Chomel admits several forms or varieties of typhoid fever, not depending upon degrees of severity. These are the inflammatory, the bilious, the mucous, the ataxic, and the adynamic. They depend upon the relative severity, or predominance, of certain symptoms, or groups of symptoms. In the inflammatory form, there are unusual strength and fulness of pulse; great heat and moisture of the skin, urgent thirst, and diminished secretion of urine. These symptoms are especially prominent only in the early period of the disease. According to Chomel, they occur oftenest in the robust, and during the winter months. The bilious variety is characterized by some yellowness about the lips and nose; a thick, yellowish, or greenish coat on the tongue; a bitter taste; nausea, and bilious vomiting. Chomel regards this form of typhoid fever-which occurs oftenest, he thinks, during the summer and autumn, and in particular localities-as identical with the bilious fever of authors. There is no doubt, whatever, that, in the confusion worse confounded which has always prevailed throughout the medical world in relation to the diagnosis of fevers, and which is even now but very partially dissipated, typhoid fever has often been described under the name of bilious fever; but it is also quite certain that, if Chomel supposes typhoid fever and bilious remittent fever to be identical diseases, he is widely mistaken. It is easy to see that there may be a bilious variety of typhoid fever, just as there is a bilious form of pneumonia. The mucous variety of typhoid fever is not very distinctly characterized, even in Chomel's description of it. It can hardly be said to exist as a distinct variety. The term ataxic is applied to those cases in which there are great severity and predominance of the nervous symp. toms, such as dulness, stupor, perversion of the senses, delirium, and spasms; or to those in which the disease is masked, and rendered irregular, by a want of the usual correspondence in degree of severity between the more important symptoms. In these cases there may be little or no delirium, or the pulse may be almost natural when the disease is manifestly hurrying on to a fatal termination. The adynamic form is marked by extreme debility, and prostration of strength, present at the commencement, or coming on in the course of the disease. The mind is lethargic; the pulse is feeble and soft; the urine and the cutaneous transpiration are fetid; and the disease is often prolonged beyond the fourth week.1

Chomel's Leçons de Clinique Médicale, p. 340 et seq.

CHAPTER VI.

DURATION, MARCH, AND COMPLICATIONS.

ARTICLE I.

DURATION.

It is not often an easy matter to determine, with accuracy, the duration of a disease. Both extremities of the space to be measured are distinctly defined. This is especially true of typhoid fever. The access of the disease is often gradual, and convalescence establishes itself by slow and almost imperceptible degrees. There is often, also, here another source of difficulty, arising from the state of mind in which the patient is found. His impressions are cloudy, his recollections are indistinct, and he will often date the commencement of his illness several days later than it really occurred. Dr. Jenner says the patient always believes that a longer time has elapsed since the commencement of his disease, or since the occurrence of any given event, than has really passed away.

Bearing these circumstances in mind, I proceed to state, as nearly as has been ascertained, the usual duration of the disease.

Dr. Jackson, following the example of Louis in regard to pneumonia, fixes the commencement of convalescence at the time when the patient is able to take a moderate quantity of solid food, the febrile symptoms having subsided for at least two or three days. previous to this period. In two hundred and fifty-five cases, at the Massachusetts General Hospital, between the years 1824 and 1835, inclusive, the average duration of the disease was twenty-two days. It was a little less than this in those under twenty-one years old, and a little more in those over. The duration varied in different years, from eighteen to twenty-six days. Dr. Jackson thinks that convalescence commences, in a few rare instances, as early as the seventh day. Of one hundred and eighty-six cases, at the same

1 Dr. Jackson's Report on Typhoid Fever, pp. 108, 109, 110, 111.

hospital, between October 1, 1833, and October 1, 1839, the average duration was thirty-nine days.1 Of sixty-eight cases terminating favorably, cited by Chomel, he says that there was a decided change for the better, in fifty, between the fifteenth and thirtieth days; and in more than one-half of these, it took place between the twentieth and twenty-fifth." Nathan Smith says that he has rarely seen the disease terminate under the fourteenth day from its commencement; and that it rarely extends beyond the sixtieth.3 Of the forty-six fatal cases, analyzed in the great work of Louis, ten terminated between the eighth and fifteenth day; seven, between the sixteenth and twentieth; twenty, between the twentieth and thirtieth; and nine, after this period. Of forty-six cases occurring in Richmond, Berkshire County, Massachusetts, between August, 1840, and February, 1841, the average duration was nearly forty-one days. It ought to be stated, however, that the duration in three of these cases is stated, respectively, at one hundred, one hundred and seventy-three, and two hundred days. This extreme prolongation was probably caused by some accidental complication. Forty-six cases occurred in the same town, between August, 1841, and May, 1842; the average duration in these being a little more than thirty three days. No death took place earlier than the twelfth or thirteenth day; in no case of recovery, was the duration less than sixteen days."

ARTICLE II.

MARCH AND COMPLICATIONS.

The march of the disease is, on the whole, pretty uniform and regular. In cases of average severity, the patients get gradually sicker, from day to day, for two or three weeks; or, after the first week, their condition may continue, with very little change, until convalescence commences. The disease is not usually marked by great and sudden alterations, either favorable or unfavorable, though these do sometimes occur. Neither is it marked by distinct stages, although Chomel divides it into three septenary periods, dating

Hale on the Typhoid Fever of New England, p. 241.

2 Chomel's Leçons de Clinique Médicale, p. 44.

3 Smith's Med. and Surg. Memoirs, p. 56.

Louis on Typhoid Fever, vol. i. p. 134, 2d ed.

Dr. Jennings's Letter to Dr. Clark.

from the distinct and formal onset of the disease. This is arbitrary, but very well as a matter of convenience.1

Typhoid fever is occasionally, but not often, complicated with other diseases. Nathan Smith says that he has often seen it follow dysentery, and that he has known it to coexist with epidemic catarrh. Chomel gives a case in which it was complicated, at its commencement, with acute pneumonia. Erysipelas sometimes occurs in the course of the disease, and this more frequently during some seasons than others. During the winter of 1846-7, în Lexington, Kentucky, there were several cases attended' with a bright erysipelatous redness of the nose; and the same redness was seen in some persons not suffering with the fever.

ARTICLE III.

PERITONITIS.

There is one other accident liable to occur in the progress of typhoid fever, of which it is necessary to speak more particularly; I mean acute inflammation of the peritoneum, occasioned by the discharge into its cavity of the contents of the small intestine through a perforation. The lesion itself has already been described. It was first fully investigated, its nature and causes pointed out, and its diagnosis established, by Louis. In a majority of instances, it takes place in cases of moderate severity, or in those which have been described as latent, and at a late period of the disease. Its occurrence is marked by the sudden supervention of acute pain in the abdomen. This pain comes on all at once, with no premonitory symptoms, with nothing in the condition of the patient to account for it, and the suffering which it occasions is excessive. The access of the pain is frequently accompanied by chills, the abdomen becomes rapidly and acutely tender on pressure, and, if it was not so before, hard and tympanitic. The pulse is quick and compressed. An instantaneous change takes place in the physiognomy of the patient. The countenance is expressive of intense suffering; the features are pinched and cadaverous; and the face is covered with a profuse sweat. There is a constant and urgent desire for cold drinks. Nausea and vomiting are present soon after the inflam

Leçons de Clinique Médicale. Chomel, p. 6.

2 Mémoires sur diverses Maladies, Paris, 1826, p. 156 et seq.

mation has commenced; the matter ejected from the stomach is of a grass green color, and it continues to be thrown up to the last moment of life. Notwithstanding the constancy and the intensity of the distress, the patient preserves the same position, lying upon his back, and dreading every movement that may add to the pain and tenderness of the abdomen. Such, in most cases, is the formidable array of symptoms which indicate the occurrence and mark the progress of this fatal complication. Occasionally, they are more obscure; and this peritoneal inflammation, like the fever itself, is to a certant extent latent. It is exceedingly rare, however, that there can be any difficulty in ascertaining its existence. Death usually takes place in from one to three days after the occurrence of the perforation.

ARTICLE IV.

RELAPSES.

It seems to be very well settled that true relapses, as they are called, not unfrequently occur in this disease. Dr. Jackson remarks that an error in diet and regimen is often followed by a new train of symptoms, after convalescence from typhoid fever; and that they appear to be such symptoms as belong to the fever, although not always so strongly characteristic as to leave no doubt on the subject. He cites a case in which, during the relapse, there was an eruption of the rose spots. Dr. Stewart reports two cases wherein, amongst many others of the more peculiar symptoms of the disease, the relapses were also attended by a reappearance of the typhoid eruption.' Indeed, there are probably few physicians extensively conversant with typhoid fever, who have not, more than once, seen convalescence fatally interrupted by a sudden return or an aggravation of many of the most characteristic symptoms of the disease, the delirium, the diarrhoea, the subsultus, the tympanites, and so on; constituting, not the supervention of a new accidental affection, but a genuine relapse.

Edin. Med. and Surg. Journ., Oct., 1840.