it has been more or less constantly present until within the last few years, when its visitations have been less frequent as well as less severe. Even in countries which are popularly supposed to enjoy an immunity from it there is evidence of an incontrovertible character that it has occasionally occurred. Such an immunity has been claimed for France, but in the works of Riverius,[13] {341} Ambrose Paré,[14] and others will be found descriptions of the disease which leave no doubt upon the mind of their entire familiarity with it; and Hirsch, in his work on Historico-Geographical Pathology, is able to give references to several writers who describe outbreaks that have recently occurred there. The disease has also been observed in Iceland. Typhus fever is of much less frequent occurrence in the other divisions of the eastern hemisphere than in Europe. According to Murchison, there are no authentic records of its having been met in Africa, or, with the exception of India, in Asia, such as it is seen in England and Ireland. There are, however, reports of its occurrence in Asia Minor, Syria, Persia, Egypt, Nubia, Tunis, and Algeria, which Hirsch,[15] on the other hand, believes place the occasional presence of this disease in these countries beyond doubt. The same difference of opinion exists between these two distinguished observers in regard to the accounts which have been published of typhus fever occurring in Mexico, Central America, and South America, the latter holding that they are entirely reliable, the former that the cases described in them were really cases of malarial or typhoid fever. The disease has never been met with on the continent of Australia, in New Zealand, or in the valley of the Mississippi and the States bordering on the Pacific Ocean in our own country.

[Footnote 13: The Practice of Physick, being chiefly a Translation of the Works of Lazarus Riverius, London, 1678.]

[Footnote 14: Traité de la Peste, de la Petite Verolle et Rougeolle, par Ambrose Paré, Paris, 1568.]

[Footnote 15: Loc. cit.]

While Hirsch's researches go to show that the tropical zone has not been so wholly exempt from the visitation of typhus fever as some authors have asserted, they establish the fact that it is of much less frequent occurrence there than in the colder portions of the temperate zone, where the modes of life are certainly much more favorable to its extension. Natives of warm climates are as liable to be attacked by it as others upon coming to places where it is prevailing, and in the Philadelphia epidemic of 1836, which Gerhard[16] has described, negroes and mulattoes suffered from it more severely than the whites.

[Footnote 16: Loc. cit.]

ETIOLOGY.--The etiology of typhus fever will be best studied under the heads Predisposing and Exciting Causes.

PREDISPOSING CAUSES.--It may be stated, generally, that whatever impairs the health or reduces the strength of an individual, even temporarily, or acts depressingly on his nervous system, predisposes him to typhus fever. But there are among the predisposing causes some which exert a more special influence on its production than others. Among the more powerful of these is the overcrowding of human beings, with deficient ventilation. Indeed, there are some authors who consider that this has been in many cases alone sufficient to occasion the disease; and although this opinion, as it involves the admission that it may be generated de novo, is contested by others, there is great unanimity among authors in attaching great importance to it. Of the patients admitted into the London Fever Hospital with typhus fever, a large proportion came from the more crowded districts of the city. The disease has always been most prevalent in the poorer quarters of Glasgow, Dublin, and Edinburgh, and when epidemic in Philadelphia in 1836 it was confined to a portion of the town which has always been noted for the squalor and misery of its inhabitants. Among those admitted during that year to the Philadelphia Hospital were seven negroes, said by Gerhard to {342} be "the entire population of a cellar." It is probably largely due to the fact that the better social condition of the poor in this country prevents the degree of crowding which often exists in European cities that the disease is comparatively rare here. The effect of overcrowding is of course much increased by want of cleanliness, either of the person or of the clothes.

Poverty, not merely from its own depressing influences, but also from the fact that it leads to overcrowding, is a powerful predisposing cause of typhus fever. Insufficiency of food, which is one of its many consequences, by impairing his nutrition and thus diminishing his vital resistance, renders the individual more susceptible to the action of the specific cause. Gerhard says that of the patients seen by him in 1836 a very small proportion came from the better class of mechanics, and Tweedie[17] and Sir William Jenner[18] state that it is rare to meet with instances of the disease, except in the case of medical practitioners and students, among those in comfortable circumstances. Bateman[19] goes so far as to assert that "deficiency of nutriment is the principal source of epidemic fever;" and there is certainly a remarkable coincidence in time between outbreaks of this fever and seasons of want and distress. But, as Murchison has shown, destitution is not essential to the production of typhus, for the Dundee epidemic of 1865 was due to overcrowding of the town, brought about by the inhabitants of the surrounding country flocking into it in consequence of labor being unusually abundant and wages good.

[Footnote 17: Lectures on the Distinctive Character, Pathology, and Treatment of Continued Fevers, by Alexander Tweedie, M.D., F.R.S., London, 1842; and Clinical Reports on Fever, by same author, London, 1830.]

[Footnote 18: On the Identity or Non-Identity of Typhoid and Typhus Fevers, by William Jenner, M.D., London, 1880; also Lancet, November 15, 1879.]

[Footnote 19: A Succinct Account of Typhus or Contagious Fever of this Country, by Thomas Bateman, M.D., F.R.S., London, 1820.]

Similar in its action to the above cause is intemperance. Not only is the habitual drunkard more likely to suffer from typhus fever than the temperate man, but a single debauch has been followed by an attack in individuals who had previously resisted the contagion. On the other hand, the most rigid temperance will not afford in all cases a complete immunity from its effects. The debility left by an illness is also a condition favoring the occurrence of an attack of the disease in those who are exposed to its exciting cause. Fatigue of all kinds renders the body less able to resist the causes of disease, and typhus fever is not an exception to the general rule. Overworked nurses are specially liable to contract it. The depressing emotions also favor its occurrence. It has been observed during epidemics that those who exhibit an excessive fear of the contagion are much more likely to suffer from it than the cheerful and courageous.

No age enjoys an immunity from the disease. In fact, it is probable that all ages are equally liable to it. Buchanan[20] has seen it at the London Fever Hospital in an infant a fortnight old and in a man of eighty, and attributes the prevailing opinion that children rarely suffer from it to the fact that they are not often taken to hospitals, but are retained in their own homes for treatment. Gerhard[21] says that no children in the asylum attached to the Philadelphia Hospital were {343} attacked with the disease during the prevalence of the epidemic there, but the distance of the asylum from the wards in which the cases were treated was probably the reason of their escaping. In the few cases which have come under my own observation the patients were young men, varying in age from twenty-five to thirty-five. The sexes also suffer from it equally. In some epidemics there may be a preponderance of one sex over the other, but in others the reverse has been the case.

[Footnote 20: A System of Medicine, edited by J. Russell Reynolds, M.D., F.R.C.P., etc., vol. i., article "Typhus Fever," London, 1866.]

[Footnote 21: Loc. cit.]

Occupation, except so far as it brings the individual into immediate contact with the sick, as in the case of physicians, nurses, and clergymen, does not predispose to the disease. There would seem also to be no difference in the susceptibility of the different races to the contagion. Acclimatization affords no protection from the disease, as it does in the case of typhoid fever, and change of the habits of life does not appear to exercise any influence upon the liability to it. On the other hand, the susceptibility of different individuals, and of the same individual at different times, varies considerably. Thus, while in many persons a single exposure to the contagion is followed by an attack, in the case of an engineer mentioned by Murchison it did not occur until after fifteen years of continuous service at the London Fever Hospital. A person who has once suffered from typhus fever is not likely to contract it again, but this protection is not complete, as there are a few well-attested instances of a second attack on record.

The disease prevails most frequently during the winter and early spring, principally because the cold weather of these seasons leads to the closing of windows and all other avenues of ventilation, thus intensifying its exciting cause. Still, some epidemics of great severity have occurred in the warmer months of the year, as, for instance, the one described by Gerhard. It is also doubtful if there is any relation between variations in temperature and the amount of moisture in the air and the prevalence of epidemics of typhus fever, although Hirsch regards a low and damp situation as powerfully predisposing to the endemic and epidemic prevalence of the disease. It is usually met with in towns on the sea-coast or on navigable rivers, but it has also been observed frequently in country districts, and even in regions at a considerable elevation above the level of the sea.

EXCITING CAUSE.--The principal if not the only exciting cause of typhus fever is a specific contagion developed in the bodies of the infected and transmitted from them to the healthy by actual contact, by fomites, or through the atmosphere. The nature of this contagion is unknown. A careful study of its peculiarities seems to justify the opinion that it depends upon the presence of a minute organism in the emanations given off by the sick, which is capable of indefinitely multiplying itself in the human body. But this is only an hypothesis, which rests principally upon the analogy between typhus and some other diseases, as, for instance, relapsing fever and diphtheria, in which such a growth is thought to have been discovered, and upon the fact that the contagious principle whatever it may be, is destroyed by a temperature over 204° F.

The evidence in favor of the contagiousness of typhus fever is conclusive, and may be briefly stated as follows: When it breaks out in a community the disease not only attacks those persons who have been subjected to the same influence as the sick--as, for instance, members of {344} their own families, occupants of the same house, etc.--but also those who have come from healthy localities to visit them. In fever hospitals it is rare for any member of the household who has not already had the fever to escape an attack, and the probability of his suffering is in direct proportion to the intimacy of his relations with the patients. Thus, the nurses are far more likely to be attacked than servants whose duties do not take them into the wards, except those employed in the laundry, who are so often affected by it that Murchison says it is difficult to find women who are willing to take the position. The spread of the disease may often be promptly arrested by the complete isolation of the first few cases, while free intercourse between the sick and the well is invariably followed by its extension, not only in the locality in which it first appeared, but to other localities. But the strongest argument in favor of its contagiousness is found in the fact that patients taken into a previously healthy place have frequently become the starting-point of an epidemic. In this way the disease has often been introduced by Irish immigrants into the cities on our seaboard, and even into some of our interior towns.

Actual contact is not necessary for the communication of typhus fever from the sick to the well. The contagion may be transmitted through the atmosphere. How far it will be transmitted in this way will depend upon many circumstances. In a spacious and well-ventilated ward it is probable that the presence of one or two patients with this disease does not seriously endanger the safety of the other patients, and that the only persons who run much risk of contracting it are the physicians and nurses, who are often compelled in the performance of their duties to inhale the emanations from the bodies of the sick. At the Pennsylvania Hospital, where cases of this disease are occasionally admitted, it has been usual to isolate them by placing them in a room a few feet distant only from the dining-room of the men's medical ward and separated from the ward by a short corridor. The steward of the hospital informs me that during his connection with it, which extends over a period of more than sixty years, he has never known the disease to extend to other persons, except on two occasions. One of these was during the epidemic described by Da Costa, when an unusual number of cases was received, and when one resident physician and two nurses contracted the disease. On the other occasion, which happened during my own term of service in the spring of 1881, a young Danish sailor appeared to have taken the disease from two British seamen. As it was ascertained positively that he had not entered the room in which these two seamen were isolated, and as his bed in the ward was one of the farthest removed from the room, and he had not therefore been more or as much exposed to the contagion as the other patients, it was difficult to understand why he alone of all of them should have suffered from it. The explanation was, however, found in the fact that he had been taken over to the women's ward to act as interpreter for a countrywoman who was not known at the time to be suffering from typhus fever, and that he had remained there some time in conversation with her. Murchison and Buchanan both assert also that typhus fever has never extended from the London Fever Hospital to the inmates of adjacent houses, even when it was itself one of a row of houses. If, on the other hand, several patients with typhus fever are placed in a crowded and ill-ventilated ward, the contagion will then be found to have {345} acquired so much more virulence that few of the other patients will escape its effects.

There is also no question that typhus fever may be communicated by fomites. Numerous instances are on record in which the disease has been communicated by the wearing apparel and bed-clothes of patients, and we have already called attention to the frequency with which laundry-women in fever hospitals are attacked by it. The clothes of persons who are themselves free from the disease, but who have been in close attendance upon the sick for some time, are often also the medium of communication. Indeed, Murchison goes so far as to say that men who have not changed their clothes and "who have been living in close, ill-ventilated apartments and on short allowance, may at length have their garments so impregnated with the poison of typhus as to communicate it to others without being themselves the subjects of it," even if they have not been brought in contact with fever patients. The disease was communicated in this way, he thinks, in the famous Black Assize in 1750 by several prisoners to the court that tried them, although they were themselves free from it. On the other hand, with proper precautions there is little danger of the disease being conveyed by physicians to their own families or to other patients.

Some difference of opinion exists as to the stage at which typhus is most contagious. Many authors believe that it is more infectious during convalescence than at any other time, and base this opinion upon the fact that the removal of fever patients to the convalescent ward is very often followed by the occurrence of the disease among its other occupants; but this is probably due, as Murchison suggests, to the patients being allowed at this time to wear their own clothing, which has not been thoroughly disinfected. It is much more likely that the disease is more contagious during the stage when the febrile symptoms are most marked than during either the stage of convalescence or that of invasion. It would appear also, from the observations of Dr. Gerhard and others, that dead bodies do not readily communicate the contagion or that the contagious principle is easily counteracted after death. Still, there are several well-authenticated cases on record in which individuals have unquestionably contracted the disease from dissecting the bodies of patients dead from this cause.

A question of great interest naturally arises here, as to whether or not typhus fever ever occurs except as the consequence of exposure to a previous case of the disease. Is it, in other words, ever generated de novo? Authorities are divided upon this point, many contending that an independent origin is impossible, and others that it may occasionally arise in this way. Among the latter is Murchison, who adduces in support of the position he takes several instances in which poverty, with overcrowding and deficient ventilation, appears to have been the only cause of extensive outbreaks of the disease, as in the case of the Black Assize already alluded to. These cases the opposite party explain by assuming that the germs of the disease are capable of lying dormant for a long time until roused into activity by favoring circumstances. If the disease is caused, as we have shown there is good reason to believe it is, by the presence of a minute organism, this view does not seem to be untenable. Pasteur has demonstrated that the germs of the splenic fever of some of the lower {346} animals may be deprived of their virulence by cultivation in appropriate liquids. If their virulence is diminished under certain circumstances, the assumption does not seem unwarrantable that under others it may be increased, and if we may draw this conclusion in regard to one form of microscopic growth, we may do the same for others; and the hypothesis is therefore not an unreasonable one that the typhus germ needs the atmosphere engendered by overcrowding for it to acquire the power to produce the disease.

PERIOD OF INCUBATION.--The period of incubation of typhus fever appears to vary considerably in length, but is usually about twelve days. In some cases the interval between exposure to the contagion and the occurrence of the first symptoms of the disease is asserted to have been considerably longer, and in one instance as long as thirty-one days; but it is probable that there has been in most, if not in all, of these cases a second exposure which has been overlooked. On the other hand, it is said to have followed at once upon exposure, as in cases reported by Gerhard, in one of which a nurse inhaled the breath of a patient whom he was shaving, and in an hour afterward was taken with cephalalgia and ringing in the ears, which were immediately succeeded by the other symptoms of typhus. In this and other similar cases which are on record it is difficult to exclude the possibility of a previous infection. In a case, however, reported by Murchison there would seem to be no reason to suspect that any such previous infection could have taken place, as the patient, the matron of an orphan asylum where there was no typhus, was taken ill immediately after opening a bundle of clothes which a child had brought with her from a fever hospital, and which had not been thoroughly disinfected.

SYMPTOMATOLOGY.--It will facilitate the study of typhus fever to give, in the first place, as most of the systematic writers on fever have done, a brief clinical sketch of the disease as it ordinarily occurs, and then afterward to consider its leading symptoms in greater detail.

GENERAL DESCRIPTION.--An attack of typhus fever is sometimes preceded for a few days by prodromata, such as a feeling of malaise, indisposition to exertion, pain in the head and limbs, anorexia, and vertigo; but it oftener begins abruptly with a slight chill, or more rarely with a decided rigor. This is followed in a short time by headache, by a marked rise of temperature, and by an increased frequency of pulse and respiration. Nausea is also occasionally present, and less frequently vomiting. The tongue is at first moist and covered with a thin whitish fur, but soon becomes dryish, and its coating is apt to assume a brownish appearance in a day or two. With these symptoms there are loss of appetite, great thirst, constipation, a dull, heavy expression of countenance, a dark, dusky hue of the face, and injection of the conjunctivæ. Mental confusion is early observed, so that, although the patient may be able to answer questions correctly when thoroughly roused, it is readily seen that his mind is working with difficulty. The sleep is very often disturbed by dreams, so that he awakes from it unrefreshed. Prostration and loss of muscular power are so decided from the very beginning of the disease that the patient is obliged usually to take to his bed at once, and it is much rarer to meet with walking cases of the disease than in typhoid fever. The urine is dense, scanty, and high-colored.

{347} Usually, about the fourth day of the disease the characteristic eruption of typhus fever makes its appearance. It consists of numerous spots of irregular form with ill-defined margins and of a dark red or purplish color, occurring singly or in groups, and varying in size from that of a pin's point to two or three lines in diameter. They disappear at first under pressure, but in twenty-four hours become persistent, and in severe cases may be converted later into petechiæ. Besides this eruption there is another which consists of a faint, irregular dusky red, subcuticular mottling. The two eruptions together constitute the mulberry rash of Jenner, and have been variously described by different authors under the name of measly or morbilliform rash.

As the disease advances the prostration becomes greater and the pulse grows weaker. The tongue becomes dry and brown and trembles when protruded. Later, it is so dry and contracted that it can scarcely be put out of the mouth. Sordes collect about the teeth and lips, and the surface exhales a peculiar odor. The headache grows more severe or gives place to delirium, which may at first be active and violent, and then pass into the low and muttering form, or the delirium may be of the latter variety from the start. The sleeplessness of the early stages may continue, and the condition known as coma vigil not infrequently supervenes. The delirium is usually followed by stupor, which is more or less profound in accordance with the severity of the case, and which is accompanied by all the symptoms which characterize the so-called typhoid state, such as subsultus tendinum, picking at the bed-clothes, slipping down in bed, retention or incontinence of urine, and sloughing of the parts exposed to pressure. In this condition the temperature, although usually still considerably above normal, is lower than during the first week of the disease.

Meanwhile, the issue remains in doubt, and may continue uncertain for several days before any improvement in the symptoms can be observed, or, the stupor passing into coma, the case may speedily terminate in death. When death is the result, it usually takes place about the close of the second week or a little later, but it may occur earlier in consequence of the violence of the fever, or, when due to a complication, may be postponed until after the end of the third week. Fortunately, however, recovery is the rule in this disease. The beginning of convalescence is often as abrupt as that of the attack itself. The temperature will often be found to have fallen to the normal or below the normal, the pulse and respiration to have returned to a healthy condition, and all confusion of the intellect to have disappeared in the course of a few hours. Occasionally, however, its approach is more gradual, and a slight fall in temperature and a corresponding improvement in the other symptoms may be observed before it actually occurs. Diarrhoea, an excessive secretion of urine, with a tendency to the deposition of urates, and moderate sweating, often take place simultaneously with the cessation of the fever, and were formerly regarded as critical discharges. The return to health is usually rapid, and very rarely retarded by the occurrence of complications or relapses, as in typhoid fever. The disease itself leaves no tendency to any other disease.

DESCRIPTION OF SPECIAL SYMPTOMS.--The appearance of a patient with typhus fever is pathognomonic, and is often alone sufficient to enable {348} a physician or nurse familiar with it to recognize the disease when brought in contact with it. The surface generally is congested; the face is flushed, and in bad cases dusky red or even livid in hue; the expression is dull and vacant, except during delirium, when it may be wild or even fierce; the conjunctivæ are injected, the eyes watery, and the teeth encrusted with sordes. The skin is generally hot and dry, except toward the close of bad cases, when it may be cool and bathed in a profuse sweat.

The symptoms connected with the nervous system are among the most characteristic of the disease, and of them none is more marked than prostration. It shows itself early, the patient usually taking to his bed immediately after his seizure or within a few days of it. It is much rarer than in typhoid fever to meet with walking cases of typhus, but Buchanan[22] mentions that patients with the rash already out upon them do occasionally present themselves at the out-door department of the London Fever Hospital. It generally increases as the disease progresses, and is often accompanied by a tendency to syncope. It may attain such a degree that the patient is unable to turn himself in bed or to help himself in any way. Among the most distressing sensations which attend this condition of excessive feebleness is a feeling as if he were sinking into the earth with nothing to support him. Headache is also an early symptom. It is often observed among the prodromata of the disease, and when these are absent supervenes directly after the chill. It is usually frontal, but may be diffused. It is generally dull and heavy, but is sometimes acute, and may be accompanied by a tendency to vertigo, increased by sitting up, and by pains in the back and limbs. It becomes more severe with the progress of the disease until the occurrence of delirium, when it is, as a rule, less complained of. With the headache there is generally some dulness of intellect, except in mild cases. This may be slight at first, and may continue so throughout the whole course of the attack, exhibiting itself principally in some confusion as to dates. In more severe cases it is much more marked, and may finally pass into actual stupor. On the other hand, it may be entirely absent, even in severe attacks, as in a case reported by Da Costa and in some cases recently observed by myself. It is usually soon replaced by delirium, which may be low and muttering or wild and noisy, the former being the more common. Delirium is said to occur most frequently among the educated classes and those oppressed with care and anxiety, but is not rare among those who occupy a lower position in the social scale, especially the intemperate. It is, as a rule, most marked at night, and in mild cases may occur only at that time or upon waking in the morning. When the delirium is active the patient may shout and scream, or leave his bed and attempt to throw himself from the window, being endowed apparently for the moment with strength sufficient to enable him to commit these acts of violence. After the paroxysm is over he sinks back in bed exhausted. The confusion of intellect or delirium continues in bad cases until death supervenes or until the establishment of convalescence. Indeed, the mental disturbance does not always end with the latter, and it is not rare for feebleness of intellect to persist for some time after the patient has in other respects regained his usual health, and in a few cases insanity has followed an attack of typhus fever. Among the most {349} formidable of the symptoms of typhus are convulsions, which are fortunately of infrequent occurrence.

[Footnote 22: Loc. cit.]

The patient generally suffers from wakefulness, except during the first few days. When sleep is obtained it may be unrefreshing or broken and disturbed by dreams. In other cases the opposite condition of somnolence may be present. Occasionally, after having apparently slept for hours, he may deny having been asleep at all. This condition, which constitutes the coma vigil of Chomel, is entirely distinct from that described by Jenner under the same name, in which the patient lies with his eyes wide open, gazing into vacuity, his mouth only partly closed, his face pale and devoid of expression, and which is invariably fatal. Muscular tremor is more or less present in all cases of the disease, and in bad cases may be a prominent symptom. The disease, when this symptom is marked, especially if there is at the same time low, muttering delirium and a moist skin, presents a considerable degree of resemblance to delirium tremens. There is very often intolerance of light, tinnitus aurium, and loss or perversion of the senses of taste and smell. Deafness is also not uncommon, and is regarded by many authors as a favorable symptom. In bad cases, in addition to subsultus tendinum, there are carphologia, incontinence or retention of the urine, and paralysis of the sphincter ani.

Some discrepancy is found to exist in the statements of different authors in regard to the temperature curves of typhus fever. They all agree, however, in assigning them certain characters, the knowledge of which is often of great assistance in diagnosis. One of these is a rapid rise of temperature immediately after the invasion of the disease. Wunderlich[23] asserts that he has observed a temperature of 104.9° F. on the evening of the first day, and Lebert has found it as high as 106.4° F. on that of the second. Such temperatures, occurring so early in the disease, must be infrequent, as Murchison has never met with them. Usually, the temperature attains its maximum on the third or fourth day. The maximum is about 104° or 105° F. Murchison says it scarcely ever reaches 106°, except in children, in whom it rarely is as high as 107°, but Lebert states that he has known it to be as high as 107.8°. On the other hand, it may never exceed 103°, even in fatal cases. When the maximum is attained early in the disease there may be for several days, or until defervescence takes place, very little variation in the evening temperatures, but, as a general rule, they are slightly less elevated in the second than in the first week. This usually occurs from the tenth to the fourteenth day, but it may be postponed until the eighteenth, or even until much later. In some cases on the day before the crisis a slight fall, and in others a considerable fall with a subsequent rise of temperature, are observed. Defervescence is often very rapid, the temperature falling five or six degrees in the course of twelve hours. A true lysis is rarely observed. The occurrence of a complication in the course of a disease will not only cause a decided rise of temperature and a modification of the temperature curve, but may also postpone defervescence beyond the usual time. Not infrequently the thermometer indicates subnormal morning temperatures with slight evening rises for several days after the crisis, unless complications arise, {350} when fever of the hectic type may occur. A very slight cause will also often produce a considerable, although temporary, elevation of temperature in this condition. The morning remissions are less decided than in typhoid fever, especially in the first week. As a rule, they do not exceed 1°, but Lebert lays stress upon the fact that in the same curve variations from 0.3° to 1.8° and from 0.6° to 2.1° often occur. Cases which terminate fatally are generally characterized by high fever, with absence of the morning remissions, which may continue uninterruptedly through the second and even the third week. During the death-agony there is frequently a rise of temperature of two or more degrees. A very high temperature in the first week is often the forerunner of severe cerebral symptoms in the second, and a fall of temperature unaccompanied by an improvement in the other symptoms is not always indicative of the approach of convalescence.

[Footnote 23: On the Temperature in Disease, New Sydenham Society's translation, London, 1871.]

Anorexia is generally present in typhus fever from the beginning of the attack, and may persist until its close. It is not, however, usually attended by the same repugnance for food as in other fevers. Patients can generally be persuaded at first to take nourishment. Indeed, Dr. Gerhard asserts that the negroes who fell under his care in 1832 frequently asked for solid food. Nausea and vomiting are rare symptoms; the latter may occur late in the disease, and then, not infrequently, is caused by irritation of the brain. Thirst is present in all cases. In the later stages of the disease, when the senses are blunted, water may not be asked for, although urgently called for by the condition of the system. The bowels are, as a rule, constipated in this disease. The exceptions to this rule are, however, more numerous than is usually thought. Wood[24] says that he has frequently seen diarrhoea in typhus fever when it occurs in recently-arrived immigrants. Da Costa[25] mentions that it has occurred in several of the cases which have come under his care, and Buchanan[26] says that he has observed it in at least one-third of the patients admitted into the London Fever Hospital in recent years. When there is no diarrhoea the stools are of normal color and consistence. When it exists they are watery and usually dark greenish in color, and never present the peculiar ochrey-yellow appearance seen in typhoid fever. They are said to be alkaline in reaction. Tympanites is rare in typhus fever. It may be present in cases in which there is diarrhoea, and may then be associated with gurgling in the bowels, but rarely attains the degree common in typhoid fever. Gurgling when present is, moreover, not confined to the right ileo-cæcal region, but may be produced in different parts of the abdomen by pressure. There may also be tenderness in the epigastric and hepatic regions, but the enlargement of the spleen so constantly observed in typhoid is generally wholly wanting in this fever.

[Footnote 24: Loc. cit.]

[Footnote 25: Loc. cit.]

[Footnote 26: Loc. cit.]

The tongue in the beginning of the disease is covered with a thin whitish fur and is moist, and may continue so throughout in mild attacks. Generally, however, it soon becomes dryish, and in bad cases absolutely dry, and is tremulous when put out of the mouth, while its coating becomes thicker and brownish, and finally brown, or even black and cracked. It is rare to see the tongue itself fissured as in typhoid fever. Less frequently it remains red, smooth, and glazed throughout the attack. Occasionally the tongue is contracted in bulk, and it may {351} then, in consequence of its dryness and that of the mouth, be impossible to protrude it. Sordes frequently collect about the gums and lips in severe cases.

The pulse is usually increased in frequency in typhus fever, and varies from 100 to 120, but in many cases it never rises above 90, and in very severe cases it may be as high as 150. This increase is observed from the beginning, and generally bears some proportion to the severity of the fever; but toward the close, when the prostration is great, the pulse may continue frequent even after a fall in temperature has taken place, and is always more frequent when the patient is sitting up than when he is lying down. Occasionally, however, a very slow pulse is associated with symptoms of great severity. When this association occurs the prognosis is grave. In the young and robust the pulse may be full and bounding, but it is more often compressible or small and weak. It is not so often dicrotic as in typhoid fever. There is sometimes, according to Lyons, a singular want of uniformity in the force and volume of the arterial pulse in different parts of the system, and there may be but one pulsation at the wrist for two of the heart. A very sudden fall in the frequency of the pulse without an improvement in the other symptoms is not a favorable indication, as it may be due to impaired innervation or to degenerative changes in the muscular tissue of the heart. Usually the beginning of convalescence is marked by a gradual fall of the pulse. Later it may fall to 50 or below it, and continue slow for some time, just as it does in typhoid fever.

The heart shares in the general enfeeblement of the system. In severe attacks the impulse soon becomes weak and diffused, and may be entirely absent for some time even in cases which eventually terminate in recovery. Stokes long ago called attention to an alteration in the systolic sound of the heart which he taught indicated the urgent necessity for the administration of stimulants. This sound is observed in the progress of the disease to become shorter and less distinct, and finally inaudible, while the second sound is unaffected. This modification of the heart-sounds is always an accompaniment of great prostration. Occasionally the first sound is replaced by a functional murmur.

The characteristic eruption of the disease is generally preceded by the fainter subcuticular mottling already alluded to, and usually appears between the fourth and seventh days, but it has been observed as early as the third day, and, on the other hand, its appearance is said by Wood to have been delayed until the thirteenth. It consists of minute spots with ill-defined margins, varying in size from that of the point of a pin to two or three lines in diameter, irregular in shape, slightly elevated above the skin at first only, and occurring singly or in groups. They are pinkish in color, and disappear readily under pressure when first observed. They may then, as Gerhard and others have pointed out, present a considerable resemblance to the rose-colored spots of typhoid fever. In the course of twenty-four hours they become brownish, and later, when the attack is a severe one, livid in color. In malignant or even severe cases they are frequently converted into true petechiæ. They do not appear in successive crops, but usually require a couple of days for their full development. Their duration is variable. In mild attacks they may disappear in the course of a few days, but in bad cases often {352} persist until after convalescence, and are recognizable after death. They are confined to no part of the body, but appear usually earliest and most abundantly upon the folds of the axilla and upon the abdomen. Occasionally, however, they are first observed upon the wrists, and in some cases are more numerous upon the arms and legs than upon the body. They are rarely found upon the neck and face, but in children the latter may be so much covered by them that the disease may be readily mistaken for measles. They present some resemblance to flea-bites, but the latter may be easily distinguished from them by the minute discoloration in the centre left by the puncture of the insect. The eruption is oftenest wanting in young subjects. It is usually, but not invariably, most copious in severe attacks, but cases have ended fatally in which it was wholly wanting from beginning to end. Its color is also to a certain extent an index of the severity of the attack; the darker and more livid it is, the graver the prognosis. In malignant cases or those complicated by scurvy, in addition to the petechiæ above referred to, purpura spots and vibices are not infrequently observed. Some authors assert that the eruption is followed by a slight desquamation of the cuticle, but this is denied by others. Sudamina occasionally occur, but they are much rarer than in typhoid fever. The blue spots described by the French under the name of tâches bleuâtres are also sometimes met with.

A very disagreeable odor is exhaled from the bodies of typhus-fever patients after the first week. Although readily recognizable by those who have once perceived it, it is difficult to describe. Gerhard spoke of it as pungent, ammoniacal, and offensive, especially in fat, plethoric individuals, and believed that those patients who presented this symptom in the highest degree were most likely to communicate the disease to others. Murchison has also expressed the opinion that the typhus poison is associated with this odoriferous substance. Others have compared the odor to the smell given off by rotten straw, the urine of mice, and various other substances. Wood says that he has often perceived the same odor in badly-ventilated rooms in which a number of people have been shut up together for some time.

The sensibility of the skin in cases in which the stupor is not so great as to render the patients insensible to all external impressions is said by some writers to be much increased. There is also occasionally so much tenderness in the epigastric region as to give the impression at first to the attendant that there is inflammation of the stomach or liver.

Pulmonary complications are quite frequent in typhus fever, and, as they often come on insidiously and give no evidence of their presence by cough, expectoration, or even more hurried breathing, that is often seen in uncomplicated cases, it is well to make it a rule to examine the chest of every patient with this disease. To do this thoroughly it is not necessary to make him sit up, which, where great prostration exists, is often attended with danger. If he be turned gently upon his side the auscultator will usually have no difficulty in ascertaining the precise condition of his lungs.

The respiration is usually much more frequent in this disease than in health. Even in cases in which there is no disease of the lungs it is often as high as 30, and in cases in which there is such a complication it may be 60. Its frequency is generally proportional to the severity of {353} the fever. On the other hand, in grave cases in which cerebral symptoms are predominant it may be reduced in frequency much below the normal. When coma or profound stupor exists, it may become jerking and spasmodic, or even simulate the stertorous respiration of apoplexy. Bronchitis, if not of such constant occurrence as in typhoid fever, is certainly not rare. It usually occurs early in the attack, and makes itself known by the presence of sonorous and sibilant râles, which give place later to mucous râles. Expectoration is often absent in these cases; where it exists the sputa are either mucous or muco-purulent. In mild cases no further lesion of the lungs occurs. When the attack is more severe hypostatic congestion is very likely to supervene. This is a condition which is often attended with danger, and which frequently, as has been said already, escapes recognition unless the chest be thoroughly examined, when dullness on percussion, feeble respiration, and subcrepitant râles may readily be detected. Occasionally the physical signs indicate the existence of pneumonia. This, when it occurs in the course of this disease, is always of low grade, and is attended by the expectoration of mucus streaked with blood.

The breath of the typhus-fever patient has a very disagreeable odor, not unlike that given off from the body, and is said by Murchison to contain an increased amount of ammonia.

According to Parkes,[27] the changes in the urine are those usual in ordinary pyrexia. During the fever it is generally diminished in quantity, dark in color, and of high specific gravity. It contains an increased amount of urea and of uric acid, the latter of which is not infrequently spontaneously precipitated. Sulphuric acid is also in excess. On the other hand, the chlorides are diminished in amount or entirely absent. This diminution cannot be ascribed to a decrease in the quantity ingested, for when they are administered with the food they are not found to be eliminated by the kidney. The amount of phosphoric acid does not appear to be affected by the disease. The urine is acid in reaction at first, but its acidity soon diminishes, and it may become alkaline toward the close of bad cases. It may also contain albumen, or even blood, the former being present oftenest in cases characterized by high temperature. According to Da Costa, tube-casts are more often present than absent in severe cases. Those seen by this observer were either coated with rather opaque epithelial cells, many of which were finely granular or covered with granules, which, when tested with reagents, were sparingly soluble in acetic acid, and which with very high magnifying powers did not present the round shape of oil, and were probably the urinary salts collected in the tube-casts. The crisis is sometimes marked by a copious deposit of urates. During convalescence the urine is usually increased in quantity, is pale and limpid, and of low specific gravity, and is found to contain the chlorides in gradually increasing quantity.

[Footnote 27: The Composition of the Urine, etc., by Edmund A. Parkes, M.D., London, 1860.]

VARIETIES.--Many of the varieties of typhus fever recognized by authors--as, for example, jail fever, ship fever, camp fever, and hospital fever--really differ in nothing but name and the circumstances under which the disease has arisen. Others are mere modifications of it, due to the predominance of one symptom or of a certain set of symptoms or to the intercurrence of a particular complication, and likewise do not {354} need a full description here. To this latter class belong the inflammatory typhus, the nervous or ataxic typhus, the adynamic typhus, and the ataxo-adynamic typhus of Murchison. The first variety occurs in young and robust subjects, and, it is also said, in persons of the upper class. It is characterized by high fever, intense headache, and active delirium. In the second variety the nervous symptoms, such as delirium, somnolence, stupor, and muscular tremblings, are the most prominent. The most marked feature of the third variety is the excessive prostration, which is shown in the feebleness of the heart's action and the loss of muscular strength and of control over the sphincters. In this form the eruption is dark colored. Purpura spots and vibices also are very apt to appear, and even hemorrhages from the gums, nose, or other parts to occur. In the ataxo-adynamic form the symptoms of the ataxic and those of the adynamic form are found united. In addition to these there are certain other varieties, arising from differences in degree. These differences are sometimes owing to diversities in the constitution and habits of the patient, sometimes to variations in the character of the epidemic, and are sometimes not readily explainable. One of these is the mild form, in which the symptoms are those of moderate fever, and in which the disease may run its course in seven days. In this form the temperature may never rise above 102° F., the eruption be absent or very scanty, and the characteristic stupor or dulness be wholly wanting. Unless complications arise recovery invariably takes place. A walking form of typhus fever, as has already been said, is much rarer than of typhoid, but it does sometimes occur, Dr. Buchanan having often seen the eruption out upon patients who have walked to the London Fever Hospital to seek admission. In this form the disease, however, does not always run a mild course, as alarming prostration is very apt to come on later in its course. Another variety, the abortive form, has been described by authors. In this an individual, in due time after exposure to the contagion, may present all the characteristic symptoms of typhus fever, but the disease, instead of running its usual course, may terminate abruptly with a critical discharge of some kind. This form occurs during epidemics, and is analogous to the abortive attack of scarlet fever or some other diseases which are occasionally met with. On the other hand, a very severe form, the typhus siderans of authors, also sometimes occurs. In this variety the temperature rises rapidly, and soon attains its maximum; there are frequent pulse and respiration, severe headache, and early delirium and stupor. The mortality in this form is very great. Very frequently death takes place so rapidly as often to leave the physician in some doubt as to the nature of the disease in those cases in which exposure to the contagion cannot be positively traced.

COMPLICATIONS AND SEQUELÆ.--The complications of typhus fever often exercise a decided influence upon the course of the disease, for they not only retard convalescence, but are often the immediate cause of death. Their early detection, therefore, becomes a matter of the greatest importance. They will be found to vary in different years, one epidemic being characterized by complications which are entirely wanting in the next. Among the commonest of them are several different conditions of the respiratory organs. Bronchitis, if not quite so frequent as in typhoid fever, occurs in a large number of cases. It may come on at any stage {355} of the disease, either immediately after the beginning of the attack or in its course, or not until convalescence. In cases accompanied by prostration mucus may accumulate in the bronchial tubes, and be the cause of the patient's death by preventing the due aëration of the blood. It would seem to be an especially frequent complication in Ireland, and it is rather surprising that so acute an observer as Graves appears not to have been aware of its real relation to typhus, and speaks of it as if it were a predisposing cause. "Nothing can be more remarkable," he says, "than the facility with which a simple cold, which in England would be perfectly devoid of danger, runs into maculated typhus in Ireland, and that, too, under circumstances quite free from even the suspicion of contagion; in truth, except when fever is epidemic, taking cold is its most usual cause." A much more serious complication than bronchitis is the form of pneumonia already alluded to as liable to occur in the course of typhus. This may often occur so insidiously that it may be considerably advanced before its presence is even suspected; hence the necessity for examining carefully the lungs of every patient with this disease who comes under our care. Generally, however, it makes itself known by giving rise to rapid breathing and great lividity of the surface, but, as has already been said, both of these symptoms may exist in cases in which there is no chest complication. This pneumonia, if it does not immediately prove fatal, may, by becoming chronic, retard the convalescence. It occasionally is followed by gangrene, and sometimes by phthisis, which may then run a very rapid course. Phthisis is, however, a much less frequent sequela of typhus than of typhoid fever. Pleurisy may also complicate typhus fever, but it is much more rarely met with than pneumonia.

Perhaps next in frequency to pneumonia and bronchitis are diseases of the kidneys. These are very serious complications, whether they antedate the fever or have occurred in its course. Careful examination of the urine will generally lead to the discovery of a small amount of albuminuria in bad cases, but this is fortunately, in the majority of them, only temporary. The urine should, however, always be re-examined before the discharge of the patient, as there is good reason to believe that many otherwise inexplicable cases of chronic albuminuria have originated in an attack of typhus. The presence of albumen and of casts in the urine of a patient apparently convalescent from this disease should therefore make us careful in our prognosis as to his future health. The occurrence of diarrhoea may also very seriously affect the patient's chances of recovery. Dysentery has also been observed in certain epidemics in Ireland, and is not infrequent when the disease breaks out in besieged towns or when it occurs in summer. In grave cases or those complicated with scurvy the blood may be so broken down as to escape readily from the vessels. Under these circumstances, in addition to the purpura spots beneath the skin, we may have epistaxis, hæmoptysis, hæmatemesis, intestinal hemorrhage, or hemorrhage from any other part. Erysipelas, too, may be a troublesome complication, for not only does it exhaust the strength, but, when it invades the mucous membrane of the larynx, as it sometimes does, it may prove rapidly fatal by producing oedema of the glottis. Degeneration of the muscular structure of the heart may also take place. This gives rise to a slow and feeble pulse and to a disposition to syncope. Bed-sores are not so frequent as in typhoid fever. They {356} do, however, sometimes occur, as does also gangrene of the toes and of other parts not subjected to pressure.

Less common complications are jaundice, peri- and endo-carditis, meningitis, local and general paralyses, cancrum oris, a diffuse cellular inflammation ending in purulent infiltration, and inflammatory swellings of the glands, or buboes. The salivary glands--and especially the parotid gland--are very apt to be affected by this inflammatory swelling. This occurs rapidly, is very tender, and in most cases soon runs on to suppuration, although it occasionally in children spontaneously subsides. It may occur at any time during the course of the fever, or not until convalescence, and sometimes affects the glands of both sides of the face. These buboes form a connecting link between typhus fever and the Oriental plague, and Murchison says that the distinguished Egyptian physician Clot Bey, on seeing some cases of the former disease complicated with parotid swellings, declared that in Egypt they would be regarded as examples of the latter.

Many of the above-named complications may occur also as sequelæ, and in addition to these we may have pyæmia, giving rise to purulent collections in the joints and phlegmasia alba dolens. The last named is not in itself serious. Its chief danger is from the breaking down of the clot and the subsequent occurrence of embolism.

Menstruation is said not to be uncommon in the early stages of typhus fever, and may be so profuse as to greatly increase the prostration or even to cause death. According to Murchison, miscarriage does not inevitably occur when pregnant women are attacked with the disease, and if it does occur it is not necessarily fatal to either mother or child.

POST-MORTEM APPEARANCES.--Emaciation when death has occurred early in the course of the disease, and is due solely to the violence of the fever, is usually not well marked, but in those cases which have been protracted through the intercurrence of complications it may sometimes reach an extreme degree. Bed-sores, except under the circumstances just mentioned, are also rare. Rigor mortis is generally not well developed, and is of short duration. In a few cases it would seem, however, to have been well marked. The typhus maculæ are persistent after death, and so are any purpura spots and vibices which may have been present during life, but the subcuticular mottling usually disappears. The skin of the dependent portions of the body is discolored by the settling of blood in it, and putrefactive changes are apt to set in rapidly.

The only constant lesion observed is a profound alteration of the blood, which is darker in color and abnormally fluid. If clots are found at all, they are large, soft, and friable. The fibrin is diminished in amount. In the early part of the disease the red blood-corpuscles are said to be slightly increased in number, but later they are diminished, and under the microscope are observed to be crenated and not to form themselves readily into rouleaux. The white corpuscles are increased in number. No accurate chemical examination of the blood appears to have been made. Many of the post-mortem appearances which have been described as characteristics of typhus fever are really the consequence of this abnormal condition of the blood.

The respiratory organs generally present evidences of disease; the lesions of laryngitis, bronchitis, pneumonia, hypostatic congestion of the {357} lungs, and pleurisy have all been observed after death from typhus fever. Usually, the traces of previous inflammation of the larynx are but slight; in a few cases, however, ulceration has been found, but the ulcers are stated to be always minute and superficial. Ulcers are also occasionally found in the bronchi, and frequently indicate by their appearance the pre-existence of a much higher grade of inflammation. The bronchial mucous membrane is, however, oftener merely reddened and softened and covered with a tenacious frothy secretion. True pneumonia is of infrequent occurrence as compared with that of hypostatic congestion of the lungs, but it nevertheless does occur, and may be of either the catarrhal or croupous variety. When pleurisy exists, it is usually accompanied, according to Murchison, by purulent effusion into the pleural cavity. On the other hand, Lebert says the variety of inflammation of the pleura oftenest met with is the plastic. The intestines present no constant lesion. Gerhard says that in fifty examinations there was but in one case, and that doubtful in diagnosis, the slightest deviation from the natural appearance of the glands of Peyer. In a few cases the Peyer's patches have been found more prominent than usual, but not more so than they are in measles and in some other diseases. Lebert alone of recent authors makes a contrary statement. In an epidemic at Breslau, he says, the solitary glands, as well as the patches of Peyer, were the seat of small, isolated, and superficial ulcers, which were usually situated in the vicinity of the ileo-cæcal valve. The mesenteric glands are generally unaffected, but in the Breslau epidemic just referred to they were not infrequently found moderately swollen. In cases in which dysentery has occurred as a complication the characteristic appearances of the disease will of course be observed, as well as those of typhus fever. The spleen is generally softened and slightly enlarged. The enlargement is not, however, always present, as Gerhard found it in one only out of every five or six of the cases which he examined. Extravasations of blood into its structure are occasionally met with. The liver is usually congested, somewhat enlarged, and frequently under the microscope presents the appearances of commencing fatty degeneration. The kidneys often present unmistakable signs of renal disease in the swollen granular and more or less fatty condition of their gland-cells according to the duration of the disease. The muscles are darker in color than in health. Under the microscope they are found to have undergone the peculiar granular or waxy degeneration described by Zenker, and which have been fully referred to in the article on typhoid fever. Extravasations of blood are occasionally found in them, which may soften and form pseudo-abscesses.

Other post-mortem appearances which are met with less frequently than those above detailed are inflammation, and even ulceration, of the mucous membrane, of the bladder, inflammation of the salivary gland, peritonitis, and congestion of the pancreas and of the stomach.

The muscular tissue of the heart is generally softened and easily torn. It is not, however, as stated by some authors, invariably so, for in several cases in which it was examined by Da Costa it had undergone this change in one case only, in which there was no reason to suspect previous disease of the heart. The alteration is similar in kind to that which takes place in the voluntary muscles. An effusion of serum, which may be of a deep-red color from the transudation of the coloring matter of the blood, is {358} sometimes found in the pericardial sac, as are ecchymotic patches upon the surface of the heart. The endocardium may be stained from the imbibition of blood. On the other hand, endo- and peri-carditis are excessively rare.

Notwithstanding the severity of the cerebral symptoms in typhus fever, there are few or no important changes found in the brain or its membranes after death. The sinuses are occasionally filled with dark fluid blood, and the appearances of congestion of the brain are sometimes present. In other cases there may be an increased amount of serum beneath the arachnoid and into the lateral ventricles, but not more than is often seen after death from other causes. Very rarely a slight film of hemorrhage has been found in the cavity of the arachnoid, and sometimes also the evidences of non-inflammatory softening of the brain. Actual inflammation of the meninges has only been detected in a very few cases. There may also be congestion of the spinal membranes, increase of the spinal fluid, and softening of the cord itself. The ganglia of the sympathetic system appear to undergo a form of granular degeneration.

DIAGNOSIS.--The diseases which most closely resemble typhus fever are typhoid fever, measles, meningitis, and typhoid pneumonia.

The circumstances under which typhoid and typhus fever occur are different. Typhoid is never generated by overcrowding, and if contagious at all is much less so than typhus. Prostration occurs much earlier and is usually much more marked in the latter. The eruption in the former does not appear until the eighth day, and comes out in successive crops, and usually disappears under pressure as long as it lasts, and therefore may be easily distinguished from that of the latter. The duration of typhus is from ten to twenty days; that of typhoid is rarely less than twenty-one. Nevertheless, cases are occasionally met with in which it is impossible to arrive at a correct conclusion as to their nature unless some light is thrown upon it by the existence of other and more characteristic cases in the same house or neighborhood. I have recently had under my care a case which eventually proved to be typhoid fever, but which I and many others who saw it at first believed to be typhus in consequence of the presence of an abundant eruption, which did not disappear under pressure, and was finally converted into petechiæ.

The eruption of typhus is sometimes found upon the face, especially in children, and then presents a considerable similarity to that of measles, which, however, usually appears a little earlier. There is, moreover, rarely the same amount of prostration or stupor in the latter disease, which is also attended by coryza and more bronchial catarrh than is often present in the former. The eruptions in the two diseases differ. In measles it is crescentic in shape, and is more elevated than in typhus. It is also brighter in color, disappears under pressure, except in malignant cases, as long as it lasts, and is followed by free desquamation of the cuticle, which is not often observed in typhus. The temperature may be high in the former, but it usually falls upon the sixth day.

In meningitis the headache is much more severe, and does not disappear upon the occurrence of delirium. It may be so severe as to cause the patient to cry out. The senses are painfully acute. There are intolerance of light and sound, and some hypersensitiveness of the surface, {359} strabismus, inequality of the pupils or some other local paralysis, and retraction of the head. Nausea and vomiting are more common than in typhus, while the utter prostration of the latter disease is wholly wanting, and so is of course the characteristic eruption. The tâche meningitique is wanting in the latter, but too much reliance should not be placed upon either the presence or absence of this sign. The diagnosis is only likely to be difficult in those cases of typhus in which the delirium is active. In that form of typhus in which the symptoms simulate those of delirium tremens some difficulty may also be experienced in making a diagnosis, especially if the patient be a drunkard. In delirium tremens it will be remembered, however, that there is little or no elevation of temperature, that the skin is bathed in perspiration, the tongue moist, and the characteristic eruption absent. Typhoid pneumonia can be distinguished from pneumonia complicating typhus fever by the presence of the eruption in the latter.

Other diseases which have occasionally been mistaken for typhus fever are remittent fever, Bright's disease, giving rise to uræmia and purpura. It does not seem likely that even the severest forms of malarial fever should ever present such a resemblance to typhus fever as to make the differential diagnosis a matter of difficulty; but it would appear from the history of the latter disease given by Murchison that such a mistake has occurred in some of the Spanish American countries. The enlargement of the spleen and liver is much less marked than in remittent fever, and the remissions of temperature are much less decided. Uræmia may at times present a good deal of resemblance to the condition often seen in typhus fever after the supervention of coma or stupor, but the history of the case, the absence of fever and of eruption in the former, will generally enable us to distinguish between the two conditions. It should be remembered, however, that Bright's disease may occur in the course of typhus fever. Purpura may generally be recognized by the absence of fever and by the occurrence of hemorrhages from the nose, gums, and bowels.

PROGNOSIS.--The age, habits of life, and previous condition of health, as well as the character of the prevailing epidemic, must all be fully considered before making a prognosis in any special case. The disease usually runs a much milder course in children and young people than in adults past thirty years of age. After this age the mortality progressively increases, and in advanced life it becomes very high, being often as much as 50 per cent. or over. Sex does not of itself exercise much influence upon the course of typhus fever, for, although a few more men than women die of it, this appears to be attributable to the greater prevalence of drinking among the former. Previous intemperance acts unfavorably by producing a degeneration of the tissues of the body, thus rendering the patient less able to withstand the effects of the disease. Drunkards have therefore always furnished a large proportion of the fatal cases. The mortality among patients who are unfortunate enough to take typhus fever as they are convalescing from other diseases is usually also very great. This has often been observed in general hospitals in which cases of fever as well as those of other forms of disease are admitted. Fat, lymphatic, or muscular people more frequently die of it than those of a different conformation. Gerhard found it especially {360} fatal among negroes in the epidemic of 1836, and Buchanan seems to have had a similar experience at the London Fever Hospital. It is a fact noticed by English writers that people of the better class, although seldom attacked by typhus, often suffer severely from it. The mortality is always high among those patients who previously to contracting the disease have been for some time deprived of sufficient food, or have been overworked, or who have been the subjects of mental anxiety, worry, or any other depressing emotion. It is high also among those who in the beginning of the disease have exhausted their strength in the vain effort to resist the disposition to go to bed. The chances of recovery are, on the other hand, very much improved by the removal of patients from crowded, ill-ventilated houses to the wards of a spacious, airy hospital.

Unfavorable symptoms are a profuse dark-colored eruption associated with purpura spots and vibices, general lividity of the surface, great injection of the pupils, and a dusky hue of the countenance; extreme prostration; an excessively frequent and feeble pulse, especially if it is at the same time irregular or intermittent; absence of the cardiac impulse and of the systolic sound; hurried and spasmodic or abnormally slow respiration; great dryness and retraction of the tongue; excessive prominence of the nervous symptoms, such as headache, delirium, whether active or muttering; unequal or pin-hole contraction of the pupils; strabismus or other local paralysis; sleeplessness; muscular tremblings; subsultus tendinum; carphology; protracted hiccough; retention of the urine; relaxation of the sphincters of the bladder and rectum; coma and especially coma vigil, and convulsions; continued high temperature, rising instead of falling after the tenth day, especially if it is associated with coldness of the extremities and of the breath; a profuse perspiration without a general improvement in the symptoms; diminution in the quantity of the urine, or the presence in it of albumen, blood, or casts; vomiting; and diarrhoea. Hope, however, should never be abandoned even in the most unfavorable cases, as recovery has sometimes occurred when the patient seemed almost in articulo mortis. Convulsions are said to be invariably followed by death, and Graves regarded the presence of the pin-hole contraction of the pupils as of very grave import.

Favorable symptoms are--reduction of the frequency of the pulse, a fall of temperature, a diminution of the stupor or a resumption of consciousness, and a return of appetite and of moisture to the tongue. When the patient begins to improve he will often without assistance turn upon his side after having lain for a long time upon his back, and this change of position is sometimes the first indication of the approach of convalescence.

The mortality varies of course in different epidemics. The cases which have come under my own care being too few in number to draw deductions from on this point, I must rely upon the experience of those whose field of observation has been more extended than my own. According to Murchison, out of 18,268 cases of typhus fever admitted into the London Fever Hospital during twenty-three years, 3457 proved fatal, making a mortality of 18.92 per cent., or 1 in 5.28. Deducting 686 cases fatal within forty-eight hours, the mortality falls to 15.76 per cent., or 1 in 6.34. Included among the fatal cases is a large number in which {361} the disease had run its course to a favorable termination, and in which death was really due to sequelæ, such as pneumonia, erysipelas, etc. Moreover, the death-rate in the hospital is greater than in the community, because children, who rarely die of typhus fever, are seldom brought to it; while, on the other hand, it receives a large number of the infirm and aged inmates of the metropolitan workhouses. Making allowance for these sources of fallacy, Murchison believes that the actual mortality of typhus is not more than 10 per cent. In Gerhard's cases the proportion of deaths amongst the black was much greater than amongst the white men; thus, of the whites 1 died in 4-2/3, of the blacks 1 in 2-19/28. Amongst the women the reverse was true; thus, 1 white woman died in 4-3/5, but only 1 colored woman in 6-1/2, nearly. Da Costa lost 6 out of 39 cases. In one of the fatal cases the diagnosis was doubtful; in another there was a great deal of previous disease; in two others death was due to complications--so that there were but two in which the fatal result could fairly be attributed to the disease itself.

TREATMENT.--Typhus fever is an eminently preventible disease. It is therefore proper that the description of its curative treatment should be preceded by a few words in regard to its prophylaxis.

It is still an unsettled question whether or not typhus fever ever occurs de novo, and although the recent discovery by Klebs and others of bacillus peculiar to typhoid fever (the bacillus typhosus), and of special bacilli in other analogous diseases, renders it highly probable that typhus fever has also its own bacillus, and that therefore it is not likely to arise except as the result of infection, it must be admitted that it has often prevailed in localities into which it has not been possible to trace its importation. Under these circumstances it will be well to refer to those conditions which are asserted by some authors to favor its spontaneous generation, especially as these same conditions are certainly known to favor its propagation. It will not be necessary to do this at any great length, as they have all been fully described in discussing the etiology of the disease. The most important of them is the overcrowding of human beings, especially when combined with deficient ventilation, destitution, and want of personal cleanliness. The knowledge of the laws of hygiene is now so universally diffused that this combination of conditions never occurs at the present time to anything like the degree it often existed in the eighteenth century, and consequently epidemics of this disease are not only less frequent, but are also much milder in character, than formerly. Much work, however, still remains for sanitarians in the improvement of the homes of the poor, which even in this country are too often overcrowded and ill-ventilated.

The extension of the disease in a community will almost always be prevented by the prompt isolation of the first few cases. This can often be thoroughly done, if the patient is in easy circumstances, by placing him in an upper room, which should be stripped of its carpets, curtains, and other unnecessary furniture; by cutting off all communication between him and his attendants and the rest of the household; and by the free use of disinfectants. The room should be airy, and to ensure good ventilation a window should be left partly open. This may be done during the febrile stage, even in winter, without the risk of any injury to the patient. Among the poorer classes, however, {362} isolation can rarely be effectually carried out, and it is therefore much better to remove the patient to a hospital. Upon the admission of such a patient to an institution of this character his clothes should be at once disinfected. This may be done by washing the underclothing in a disinfecting fluid, and then exposing them to a free current of air, and by subjecting the outer clothing to a very high temperature in an oven or to the fumes of burning sulphur. Murchison believes that a neglect of this precaution has often been the cause of the extension of the disease to other inmates of the hospital, especially when the patient resumes during his convalescence the same clothing he wore upon admission. If the hospital is a general one, he should be placed, whenever practicable, in a well-ventilated ward by himself or with other patients suffering from the same disease. As this is not always possible, the number of the other occupants of the ward should be reduced and their beds placed as far away as possible from his. As the infectiousness of typhus fever is very much lessened by free ventilation, this precaution is often alone sufficient to prevent its extension to them. It is also well, however, to supplement it by the use of disinfectants. The diffusion of a solution of carbolic acid in the atmosphere of the ward by means of the steam atomizer has not only rendered the odor emanating from the patient less perceptible, but has also appeared to diminish decidedly the risk of infection. As a still further precaution the patient may be sponged with a weak solution of carbolic acid or some other disinfectant. His nurses should be selected, whenever practicable, from among those who have had the disease themselves. They should never sleep in the sick room, lounge about the patient's bed, or inhale his breath. They should be allowed a certain amount of time every day for rest and recreation in the fresh air, and should have a full supply of nourishing food. On the other hand, they should be warned against the danger of over-stimulation, which is often resorted to in the hope of warding off the disease, and should be relieved as far as possible from attendance upon other patients. It may be well here to say that the nursing of a case of typhus fever should never be undertaken by the relatives or friends of the patient, except as a matter of necessity. Not only do the anxiety and distress they naturally feel unnerve them and render them unfit to carry out the directions of the physician, but they can rarely execute the many offices required in the sick room with half the skill of a trained nurse or with so little annoyance to the patient.

Before the patient is allowed to leave his ward he should have a warm bath. If the disease has occurred in a private house, the room which he has occupied should be thoroughly disinfected. This is best done by replastering, repapering, and repainting it. In many cases, however, it will be sufficient to fumigate it with burning sulphur, and then to air it for several days. The bed and bedding should also be disinfected, and, where this cannot be thoroughly done, the latter had better be destroyed.

Of primary importance in the treatment of typhus fever is the regulation of the diet. Although there are no ulcers in the bowels in this as in typhoid fever, and although, consequently, there is not the same imperative necessity in this as in the latter disease to restrict the patient to liquid articles of food, experience has shown that such articles are much more readily digested and assimilated than solids. The diet {363} should consist, therefore, of milk, beef-tea, and chicken or mutton broth. Of all of these, milk is incomparably the best, and it should form, unless the patient manifest an unconquerable repugnance to its use, a large part of the nourishment in every case. Farinaceous articles of food are generally not well borne in this fever, because the diminution in the secretion of the salivary glands which almost always exists prevents their proper digestion. After the third or fourth day nourishment should be given in small quantities at short intervals, as every two hours, every hour, or even every half hour when the prostration is extreme. It should be the aim of the physician to give an adult at least two quarts of milk or their equivalent daily.

It is sometimes necessary to put a delirious patient under some restraint to prevent him from leaving his bed or doing some other act of violence. Frequently a judicious nurse will be able to accomplish this without the use of an undue amount of force, but at other times it will be necessary to have recourse to mechanical means of restraint. Usually, all that is necessary is to pass a folded sheet across the patient's chest, the ends of which are fastened to the sides of his bed.

It is now a universally accepted axiom among physicians that typhus fever is a self-limited disease, and that any attempts to cut it short is worse than useless. Not only do remedies which are employed for this purpose often produce alarming prostration, but there can be no doubt that they have in some cases been the cause of a fatal termination, which under another plan of treatment would have been averted. During the last century it was not uncommon to bleed, and to bleed largely, in the beginning of an attack of typhus fever, but even then there were physicians--as, for instance, O'Connell, Rogers,[28] Pringle,[29] and Rutty[30]--who raised a warning voice against the practice. Sir John Pringle goes so far as to say that "many have recovered without bleeding, but few who have lost much blood." A very similar opinion was also expressed by Baron Larrey in the early part of this century. Indeed, it is very evident that the same difference of opinion existed as to the employment of venesection in the treatment of acute affections when these authors wrote as prevailed in England and this country until within the last thirty years, and that the disastrous results which occasionally follow the abstraction of large amounts of blood from patients affected with fevers and inflammations were as fully recognized then as now by many physicians. This would seem effectually to dispose of the change-of-type-in-disease theory which was generally accepted in the first half of this century as sufficient to explain the fact which could no longer be overlooked that this class of patients did much better under a supporting than a depleting plan of treatment. Purgatives were also at one time freely given for the purpose of arresting the disease, but the results obtained from their use were scarcely less unfavorable, and they are now never employed with this view. The use of quinia in large doses has also been advocated for the same purpose, but experience, while it has shown that it is a valuable remedy, has demonstrated also that it does not possess {364} this power. Exactly the same thing may be said of the cold-water treatment of typhus fever. There is no evidence that it has ever shortened the duration of the disease.

[Footnote 28: An Essay on Epidemic Diseases, p. 60, by Joseph Rogers, M.D., Dublin, 1734.]

[Footnote 29: Loc. cit.]

[Footnote 30: A Chronological History of the Weather and Seasons, and the Prevailing Diseases, in Dublin during the Space of Forty Years, by John Rutty, M.D., London, 1770.]

If the physician is called to a case of typhus fever during the chill, before reaction has taken place, he will of course have recourse to diffusible stimulants and external warmth to aid in the establishment of this process. More frequently he is not sent for until after the chill has been succeeded by fever. His treatment will then, of course, vary with the condition of the patient. If his stomach is loaded with food, an emetic should be administered to him. If the bowels are constipated, a mild cathartic will often be of service, but after the bowels have been once well moved it is generally unnecessary to disturb them further. During the first day or two, while the fever is still moderate in degree, and during the uncertainty which then usually exists as to the diagnosis, it will be sufficient to prescribe the neutral mixture or the spirit of Mindererus in tablespoonful doses every two or three hours. Upon the third day more active remedies will generally be required to reduce the temperature. This is best done by the cold-water treatment in some form or other, or by the internal administration of antipyretic doses of quinia. The manner in which the cold water is to be used and the cases to which it is applicable must be left in a great measure to the judgment of the physician. In the form of the cold affusion it is now rarely resorted to, although Currie[31] obtained most excellent results with it. It is calculated, however, to alarm a timid patient, and it is probably owing largely to this fact that it has fallen into disuse. The cold bath, packing in a cold wet sheet, and sponging with cold water are the more usual means of employing cold in the treatment of typhus fever at the present day. The cold bath is much used in Germany in the treatment of different forms of fever, and even of inflammation. It is also resorted to in this country, but it has never attained the same popularity here as abroad. The best way of using it is as follows: The patient as soon as his temperature rises above 103° F. should be placed in a bath having a temperature between 80° and 90°, and which, whenever practicable, should be brought to his bedside, as when he has to be carried to the bathroom he is sometimes not only alarmed and rendered very nervous by the operation, but may exhaust himself in his struggles to free himself from his attendants. After his immersion cold water should be gradually added until the temperature of the bath is between 60° and 70° F. The length of time he should be allowed to remain in the bath will of course depend upon circumstances. If shivering is produced by it, he should be at once removed from it and thoroughly dried and put back to bed. If no such symptoms are observed, he may be allowed to remain in it longer. As a general rule, a half hour is as long as will be necessary or safe for him to continue immersed at any one time. His temperature will usually continue to fall for some time after his removal from the bath, but in the course of a few hours it will be found to have risen again to 103° or over, when he should have another bath. In this way it may be necessary to repeat the baths from eight to twelve times a day. Some authors recommend that the patient should be placed at once in a bath having a temperature of 50° F., {365} but this method of applying cold possesses no advantage over that above described, and is, like the cold affusion, very apt to excite alarm in the patient. The cold bath is not, however, well borne by all persons, and alarming symptoms, and even fatal collapse, have followed its use in the old and feeble. It is also contraindicated when the skin is covered with a profuse sweat or when the disease is complicated by an internal inflammation. When the means of giving a cold bath are not at hand, the cold pack will often be found a very efficient substitute for it. Sponging with cold water, although not so efficacious in reducing the temperature, has advantages over either of these methods of applying cold. In the first place, it is more agreeable to most patients and less calculated to excite alarm in those who are timid. Again, it may be more frequently repeated, and may be used in cases in which the cold bath is contraindicated. Occasionally alcohol or vinegar may be added with advantage to the water, with the view of increasing its refrigerant effects.

[Footnote 31: Medical Reports on the Effects of Water, Cold and Warm, as a Remedy in Fever and Febrile Diseases, by James Currie, M.D., F.R.S., London, 1805.]

When quinia is given for the purpose of reducing the temperature in the treatment of typhus fever, it must be used in large doses, as much as ten or fifteen grains repeated once or twice in the course of twenty-four hours being required for this purpose. When given in these quantities it has the disadvantage of producing deafness and occasionally of increasing the headache. I have therefore contented myself in the cases which have fallen under my own care with giving it in more moderate quantities, in combination with one of the mineral acids, as, for instance, a couple of grains of quinia in solution with from eight to ten drops of dilute muriatic acid, repeated from four to six times a day. The mineral acids were originally recommended in the treatment of typhus fever in the belief that they neutralized the poison which caused the fever, and which was supposed to be ammonia or some of its compounds. Although this theory is now no longer entertained, there can be no doubt that the tendency in this disease to the accumulation of ammonia in the blood is prevented by their administration. Digitalis, aconite, or veratrum viride may also be given in appropriate doses if with a high temperature there coexists great frequency of the pulse. The first-named remedy is especially indicated if there is at the same time diminution of the secretion of urine.

As the disease progresses other symptoms present themselves for treatment. One of the most urgent of these is the prostration. This not only appears early, but is often extreme, and if not met by appropriate remedies will often of itself be sufficient to cause the death of the patient. As soon as it makes itself manifest stimulants must be prescribed. These are, however, not to be resorted to simply because the patient has typhus fever. Many cases do perfectly well without them. In the young and robust it is often unnecessary to have recourse to them. On the other hand, in the old, the feeble, and the intemperate they should be employed early. The rule laid down by Stokes, that they should be administered as soon as the first sound of the heart becomes indistinct and inaudible, may be adopted for our guidance in this respect. At first they should be given tentatively. If the delirium, headache, and other nervous symptoms are increased after their administration, it is best to withhold them. They should be continued, on the other hand, when under their use the delirium ceases or grows milder, the other nervous {366} symptoms subside, and the patient falls into a refreshing sleep. The amount required to prevent fatal prostration will of course vary in each case. I have rarely myself found it necessary to prescribe more than half an ounce of whiskey or brandy every two hours, and frequently a very much smaller quantity has been found sufficient. Cases are, however, reported in which from twenty to twenty-four ounces daily have been given with asserted advantage.

Another symptom which often demands prompt relief is the headache. When not severe, it may be relieved by the application of cold to the head, either in the form of the ice-cap or by means of cloths frequently wrung out of cold water, and by the administration of moderate doses of potassium bromide; but when intense it requires more active treatment for its removal, such as the application of cups to the back of the neck or of leeches to the temples. General bleeding will accomplish the same result, but the good which is done by it is often more than counterbalanced by the prostration it induces. Sleeplessness is also sometimes the cause of a good deal of distress to the patient. When it occurs early in the disease and is caused by the headache, it will generally subside under the use of the remedies which are employed for the relief of the latter symptom; but when it comes on at a later period, it will often require special treatment. There is some doubt as to the propriety of giving opium under these circumstances, but Murchison, Gerhard, and others assert that it may be given not only without injury, but with positive advantage to the patient. Graves was in the habit of combining it with a small quantity of tartar emetic in the condition in which the sleeplessness is associated with active delirium. If, on the other hand, the delirium is of a low muttering character, it should be given with a diffusible stimulant.

In this condition I have often found a pill containing a small quantity each of opium and camphor, frequently repeated, to answer an admirable purpose, not only in procuring for the patient the needed repose, but also in diminishing the restlessness, jactitation, and subsultus tendinum. Opium should, however, not be used at all or used very carefully in cases in which there is congestion of the lungs or disease of the kidneys. The existence of the pin-hole pupil is also a contraindication to its employment. In young and robust patients, if the insomnia is attended by active delirium, chloral in twenty-grain doses, repeated if necessary, may often be given with advantage, but it should never be prescribed in cases in which the action of the heart is feeble. Other remedies which have been recommended in the treatment of this condition are belladonna, hyoscyamus, musk, chloroform, and cannabis indica. Potassium bromide appears to have no power to relieve it. No special modification of the above treatment is needed when delirium occurs independently of sleeplessness and headache. When the stupor is profound, efforts should be made to rouse the patient by the use of counter-irritants to the shaven scalp or to the nape of the neck. Murchison speaks well of the administration of strong coffee under these circumstances. If there is at the same time suppression or diminution of urine, diuretics should be administered in the hope of stimulating the kidneys to increased secretion. Retention of the urine is not an infrequent occurrence in this condition, and the physician ought never, therefore, to accept the assertions of the {367} nurse or friends of the patient that the latter has passed water, but should satisfy himself by an examination in regard to the condition of the bladder at every visit. He will often find that the apparent passage of urine is nothing more than the dribbling due to an over-distension of this organ. Neglect of this precaution has occasionally been the cause of much subsequent distress to the patient, as cystitis is sometimes set up as a consequence of it. In one case which came under my observation, and in which this precaution had been neglected, the patient suffered from incontinence of urine for some time after his recovery from the fever. Thirst is a symptom which is always present and complained of at the beginning of the fever, and usually bears some proportion to the severity of this process. Weak tea, an infusion of cascarilla-bark, and camphor-water have all been recommended by different authors for its relief, but it is probable that no one of them possesses any superiority over water. If the stomach is irritable and water is not retained, small pieces of ice should be allowed to dissolve in the patient's mouth. Later, when the stage of stupor supervenes, it is very important to see that the patient obtains a full supply of water. In this condition he will not call for it, although it is even more urgently required than before.

Vomiting may occur at any time in the course of typhus fever. If it is observed at the very beginning of an attack, an emetic will often arrest it, but when it supervenes at a later period, it is generally of cerebral origin, and will usually subside under the use of the remedies already referred to which are prescribed for the relief of the nervous symptoms. In addition to these, sinapisms may be applied to the epigastrium, and champagne, when the circumstances of the patient will permit it, should be given in the place of whiskey or brandy. When everything is rejected by the stomach, recourse must be had to nutritious enemata. Constipation is to be overcome by gentle purgatives, as the use of powerful cathartics is very apt to be followed by troublesome diarrhoea. If this should come on, it is best treated by small doses of opium in combination with a mineral or vegetable astringent. When these fail, it may sometimes be relieved by a prescription containing sulphuric acid and morphia, and at others by enemata of from twenty to thirty drops of laudanum in warm water. When glandular swelling occurs in the parotid region or in other parts of the body, an effort should be made to promote resolution by painting them with tincture of iodine. Blisters have also been recommended for the same purpose, but they should be used carefully, as in low conditions of the system they are sometimes followed by sloughing of the integuments. If these remedies fail, poultices should be applied. As soon as pus has formed it should be evacuated by one or more free incisions.

Very few attacks of typhus fever run their course without the occurrence of some pulmonary complication. When this is slight it demands no special modification of the previous treatment, and it is sufficient to apply mustard poultices or stimulating liniments to the chest. But in cases of greater gravity, it matters not whether the complication is bronchitis, congestion of the lungs, or pneumonia, a more active treatment is required. Under these circumstances the ammonium carbonate in five-grain doses, given in mucilage of acacia, frequently repeated, or from thirty minims to a teaspoonful of the aromatic spirit of ammonia every {368} two hours, sufficiently diluted, may be prescribed with great advantage. When gangrene supervenes the prognosis is almost hopeless, but an effort should be made to save the patient's life by the administration of potassium chlorate and of an increased amount of stimulus. Murchison also speaks well of the inhalation of tar vapor and of carbolic acid.

As the other complications of typhus are at least of as common occurrence in typhoid fever, it will avoid a good deal of useless repetition to refer the reader to the article on the latter disease for a description of the treatment which they render necessary.

The patient should be kept in bed for some time after the subsidence of fever. Although relapses are rare in this disease, recrudescences of fever not infrequently occur as a consequence of undue exertion in the early part of convalescence. Syncope is also not infrequently produced by the patient's sitting up too soon. The diet should be carefully regulated until the recovery is complete. It should at first consist wholly of liquid or semi-liquid articles of food, but later meat in some digestible form may be allowed. Stimulants are often as urgently demanded at this time as during the fever itself. They should be given as the strength returns in gradually diminishing quantities. The length of time during which it is necessary to continue them will depend in great measure upon the previous habits of the patient. As a general rule, their use should not be abandoned until he is able to leave his bed, and they may often be continued after this with benefit to him. As convalescence progresses it will be well to substitute ale or porter for the brandy or whiskey the patient had previously taken. A return to health will also be promoted by the judicious use of tonics, such as iron, quinia, Huxham's tincture, tincture of nux vomica, the mineral acids, and even cod-liver oil in some cases.

{369}

RELAPSING FEVER.

BY WILLIAM PEPPER, M.D., LL.D.

SYNONYMS.--Febris recidiva, vel recurrens; Fièvre a rechutes; Fièvre recurrente; Typhus icterodes, vel recurrens; Bilious Typhoid Fever; Rückfall's Typhus; Tifo recidivo; Famine Fever, Hunger-pest, Armentyphus, Hunger-typhus, Spirillum Fever.

DEFINITION.--Relapsing fever is an epidemic contagious disease, the specific cause of which is not certainly known, although a peculiar spirillum appears to be constantly present in the blood. It occurs chiefly among the over-crowded and destitute, but may spread widely when introduced among more favorably situated populations. Its invasion is abrupt, and is marked by a distinct chill or rigor, followed quickly by high fever (104° to 106°), with severe headache and pains in the back and limbs. Delirium is comparatively rare. The tongue is heavily coated, and there are epigastric tenderness, vomiting, constipation, and enlargement of the liver and spleen, with frequent jaundice. There is no characteristic eruption. These symptoms cease abruptly from the fifth to the seventh day, with copious sweating; but after an apyretic interval of about a week's duration a relapse occurs similar to the first attack, but of less duration (three to five days). Second, third, or even more numerous relapses may subsequently occur at less regular intervals. One attack does not protect against a second one to the same extent as with other contagious diseases. The mortality is usually small.

HISTORY AND GEOGRAPHICAL DISTRIBUTION.--It is not important to consider here at any length the history of this disease. Allusions to it were made by Strother, 1729, and by Huxham, 1752, but the first reliable account on record is the description of an epidemic in the year 1739 by John Rutty.[1] Relapsing fever undoubtedly occurred at different times and at various places during the next hundred years, although the records of it are scanty, and for the most part imperfect, owing chiefly to the want of a clear recognition of its essential difference from typhus and typhoid fevers.

[Footnote 1: A Chronological History of the Weather and Seasons, etc., London, 1770, pp. 75-90.]

During the decade from 1842 to 1852 relapsing fever prevailed in a very active and widespread form. Epidemics occurred in England, Scotland, and Ireland, in various parts of Germany, and it was during this time that it was first observed and described in America. In June, 1844, an emigrant ship from Liverpool came to America with eighteen cases on board, which were taken to the Philadelphia and Pennsylvania {370} Hospitals. In 1848 a few cases were imported by emigrants to New York, and in 1850 to Buffalo in the same way.[2]

[Footnote 2: See Fevers, their Diagnosis, Pathology, and Treatment, Meredith Clymer, Phila., 1846, p. 99; Clinical Reports on Continued Fever, A. Flint, Phila., 1855, p. 364; Dubois 1848.]

The next great outbreak of relapsing fever began in Odessa in 1863 and lasted until 1872. It prevailed in various parts of Russia, in Germany, France, and Great Britain, and for the first time occurred extensively in the United States, especially in Philadelphia and New York. The present article is based largely on a study of this epidemic as it presented itself in Philadelphia during the years 1869-70, when the writer, in conjunction with the late Edward Rhoads, had the opportunity of observing about two hundred cases, in the wards of the Philadelphia Hospital. An admirable article on the same epidemic appeared from the pen of the late John S. Parry, in the Amer. Jour. Med. Sciences, N.S., vol. lx., Oct., 1870, p. 336.

Between the years 1877 and 1880 relapsing fever occurred quite extensively at Bombay, and was there studied by Carter[3] and Lewis; and during 1879-80 it prevailed in Königsberg, an account of which epidemic has been published by Meschede.[4]

[Footnote 3: Spirillum Fever, by H. Vandyke Carter, M.D., London, 1882.]

[Footnote 4: Virchow's Archiv, Bd. lxxxvii. p. 393.]

The geographical distribution of relapsing fever is seen, therefore, to have been very extensive; and not only has it occurred in the above-mentioned localities, but there have also been less extensive outbreaks in France, India, Egypt, Algeria, South America, and elsewhere.

CAUSES.--In all probability the essential cause of relapsing fever is a specific poison, but we know nothing of its real nature nor of the precise conditions under which it originates. Recent investigations have shown that the spirillum discovered by Obermeier is constantly present during the febrile stages of relapsing fever, but it cannot yet be decided whether this minute organism is the actual cause or only an invariable accompaniment of the disease.

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