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 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 blind ness. 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 'Sir Joseph Fayrer, K. C. S. I., M. D., F. R. S., Brit. Med. Jour., April 29, 1881, p. 607. rise to no specific lesions. According to Murchison and Martin,' 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. TREATMENT.-In the milder forms of the disease little or no treatmen 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. 1 The Influence of Tropical Climates on European Constitutions, by James Ranald Martin, F. R. S., London, 1856. 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, 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' 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, 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 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 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 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 of Rome in the latter part of the seventeenth century described the hæmitritæus of previous writers 4 3 1 De Febre Semitertiana, Frankf., 1624; Op. Om., Amsterdam, 1745. Quoted by Mur chison. 2 Handbuch der Historisch-Geographischen Pathologie, von Dr. August Hirsch, Stuttgart, 1881. 3 Observat. Med. Pentecosta; Roma, 1652. Quoted by Murchison. Dr. Willis's Practice of Physick, translated by Samuel Pordage, London, 1684. 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. • Opera Omnia Medico-practica et Anatomica, Paris, 1788. 3 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,' and by Lancisi 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 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 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. 5 To Bretonneau 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 door, a tumor, and εTεpov, 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. 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, 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 excep 1 2 Opera Omnia Physico-Medico, 1699. Quoted by Murchison. Opera Omnia, Geneva, 1718. The Symptoms, Nature, etc. of the Febricula or Little Fever, London, 1746. Quoted by Hirsch. 5 Quoted by Trousseau, Archives Générales, 1826. • Researches Anatomiques, Pathologiques et Therapeutiques sur la Maladie connue sur les Noms de gastro-entente, etc., par P. C. A. Louis, Paris, 1829. |