xt7wst7ds10h https://exploreuk.uky.edu/dips/xt7wst7ds10h/data/mets.xml Bartlett, Elisha, 1804-1855. 1842 books b92-182-30418010 English Lea and Blanchard, : Philadelphia : Contact the Special Collections Research Center for information regarding rights and use of this collection. Typhoid fever. Typhus fever. Malaria. Yellow fever. History, diagnosis, and treatment of typhoid and of typhus fever : with an essay on the diagnosis of bilious remittent and of yellow fever / Elisha Bartlett. text History, diagnosis, and treatment of typhoid and of typhus fever : with an essay on the diagnosis of bilious remittent and of yellow fever / Elisha Bartlett. 1842 2002 true xt7wst7ds10h section xt7wst7ds10h
THE
HISTORY, DIAGNOSIS, AND TREATMENT
OF
TYPHOID AND OF TYPHUS FEVER;
WITH AN ESSAY ON THE
DIAGNOSIS OF BILIOUS REMITTENT
A-ND OF
YLLLOW FE VER.
All deieaen, then, o-ght to bc r,-docel to cert-nI nnl determinate loitl, with the e -m eit-ctnea u we
t it da- by botanieitiso, tttlirIr ta t Opluat. hFoc th-erex ae dlintos- th at -ome nader the same
be, e ihtI, --hw.lla-,andlig, binto f aitffeit
o1 vttare, r qaelle :A tiltr' t tta t.....lIwe ioog, tihetatar, a hisntry t dlii t-co, every .ilolonoph-ct
Ityputheuta, oollcl .lttit pei paocohb'l to t r inl itosnour, tight to he titt.ily o-Il -oe, and tha. the
t .i.ithbenoted tttl tlei itn-ont acc"racy, miIt.
tin thins the gretI exocln ol paititern, h.lo in their pictures copy the soinilent spots or (t1 h.s 1tt the
t-igitiolt. "-Sydeetlsom.
BY ELISHA BARTLETT, M. D.,
PaOFESSOR oF THE THEORY AND PRACTICE OF MEDICINE IN
TRtANSYLVANIA UNIVERSITY.
PHILADELPHIA:
LEA AND BLANCHARD.
1842.
Entered according to Act of Congress, in the year 1842, by
ELI-II A BARTLETT,
iIn the Clerk's Otflic of the Distii t Court ci the Dissrict o Massachusetts.
BOSTON:
FREEM1AN AND BROLLES, PRINTERS,
WA.1SHINOTON 5ThEE'r.
LATE rROFE
TO
JAMES JACKSON, M. D.
OF BOSTON,
SSOR OF THE THEORY AND PRACTICE OF I
HARVARD UNIVERSITY,
A-D TO
W. W. GERHARD, M. D.
OF PHILADELPHIA,
MEDICINE IN
LECTURER ON CLINICAL MEDICINE IN THE UNIVERSITY OF
PENNSYLVANIA,
This history of two diseases, many points of which, they, especially, amongst
his own countrymen, have diligently and successfully
studied and illustrated,
THIS VOLUME IS RESPECTFULLY INSCRIBED,
BY THEIR PERSONAL FRIEND,
THE AUTHOR.
SEPTEMBER 1st, IS-12.
This page in the original text is blank.
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 excel-
lence and value; but for other reasons, whichi will be
abundantly obvious in the course of the following pages.
Vi PREFACE.
I may simply say, here, that their authors describe, prin-
cipally, a fever, or form of fever, wvhich 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
regarded 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 gene-
rally 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 histo-
ries 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 others,
amongst ourselves, were generally accessible, and gene-
rally read, there would have been no want such as I have
alluded to; and, certainly, I should not have added an-
other to the long catalogue of books on fever. A trans-
lation, by Dr. Bowditch, of Louis's Researches, was pub-
lished a few years ago under the auspices of the Massa-
chusetts 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 pro-
found 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.
Chomel's 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-
Viii PRFFACE.
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 lead-
ing purposes has been to bring out more clearly and
strongly than has hitherto been done, our means of diag-
nosis 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, alto-
gether, 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; Typhus Fever; Peri-
odical 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
Ep,'emera of many writers. I know, that adults, some-
times, in consequence of great, or protracted, fatigue;
and, that children, still oftener, from inappreciable causes,
are attacked with headache, loss of appetite, debility,
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 Inflanmma-
tory Fever distinct from Typhus or Typhoid Fever, I
can only say, with Nathan Smith, and Chomel, that I
have no knowledge of any such disease.
SEPTEMBER Ist, IS42.
This page in the original text is blank.
CONTENTS.
PART' I.
TYPHOID FEVER.
CHAPTER I.
PRELIMINARY MATTERS.
ART. I.-Introductory
ART. II. - Names of the Disease
ART. III. - Methods of Description
CHAPTER II.
SYMPTOMS.
ART. I. - Mode of Access
ART. II. - Febrile Symptoms
Sec. 1. -Chills .
Sec. 2- Heat and State of the Skin
Sec. 3. - Pulse
ART. III. - Thoracic Symptoms
Sec. 1. - Respiration .
Sec. 2.-Cough
Sec. 3. - Physical Signs
Page.
3
5
S
10
13
13
14
16
18
18
19
19
CONTENTS.
ART. IV. - Cerebro-Spinal, or Nervous Symptoms . 20
See. 1. -Headache . . . . . . 20
See. 2. - Pains in the Back and Limbs . . 22
Sec. 3. - State of the Mlind. . . . . 22
See. 4. - Physiognomy . . . 25
See. 5. -Somnolence . . . . . 26
Sec. 6. - Vigilance . . . . . . 27
Sec. 7. - State of the Senses . . . . 27
Sec. 8.- State of the Muscles . . . . 28
ART. V. - Digestive, and Abdominal Symptoms . 31
See. 1. - Tongue and Mouth . . . . 31
Sec. 2. - Appetite and Thirst . . . . 33
See. 3. - Nausea and Vomiting . . . . 34
See. 4. - State of the Bowels . . . . 35
See. 5. -Abdominal Pains . . . . . 37
See. 6. - Tympanites. . . . . 37
ART. VI. - Miscellaneous Symptoms . . . 39
See. 1.-Emaciation . . . . . . 39
Sec. 2. - State of the Urine . . . . 39
See. 3. - Epistaxis . . . . . . 40
Sec. 4. - Cutaneous Eruptions . . . . 40
See. 5. - Eschars . . . . 44
See. 6. - Sequelw . . . . . . 45
CHAPTER III.
ANATOMICAL LESIONS . . . . . . 46
ART. I. -Lesions of the Circulatory Apparatus . 47
See. 1. - heart and Aorta. . . . . 47
See. 2. - State of the Blood . . . . 49
ART. II. -Lesions of the Respiratory Apparatus . 51
See. 1.-Lungs . . . . . . 51
Sec. 2. - Bronchia, Epig lottis, c. . . . 52
ART III. - Lesions of the Brain and its Membranes . 53
ART. IV. -Lesions of the Digestive and Abdominal
Organs . . . . . . 55
See. 1. - Pharynx and Esophagus . . . 55
Xii
CONTENTS.
Sec. 2.- Stomach
Sec. 3. -Small Intestines
Sec. 4. - Large Intestine
Sec. 5.- Lymphatic Glands
Sec. 6. - Spleen
Sec. 7. - Liver
Sec. 8. - Pancreas; Salivary Glands; Urinary Ap-
paratus; and Sexual Organs
Sec. 9. - General Remarks
CHAPTER IV.
CAUSES.
ART. I. - Age
ART. II. - Recency of Residence
ART. III. -Contagion
ART. IV. - Miscellaneous supposed C
Sec. 1 -Locality
Sec. 2. - Season
Sec. 3.-Sex .
Sec. 4. - Miscellaneous
ause
76
78
79
es . . 85
85
94
95
95
CHAPTER V.
VARIETIES AND FORMS
97
CHAPTER VI.
DURATION, MARCH AND COMPLICATIONS.
ART. I. - Duration
ART. II. -March and Complications
ART. IIl. - Peritonitis
ART. IV. -Relapses
CHAPTER VII.
. 103
. 105
. 106
. 107
. 108
Xiii
55
58
66
68
68
70
71
71
DIAGNOSIS
CONTENTS.
CHAPTER VIII.
MORTALITY AND PROGNOSIS
CHAPTER IX.
THEORY OF TYPHOID FEVER
CHAPTER X.
TREATMENT
AlT. I. -Dr. Jackson's Method of Treatment
ART. II. -Dr. Nathan Smith's Method
ART. III. - Chomel's Method
ART. IV. -Louis's Method
ART. V. -Bouillaud's Method
ART. VI. - De Larroque's Method
ART. VII. - Miscellaneous
CHAPTER XI.
DEFINITION OF TYPHOID FEVER
PART II.
TYPHUS FEVER.
CHAPTER I.
PRELIMINARY MATTERS
CHAPTER II.
SYMPTOMS
ART. I. - Mode of Access
. 123
. 135
. 146
. 148
. 154
. 158
. 166
. 171
. 172
. 174
. 178
. 183
. 186
xlv
CONTENTS.
ART. II. -Febrile Symptoms . . . . 187
ART. III. - Thoracic Symptoms . . . . 191
ART. IV. - Cerebro-Spinal Symptoms . . . 192
Sec. 1. - Headache; pains in the Back and Limbs 193
Sec. 2. - State of the Mind. . . . . 194
Sec. 3. - Physiognomy . . . . . 197
Sec. 4. - State of the Senses. . . . 198
Sec. 5. - State of the Muscles. . . . 199
ART. V. -Digestive and Abdominal Symptoms . 201
ART. VI. - Miscellaneous Symptoms . . . 206
CHAPTER III.
ANATOMICAL LE,-IONS . . . . . . 214
ART. I. -Lesions of the Thoracic Organs . . 216
ART. II. -Lesions of the Brain. . . . 218
ART. III. - Lesions of the Abdominal Organs . . 220
CHAPTER IV.
225
CAUSES
CHAPTER V.
VARIETIES AND FoRMS
CHAPTER VI.
DUR. TION AND MARCE .
CHAPTER VII.
MORTALITY AND PROGNOSIS
CHAPTER VIII.
DIAGNOSIS
CHAPTER IX.
TIiEoWiY OF Tyrvpuus FEVER
. 245
. 247
. 256
. 266
. 311
TV
xvi
CONTENTS.
CHAPTER X.
TREATMENT.
Sec. 1.-Bleeding
Sec. 2. -Purgatives
Sec. 3.- Affusions and Ablutions
Sec. 4.- Stimulants and Tonics .
Sec. 5.- Miscellaneous Remedies
CHAPTER XI.
DEFINITION OF TYPHus FEVER
. 313
. 319
. 319
. 320
. 323
. 328
PART III.
BILIOUS REMITTENT AND YELLOW FEVERS.
CHAPTER I.
BILIOUS REMITTENT FEVER
. 335
CHAPTER II.
YELLOW. FEVER
. 355
PART FIRST.
THE
HISTORY, DIAGNOSIS, AND TREATMENT
OF
TYPHOID
FEVER.
This page in the original text is blank.
PART FIRST.
TYPHOID FEVER
CHAPTER I.
PRELIMINARLY MATTERS.
ARTICLE I.
INTRODUCTORY.
IN Writing a hiistory of typhoid and of typhus
fever, I begin with that, of typhoid fever, for three
reasons.
In the first place,. Ily ovn kno.vledge of the
disease, derived from peisoinal 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 popula-
tion, 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 oppor-
tunity to become somewhat familiar with its char-
TYPHOID FEVER.
acter; more so, at any rate, than with the remain-
ing 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 ac-
curate observation for its settlemnent; 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 formr of essential or idiopathic
fever. Although: a coroplex, .and in many respects,
an obscure, diseases its diagnosis is,.in. most cases,
easily and positively rmade 6ut; 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 ascer-
tained and settled ; and they have been very pa-
tiently compared with the symptoms, the lesions,
and the causes of other diseases. This more com-
plete knowledge of the disease renders it a very
convenient starting point, and an exceedingly val-
uable 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 definitively and precisely established.
4
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 TIHE D)ISEASE.
I have adopted the term typhoid fever as the
name of this disease, simply because it is not par-
ticularly objectionable, and because it seems to be
coming ilto general use. It is that which is most
commonly given to the (lisease by the French,
although mniny 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-judgi-g, by any im-
plication, its nature or character. Bretonnjeau calls
it a dotIlincitcrite, from the l)iSttilar inflani-nmation
of the it.'testine. Cruveillhier and others have al)-
plied to it the name of follicular enteritis. By the
Germans it is commonly called abdominal typlihus.
In New England it has generally been known un-
der the name of typhus or ty3phlous fever ; and by
the great majority of l)ractitionles it still continues
to be so designated. Since, however, it hias been
ascertained, that the disease dillers, in many impor-
tant respects, from the typhus of British writers, it
has become manifestly necessary to ap)ply to it somc
5
6r YPHOID FEVER,
other appellation, and in conformity to the example
of Louis, Gerhard, Jackson, and others, I have
chosen that of tvyphloi(l lever.
It may l)e wenl to say a word here in re-ard to
the identity of the continued fever of New En-land
with the typlhoid fever of the French pathologists.
This identity is very clearly and p)0sitively settled.
No one familiar with the disease, as it showvs itself
in Paris, and as it is described bV Louis, Chmomel,
and Andral, and who reads Nathan Smith's descrip-
tion of the Typhous Ferer of New England, can
doubt for a moment, so far as the symtoinatology is
concerned, that such is the case. Time identity of
the p)athological lesions in the fever of the two
countries has been more recently established. Dr.
E. Hale, Jr., of Boston, published in the Medical
Magazine for December, 18.33, 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 wvould constitute, so far as I know, the first
pul)Iishecl examples of the intestinal lesion of the
disease, as it occurs in New England. The diag-
nosis, however, in all the instances, must be re-
garded as somewhat doubtful, and the alteration of
the intestinal follicles does not seem to have been
very clearly or strongly marked. The first authen-
tic and unequivocal cases on record, that I have
I)een able to find, are two, which were published
by Dr. Gerhard, in the American Journal of Medi-
cal Sciences, for February, 1835. In the Medical
6
NAMES OF THE DISEASE.
Magazine for June, 1835, I gave a short account of
the entero-mesenteric alterations in five cases of
unequivocal typhoid fever, which alterations corres-
ponded 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,
althoug1h the account of the observation was not
made public till 1835.1 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 fol-
licles and mesenteric glands. An account of these
observations w,-as published in 1835. Dr. Jackson,
Sen., in his Report on Typhoid Fever, communi-
cated to the Massachusetts Medical Society in June,
1838, says, that the alteration of Peyer's glands
had been noticed at the Massachusets General
hospital, previous to 1833, in cases which were
carefully examined. Since the periods above re-
ferred to, more extensive and accurate observations,
by Dr. J. Jackson, Dr. Male, Dr. Bigelow, Dr.
Bowditch, Dr. J. B. S. Jackson, Dr. Shattuck, Jr.,
Dr. Holmes, and others of Boston; and by Dr.
I Memoir of Jaines Jackson, Jr., . 222, U sca
7
S TYPHOID FEVER.
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.
ARTICLE 111.
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 enumera-
tion 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 wri-
ters within the last fifteen years, especially amongst
the French, consists, not merely in this general
enumeration of the phenomena, their combinations
and progress; but in a thorough and careful analy-
sis 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-
8
METHODS OF DESCRIPTION.
nomical portraiture of disease, may he mentioned
Sydenham's description of measles and St. Vitus's
dance, and Dr. Ware's description of delirium tre-
mens. The first and one of the most perfect ex-
anmples of the latter is to be found in Louis's Re-
searches up)on Phthisis, published in 1823.
Each of these methods has its advantages and
its disadvantat)es, 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. WVe are enabled
to see, at a single glance, the formn, the outlines,
the features, the physiognomy of the disease. But
in many very important particulars, this 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 whiclh are made by the
former. The mind, in order to get at the integral
and entire picture, must arrange and combine 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
stablish, as far as possible, a clear and positive
9
TYPHOID FEVER.
diagnosis; to ascertain the resemblances and the
differences between them ; I shall rely almost ex-
clusively upon the last mentioned method.
C1HAIPTER 1I.
SYMPTOMS.
ARTICLE L.
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 wvith any accuracy upon the day when his fever
commenced. Neither, in many of these same
cases, is he al)le to tell in what his sickness con-
sisted. lie 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 lie may
have experienced some sensations of chilliness, alter-
10
MODE OF ACCESS.
nating with heat. There may have been, also,
diminution, or loss of appetite, moderate thirst, with
a dry or clammy state of the mouth. The expres-
sion 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 diarrhea with some pains in
the abdomen. This obscure and indefinite condi-
tion of ill health may continue for more than a
week, occasionally for two or three weeks even,
vith but sliglt changes from day to day. Often-
times 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
characteristic symptoms of the disease, these latter
comifng out, day by day, one after another, a com-
plete and successive development of the peculiar
and stronglv 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. Na-
than Smith says, ",the disease attacks in such a
gradual manner that we hardly know oil what day
to fix its commencement." Dr. James Jackson
says, " there is more difficulty, perhips, in ascer-
taining the commencement in cases of typhoid fe-
ver, thati in mnanv other acute diseases." 2
In a certain proportion of cases, however, pre-
cisely how large, 1 am not able to say, the access
l A Practical Essay on Tvpheus Fever. By Nathan Sinmi, M D.
2 Report on the 'T'yphoid Fever. By James Jackson, M. D.
I I
TYPHOID FEVER.
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 1834-5, 1 saw two
cases, in which the first feelings of ill health, ex-
perienced by the patients, so far as could be ascer-
tained from them, consisted of severe, griping pains
in the bowels, accompanied with tenderness on
pressure. In these cases, diarrhea 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
lame, this being the first feeling of sickness of which
she was conscious. But, whatever be the mode
of attack, whether this be slow, insidious, creep-
ing and obscure, marked by no obvious and promi-
nent symptoms, or, on the other hand, sudden and
violent, -in either case, the disease goes on, for a
considerable period of time, varving, of course, ac-
cording to its severity and its favorable or fatal ter-
12
FEBRILE SYMPTOMS.
mination ; during which progress it is characterized
by a greater number and variety of symptoms; in
themselves, in their combinations, and their succes-
sive 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 me so
to do.
ARTICLE 11.
FEBRILE SY MPTOMS.
SEC. I. - Chills. Like most acute diseases, ty-
phoid 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
iumber they were severe, accompanied with trem-
bling. 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 attend-
ants upon the formal access of the fever. The
I13
TYPHOID FEVER.
chill occurs oftenest in the course of the day, and
in a large proportion of cases is repeated, more or
less frequently, during the early period of the dis-
ease. It is not less constantly present in cases
amongst children than it is amongst adults.
SEC. II. - Heat and State of the Skin. Follow-
ing the chill or rigor, and in the intervals, when
these are repeated, there is, almost always, increas-
ed 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, when 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
beat subside, they seem to cross over and affect the
opposite check in the same manner. This color
and heat usually extend so far as to include the ear
of the affected side." In. the latter state 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 their early periods.
This morbid heat. as one of the elements of the
exace