The History, Diagnosis, and Treatment of Typhoid and of Typhus Fever: With ...

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Preface

I HAVE written this book^ because I thought^ that I saw a want in medical literature^ which it might supply. Our science, so far as the great subject of idiopathic fevers is concerned, is passing through a transition period; and many authorities, that were received as standard and classical, only a few years ago, are fast becoming obsolete ; at least for American readers. This is particularly true of the leading English treatises on Fever. Neither the works of Fordyce, Armstrong, Southwood Smith, nor Tweedie; nor the elaborate articles on Fever, in the Medical Cyclopedias, Libraries and Dictionaries, can henceforth be regarded as sufficient, or even safe, guides for American practitioners ; and the remark is applicable to them, not because they are not works of great excellence and value ; but for other reasons, which will be abundantly obvious in the course of the following pages.

VI PREFACE.

I may simply say, here, that their authors describe, principally, a fever, or form of fever, which is rarely met with in this country ; and that they do not represent the actual state of our knowledge upon this subject. It must be r^arded as especially unfortunate, that, until within a few years, the greater part of our information, relating to continued fever, has been derived from writers, who have treated, mostly, and under the same name as that generally used by ourselves, of a disease, or form of disease, differing, in many important respects, from that which is most common with us ; and, that, in this way, so great a degree of confusion has been introduced into our notions of fever.

If the radical defect in our literature of continued fever, thus indicated, had not existed ; and if the histories of the disease, which have been given to us by LouiS| Chomel and Andral, amongst the French ; and by Nathan Smith, Dr. James Jackson, Dr. Hale, and some othersi amongst ourselves, were generally accessible, and generally read, there would have been no want such as I have alluded to ; and, certainly, I should not have added another to the long catalogue of books on fever. A translation, by Dr. Bowditch, of Louis's Researches^ was published a few years ago under the auspices of the Massachusetts Medical Society, and has since been in the hands of most of its Fellows. But it is very far from being so generally and thoroughly known as it deserves to be. I may add, that the character of this remarkable work is

PREFACE. VII

hardly adapted to the actual wants and tastes of the great majority of our practical men. I may say this, I think, without any risk of giving offence ; for no man's admiration of this work can be more unqualified and profound than my own. Constituting, as it does, one of the few imperishable monuments, that have, from time to time, and at distant intervals, been raised up along the pathway of our science ; it is, nevertheless, true, that in the present state of the profession in this country ; amidst the daily cares and duties of its active members, there are but few, who will devote to this object the time and the labor which are necessary, thoroughly to comprehend its principles, and to master its accurate and minute details. ChomePs Clinical Lectures, so far as I know, have not been published here; Nathan Smith's Essay, excellent as it is, is still very incomplete; and the Reports of Dr. Jackson and Dr. Hale, besides not professing to treat systematically of the disease, are not generally accessible.

These, in brief, are the reasons, which have prompted me to undertake the preparation of this treatise. I thought, that the wants of medical science, here at least, demanded a history and comparison of the two chief forms of continued fever, as they are now ascertained to exist, fuller and more discriminating than had yet been written ; and these wants I have endeavored to supply. My book aims at no other excellence, and no higher merit, than that of being a methodical and com-

VIU PREFACE.

pendious summary of the actual state of our knowledge upon two most common and most important diseases. If it has reached this excellence^ and if it possesses this merit, I am satisfied.

I have only to add, in conclusion, that one of my leading purposes has been to bring out more clearly and strongly than has hitherto been done, our means of diagnosis between the different species or forms of fever ; and to ascertain and establish their nosological relations. It cannot be necessary to go into any formal vindication of the importance of this diagnosis. Setting it aside, altogether, as a matter of science ; it is the first, essential condition of all sound practice. In the following history it will be noticed, that I have spoken of no individual fever, excepting the four, which are more or less fully described; to wit, Typhoid Fever ; Tj^^^^s Fever ; Periodical Fever, in its three forms, of Intermittent, Bilious Remittent, and Congestive; and Yellow Fever. The simple reason of this is, that I do not know anything of any other distinct fever amongst us. There may be such a disease as the Simple Fever of Fordyce, or the Ephemera of many writers. I know, that adults, sometimes, in consequence of great, or protracted, fatigue; and, that children, still oftener, from inappreciable causes, are attacked with headache, loss of appetite, debiUty, and general febrile excitement, not referable to any local origin ; which symptoms, after rest of from one to two or three days, either with or without medicine, usually

PREFACE. IX

subside, leaving the individual in good health. But whether this kind of disorder should be looked upon as a distinct, established form of fever, seems to me, to say the least of it, very doubtful. As to an Inflammatory Fever distinct from Tjrphus or Typhoid Fever, I can only say, with Nathan Smith, and Chomel, that I have no knowledge of any such disease.

September Ist, 1842.

Part I. Chapter L

Pttffe.

Pbeliminaity Matters.

Aet. I. — Introductory 3

Aet. n. — Names of the Disease .... 5

Akt. in. — Methods of Description .... 8

CHAPTER n.

Symptoms.

Akt. I. — Mode of Access 10

Aet. n. — Febrile Symptoms 13

Sec. 1. — Chills 13

Sfec. 2 — Heat and State of the Skin . . , 14

Sec. 3. — Pulse 16

Art. m. — Thoracic Symptoms . • . . 18

Sec. 1. — Respiration 18

Sec. 2. — Cough 19

Sec. 8. — Physical Signs 19 xn

CONTENTS.

Art. IV.

Sec. 2.

Sec. 3.

isec. 4.

Sec. 5.

Sec. 6.

Sec. 7.

Sec. 8.

Aet. V. -

Sec. 1.

Sec. 2.

Sec. 3.

oec. 4.

Sec. 5.

Sec. 6.

Art. VI. ■

oec* A.

Sec. 2.

Sec. 3.

oec. 4.

Sec. 5.

Sec. 6.

ptoms

— Cerebro-Spinal, or Nervous Symptoms

— Headache . . . ,

— Pains in the Back and Limbs

— State of the Mind .

— Physiognomy

— Somnolence .

— Vigilance

— State of the Senses

— State of the Muscles -Digestive, and Abdominal Sym]

— Tongue and Mouth

— Appetite and Thirst

— Nausea and Vomiting .

— State of the Bowels — Abdominal Pains .

— Tympanites .

— Miscellaneous S3rmptoms

— Emaciation .

— State of the Urine

— Epistaxis — Cutaneous Eruptions

— Eschars

— Sequelss

CHAPTER m.

Anatomical Lesions 46

Aet. I. — Lesions of the Circulatory Appcuratus 47

Seel. — Heart and Aorta 47

Sec. 2. — State of the Blood . . . .49

Aet. n. — Lesions of the Respiratory Apparatus . 51

Sec. 1. — Lungs 51

Sec. 2. — Bronchia, Epiglottis, &c. ... 52

Aet m. — Lesions of the Brain and its Membranes . 53 Aet. rV. — Lesions of the Digestive and Abdominal

Organs 55

Sec. 1. — Pharynx and Esophagus ... 55

CONTENTS. Xm

Sec. 2. — Stomach 55

Sec. 3. — Small Intestines 58

Sec. 4. — Liarge Intestine 66

Sec. 5. — Lymphatic Glands .... 68

Sec. 6. — Spleen 68

Sec. 7. — Liver 70

Sec. 8. — Pancreas ; Salivary Glands ; Urinary Apparatus ; and Sexual Organs . . 71 Sec. 9. — General Remarks . . . .71

CHAPTER IV.

Causes.

Art. I. — Age 76

Art. II. — Recency of Residence .... 78

Art. ni. — Contagion 79

Art. IV. — Miscellaneous supposed Causes . . 85

Sec. 1 — Locality 85

Sec. 2. — Season 94

Sec. 3. — Sex 95

Sec. 4. — Miscellaneous 95

CHAPTER V.

Varietibs and Forms 97

CHAPTER VI.

DtJRATioN, March and Complications.

Art. I. — Duration ... ... 103

Art. II. — March and Complications . . . 105

Art. III. — Peritonitis 106

Art. IV. — Relapses 107

CHAPTER Vn.

DUGNOSIS 108

c

XIV

CONTENTS.

CHAPTER VIII.

CHAPTER IX.

Theory of Typhoid Fever

CHAPTER X.

Art. I. — Dr. Jackson's Method of Treatment Art. II. — Dr. Nathan Smith's Method Art. III. — Chomel's Method Art. IV. — Lfouis's Method Art. V. — Bouillaud's Method Art. VI. — De Larroque's Method . Art. VII, — Miscellaneous

CHAPTER XI.

Definition of '^filoid Fever 178

PART 11.

CHAPTER I. Preliminary Matters

CHAPTER n.

Symptoms Art. I. — Mode of Access

CONTENTS.

XV

Art. II. - Art. m.

Art. IV.

Sec. 1.

Sec. 2.

Sec. 3.

Sec. 4.

Sec. 5.

Art. V. - Art. VI.

— Febrile S3nanptoins

— Cerebro-Spinal Symptoms

— Headache ; pains in the Back and Limbs

— State of the Mind ....

— Physiognomy ....

— State of the Senses

— State of the Muscles

— Miscellaneous Symptoms

CHAPTER m.

Anatomical Lesions ....

Art. I. — Lesions of the Thoracic Organs Art. n. — Lesions of the Brain Art. ni. — Lesions of the Abdominal Organs

214 216 218 220

CHAPTER IV.

CHAPTER V.

CHAPTER VI.

CHAPTER Vn.

CHAPTER Vffl.

CHAPTER DL

Theory op Typhus Fever

XVI

CONTENTS.

CHAPTER X.

Treatment.

Bleeding ■Purgatives .

-Affusions and Ablutions • Stimulants and Tonics .

Miscellaneous Remedies

313 319 319 320 323

CHAPTER XI.

Definition op Typhus Fevee 328

PART HI.

BILIOUS REMITTENT AND YELLOW FEVERS.

CHAPTER L

CHAPTER n.

Part First. The

HISTORY, DIAGNOSIS, AND TREATMENT or

TYPHOIB FEVER.

Part First. Typhoid Fever

CHAPTER I.

PRELIMINARY MATTERS.

ARTICLE I.

INTRODUCTORY.

In writing a history of typhoid and of typhus fever, I begin with that of typhoid fever, for three reasons.

In the first place, my own knowledge of the disease, derived from personal observation, is much better than it is of typhus fever. My attention was early and strongly called to its investigation by the remarkable work of Louis upon the same disease, as it shows itself in Paris. My professional life, thus far, has been passed in the midst of a population, especially exposed to some of its predisposing causes, and amongst whom, it has, very constantly, and at times very extensively, prevailed ; so that a personal acquaintance with this fever of fifteen years' continuance has given me sufficient opportunity to become somewhat familiar with its character ; more so, at any rate, than with the remaining diseases, which I propose, in part, at least, to describe.

In the second place, there is good reason to think, that typhoid fever is more generally and extensively prevalent, in various parts of the world, than the other distinct forms of essential or idiopathic fever. This is a point which requires further and more accurate observation for its settlement ; but it is pretty certainly true of the temperate latitudes of Europe and America. The actual extent of its prevalence will be more fully spoken of hereafter.

In the third place, typhoid fever has been more minutely, more accurately, more thoroughly studied, than any other distinct form of essential or idiopathic fever. Although a complex, and in many respects, an obscure disease, its diagnosis is, in most cases, easily and positively made out. Its natural history has been very fully investigated, and the results of this investigation faithfully recorded and summed up. Its symptoms, its lesions, its causes, so far as these latter are appreciable, have been very exactly ascertained and settled ; and they have been very patiently compared with the symptoms, the lesions, and the causes of other diseases. This more complete knowledge of the disease renders it a very convenient starting point, and an exceedingly valuable standard of comparison, in our subsequent study of other forms of fever, more or less related to this, but whose history and character have not been so definiti?ely and precisely established.

NAMES OF THE DISEASE.

These, very briefly, are the simple and obvious considerations, which induce me to commence this history with a description of typhoid fever.

ARTICLE II.

NAMES OF THE DISEASE.

I have adopted the term typhoid fever as the name of this disease, simply because it is not particularly objectionable, and because it seems to be coming into general use. It is that which is most 'commonly given to the disease by the French, although many of their writers have coined other, and as they think, more appropriate appellations. Petit and Serres described it in 1813, under the name of entero-mesenteric fever. This term, as has been observed by Andral, has the advantage of marking the peculiar lesion of the disease, while it is free from the objection of pre-judging, by any implication, its nature or character. Bretonneau calls it a dothinenierite^ from the pustular inflammation of the intestine. Cruveilhier and others have applied to it the name of follicular enteritis. By the Grermans it is commonly called abdommal typhus. In New England it has generally been known under the name of typhus or typhous fever ; and by the great majority of practitioners it still continues to be so designated. Since, however, it has been ascertained, that the disease differs, in many important respects, from the typhus of British writers, it has become manifestly necessary to apply to it some

Other appellation, and in conformity to the example of Louis, Gerhard, Jackson, and othera, I have chosen that of typhoid feven

It may be well to say a word here in regard to the identity of the continued fever of New England with the typhoid fever of the French pathologists. This identity is very clearly and positively settled. No one familiar with the disease, as it shows itself in Paris, and as it is described by Louis, Chomel, and Andral, and who reads Nathan Smith's description of the Typhous Fever of New England, can doubt for a moment, so far as the symtomatology is concerned, that such is the case. The identity of the pathological lesions in the fever of the two countries has been more recently established. Dr. E. Hale, Jr., of Boston, puUished in the Medical Magazine for December, 1 833, an account of three dissections of persons, considered by him to have died with this disease. If the diagnosis in these cases could be looked upon as certain and positive, they would constitute, so far as I know, the first published examples of the intestinal lesion of the disease, as it occurs in New England. The diagnosis, however, in all the instances, must be regarded as somewhat doubtful, and the alteration of the intestinal follicles does not seem to have been very clearly or strongly marked. The first authentic and unequivocal cases on record, that I have been able to find, are two, which were published by Dr. Gerhard, in the American Journal of Medical Sciences, for February, 1 835. In the Medical

NAMES OF TRK mSEASE. 7

Magazine for June, 1835, 1 gave a shcnrt account of the entero-mesenteric alterations in fire cases of unequivocal typhoid fever, which alterations corresponded exactly to those described by Louis. I have upon my note book the anatomical history of two similar cases, which occurred during the months of January and February, 1833, but which were never published. Dr. James Jackson, Jr., then a medical student, observed the intestinal lesion in a clear case of the disease as early as October, 1830, although the account of the observation was not made public till 1835.^ Dr. Jackson, Jr., after having studied typhoid fever in Paris, aided and guided by the personal instructions of Louis, again saw the disease in Boston, and in two cases, one of which occurred in 1833, and the other in 1834, he found the characteristic lesion of the intestinal follieles and mesenteric glands. An account of these observations was published in 1835. Dr. Jackson^ Sen., in his Report on Typhoid Fever, communis cated to the Massachusetts Medical Society in June, 1838, says, that the alteration of Peyer's glands had been noticed at the Massachusetts General Hospital, previous to 1833, in cases which were carefully examined. Since the periods above referred to, more extensive and accurate observations, by Dr. J. Jackson, Dr. Hale, Dr. Bigelow, Dr. Bowditch, Dr. J. B. S. Jackson, Dr. Shattuck, Jr., Dr. Holmes, and others of Boston ; and by Dr.

' Memoir of Juimi Jaekftii» Jr., p. 398, M atq.

Gerhard and Dr. Stewardson of Philadelphia, have uniformly sustained the correctness of these early conclusions, and demonstrated the entire identity of the typhoid fever of Paris and of the United States.

;ii(^RTICLE UI.

METHODS OF DESCRIPTION.

There are two methods, either of which may be adopted, in the description of a disease. One of these, and that which, with a few exceptions, has been in universal use from the time of Hippocrates to the era of Louis, consists in a general enumeration of the more striking and obvious phenomena of the disease, in their various combinations and progress, constituting a kind of portrait or picture. The other, which has been followed by many writers within the last fifteen years, especially amongst the French, consists, not merely in tliis general enumeration of the phenomena, their combinations and progress ; but in a thorough and careful analysis of these phenomena ; in a special and particular study of each individual element, which goes to make up the disease ; and in a strict estimate of the relative value and importance of each and all of these several elements. This analytical process, this " searching operation,'' is applied in study as well as in description, not only to the symptoms of a disease, but, to a considerable extent, also, to its pathology, etiology and therapeutics. Amongst the best examples of the first method, the physiog-

METHODS OF DESCRIPTION. V

Domical portraiture of disease, may he mentioned Sydenham's description of measles and St. Vitus's dance, and Dr. Ware's description of delirium tremens. The first and one of the most perfect examples of the latter is to be found in Louis's Researches upon Phthisis, published in 1825.

Each of these methods has its advantages and its disadvantages, its excellencies and its defects. By the first, a more complete and integral picture of the disease is presented, at once, to the mind, than can be done by the second. We are enabled to see, at a single glance, the form, the outlines, the features, the physiognomy of the disease. But in many very important particulars, tliis method is inferior to the second. It is merely a picture of disease ; like all other pictures, more or less like the original, strongly or feebly colored, according to the peculiar taste or ability of the individual artist. It is necessarily wanting in the scientific accuracy of which the second is susceptible. It is less complete, less perfect. The disadvantages of the latter consist in the absence of that wholeness and unity of impression which are made by the former. The mind, in order to get at the integral and entire picture, must arrange and comUne the scattered materials, which it has studied separately. As one of the leading purposes of the present work is to point out, as far as our actual knowledge will enable us. to do so, the characteristic features of each of the two great forms of continued fever ; to establish, as far as possible, a clear and positive diagnosis; to ascertain the resemblances and the differences between them ; I shall rely almost exclusively upon the last mentioned method.

Chapter II. Symptoms

ARTICLE I.

MODE OF ACCESS.

There is a good deal of difference, in different cases of typhoid fever, so far as the suddenness or violence of the seizure is concerned. There is no other acute disease, perhaps, in which the attack is more frequently slow and gradual than in this. In many cases it is quite impossible for the patient to fix with any accuracy upon the day when his fever commenced. Neither, in many of these same cases, is he able to tell in what his sickness consisted. He can only say, that, for several days, he has not enjoyed his accustomed degree of health. He may have merely felt a sensation of mental and bodily languor, an indisposition, or an inability to accomplish his usual labor, either of mind or body. He may have had slight and dull pain in the head, or in the back and limbs, with a general feeling of soreness or of fatigue. At the same time he may have experienced some sensations of chilliness, alter-

MODE OF ACCESS. 11

nadng with heat. There may have been, also, dimiDution, or loss of appetite, moderate thirst, with a drj or clammy state of the mouth. The expression of the countenance sometimes becomes listless and dull, the eye loses its animation, and the mind is either indifferent or apprehensive. There may have been moderate diarrhoea with some pains in the abdomen. This obscure and indefinite condition of ill health may continue for more than a week, occasionally for two or three weeks even, with but slight changes from day to day. Oftentimes there is a slow but steady increase in the severity of these morbid sensations, with a like gradual but regular appearance of other and more chaiacteristic symptoms of the disease, these latter coming out, day by day, one after another, a complete and successive development of the peculiar and strongly marked phenomena of the disease. In other cases, after an indefinite continuance of this obscure precursory period, there is a sudden supervention of the more violent symptoms. Nathan Smith says, " the disease attacks in such a gradual manner that we hardly know on what day to fix its commencement."^ Dr. James Jackson says, ^^ there is more difficulty, perhaps, in ascertaining the commencement in cases of typhoid fever, than in many other acute diseases.'^ '

In a certain proportion of cases, however, precisely how large, I am not able to say, the access

* A Practical Essay on Typhous Fever. By Nathan Smith, M. D.

• Report on the Typhoid Fever. By James Jackson, M. D.

of the fever is more violent, and its period much more distinctly marked. Chomel, indeed, says, that most frequently the invasion is sudden, coming on in the midst of perfect health, unexpectedly, and not preceded by any precursory symptoms. Of one hundred and twelve cases, in which this point was exactly observed, the access was sudden in seventy-three ; in the others there were obscure, premonitory symptoms. The mode of attack, in these cases, is various ; most frequently, perhaps, by a chill, accompanied by debility and head-ache, and followed by heat and thirst. In other cases, the mode of attack is different. During a grave epidemic of typhoid fever, which prevailed in the city of Lowell, in the winter of 1834-6, 1 saw two cases, in which the first feelings of ill health, experienced by the patients, so far as could be ascertained from them, consisted of severe, griping pains in the bowels, accompanied with tenderness on pressure. In these cases, diarrhoea was an early and prominent symptom. In another, and that a fatal case, the patient had been at her usual work during the day, and on getting into bed at night, felt lamsj this being the first feeling of sickness of which she was conscious. But, whatever be the mode of attack, whether this be slow, insidious, creeping and obscure, marked by no obvious and prominent symptoms, or, on the other hand, sudden and violent, — in either case, the disease goes on, for a considerable period of time, varying, of course, according to its severity and its favorable or fatal ter-

F£BRILE SYMPTOMS. 13

mination ; during which progress it is characterized bj a greater number and variety of symptoms ; in themselves, in their combinations, and their successive appearance, peculiar to this fever, than are to be found in any other form of acute disease. These several symptoms, classified and arranged,' I now proceed to describe, as fully and faithfully as the present state of our knowledge will enable roe so to do.

ARTICLE 11.

FEBRILE SYMPTOMS.

Sec. I. — Chills. Like most acute diseases, typhoid fever is attended by chills or rigors. These are, generally, not very severe. Dr. Jackson says, that in the Massachusetts General Hospital, rigors were much less frequent than chills. Nathan Smith observes, merely, that in the commencement there is, generally, some degree of chilliness felt by the patient. Of thirty-three fatal cases, cited by Louis, thirty-one had chills ; in one fourth of which number they were severe, accompanied with trembling. Of forty-five grave cases, recovered, all were marked by chills, excepting three ; and of thirty-one mild cases, there were chills in twenty-four.

This symptom, in a great majority of instances, is present at the commencement, or very early in the disease. It is one of the most constant attendants upon the formal access of the fever. The chill occurs oftenest in the course of the day, and in a large proportion of cases is repeated, more or less frequendy, during the early period of the disease. It is not less constantly present in cases

amongst children than it is amongst adults.

•

Sec. II. — Heat and State of the Skin. Following the chill or rigor, and in the intervals, when these are repeated, there is, almost always, increased heat of the skin. This heat varies very much in different respects. In many patients it is quite moderate in degree, and pretty uniformly diffused over the body. In others the morbid heat is high and burning, and not unfrequently very unequally distributed. Nathan Smith says, ^^ sometimes the head and trunk will be excessively hot, while the extremities are cooler than natural ; at others, the extremities will be preternaturally hot, tvhen the body is but moderately so. One cheek will often appear of a deep red color and be very hot, while the other remains pale and cool ; as its color and heat subside, they seem to cross over and affect the opposite cheek in the same manner. This color and heat usually extend so far as to include the ear of the affected side.'' In the latter stage of grave and fatal cases, the intensity of the morbid heat frequently diminishes, and in mild cases it is not often very high, even in theur early periods.

This morbid heat, as one of the elements of the exacerbations, or fever fits, is subject to frequent variations in the course of each day. In grave

STATE OF SKIN. 16

cases these are of very constant daily occurrence. Sometimes they are irregular in their appearance, coming on at different and uncertain times of the day, although more commonly there are two each day. In the early period of the disease the most strongly marked exacerbation is usually in the afternoon. During these fever fits, there is increased redness of the cheeks, acceleration of the pulse, and a general aggravation of the severity of all the uncomfortable and .painful sensations.

The state of the skin, in regard to dryness and moisture, is quite different in different patients. In a small proportion of severe cases, the skin is almost constantly dry during the whole course of the fever. In others there is more or less moisture. Sometimes the sweats are limited to a short period following the evening exacerbation, or they break out in the night, during sleep. Not unfrequently they are profuse, sometimes confined to certain portions of the body, at others extending over the whole surface. Chomel says, that they often exhibit a strong acid odor. Louis observes that the sweats are in no degree proportionate to the morbid heat, and that not unfrequently they are prolonged during convalescence, preventing the re-establishment of the strength, and resisting the influence of aromatics and bitters. Nathan Smith speaks of "what has been called the Wdsher-woman^s sweaty which is extremely profuse over the whole surface of the body and extremities ; standing in large drops on the face, and giving to the cuticle, on the palms of the hands and soles of the feet, a corrugated appearance and a light color, as if it had been long macerated in water. In such cases, the perspiration is warm till a short time before the patient expires." He never saw an instance of recovery after this kind of sweating.

Dr. Smith also says, " there is a remarkable odor arising from a person affected by this disease, so peculiar that I feel assured that upon entering a room, blindfolded, where^ a person had been confined for some length of time, I should be able to distinguish it from all other febrile affections." My own experience, in this matter, coincides with that of Dr. Smith. This odor, which is not pungent and ammoniacal, like that which is said to arise from the bodies of patients with the grave forms of the British typhus, but of a semi-cadaverous and musty character, I have frequently noticed, especially during the late stages of severe and fatal cases.