tion persists into the stage of convalescence. after death.

The papules are not apparent

The eruption is not invariably present. In the 73 cases which I have analyzed, it existed in 49. The proportion of cases in which it occurs varies in different years, as my statistics show. It appears to be less frequent in the country than in the city. According to Jenner, it is less frequent in children than in adults. The copiousness of the eruption is no evidence of severity of the fever, and, on the other hand, it is as likely to be absent in mild as in severe cases. A scarlet rash occasionally precedes the characteristic rose eruption.

Miliary vesicles or sudamina are not infrequently observed in the middle and latter part of the disease on the neck, chest, and abdomen. Louis attributed to this eruption considerable diagnostic value, but on insufficient ground. It is observed in various affections in which perspiration occurs. Petechiae or minute ecchymoses are occasionally observed. These do not denote unusual gravity of the disease; they occur in mild as well as severe

cases.

Bluish patches of irregular form, from three to eight lines in diameter, are occasionally observed on the abdomen, back, and thighs. They are not peculiar to this disease, and are more likely to occur in mild than severe

cases.

Perspiration more or less abundant, and recurring more or less frequently, is observed in about one-half of cases, exclusive of its occurrence at the time of convalescence or just before death. It occurs in about an equal proportion of fatal cases and those ending in recovery. Observation does not show a connection between this symptom and any particular antecedent events; but, taking the frequency of the pulse as a criterion of the gravity of the disease, and comparing the pulse before and after the occurrence of perspiration, in the majority of cases improvement follows. While this symptom, therefore, has no bearing on the prognosis, it often betokens some amelioration. It is not certain whether the perspiration produce the amelioration or proceed from it. It is most apt to occur at night. As a rule, during the greater part of the career of the fever, the skin is dry. The temperature of the body will be noticed in connection with the circulation.

Gangrene has never occurred in my experience except in situations exposed to pressure. Spontaneous gangrene of the extremities and genitals has been observed. Gangrene, as well as troublesome ulcers, is liable to follow vesication. The liability to bed-sores on the nates, hips, and shoulders, is to be borne in mind. These may be prevented by changing from time to time the position of the body, the use of air-pillows, etc. Erysipelas is an occasional complication of typhoid fever.

Respiratory System.-Cough is not a prominent symptom, unless some unusual pulmonary complication exists; but slight or moderate cough ist almost invariably present, proceeding from subacute bronchitis, or, perhaps, from congestion of the mucous membrane similar to that of the skin. A sibilant rale is frequently heard over the chest on auscultation.

Pneumonitis is a not infrequent complication. It occurred in 12 of 73 cases which I have analyzed. This complication is rendered probable by prominence of cough and accelerated breathing; but the proof of its existence is afforded by the physical signs. This complication is sometimes quite latent as regards diagnostic symptoms, and is determinable only by physical exploration. The existence of pneumonitis adds to the danger, but by no means precludes recovery. Irrespective of any pulmonary complication, except subacute bronchitis, the frequency of the respirations is increased, the average being about 21 per minute.

Frequent sighing in the early part of the disease is apt to be a forerunner of ataxic symptoms of grave omen. A spasmodic or jerking inspiration, when pneumonitis does not exist, is an important symptom as a precursor of coma. This statement holds good in other forms of fever than typhoid. Of the cases which I have analyzed, this symptom was noted in 16, and in onehalf of these cases, death by coma followed within a period varying from twelve hours to four days. The importance of this symptom is enhanced by the fact that it may sometimes be observed when no other symptoms denote impending coma. This was true of several of the cases which I have observed.

Epistaxis has been mentioned as a symptom of diagnostic value in the forming stage. It occurs not infrequently afterward, especially in the early part of the febrile career; and in some cases it occurs repeatedly. Of the 73 cases which I have analyzed, it occurred once or repeatedly in 21. Generally the hemorrhage is small, but occasionally it is profuse, and it may even require to be arrested by mechanical means. When slight or moderate, it does not appear to exert any influence on the progress of the disease.

Laryngitis and oedema of the glottis are occasional complications of typhoid fever.

Circulation and Temperature -More or less acceleration of the pulse belongs to the history of the disease. The acceleration varies considerably in different cases and at different periods of the disease in the same case. An analysis of my cases shows a greater average frequency in fatal cases than in those ending in recovery. As a rule, the gravity of the disease is in proportion to the acceleration of the pulse. The danger is usually considerable if the pulse exceed 120 per minute, and the danger is augmented in a geometrical ratio as the frequency rises higher than this. The mean frequency in the cases not proving fatal, of those which I have analyzed, was 93; in the fatal cases, 110. In some mild cases the average frequency dur ing the whole of the disease is less than the average frequency of health. In one of my cases the average frequency was 69. But in these cases the pulse at times exceeds the healthy standard. Hence, the pulse may at times fall below the standard of health. This is not infrequently observed at or near the time of convalescence. I have noted it as low as 64, 60, and 40. Others have observed it to fall still lower. Oftener the pulse continues more or less accelerated after convalescence is declared. A sudden and considerable increase of the frequency of the pulse denotes the occurrence of some important event, such as pneumonitis or peritonitis. The frequency of the pulse may vary at different periods of the day. The increase is sometimes in the morning and sometimes in the evening. So far as my observations go, regular exacerbations of fever, as indicated by the pulse, or remissions, are rarely observed.

As regards characters of the pulse other than frequency, it is often quick and vibratory, but rarely hard or resisting. It denotes increased action, but not increased power of the ventricular systole. It becomes feeble or compressible in proportion as it is frequent. The force is always notably dimin ished if the frequency much exceed 120. An unfavorable progress of the disease toward asthenia is shown by progressive increase in frequency and diminution of force. Under these circumstances, the first sound of the heart, on auscultation over the apex, is notably lessened, and may be inappreciable. More or less increase of the heat of the body is the rule. Perhaps the rule, that at some period in the disease the temperature is raised, is without any exceptions; but, at certain periods, the heat may not exceed, and even fall below, the standard of health. The researches of Wunderlich, embrac ing an examination of 700 cases by means of the thermometer in the axilla,

show a progressive increase of temperature for the first three days to be the rule. At the end of this period, the temperature usually rises to 1030.5 Fahr. If, in the progress of the disease, the thermometer show a greater increase than this, the prognosis is unfavorable, whereas, a decline of the temperature in the morning to near the normal standard is evidence of convalescence. Wunderlich's researches show a regular oscillation of temperature between morning and evening, the difference being about one degree up to the time of convalescence, when the oscillations become much greater, the difference being four or five degrees, the temperature in the morning being at the normal standard 98° or lower. A high elevation of temperature in the morning, viz., 106° to 1080, indicates the approach of death. The laws of the disease, as regards temperature, are considered by Wunderlich and others as characteristic, so that the thermometer may be useful in diagnosis as well as prognosis.1

Urine. The urine is usually scanty and of high specific gravity until the approach of convalescence, when it becomes abundant and of a low specific gravity. During the progress of the disease, as a rule, the urea and uric acid are absolutely increased. The coloring matter is also more abundant than in health. The presence of albumen during a portion of the febrile career is not very uncommon. Abeille found it in 12 of 95 cases. Of 282 cases observed by Murchison, Parkes, Solon, and others, albuminuria occurred in 93, being about 32 per cent. Abeille, who has studied with care the occurrence of transient albuminuria in this and other affections, states that it is a symptom denoting always gravity of the disease. Of the 12 cases noted by this observer, in 6 the disease was fatal. The abundance of albumen denotes a proportionate gravity. This symptom occurs in the middle or latter part of the disease, and may continue for a period varying from 24 hours to 12 days. In the fatal cases in which it occurs, it continues up to the time of death. In the cases studied by Abeille, the kidneys after death were simply congested, no deposit or structural change existing. He supposes that the albuminuria proceeds, partly from congestion of the kidney, and in part from a morbid change in the blood.

Renal casts in the urine are sometimes observed. These denote disease of the kidneys, either existing prior to the fever, or developed as a complication. If, with or without renal casts or albuminuria, the urine be notably deficient in urea, uræmia is to be apprehended. It is probable that coma and convulsions occurring in the progress of typhoid fever are due to uræmic poisoning.

The urine is sometimes retained in cases of typhoid fever, and owing to the blunted perception, the bladder may become greatly distended. The practitioner should not omit to ascertain the condition of the bladder, by manual examination of the abdomen, during the progress of the disease, and resort seasonably to the use of the catheter when required. On the other hand, the urine is often passed in bed, sometimes from indifference and sometimes from incontinence.

In order to determine the duration of the disease, it is necessary to fix upon certain points which shall mark the beginning and the end of the febrile career. The time of taking to the bed is a convenient, and, in a collection of cases, a tolerably correct criterion of the full development of the fever. It is difficult to find any circumstance which will answer equally well to denote the date of convalescence. The career of the fever rarely ends abruptly; the termination in convalescence, like the development, is gradual. The decision that a patient is to be considered convalescent is a matter of

For further details, vide Aitken's Science and Practice of Medicine.

judgment, and is to be based on the ensemble of symptoms. Different practitioners would differ in individual cases as to the precise day of convalescence. This fact disposes at once of the doctrine of critical days. A believer in this, doctrine would be likely to fix upon a critical day as the date on which the fever ends, whereas, a non-believer would be as likely to fix upon some other day; hence, it is clear that observations collected by believers in critical days would go to support the doctrine. Of 42 cases, ending in recovery, which I have analyzed with reference to the duration of the fever, dating from the time of taking to the bed to the time when the improvement in all the symptoms was sufficient for the patients to be considered convalescent, the average duration was 16 days. The maximum duration was 28 days; the minimum 5 days. The mean duration in 75 cases observed by Murchison, was a fraction over 24 days. This greater duration is proba bly owing to the commencement being fixed at an earlier period than the date of taking to the bed. Of 45 fatal cases in my collection, the mean duration was a fraction over 14 days, the maximum being 26, and the minimum 9 days. The mean duration in 12 fatal cases observed by Murchison, was a fraction over 22 days. The average duration of convalescence is from one to two weeks.

Relapses of typhoid fever are sometimes observed. Several examples have fallen under my observation. A return of the fever may take place after ten days or a fortnight from the date of convalescence, and the patient pass through a second career, the eruption and other characteristic symptoms being reproduced. The duration of the second career is usually shorter, and the severity greater than the first, but a fatal termination is rare. In 231 cases occurring in six months, in Munich, in 1856-57, analyzed by Prof. Pfeufer, there were seven examples of relapse. Of these 7 cases 4 were fatal, the large rate of fatality being a deviation from the rule in relapsing cases. "After death two sets of ulcers were found in the intestines, corresponding to the two attacks of fever."

The complications which are apt to arise in the course of typhoid fever have been noticed in connection with the symptoms referable to different anatomical symptoms. Typhoid fever may be associated with scarlatina, rubeola, diphtheria and perhaps with typhus. Occasional sequels are, pulmonary tuberculosis, and subcutaneous abscesses. Progressive emaciation and death from inanition have been known to follow; but in many instances, nutrition becomes extremely active after recovery, and the patient attains to a greater weight than ever before. The mental powers in some cases are enfeebled for a considerable period.

CHAPTER II.

Typhoid Fever Continued-Causation-Diagnosis-Prognosis-Typhus Fever-Anatomical Characters-Clinical History-Causation-Diagnosis-Prognosis-Non-identity of Typhus and Typhoid Fever.

THE anatomical characters and clinical history of typhoid fever have been considered in the preceding chapter, and it remains to consider the causation, diagnosis, and prognosis of this disease before entering on the consideration of typhus fever.

Am. Jour. Med. Sciences, July, 1861.

CAUSATION.-Typhoid fever is not restricted within any geographical limits; it is endemic in every quarter of the globe. In certain of the socalled malarious districts it is not observed, as distinct from remitting fever; but there is reason to believe that, in these districts, it is obscured by being blended with periodical fever. It is certain that in some situations in this country, well-marked cases of typhoid fever were hardly known so long as malarious fevers were rife, but the former became the common form of fever after intermitting and remitting fevers ceased to prevail. Of this fact I have been personally cognizant in two situations, viz., Buffalo and Louisville. As regards the seasons of the year, it shows a decided predilection for the autumn. Of 45 cases which I have analyzed with reference to this point, 16 were in October, 9 in November, and 12 in December. It is stated that a warm dry summer favors the occurrence of the disease in the following autumn.

A decided predisposing influence pertains to age. Young persons are chiefly liable to it. Murchison states the mean age in 1,772 cases admitted into the London Fever Hospital, to have been a fraction over 21 years. It occurs but rarely in infancy. It is not uncommon in childhood. A considerable proportion of the cases of so-called infantile remitting fever are cases of typhoid fever. It is extremely rare after 50 years of age; but well authenticated cases of its occurrence after that age, and even in old persons, have been reported by Lombard, Trousseau, Wilks, and others. It is stated that the glands of Peyer begin to disappear after adult life, and traces of their existence only are apparent after forty-five years. This will account for absence of the lesions of these glands after fifty years of age.

Both sexes appear to be about equally liable to the disease. It was observed by Louis to occur especially among persons who had resided for a short period only in Paris. It has been observed to prevail among recent residents in other cities. Generally patients are in good health when attacked; other diseases do not seem to predispose to it. No causative influences relating to social position, occupation, or habits of life, have been ascertained. There does not appear to be any solid ground for the notion which has been held by Carnot and some other French writers, that the diminished prevalence of smallpox, in consequence of vaccination, has rendered typhoid fever more prevalent.

With respect to the contagiousness of the disease, there is not unanimity of opinion. That it may be communicated under certain circumstances is certain, and that it frequently or generally originates spontaneously, that is, irrespective of contagion or infection, is perhaps equally certain. Assuming these statements to be correct, this is one of the diseases, the special cause of which may be generated without the body and reproduced within the body.

The contagiousness of typhoid fever is proven by instances in which persons, having contracted the disease in one locality, go to another in which the disease was not prevailing, and of the residents in the latter locality with whom they are brought into contact, a greater or less number become affected. Many instances of this kind have been reported,' but the most remarkable of any on record came under my observation, in 1843, in a little settlement called North Boston, situated eighteen miles from the city of Buffalo, consisting of nine families, all being within an area of an hundred rods in diameter; but the few houses in which the disease occurred were closely grouped together around a tavern, the house farthest removed from the tavern being only ten rods distant. A stranger from New England, travelling in a stage-coach which passed through this settlement, had been

1 Vide Murchison, on the Continued Fevers of Great Britain.