CHAPTER V.

VARIETIES AND FORMS.

ARTICLE I.

BILIOUS REMITTENT FORM.

I HAVE already spoken of the subdivision of periodical fever into its three principal forms; and it is in this chapter that I find a suitable place for stating the grounds of this subdivision, and for indicating the principal features of these three leading varieties. Bilious remittent fever has now been pretty fully described; and it is sufficient to say, here, that the principal point of dissemblance between it and the pure intermittent form, consists in the continuance, in the former, of a considerable degree of febrile excitement, or of morbid action, during the intervals between the paroxysms or exacerbations of the disease. The several elements of a paroxysm-the chill, the febrile reaction, and the perspiration--are also more distinctly marked in the intermittent than they are in the remittent variety; and they are repeated from day to day, or from period to period, with greater regularity and uniformity. The remittent form is generally more inclined to run a determinate course, and then to cease, or to pass into the intermittent form than the latter. The fundamental pathological difference between the two varieties consists, probably, in the existence in remittent fever of more fixed and permanent local irritations than are to be found in intermittent fever. Bilious remittent fever itself can hardly be said to exhibit any very uniform or well-marked varieties. Still, is is important to state that the fever of one season and one locality frequently differs pretty widely from the fever of another season or another locality; and similar differences may exist between the disease during one portion or another of the same season. In this respect, periodical fever only partakes of the mutability to which almost all diseases-and especially such as are at all endemic or

epidemic in their character-are subject. During certain seasons, and throughout certain regions, it is not only more or less violent and dangerous than it is at other times and in other places, but it assumes certain peculiarities, more or less striking; at one time there is a predominance of one set of symptoms-at another, of another set. Cleghorn says: "In July, when these fevers first break out, their type is commonly simple and regular; their paroxysms are of short duration; and after three, four, or five periods, they vanish of their own accord. As the season advances, the tertians become more dangerous and difficult, often terminating in malignant forms, especially if much rain without wind fall during the dog-days. About the time of the equinox they assume a surprising variety of forms, and very often counterfeit continual fevers, having long redoubled paroxysms. But as the winter draws near, their type becomes more simple, and though they prove tedious and obstinate in cold weather, yet they are more regular and less dangerous than in the summer." Dr. Stewardson says: "In some seasons, the remissions are very well marked, and the disease very manageable; whilst in others it is more prolonged, the remissions more obscure, and the symptoms of the typhoid state more developed."

ARTICLE II.

CONGESTIVE FEVER.

SEC. I.-Names. There has been a good deal of confusion from the somewhat indefinite signification which has been attached to the term congestive fever, and from the loose manner in which it has been applied. The qualifying prefix, congestive-is generic in its character; like the term typhoid, it is expressive of a pathological state or condition which may exist in different diseases. In this way most writers speak of congestive varieties or cases of cholera, of scarlatina, of yellow fever, and so on. They mean simply those forms of these diseases in which this pathological element, thus designated, predominates. The essential nature of the pathological condition itself is obscure. It is probably complex; and it may be more or less modified by its connection with individual diseases. In its simplest form, we generally understand by it an undue accu

Rush's Cleghorn, p. 107.

2 Amer. Journ. Med. Sci., April, 1842.

mulation of blood in the vessels-usually the larger ones, and especially the veins-of an organ or part. But in its connection with the grave forms of disease, of which I have just spoken, there seerns to enter into its composition some unknown but profound modification of the great function of innervation. This function is the seat of a sudden and violent perversion; and at the same moment, there is a like sudden and violent rush of the blood towards some one or more of the organs; or a draining off of the serum, as happens in epidemic cholera. This congestive state generally occurs during the early period of the diseases with which it is associated.

The term congestive fever is now generally made use of, in the Western and Southern States, to designate the pernicious or malig nant form of malarious fever. I can see no objection whatever to this use and application of the term; it is only important that its meaning should be determinately settled, and its application generally agreed upon. I would never attempt to introduce a new name for a common disease, so long as an old and familiar one could be found, not positively and seriously objectionable.

SEC. II.-Type and Mode of Attack. Congestive fever may belong either to the intermittent or to the remittent variety; but to the former more frequently than to the latter. It may also assume any of the types of periodical fever; but the quotidian and tertian are the most common.

Sometimes the disease is fully developed, and clearly marked at the outset the congestive seal is set upon it during its first paroxysm. At other times, and this seems to be more common, the first paroxysm does not differ very essentially from an ordinary attack of simple intermittent. Dr. Charles Parry, who has written a short and fragmentary, but most excellent paper upon the disease as it occurs in Indiana, says: "In the majority of cases, the symptoms of the first paroxysm are such as occur in an ordinary intermittent attack. One main peculiarity is an expression of intense apprehension, or terror, without experiencing it. Perhaps the face is paler, or more livid, than in common cases. * * The first paroxysm attracts so little attention that, after it is over, the patient meeting a physician, or friend, says that he feels as if he was about to be sick, not that he has been sick. The second paroxysm is always severe, not so much in the violence of the rigors, as in the

extreme coldness, and in the approaching death-like hue of the face and extremities."

SEC. III.- Varieties; Comatose. Congestive fever occurs under several well-marked and pretty distinct varieties, depending, probably, upon the predominance of certain elements in its complex pathology. Torti divided the disease into seven varieties, to wit: 1. Choleric, or dysenteric; 2. Subcruenta, or atrabiliaris; 3. Cardiac; 4. Diaphoretic; 5. Syncopalis; 6. Algid; 7. Lethargic. Alibert makes no less than twenty varieties, elevating to this distinction every case marked by any peculiarity, accidental and unimportant as it may happen to be. The most common and important forms are the comatose, the delirious, the algid, and the gastric or gastro-enteric. It is necessary, in order to get a distinct and adequate idea of the disease, to give separate descriptions of these principal varieties. To aid me in doing this, I shall transfer to my pages a series of graphic delineations from the capital work

of Maillot.

"The name of the comatose variety," he says, "indicates its essential character. The coma varies from simple stupor to the most profound carus. The pulse is full, large, without hardness, ordinarily a little accelerated, sometimes slower than natural. The patient lies upon his back, the limbs as it were paralyzed; when the coma is not carried to its highest degree, if the skin is pinched, he utters a feeble and plaintive cry; there is often trismus; still, liquids can generally be swallowed, although with considerable difficulty; sometimes, however, they are rejected, either by a sudden and convulsive movement, or by a tranquil and prolonged expulsion. In some rare cases, instead of the usual resolution of the limbs, there are epileptiform movements, frothing at the mouth, and grinding of the teeth, truly frightful from their noise and rapidity. It is during the second paroxysm that the coma shows itself, in most cases nothing having occurred in the first indicative of its coming. If anything may foreshadow its appearance, it is a certain slowness of speech during the preceding apyrexia. But this indication is often fallacious, and its absence is no guarantee that the following paroxysm will not be comatose. Sometimes a case is comatose from the beginning; at others it suddenly becomes so after a certain number of paroxysms, which had not affected the

Amer. Journ. Med. Sci., July, 1843.

brain more than is usual in simple intermittents. Sometimes the coma reaches its highest degree suddenly, as by a single bound; at other times, and this is more common, the eye may follow the progress of its development. In the latter case, the physiognomy of the patient assumes that expression of stupor characteristic of comatose affections, and so striking in these; his replies are slow and unfinished; the eyelids grow heavy and close. In certain cases, the coma is preceded by delirium.

"After a period which it is impossible to determine beforehand, and which varies with a multitude of circumstances, if death is not occasioned by the violent cerebral congestion, a general sweat breaks out upon the surface, the patient executes some automatic movements, the eyelids are elevated, the eyes remain fixed and widely open, he remains a long time unconscious of what passes about him, and it is now, especially, that his look has that air of astonishment, which I have never seen so strongly marked in any other affection. He recovers by degrees the use of his senses; sight, hearing, and speech return successively. Finally, all the functions resume their natural play, and in many cases after the paroxysm, especially if bloodletting has been practised, there does not remain even headache.

"This variety is perhaps the most common. Most of the cases reported by Bailly at Rome belonged to it, and I have met with it. more frequently than with any other form in Corsica, and Africa. It may be accompanied by visceral congestions or irritations in the chest or abdomen, but these complications are accidental."

SEC. IV. Delirious Variety. "When, during the second stage of a paroxysm, the headache becomes very severe, there is reason. to apprehend the occurrence of delirium, especially if, during the preceding intermissions, this symptom has not entirely disappeared. The pulse is hard and accelerated; the skin hotter and drier than in the comatose form; the eyes are brilliant, the conjunctiva injected, and the face red and animated; the patient cries, sings, and endeavors to escape; the carotids and temporal arteries beat violently. This state of excitement commonly continues for several hours; and then it is not unusual to see coma succeed to the delirium, so that, so far as the symptoms are concerned, the paroxysm may exhibit in the course of a few minutes the principal phenomena of the two stages of acute meningitis. Death frequently occurs suddenly, without the supervention of coma; life is destroyed by a