that the patient is unable to swallow; or, where on the other hand, the rectum will not retain any injection: the prognosis is here very unfavorable; there are no means of administering the sulphate of quinine but by the skin. The delirious variety isolates itself less frequently than the comatose in the nervous system; it is more frequently associated with symptoms of acute abdominal inflammation; if with this there is vomiting, so that the febrifuges are rejected, the danger is very great. When the delirium persists, and the pulse at the same time becomes small and feeble, and the skin is covered with a cold, clammy sweat, death is imminent. In the algid variety, the prognosis varies with the intensity of the morbid phenomena. If the pulse entirely disappears, the danger is extreme. The suspension of the circulation, if it is continued for some time, is certainly followed by death. If the pulse can be still felt, although only at considerable intervals, whatever may be the degree of coldness, we may indulge hope. When algid fever is accompanied by choleric vomiting and purging; when the face and extremities are blue, the breath cold, and the voice broken and sepulchral, death is almost inevitable. Vomiting without effort, as if by regurgitation, in the course of algid fever, with a moist, white, cold, and flat tongue, is always of fatal augury; it has appeared to me to be connected with extensive and chronic softening of the mucous membrane of the stomach." Maillot thinks that in cases of fatal pernicious fever, there existed some chronic lesion before the access of the disease. Dr. Charles Parry, in his paper on the congestive fever of Central Indiana, says: "Without treatment, or with the usual treatment of bilious fever, which is little better than none in this disease, probably three-fourths of the cases terminated fatally. But with a special treatment, not more than one in eight."

"In the mean time," says Cleghorn, "it is to be remembered that, as in all acute diseases, so, particularly in these fraudulent, deceitful fevers, the presages either of death or recovery are not always certain and infallible, it frequently happening that those who have laid in the paroxysm for hours together, with few or no signs of life, have at length recovered, as it were, from the jaws of death, and asked for some uncommon sort of food, to the great surprise of everbody about them; on the other hand, the fit antici pating sometimes brings on death before the time it was indicated."

Traité des Fièvres Intermittentes. Par. F. G. Maillot, p. 343. 2 Am. Journ. Med. Sci., July, 1843.

3 Rush's Cleghorn, p. 103.

"Can we determine in advance," says Maillot," whether a simple intermittent will or will not become pernicious in its character ? I think not. Frequently, we cannot do this even at the commencement of a pernicious paroxysm. Without doubt, we have reason to apprehend the approach of this perilous form of the disease whenever any of the visceral irritations are intense-whenever the symptoms of gastro-enteritis or encephalitis are strongly marked; but this rule has many exceptions, and I have often seen the most pernicious paroxysm succeed, without any premonition, to those of the simplest character."

The prognosis is thus summed up by Cleghorn: "If the paroxysms are not attended with acute pains in the viscera, and do not last above twelve hours; if they decline with plentiful warm sweats, and leave the intervals tolerably free; if the patient bears the distemper well, and begins to have an appetite for victuals; if small pustules break out in the inside of the mouth, or scabs about the lips; if the urine has recovered its natural complexion, or is cloudy and turbid, or lets fall a white or a pale red sediment-I say if all these signs concur about the third or fourth period, we may safely prognosticate a speedy recovery. On the other hand, it announces danger when, about this time of the disease, the paroxysms are long and protracted, or are accompanied with an obstinate delirium, an intense coma, great anxiety, and pain in the loins, or about the upper orifice of the stomach; when the patient has an utter aversion to food, and even in the intervals is so feeble, and attended with such a swimming in the head, that he can scarcely walk about; when the hypochondria and epigastric region are swelled, hard, and painful to the touch; when numerous blotches, like the stinging of nettles, frequently break out on the skin; when the urine continues thin, clear, high-colored, or covered with an ash-colored membrane, like a cobweb; and lastly, it announces danger when larger evacuations come on than the strength can well bear, such as vomiting, purging, bleeding of the nose, colliquative sweats, or the like. For fevers with these appearances sometimes are immediately changed into mortal dysenteries; sometimes they become continual tertians, and run out to a great length; but for the most part, they preserve the form of remitting or intermitting fevers, and daily growing stronger, prove very dangerous about the sixth or seventh period.

Traité des Fièvres Intermittentes, p. 338.

"Those fevers are most to be dreaded, whose violence is greatest on the even days; and if the paroxysm stops on the third, fifth, or seventh day, but continues on the fourth, sixth, or eighth day, we must be upon our guard, lest a sudden storm should succeed this treacherous intermission.1 ** Nor is there only a possibility, in many cases, of foretelling the day, but likewise the hour, on which the patient will expire; for that stage of the paroxysm which he usually got over with the most difficulty will most probably in the end prove fatal. I have seen some expire in what may be called the first stage of the paroxysm; the skin being chilled and wet with cold sweats, their pulse small and irregular, and their senses entire to the very last. But the greatest numbers are hurried off in the height of the hot fit, stupefied, senseless, the breathing short and laborious, and the skin covered with a burning fiery sweat."2

Maillot observes, that in the delirious variety of pernicious intermittents, there is frequently a strong apprehension of approaching death, and that this feeling is always a fatal augury.3

Dr. Charles Parry observes, that the plethoric, young, and robust, are most apt to die; and that the age, in a majority of fatal cases, is from twenty-five to thirty-five.

The return of the paroxysm, in all the forms of periodical fever, at an earlier and earlier period of the day, is a favorable indication; its appearance at a later and later period is unfavorable.

Rush's Cleghorn, p. 98.

3 Traité des Fièvres Intermittentes, p. 58.

2 Ibid., p. 103.

CHAPTER VIII.

DIAGNOSIS.

THE diagnosis of well-marked and uncomplicated cases of nearly all diseases is a matter, in the actual state of medical science, not often attended with any considerable difficulty. This is true of periodical fever. Under such circumstances, its several forms can be distinguished from each other, and from all other diseases, with great facility and certainty. The mark which is set upon these. diseases by their family seal of periodicity separates them broadly and widely from nearly all other affections. It sometimes happens, however, that this seal becomes so blurred and indistinct, or is so nearly obliterated, as to lose much of its value as a diagnostic and distinctive indication, and we are obliged to resort to other and collateral sources for the true character of the disease. This happens most frequently under the following circumstances. In the warmer malarious regions, and during the prevalence of the graver forms of periodical fever, the bilious remittent variety, especially, frequently loses to a great extent its periodical or remittent character, and assumes more or less entirely a continued form. This modification usually takes place during the latter period of prolonged cases, and under these circumstances the resemblance between the disease and continued fever becomes very close; and this resemblance is frequently increased by the presence of typhoid phenomena-great debility, feeble pulse, dry and brown tongue, tympanitic abdomen, diarrhoea, and so on. It would be foolish to deny the difficulty, under such circumstances, of always distinguishing between this modification of remittent fever, and continued fever of the typhoid character. The resemblance here is so striking, that the opinion has extensively prevailed in this country, and still continues to prevail, that bilious remittent fever is not unfrequently changed in its progress into continued typhoid fever. The mistake here is that very common one of confounding the typhoid state or condition present in many diseases, with specific typhoid

fever. But, notwithstanding this resemblance, and the difficulty which I have admitted, a careful study of the previous history of these cases, and of all the circumstances attending them, will generally enable us to come to a pretty positive conclusion, and to establish a pretty certain diagnosis. We shall almost always find that during the first week or two of the disease, its remittent character was so decided as to remove all uncertainty as to its true nature. We shall find, further, in most cases, certain differences between the actual condition of the patient and the phenomena of typhoid fever. The rose-colored eruption will be wanting; the low, muttering, and continuous delirium, with twitching of the tendons, and picking at imaginary objects, so common in grave cases of continued fever, will at least very rarely be as prominent and striking; and the periodical tendency, masked and crippled as it is by the complication of local congestions and inflammations, will still, if closely watched for, frequently manifest its presence, by various slight and irregular but sudden changes, such as are not often met with in continued fever.

Dr. Stewardson says, that when the disease is prolonged, the remissions obscure, and the typhoid state present, the distinction between bilious remittent and typhoid fever may be rendered somewhat difficult; but that generally errors of diagnosis might be avoided by greater attention, and a more intimate acquaintance with the essential characters of the two diseases.1

During the paroxysm of the unmixed comatose or delirious form of congestive fever, the condition of the patient may be almost the same as in some local diseases of the brain. The history and the collateral circumstances of the case will generally be sufficient to remove all doubts as to its true nature.

"If, as it frequently happens in the hospitals," says Maillot, "we had no previous knowledge of a patient, whom we find with coma or delirium, we might suppose the case to be one of acute meningitis, and resort at once to bloodletting, which, indeed, would be proper in either case. But the influence of the treatment upon the march of the symptoms would soon dissipate all doubt as to the nature of the affection. If it is a pernicious intermittent, and death does not take place during the paroxysm, the coma or the delirium will disappear in a few hours, the skin will cover itself with an abundant sweat, the pulse will become apyretic, and there will

1 Am. Journ. Med. Sci., April, 1842.