intoxication; his head becomes free, and in some instances he has an instantaneous and perfect recovery of his former knowledge. The memory, however, is still peculiarly affected; so much so that the patient has great difficulty in recalling to mind the circumstances. that passed before and during his illness. The mind also experiences a considerable change, and the indifference which was previously observed in the patient now begins to disappear. The eye becomes more attentive and expressive; surrounding objects begin to excite an interest, and the patient takes more notice of what is going on; the insensibility of the soul is dissipated; and the feelings of gratitude, of love, and of friendship, as well as of every other sentiment of the soul, are gradually awakened and displayed in the most exalted degree. "While the nervous system resumes its ordinary functions, and the locomotive powers become more energetic, the functions of the circulation are re-established, and the pulse becomes calm, regular, and open, though it is frequently weaker than in the preceding stages of the disease; the heat and perspiration of the body become mild and uniform; the thirst completely disappears, and the drinks which formerly afforded so much comfort to the patient now become disgusting." Hildenbrand also notices particularly the extreme muscular debility which accompanies this stage of the disease. [There are few diseases in which the transition from unfavorable to favorable symptoms is more marked than in typhus fever. In a period of eight, or twelve, or twenty-four hours, convalescence, in the majority of those who recover, is fully promised, is even commenced. The peculiar dusky suffusion of the face subsides; the tongue becomes moist, though perhaps clammy; the mind is restored; the patient feels his weakness and exhaustion, and complains of it, for the first time in many days; the pulse falls in frequency; and the skin becomes cool. This is a crisis, for in its etymology, the word means only something decided. Such a crisis. was noticed hundreds of times in the late epidemic of typhus fever, in the Bellevue Hospital; but crisis by sweating, or other evacuations, was very rarely seen; while that by a violent struggle of nature was not noticed at all. Dr. Peacock says that the resolution of fever does not seem to be effected by means of critical evacua. tions, and he further remarks, that he has not learned to attach much importance to critical days in this disease.] 'Gross's Hildenbrand, p. 52. SEC. III.-Sequelae. Typhus fever is not often followed by chronic affections which can be referred to the previous disease. Dr. Cheyne and some others speak of an occasional case of phthisis, chronic rheumatism, hydrothorax, and so on, as amongst the sequelae of typhus fever; but the general testimony of the Irish physicians is against the frequency of such results. This is very striking in the reports from many districts of the country, which are published in Barker and Cheyne's account of the epidemic of 1817, 1818, and 1819. They almost all agree in saying that the disease rarely left any dreg behind it. Sir Gilbert Blane noticed that ships arriving in the West Indies, from England, with their men suffering from typhus, were more liable than others to extensive visitations of dysentery.' [Dr. Upham wrote the paper, from which extracts have been already made, in part to record the occurrence of "a peculiar intestinal affection" allied to dysentery (though the diseased action often extended to the ilium), during convalescence from fever, as it appeared at the Quarantine Hospital, Boston. Dr. Upham states that he found "the secondary dysenteric affection" existing in the Quarantine and Emigrants' Hospitals of New York, and that it was there "of a similar intractible and fatal type." Little or nothing of this complication was seen at Bellevue Hospital, while it seems to have existed in the New York hospitals named above. The reason for this difference may, perhaps, be found in the fact that recent emigrants are not admitted into the institution at Bellevue. Regarding phthisis, and other sequelae, the reader is referred to the section entitled Secondary Lesions, p. 221 of this volume.] SEC. IV.-Relapses. The statements of British writers in regard to the frequency of relapses are quite contradictory. In most of the communications contained in Barker and Cheyne's history of the epidemic of 1817, 1818, and 1819, relapses are stated to have been of very frequent occurrence. At Cork, the number of persons who relapsed was estimated at two thousand. At Waterford, the relapses amounted to one-fifth or one-sixth of the whole number of the sick. This tendency to relapse was most striking during the latter period of the epidemic. It would seem to exist during certain periods, and to be absent during others. Dr. Stewart says that, however long may be the period of excitement, however long the adynamic stage, however tedious the period of convalescence, 1 Obs. Dis. of Seamen, p. 356. Barker and Cheyne's Account, etc., vol. i. p. 439. he has never, amongst thousands of cases, seen a single case of relapse, in the proper sense of the term, after the symptoms had begun to decline.' Dr. Edward Percival says that relapses were extremely rare at the Hardwicke Fever Hospital; while Dr. Pickels speaks of them as common, though mild, at Cork. Dr. Alfred Hudson, in his elaborate Inquiry into the souces and mode of action. of the Poison of Fever, informs us that, in five hundred cases of fever admitted into the Navan Hospital in 1840, only two instances of true relapse occurred." These differences of statement may depend, in part at least, upon relapsing fever having been confounded with typhus. [Relapses were not uncommon at Bellevue. During convalescence, and usually after the patient had left his bed, he would be seized, often suddenly, with a chill more or less severe, more or less. prolonged. This would be followed by an ardent fever, with furred tongue, suffused face, prostration of strength, headache, marked increased frequency of pulse, in short, with a repetition of the symptoms by which the primary fever is ushered in, when the attack is sudden. Its progress for a few days differed from that of primary typhus, chiefly in the absence of the graver cerebral symptoms. Its duration was, however, much shorter, usually ending in convalescence, in from five to eight days; and its mortality was so inconsiderable that an attack excited little apprehension for the patient's safety. A few cases were more protracted, but it is believed that the fever of relapse, in no instance, reached the average duration of the primary fever. In two instances which can be distinctly remembered (probably in more), both the first attack and the relapse were marked by the peculiar typhus eruption. These cases will be remembered by many physicians, and by many who were then medical students, for they attracted considerable attention. The cases in which relapse occurred did not seem to differ from those in which it did not, and though after 1850, the physicians of Bellevue had the advantage of Dr. Jenner's views on Relapsing Fever, they did not find reason, in their subsequent observations, to change their former opinions regarding the new attacks. The author of this note still holds to the opinion that relapses, if the disease above described deserves that name, do occur after typhus fever, and if there be a distinct febrile affection to be called Relapsing Fever, he believes that it has not been his fortune to see it.] Edinburgh Med. and Surg. Journ., Oct., 1840. 2 Dunglison's Medical Library. CHAPTER VII. MORTALITY AND PROGNOSIS. THE average mortality of typhus fever, deduced from large or considerable numbers, like that of most other epidemics of a grave character, differs very greatly in different seasons and localities. Before proceeding to estimate the elements of our prognosis in individual cases, I will endeavor to ascertain, as nearly as our materials will allow this to be done, the general rate of mortality in this disease, and some of its variations under different cir cumstances. It is estimated by Drs. Barker and Cheyne, in their admirable history of the great Irish epidemic of 1817, 1818, and 1819, that the number who suffered from typhus fever in that country, between the commencement of the first-mentioned year and the middle of the last, embracing a period of only two and a half years, amounted to fifteen hundred thousand; and that the aggregate number of deaths was sixty five thousand, making the average mortality one in twenty-three. The number of patients received into the Cork Street Fever Hospital, of Dublin, between the 14th of May, 1804, and the 5th of January, 1816, embracing no remarkable epidemic period, was twenty thousand two hundred and seventy eight. The highest mortality was one in ten, in the year 1805; the lowest was one in nearly twenty, in the year 1815; and the average mortality, for the entire period, was about one in fourteen. Dr. O'Brien, in the Report from which these results are obtained says, that the hospital necessarily received an undue proportion of grave and dangerous cases; so that the rate of mortality amongst fever patients was somewhat higher in the hospital than in the city at large. The whole number of patients received into the several fever hospitals of Dublin, from the 31st of August, 1817, to the 1st of October, 1819, was forty-one thousand seven hundred and seventy-five; and the deaths, during this period, were one thousand nine hundred I Trans. of Phys. of Ireland, vol. i. pp. 446, 461. and seventy-one; making the rate of mortality one in twenty-two, nearly.' The highest rate, for any single quarter, was one in fif teen; the lowest, for any single quarter, was one in thirty-two. The average mortality, during the same epidemic, in the South Fever Asylum at Cork, was one in twenty-five. The influence of age, sex, season, and the condition and constitution of the patient upon the danger of the disease, and upon our consequent prognosis, constitutes an interesting and important subject of inquiry. Typhus, like typhoid fever, is less severe and fatal in early than in middle life. Dr. Percival says that amongst the children who were timely removed from the crowded apartments of the Bedford Asylum to the cool and ventilated wards of the hospital, and who were properly treated, the fever seldom continued longer than seven days in any case, and hardly ever proved fatal. Dr. Baker observes that very few children became the victims of the epidemic in the years 1817 and 1818. Amongst the numerous cases of children which came under his care, he recollects but one which terminated fatally; and in that instance, death was occasioned by the supervention of another disease. Dr. John Cheyne says of the fever of 1818, at the Hardwicke Hospital, that persons under twenty-five years of age had the disease mildly. This influence of age upon the mortality of typhus fever is placed in a very clear and striking light by the statistical researches of Dr. Mateer. I copy the following table from a paper of his in the tenth volume of the Dublin Journal of Medical Science, exhibiting the effects of age upon the mortality of the disease, at the Belfast Fever Hospital, from September, 1817, to May, 1835:— |