cases. It not only indicates a grave form of the disease, but it adds also to its danger. The rose spots occur with like frequency in all grades of the disease, and are destitute, of course, of any prognostic value. The same remarks may be made of eschars upon the sacrum, as have just been made in regard to erysipelas. Before leaving this consideration of the several symptoms of typhoid fever, in their relation to prognosis, it is important to notice one other circumstance, of occasional occurrence, bearing upon this subject. It sometimes happens that a very well marked amelioration of all the symptoms takes place somewhere, usually, between the tenth and twentieth days of the disease; constituting, indeed, an apparent convalescence; and that this amendment is soon after followed by the return, in an aggravated form, of the symptoms which had subsided or diminished, in severity. This species of relapse is almost invariably followed by death. This circumstance is particularly noticed by Chomel, and the truth of his remarks is corroborated by Louis. Besides the foregoing, there are some other circumstances which affect in a general way the question of prognosis in typhoid fever. The principal of these are age, season, and acclimation. Speaking now of adult patients, that is of those over fifteen years old, it seems very certain that the danger to be apprehended from this disease is somewhat in proportion to their increased age. The mortality is smaller between the ages of fifteen and twenty than it is between the ages of twenty and twenty-five; or than it is at any subsequent period of like duration. The mortality at the Hôtel Dieu, in Chomel's wards, was one in five, between the ages of fifteen and twenty; one in four, between the ages of twenty and twenty-five; and one in two, over the age of thirty-five. Louis and Chomel agree in saying that they have rarely found cases to terminate fatally, where the patients were between the ages of fifteen and seventeen years. At the Massachusetts General Hospital, Dr. Jackson found the average age in the fatal cases to be a little more than two years greater than in the cases not fatal. He found also, upon a further analysis, that in those patients whose ages were thirty-five years or more, the mortality was one in four; while in those whose ages were twenty years or less, it was only one in nearly eleven. The prognosis is said to be more favorable amongst children than amongst adults; but of Barthez and Rilliet's one hundred and eleven cases, twenty-nine terminated fatally. It would appear, from the observations of Chomel, that typhoid fever is more grave and fatal in the cold, than it is in the warm season. At the Hôtel Dieu, in 1832, the mortality was one in three during the winter, and one in six during the summer; in 1834, it was one in two and a half during the winter, and one in seven during the summer; and in 1835, the average proportions were the same as in 1832. An exception to this general result occurred in 1831, when the proportion of deaths was one in four during the winter, and one in three during the summer. The number of cases, however, in the hospital, this year, was small. Chomel appears to have no doubt as to the influence of season upon the severity and mortality of the disease. I do not know how far his conclusions are sustained by the observations of others. The most fatal form of the disease that has ever been witnessed in the city of Lowell prevailed during a winter of extreme severity. In the Massachusetts General Hospital, from 1822 to 1835, the rate of mortality during the cold months was 1 in 6.39; while in the warm months. it was only 1 in 8.21.2 Of one hundred and eighty-three cases given by Forget, fortythree terminated fatally. The rate of mortality varied with the seasons in the following manner: in the autumn, it was 1 in 4; in the winter, 1 in 3,3; in the spring, 1 in 3,5; and in the summer, 1 in 63.3 3 It seems, also, and this principally from the results obtained by Chomel, at the Hôtel Dieu, that the length of time during which. patients have resided wherever they suffer from the disease, has some influence upon its mortality. Between the 1st of November, 1834, and the 1st of August, 1835, there were ninety cases of typhoid fever in Chomel's wards at the Hôtel Dieu. Amongst those patients who had resided in Paris less than one year, the mortality was one in three; amongst those who had resided in Paris between one and two years, the mortality was one in five; and of fifteen, who had resided in Paris more than two years, only one died. There is reason to think that this result is not accidental, since the same differences, though to a less striking extent, were noticed during the three previous years, and since they are also in keeping with the observations of Louis. Chomel has suggested that a certain degree of general debility, either constitutional or the result of pre La Lancette Française. August, 1835. 2 Dr. Jackson's Report, p. 107. 3 Traité de l'Enterite Folliculeuse. Par C. P. Forget, p. 409. vious disease, may act favorably upon the severity and the termination of typhoid fever. Forget says he has often been struck with the rapidity with which the disease has run on to a fatal termination in cases of young persons with rich, vigorous, and fine constitutions, so that it was not without a secret terror that he saw these patients enter the hospital.' Whether typhoid fever is any way influenced in its severity by race, I am unable to say. During the year 1846, Dr. Sutton, of Georgetown, Ky., saw forty-three cases of the disease. Thirty of these were amongst whites, and eight of them were fatal-1 in 4; thirteen were amongst negroes, two of which were fatal-1 in 63. These numbers are of course too small to be in themselves of much value. There is no evidence that the supposed occasional exciting causes of typhoid fever, such as scanty and poor diet, depressing emotions, fatigue, and excesses, have any effect upon the severity and fatality of the disease. It must be obvious enough, from all the foregoing considerations, that the prognosis in any given individual case of typhoid fever, can very rarely, if ever, be absolute and positive. Patients sometimes recover from the most desperate condition; they are liable to the most dangerous and fatal accidents, in the mildest cases. But, notwithstanding these contingencies, we may, in a great majority of instances, by a careful study of all the circumstances which can influence the result, arrive at a good degree of approximative certainty in our prognosis. In a moderate proportion of cases, the scales of life and death may hang for many days, so far as we are able to see, in almost exact equilibrium; and no foresight or sagacity can predict, with any degree of confidence, which of the two will finally preponderate. Favorable and unfavorable symptoms will be so combined, and so attempered, as to baffle all the efforts of wisdom and experience to calculate their issues. Hope and Fear are constant an equal watchers by the bedside of the sick. In all the rest, however, the general character of the symptoms will be, one way or the other, so marked and so decided, as to enable us to judge with a reasonable degree of certainty as to the result. If during the first fortnight, the pulse is not more than one hundred or one hundred and ten in the minute; if there is only moderate drowsiness; if there is no delirium, or even if this, though present, Traité de l'Enterite Folliculeuse, p. 404. This book is ika pi COOPER MEDICAL UG SAN FRANCISOD, C. has not appeared at any early period of the disease, and is easily dissipated, or mild in its character; if there is no twitching of the tendons; if the patient gets some comfortable sleep; if the diarrhoea and tympanitic state of the abdomen are moderate in degree; the chances of recovery are vastly in favor of the patient. Bearing in mind the liability which always exists to a sudden aggravation of the symptoms, to the supervention of some secondary complication, and to the occurrence of intestinal perforation, and the qualification necessarily accompanying this liability, we may in such cases, with great confidence, anticipate a favorable result. On the other hand, if the pulse is more than one hundred and ten or one hundred and twenty in the minute; if there is great stupor or coma; if the delirium comes on early, and is wild and furious; if there are spasmodic contractions of the muscles, picking at the bedclothes, and great prostration of strength; if there is restlessness or agitation; if the diarrhoea is urgent and continued; if the distension of the abdomen is extreme; if the odor from the patient is musty and cadaverous; if the features are pinched and Hippocratic; especially if there are general epileptiform convulsions or permanent rigidity of one of the limbs; or that peculiar perversion of the intellect which leads the patient, in the midst of this terrible combination of threatening circumstances, to suppose and to declare himself free from suffering and danger; if these symptoms, or any considerable number of them, are present, we can have very little ground to look for any but a fatal termination; and this termination we may with great confidence predict. CHAPTER VIII. DIAGNOSIS. It is only since the publication of the work of Louis, by the aid of his and of subsequent researches, that typhoid fever has been distinguished, with any considerable degree of constancy and certainty, from other more or less analogous forms of disease. And even now, there are few problems in diagnosis more complex than this; although, by the application of the requisite knowledge and care, its solution is almost always attainable. The elements which enter into the composition of this problem are many and various. There is no one symptom, there are no two or three symptoms, which, in themselves, are characteristic of the disease. There is no one symptom, there are no two or three symptoms, usually occurring in the disease, which may not be absent during its entire progress. Our diagnosis can never be founded here, as it is in many other instances, on a few positive physical signs. It must always be rational, not absolute. The evidence upon which our verdict is to be rendered is wholly circumstantial. Notwithstanding all this, and although cases sometimes occur, so enveloped in obscurity as to baffle the skill of the most careful and experienced observers; it is still true that there are few general diseases, the diagnosis of which is so well established, and so certain, as that of typhoid fever.1 Perhaps, in the present state of science, a single qualification ought to be affixed to this last remark. The whole question of the diagnosis of the several individual diseases constituting the family of idiopathic or essential fevers, has been undergoing, ever since the publication of the work of Louis, a more rigorous and philosophical 1 A British reviewer of my book gravely cites this admission, of the occasional difficulty, or impossibility, of making an absolute and positive diagnosis, as sufficient proof that there is no specific difference between the typhus and the typhoid forms of continued fever-as though there could be no such individual diseases as cancer of the stomach, or softening of the brain, because we are not always able to make them out with entire certainty during life! |