VUGlo
\. 'V'";'. . ■

m

 ,.■ 'i -*.'. u < ■'.'.*■'■







' >■.   ' ,.. ■ »■».■'• »-; -.;
I- .
/-,


fc'i!
J/f
*
ft
$

•^ 
SURGEON GENERAL'S OFFICE

    LIBRARY.
Section
 No. 113,
W.D.S. G.O.
No
3rFA±£l 
/L* fi./U>t+ S,0
Tb^SL -fa*. (fcztfu*^
SU-J^yf
 
 
 
 
OBSERVATIONS
THE  TYPHOID   FEVER
OF  NEW  ENGLAND.
REAM AT THE ANNUAL MEETING OF THE MASSACHUSETTS
       MEDICAL SOCIETY, MAY 29, 1&39.
By ENOCH H^LE,  M
d.    /7?'-rc
ITTKNDIVO PHYSICIAN TO THE MASS. GENERAL HOSPITAL.
            BOSTON:
WHIPPLE AND DAMRELL, 9 CORNHILL
              IS39.
r«r-
     s
LIBRARY 
 
              REMARKS
                       ON THE

patfjoloflg of tije Egpfjottr iFelier of TSftto=ISnfllantr;

    A3 EXHIBITED IN ITS PHYSICAL. SIGNS, AND ITS ANATOMICAL
                    APPEARANCES.
  The character  of this Society  demands, for the
present occasion,  the  discussion of some  subject of
professional interest.  The physician can  never for-
get his calling.   Although we  meet for the enjoy-
ment of social intercourse, as well as for  the trans-
action of important business, we cannot so far lay
aside our ordinary habits of thought and feeling, as
to seek entertainment from any topic, which has not
a direct reference  to our peculiar duties and relations
to society.

  Of  the  many  topics from   which our  selection
might thus be made,  no one,  perhaps, possesses  a
more  general interest, than that of Fever; and no
other has so often received the attention of the So-
             2 
4
THE  TYPHOID FEVER
 ciety  at  its annual  meetings.  Fever is  a disease
 which, to  a  greater  or less  extent,  every  where
 prevails; and  every  physician  is  therefore  called
 upon  to  treat it.  Its pathology is  intimately  con-
 nected with  that  of  many other diseases, so  that
 a right knowledge  of  it would do much to explain
 them.  The  different  views of it,  too, which have
 been entertained at different times, give a  perpetual
 variety to the discussion of it.
   The researches  of  M.M.  Petit  and Serres,  of
 Bretonneau, Chomel, Andral, and  especially those
 of  Louis,  establish the fact, that  the  prevailing
 fever of Paris is constantly  attended  by certain  spe-
 cific physical appearances  during life, and as con-
 stantly exhibit certain uniform changes of  structure
 after death ; while other changes, occasionally, but
 less constantly, observed, are found in  no other  dis-
 ease.   It remains  to  be ascertained  whether  the
 same facts  prevail in respect to  other  modifications
 of  fever,  or to  the  fever of other places; whether
 every  form of  fever  is  distinguished  by  peculiar
 physical appearances,  or essential anatomical  char-
 acteristics ;  and,  secondly, whether these character-
 istics, so  far as they exist, are always the same in
 the same  disease, recurring at different periods,  and
 in different places.
  There is much reason to doubt whether the fevers
of Great Britain do exhibit the same characteristics
as those of France ; and if not, the question will then
arise, how  far the absence of these  features  will 
OF NEW  ENGLAND.
5
prove them to be distinct diseases.   How the  mat-
ter stands in regard to the fevers of our own vicinity,
it shall be the purpose of the present paper to show.
In  other words,  I  propose  to  offer some remarks
on the  Pathology  of   the  Typhoid Fever of New
England, as exhibited in  its physical signs,  and its
anatomical appearances.
   The very able  Report  on the Typhoid  Fever of
New England, by Dr. Jackson,* which was publish-
ed in the  Communications  of  this  Society the  last
year, gives so complete  a view of the phenomena of
the disease, as they are  presented in the symptoms
and the  effects  of remedies, that it  would be  both
superfluous and  presumptuous  for   me  to add  any
thing, on  that part  of  the  subject.   The  external
signs of disease, and the investigations of patholog-
ical  anatomy, have  received much more attention
among us, within the last few years, than ever be-
fore ; and, although the author of the Report had done
much, probably  more than any other man, to  excite
this attention, the period at  which his Report  closes,
prevented  him from applying the full benefit of it in
that document.
   Since  the close of 1835, as well as for the two or
three years preceding, the observations made  at the
Massachusetts General  Hospital,  and   some  cases
  * A Report, founded on the cases of Typhoid Fever, or the common con-
tinued fever of New England, which occurred in the Massachusetts General
Hospital, from the opening of that institution in September, 1821, to the end
of 1835.  Communicated to the Massachusetts Medical Society in June, 1838;
by James Jackson, M. D., late attending physician in that hospital. 
6
THE TYPHOID  FEVER
observed  in  private  practice, enable us  to collect a
considerable number of  facts in relation to this ad-
ditional  branch  of inquiry.   The  results  of these
observations I now offer  to the  Society.
   The whole number of cases of which I have  the
history in detail is 197,*  being all that have occurred
in the Massachusetts General Hospital  since the first
of October,  1833.   One hundred and seventy-five
of the cases terminated in recovery, and 22 patients
died.   Examinations were made in 18 cases;  hav-
ing been prevented in the other four by the interpo-
sition of  friends.   I have  added the  post mortem
examinations of 15 other cases,  in which the prelim-
inary history is less complete, although sufficiently
so to leave no doubt as to  the character of the dis-
ease.   These occurred  in private practice ;  a few
under my own observation, but the greater part were
furnished me by an obliging friend.
   It is difficult, in private practice, to record all the
phenomena of disease, with the same minuteness and
care with which it may be done in a public hospital.
The rule so much insisted  on  by Louis, that every
circumstance shall  be noted, whether it have an
obvious connection with the principal disease or not,
whether it be common or uncommon, however valua-
ble and important in itself, can rarely be carried into
  * In this number are included only the cases  whose history is tolerably
complete.  Wherever, from the late period of admission, or from any other
cause, the history is so  imperfect as to leave any doubt of the true nature of
the case, it is not enumerated. If all had been counted, thatare called typhoid
fever (and  most of them, probably, rightly called so), the number would
have been considerably greater. 
OF NEW  ENGLAND.
7
full effect.  So many  things  occur,  to  divide  the
attention of the practitioner, and to prevent the full
accomplishment of his purposes, that many times he
can do no more than to preserve the more prominent
features of a case.   This is especially true in regard
to examinations after death.   It  is,  indeed, highly
desirable that every part of the body should  be care-
fully  examined.   But, with the imperfect facilities
afforded in most  cases, this  often cannot be  done
without disfiguring the body of the patient to a de-
gree that the  feelings of our  community would not
tolerate, even if the physician in  his zeal for patho-
logical inquiry could bring himself to desire  it.
   The same  difficulty occurs in a  less degree  in
hospital practice, with  all the facilities which hos-
pitals afford.   Patients cannot be  examined without
the  consent of their friends,  and this  is too  often
either refused, or  granted with such limitations  as
to prevent an entirely thorough examination.   In
the  pathological  history, too, where the  record is
made only by the attending physician, there is, ne-
cessarily, much imperfection.   His mind is occupied
with a consideration of the prognosis and the means
of cure, as well as of the pathology  and diagnosis;
and many things  must escape  his observation, which
he would not fail  to  notice,  if  his  thoughts  were
 directed exclusively to a single object.
   But it does not  thence follow that such observa-
 tions are nothing worth, or  that  none but  a hospital
 physician can pursue pathological inquiries.   On the
 contrary,  every man  in  the profession  is able, and 
8
THE  TYPHOID  FEVER
ought, to add something  to the general  stock  of
medical knowledge.   It is  only necessary that  his
facts be accurately observed and stated with preci-
sion ;  and although they may be incomplete in some
of their relations, they will not fail to accomplish
some  useful purpose.   Much more caution is indeed
demanded in the deductions to be made from imper-
fect observations, however accurate their statements
may be.  We are especially precluded from all nega-
tive inferences.   If we  might be sure  that every
deviation from the natural state was carefully noticed
in our observations, we might safely  regard the ab-
sence of such notice,  in a given case,  as  evidence
that the deviation did not  exist.   But, verv  few
cases  have been recorded with sufficient complete-
ness to render such an inference entirely safe ;  and
the adoption of it,  unwarrantably, has  been one of
the most frequent sources of error.
   In the analysis of cases for the present  paper, I
have admitted no fact which is not specifically stated,
either positively or negatively, in  the daily history,
except where there was something either in the
nature of the case, or in  the record  itself,  to show
that the attention was  directed to it.
   It is my design, under the name of the  Typhoid
Fever, to speak of the specific  disease, so denom-
inated by Dr.  Jackson  in his Report.  My opportu-
nities for observing it have  been  chiefly confined to
Boston, and its immediate  vicinity ;  but it  prevails,
to a greater or less extent, throughout New Eng-
land.   Other forms of fever are occasionally seen, 
OF NEW  ENGLAND.
9
but this is far  the  most prevalent.   The  term, ty-
phus, which has usually been applied  to it, has  been
employed in a more extensive sense, so as to include
other modifications  of  fever.  It became  necessary,
therefore, either to  restrict  the  application of that
term, or to adopt a new one.   Had the  reasons for
preferring the latter course been  even  less conclusive
than they are, it would now be too late to select any
other with benefit.  The true  purposes  of a name,
distinctness, and general adoption, can only be ac-
complished  by  following the example  which has been
so ably set, and limiting the application of the terms,
typhoid and typhus, to distinct forms of disease.
   Some of the phenomena, which might with  suffi-
cient propriety be termed physical, have always been
ranked with the  symptoms of fever;  such as the
pulse,  the state of  the tongue, the  temperature, and
the  dryness or moisture of the skin.   There are
others, which have only recently been recognized as
making a part of, or  having any  connection with,
the disease.  It is to this class that our attention  is
now to be chiefly directed.   The most  important of
them are, the tympanitic distension of the  abdomen,
or  meteorism, — enlargement  of the  spleen, — rose
spots on the abdomen, and sudamina.
   It can  hardly have escaped the  observation of
physicians, at any period of time, that the abdomen
is often enlarged in fever,  with a painful sense of
tightness and distension.  But a much greater im-
portance has recently been attached to this enlarge-
ment, as furnishing a distinctive mark of a peculiar 
10
THE  TYPHOID  FEVER
 form of disease.   In the typhoid fever, it is found  in
 a very large proportion of cases.   Of 197 cases, 1
 find meteorism recognized, either in direct  terms,  or
 by necessary implication, in  130.  In 24,  there  is
 nothing to show whether it was present  or absent;
 and in 43, it is expressly said to have  been  wanting.
 It is in  most cases  accompanied  by  tenderness on
 pressure, especially  in the right iliac  region and  in
 the epigastrium, more rarely by pain.  The disten-
 sion often is not so great as to attract any  attention
 till it is sought for  by the physician,  and then it  is
 frequently  recognized  more  by an increased reso-
 nance of the abdomen  on percussion, than  by an
 obvious increase of  size.  It is found at  different
 periods  of the  disease,  most  frequently near  the
 beginning; and continues from one or two  days to
 almost its whole length.   In many cases, the tender-
 ness on pressure is  of  longer continuance  than the
 meteorism, and in some, it is discovered where there
 is no  enlargement.  The state of the  abdominal
 muscles  is various in the different cases.   In some,
 they are soft and yielding; but in many more, they
 are tense and hard.   The recti muscles are  often
 extremely rigid, and exhibit  their fleshy bellies and
 tendinous bands with great distinctness.
  Enlargement of the spleen,  as perceptible during
life, is  not of much value as  a pathognomonic  sign.
This organ  is occasionally  felt below the ribs, or by
pressing the fingers  under the cartilages, during  a
full inspiration ;  but in many cases it cannot be per-
ceived, even where examination after death  shows it 
OF NEW  ENGLAND.
11
to be much enlarged.   A careful percussion  would
aid in discovering it.  But, since there is much un-
certainty  in  regard to  the  enlargement  itself, as  a
constant occurrence, and some  difficulty in  ascer-
taining it,  when it does occur,  we can attach very
little importance to it, in diagnosis.   The spleen was
felt in 19 cases, not felt in 21, and  not noted in the
record in  157.
   It is quite otherwise  in regard to  the  rose spots.
They  are easily observed, if properly looked for ;
and are of very constant occurrence.  Of the  197
cases that I have analyzed for this paper, rose  spots
are recorded  in 177.   In  the  greater part of the
remaining 20, it is  apparent from the record that
sufficient attention was  not given to them, to render
it by  any  means  certain that they did  not exist.
Most of the omissions  are in the earlier part of the
period I have specified, before the importance of this
appearance, as  a  diagnostic  mark,  was fully appre-
ciated.   In a  few cases, the patient was brought  to
 the Hospital at too late a period of the  disease, for
 them to be visible.  With this exception, I have, for
 a long time past,  seen no case,  that  could with any
 propriety be regarded as decidedly the typhoid fever,
 in which rose spots were not found ;  and, I think, it
 is not assuming too much, to consider them a con-
 stant attendant upon that disease.
    The true rose spot is not a pimple,  as  it is  often
 called, but, as  its  name implies,  is  merely a little
 bright red  spot; so small as  often to be covered  by
 the head of a pin, and  never  much larger.  It wholly
                 3 
12
THE  TYPHOID  FEVER
disappears  under  the  pressure  of the  finger, or
upon a slight extension of the skin, and returns im-
mediately  when  the extension is  removed.   It  is
found chiefly upon the upper part  of the  abdomen
and lower part of the chest.   It is never attended by
any sensation of  itching  or soreness;  and, as  the
number is  often  small, sometimes only four or five,
rarely so many as twenty or thirty, it is extremely
liable  to be overlooked, unless it is  expressly sought
for  by the  physician  himself.  The patient,  if in-
quired of, will almost always regard it as accidental,
or too trivial to notice.   They are never found ear-
lier than  the  sixth or  seventh  day of the  disease,
often  not till the  12th or  15th.   Sometimes they
remain only two or three days; but more commonly
are  visible  in greater or less numbers until conva-
lescence is  pretty  well established.  In a few instan-
ces, there are found interspersed with these spots, true
papulae, of  the  same color, but larger and  with the
skin slightly elevated and  hardened, and not  disap-
pearing under  pressure.  These pimples  are gen-
erally quite numerous, and extend  to other parts of
the  body besides the  front of the abdomen and chest,
and are occasionally attended by considerable itch-
ing.   It might be  questioned, whether these should
be regarded as a sort of exaggerated rose spot, or as
a complication of a different eruption.  But, inasmuch
as the elementary form is different, and the eruption is
not confined to  the same part of the body,  the latter
seems the most correct view of it.  I have not been
careful to enumerate the cases in which I have found 
OF NEW  ENGLAND.
13
this  more extended eruption  noticed;  but  I  think
the number is not more than ten or twelve.
   The little  colorless, transparent vesicles, known
by the name  of sudamina, are found in  the  typhoid
fever less constantly than rose spots,  and  are less
exclusively confined to it.  1  find them noticed in
75 cases.   There is, however, reason to believe, that
they existed  in many cases in  which they were not
recorded.   The negative fact, that they were  not
found, is mentioned in 15 cases.   In the remaining
107 cases, they are either not  noticed at all, or  not
in such a manner  as  to  afford any  evidence, that
they  might  not have been observed if sufficiently
sought for.   They occur later in the  disease than
rose spots, often not till the patient has become de-
cidedly convalescent, when there is less inducement
to examine every circumstance minutely ; and, being
of little importance in themselves, and giving rise to
no sensation  to attract attention, they are  extremely
liable to be overlooked.
   It is not enough to know that certain phenomena
are attendant upon  a particular  disease; we should
know, also, whether they accompany other diseases.
With this view, I  have examined  all  the  cases of
acute febrile diseases, in the  records of the Massa-
chusetts  General Hospital, for the same period of
time as that  in which the  cases of fever  occurred;
that is, since the first of  October, 1833.  Omitting
those in which  there was primary local disease in
the abdomen, peritonitis, dysentery, &c, the  whole
number is 159.  In these, meteorism is recorded in 
14
THE  TYPHOID  FEVER
nine cases,—the spleen was felt below the cartilages
of the ribs in  none,—rose spots were observed  in
none,—sudamina in eight.   The cases  thus enu-
merated  were as follows: pleurisy 22 cases, pneu-
monia 59, gangrene of the lungs 1, acute rheumatism
54, intermittent  fever  8,  measles 3,  scarlatina  2,
inflammation of the tonsils 5,  inflammation of the
larynx 1, of the pericardium 2, of the brain 1, of the
veins 1.   It should be  observed, however, in regard
to this comparison, that much more  attention  was
given to the phenomena in question, in cases of fever,
than of other diseases, and they are, therefore, more
liable to  have been  overlooked in the latter than the
former.   The attention of the physician is neces-
sarily occupied  with those phenomena, which, from
their more frequent recurrence  in a  particular asso-
ciation are most readily presented to his observation,
and which are of the greatest importance in the par-
ticular case before him, while others, of less immedi-
ate consequence, and of less probable occurrence, are
for the time disregarded.  Making every allowance,
however, for omissions of this sort, it is apparent that
there is a very great difference in the  frequency  of
each of these appearances. Without such allowance,
taking the records as  our authority, the comparison
is as follows:
	THE TYPHOID FEVER.		OTHER ACUTE DISEASES.	
	No. Cases.	Per Cent.	No. Cases.	Per cent.
Whole Number,..	197 130 19 177 75	66 9 90 38	159 9 0 0 8	6 0 0 5
 
OF NEW  ENGLAND.
15
  It thus appears  that  meteorism, while it is rarely
found in other acute diseases, is quite common, but
not entirely constant, in the  typhoid fever.  If we
had connected with it tenderness of the  abdomen on
pressure, as another probable  sign of the same  local
affection, the exceptions  to  its general prevalence
would have been much fewer.   Enlargement of the
spleen is not discovered during life, with  constancy
enough to be often available as a pathognomonic sign ;
yet, since it is rarely perceived  in other  diseases
prevalent among us,—when it is felt, it pretty strong-
ly indicates the character of the disease.  The appear-
ance of rose spots in the typhoid fever  is  so nearly
universal, that it  is  fair to regard the few cases,  in
 which  they  are not recorded, either as  subject  to
 some accidental omission in the observations, or else,
 as mere exceptions  to a general fact.   And, as true
 rose spots are never found in any other  disease, they
 become a mark of distinction of great value in diag-
 nosis.   Sudamina, on the contrary, appear to be of
 very little worth  as a diagnostic mark.   Although
 more often  observed in typhoid fever than in  other
 diseases, they are neither constant in it, nor limited
 to it.   I doubt not  they might have been observed,
 in  either class  of  diseases  more  often  than  they
 appear in the tables, if they had been more diligent-
 ly searched for.   But in  each case, their occurrence
 seems to depend, rather upon the state of the skin
 itself,  than upon  the character of the general disease.
 Wherever the  skin  is for a length of time  kept in a
 state  of  perspiration, from  whatever cause, there
 sudamina will  generally be found. 
16
THE  TYPHOID  FEVER
   Pathological anatomy furnishes us with additional
 marks of distinction between the typhoid fever and
 other diseases.  That no more has been effected by
 it in  times past, is to be  attributed, in part, to the
 long prevalence of the opinion, that fever is a gener-
 al disease,  not dependent upon, or accompanied by,
 specific changes of  structure ; and  partly to the dif-
 ficulty of  making examinations of the dead  body
 with  sufficient care and thoroughness, to detect all
 the changes which it may have undergone.
   In  the  cases upon which  these  observations are
 founded, the  examinations  have  been  made  with
 different degrees  of completeness, according to the
 circumstances of  each case.   At the  Massachusetts
 General  Hospital, especially  since the  appointment
 of an  assistant physician, who has  the particular
 charge of this  duty, every part of  the body was, in
 most cases, fully inspected, and the results carefully
 recorded.
   The whole  number of examinations, of those who
 had died of typhoid fever, was 33.  The head was
 examined in 14.  There was some effusion of serum
 in the arachnoid or pia mater in 10 cases ; an increase
 of bloody points in the cerebrum, with other marks
 of fulness  of  the blood-vessels  in  four;  glands of
 Pacchioni  large in  two;  and  three  were healthy.
 These appearances  are not peculiar to this disease;
but are found, perhaps, quite  as frequently in  many
others.
   The passages in the  neck were  examined in only
seven cases.   Ulceration of the epiglottis was ob- 
OF NEW ENGLAND.
17
served in one case, and ulceration of  the  larynx in
two.   In the remaining  four cases, all the passages
were healthy.
  The state of the lungs was noticed in 31  cases.  In
18, they were healthy, as well as the pleura; in three,
there  was effusion into the cavity of  the pleura; in
eight, there was more  or less of hepatization of the
lungs,  sometimes in only one  or two  small  masses,
at others extensive, and in one or  two cases in both
lungs ; in two, the lungs  were engorged with blood ;
in one, infiltrated with  serum ;  and in  two, there was
more  or  less of  emphysema.   The  heart was ex-
amined in 28 cases.   In three, there  was  somewhat
more  than the usual quantity of serum in the peri-
cardium.   The structure of  the heart itself  was
healthy in  all, except  that in  two or three it was
rather flaccid ;  in about  the  same number, a little
thickening about the mitral and semilunar valves.
   In  the abdomen, the  morbid  changes  are  more
important.   The peritoneum was  sometimes exten-
sively and  highly  inflamed.   But the peculiar cir-
cumstances under which  this  inflammation occurred,
will be better described hereafter.   In other, and by
far the greater number of cases, it was not particu-
larly  affected.   The condition  of the stomach  is
noticed in 32  cases.  In 17, it was nearly or  quite
healthy ; in six, there were ulcerations in the mucous
membrane,  in one case  perforating it;  in  the  re-
maining  five, small and  superficial; in five, the mu-
cous membrane was softened more or less extensively,
but in no case  thickened ; and in five, it was some- 
18
THE  TYPHOID  FEVER
what mamelonnated.  In the small  intestines, the
mucous membrane  generally was healthy, except
that it was often of  a  deep red color in the lower
part of the ileum, and sometimes was a  little soft-
ened.
  The  principal  seat of  disease  was  in  Peyer^s
glands.  These glands have  become so important
in all discussions of  the subject of fever, that I shall
be excused for speaking of them in some detail.
  Peyer's glands, in their natural  state, are so little
elevated  above the  surrounding parts, and  differ so
little in color and appearance,  that they can scarcely
be  distinguished, except  by the interruption which
they  cause  to the  valves  of the intestines.  By
this means, they  may be discovered  in oval patch-
es,  of different sizes from one or  two lines  to an
inch  and  more, chiefly  occupying the  portion of
intestine opposite  the mesentery.  They are  most
numerous in  the  ileum near the ccecum, and gradu-
ally diminish as we ascend ; but are occasionally found
as high as the duodenum.  On holding the intestine
up  to the  light, they are  observed  as little  granular
bodies aggregated  together,  producing  some  little
opacity in the coats of  the intestine, and  a slight
appearance of thickening.   Sometimes this  thicken-
ing is apparent upon the  surface of the mucous coat,
without any  change of color, or other indication of
disease.
  When diseased in  typhoid  fever,  these patches
become thickened and their color somewhat changed.
Their outline is  strongly marked, and  the surface 
OF NEW  ENGLAND.
19
studded  with  granular  elevations, presenting  an
aspect not  unlike that of  ringworm  on the  skin.
These appearances  are  modified, according to the
period of the disease at  which death  takes  place.
When the patient has  died early, there  is a  well-
defined,  uniform  thickening of the patch, commonly
of a light  red  color over the whole surface, some-
times  surrounded by a deeper  red line; the inter-
vening surface  being softened, and  studded with
numerous minute, opaque points.   Twenty or more
of  these patches are often discovered.  They  are
always the most  numerous at the lower extremity of
the  small  intestine ; and the disease is always more
advanced in those near the  ccecum, than at  a greater
distance.
   In a somewhat later stage of the fever, ulcerations
are  observed  in some of  the  diseased  patches.
These are of different  sizes,  sometimes being quite
small, at others, occupying nearly the whole patch.
They are  situated in the  sub-mucous cellular coat of
the  intestine, laying bare, and sometimes destroying
 the  muscular  coat; and, in  some instances, as we
 shall  presently state more distinctly, penetrate  the
 peritoneal  coat.   In these, there is  the same  evi-
 dence of greater progress  in the patches  near the
 ccecum.   Not unfrequently,  there is a  particularly
 large and  deep ulcer, situated almost, or quite,  in the
 ccecal valve, while some elevated patches,  higher up
 the intestine, are free from ulceration.
   In some instances, life is  much more prolonged.
 The fever abates, and the  patient is for a time more
                 4 
20             THE  TYPHOID FEVER

or less convalescent.   He then relapses, either  by a
return of the original  fever, or, more  often, by  an
attack of pneumonia, or other complication, and dies
after  a  long  struggle with disease.   In these cases,
some of the ulcerations in Peyer's glands are found
to be more or less cicatrized.  The  margin is of a
blueish or greyish color; and sometimes the color is
diffused  over the whole surface of the patch ;  and,
on a careful inspection, a delicate mucous membrane
is found to have extended itself over the  cicatrized
part.   This cicatrization is found to have made more
progress near the termination of  the ileum,  than
above, showing,  as  in the  other  cases,  that the
affection of the glands  began in that part.
  A fourth class  of appearances is formed by the
perforation of the intestine.    The ulceration, which
we have already described as being of various depths
in  different cases, sometimes  penetrates the perito-
neal coat;  and  the  contents of the  intestine are
poured  into the peritoneal  cavity.   The  inevitable
consequence  is  violent inflammation, and death.
This  termination is  not confined to cases,  that  in
their  previous history have been  remarkably severe.
On  the contrary,  it  is  as  often  seen  in those
of  a  mild character.   The  patient  was, perhaps,
walking about,   with  a  confident  expectation  of
speedy  recovery, when he  was  suddenly attacked
with  excruciating pain in the abdomen, and died  in
a few hours.   There  are  no  means by which it can
be  known  to what  extent  there is  danger of this
occurrence, in any individual case.  We are obliged, 
OF NEW  ENGLAND.              21
therefore, to give a cautious prognosis, in every case,
in order to avoid exciting too confident expectations
of a favorable result.
   In one or more of these modifications, the affec-
tion of Peyer's glands is found in every case of the
typhoid fever.   Of 33 cases, nine presented only the
first stage of the affection, thickening, softening and
a  red surface;  in 18, while some of  the diseased
patches were  in this  stage, others, nearer the lower
extremity of the intestine, had passed into ulceration,
the  ulcers varying in number from  two or three to
20 or  more;  in  three, some of  the ulcers near the
ccecum,  had become more or less cicatrized; and in
three, the intestine was perforated.  It is worthy of
remark,  that  the perforation was in  no  instance in
the  ulcer nearest the ccecal valve; and  in one case,
it was at the  distance of 44 inches.  The  period at
which these various changes take place, is various,
according to  the rapidity  of the disease.   In  two
cases, ulcerations were found before the 20th day;
while in one,  the  disease  had  continued  four
months,  and  yet there were  but eight ulcers, and
no cicatrization.
   The Solitary  glands in  the small  intestines were
found enlarged  in  15 cases.   In 11, they were not
visible ;  and  in  seven, although  the intestines were
opened,  they are not  mentioned.  Probably in most
of these, they were not enlarged.  The affection of
these glands, in  the  small  intestine,  like  that of
Peyer's, is chiefly found in the  inferior  portion.  In
the large intestines, the solitary glands were enlarged 
22
THE  TYPHOID FEVER
in five cases.  These organs were found healthy in
seven cases ; in six, their condition is not mentioned;
in two, the mucous membrance was  softened;  in
17, ulcers, often quite  numerous, were found in the
ccecum, or  first part of the  colon.  These ulcers
were not large like many of those in Peyer's glands ;
but small and distinct.  In one case, in which the
immediate cause of death was hemorrhage  from the
bowels, a firm coagulum of blood was found hanging
from an ulcer in the ccecum, showing that it was the
source of the hemorrhage.   In this and some other
cases  of hemorrhage, both the large and small intes-
tines contained a considerable  quantity of blood.
   The condition of the  Mesenteric glands corresponds
to the state of disease in the intestinal canal.  Those
glands which belong to the healthy portions of the
intestines were healthy ;  while those of the portions
containing diseased patches, were enlarged, red, and
infiltrated,—and at later stages, softened, and some-
times  suppurated.   The Spleen was  large  in  21
cases.   In  some, it was  quite large, twice  or three
times  its natural size;  and then it was commonly
soft in its internal  texture, breaking down by pres-
sure into a  sort of  thick, dark red fluid.   In seven
cases, it was of natural  size ; in two, it was  small;
and in three, its condition was not noted.
   The Liver was examined in 27 cases. Its  structure
was healthy in 14; it was  more or less soft  or  fri-
able in 10;  hard  in  one;  congested in one;  and
in one the serous coat  of the left  lobe was  highly
inflamed, and covered with a coating of lymph. 
OF NEW  ENGLAND.
23
  The  following cases, abridged from the  Hospital
records, will serve as illustrations of the pathological
changes observed at the different periods of the dis-
ease.   The examinations after death were  made by
the late assistant physician of that institution,*  a
gentleman highly distinguished, as well  for the ex-
tent and accuracy of his  knowledge  in pathological
anatomy, as for the zeal and diligence by which that
knowledge has been acquired, and is maintained.


                    CASE   I.

Death the 12th  day:  Peyer's glands, thickened, red and,
  softened; solitary glands enlarged; mesenteric glands
  enlarged and softened ; spleen large.

   W. S., aged 23,  was admitted into the Massachu-
setts  General  Hospital,  September  24,  1835.   He
had been ill enough to  call a physician on  the 15th,
but had complained  of  lassitude and loss  of appetite,
for some  days  previously.   He  had  been under
medical  treatment  from that time;  at first,  with
relief, but the disease had afterwards increased.   He
had had  diarrhoea, which had ceased before his en-
trance into the Hospital.  He was now delirious, so
as to be unable to give  any account of himself; his
countenance  pale,   and  without  expression;  eyes
wandering, pupils  dilated;  tongue  red  at tip  and
edges, cracked  and scaly over the surface, articulates
with difficulty;  teeth covered with dark brown sordes;
* John B. S. Jackson, M. D. 
24
THE  TYPHOID  FEVER
 mouth open; skin warm, except of feet; pulse 144,
 compressible,  not very  small;  abdomen  full  and
 tense,  shrinks from  pressure at epigastrium and in
 right hypochondrium ;  no  rose  spots ; makes  no
 complaint of thirst, or of any suffering, talks much
 and  incoherently ; restless ;  makes frequent efforts
 to rise and escape, as if from danger.
   Apply ice to head;  sinapism to feet.
   Sept. 25.   Had no sleep  in night; one dejection
 in bed;  eyes very  much suffused,  as  if  bruised;
 tongue  perfectly  dry and crusty;  head hot;  skin
 dry; pulse 120, sharp, not very small;  subsultus of
 tendons; abdomen firm, meteorism not  very great;
 no sudamina.
        K.    Antimon. Tartar, gr.  ii.
              Aqu. bullient. § vi.
                       M.
        ft.   Hydrarg. Submur. gr. viii.
              Pul. Acacias, gr. xvi.
              M.  in chart div. No.  viii.
   One powder, floating  in half an ounce  of  the
solution every four hours.
   Sept. 26.  Countenance  less sunken; eyes  less
suffused; tongue  scaling, crusts  separating;  skin
moist, cooler;  pulse  132,  better  volume; no rose
spots, sudamina well  marked; is more  manageable
without  restraint;  has had four  dejections; dejec-
tions  and urine involuntary.  Medicine of yesterday
every six hours.
   Sept. 27.  Countenance much sunken, mouth partly
open, teeth covered with sordes, eyes much suffused, 
OF NEW  ENGLAND.
25
glazed and motionless ;  excretions involuntary; skin
warm and moist; much subsultus; pulse very small
and  weak; sudamina very numerous and  distinct.
He died an hour after the visit.

     EXAMINATION--TWENTY-TWO HOURS AFTER DEATH.
   Exterior.—Very  rigid ; lividity on back of thorax ;
sudamina on each side of neck; abdomen moderately
full.
   Head.—Brain firm;  slight effusion of  serum in
pia mater.
   Thorax.—Pleura healthy ; and lungs  also, except
some serous injection of upper left lobe.   Pericar-
dium natural;  heart rather flaccid, blood in moderate
quantity, liquid.
   Abdomen.—Stomach  not contracted,  containing
several ounces of rather thick, greenish  fluid.  Mu-
cous membrane, towards cardiac orifice, of a deep
red color, but natural as to thickness and consistence.
In it, but not  penetrating its substance, were five or
six narrow superficial ulcerations, about one-third of
an inch long.   Elsewhere mucous membrane of nat-
ural  color, with   some  mamelonnement  towards
pylorus.  Small intestines  not  contracted, contained
a  considerable  quantity of  mucous and  other secre-
tions, of healthy appearance, except for about  two
feet in  middle of ileum, where  they were deeply
stained as  if with blood.   Throughout the last nine
feet, Peyer's glands were in a state of acute disease ;
about 26 patches  counted.   The  disease increased
progressively  towards  ccecum.   It consisted  of  a
very remarkable, well-defined, and uniform thicken- 
26
THE  TYPHOID  FEVER
  ing, and such a degree of softening that the surface,
  to some depth, might  be scraped  off  like  a  pulp;
  many  of these  were immediately  surrounded by a
  red liiie, while  the  surface generally was of a light
  red color, contrasting strongly with  the  deep red of
  the surrounding mucous  membrane.   There  were
  no ulcerations;  but numerous opaque, whitish, very
  minute points were visible in the softened portions.
  Several of  the patches were by estimate, two inches
  in  length, and one near the ccecal valve was five
  or six inches; some were not more than a  third or
  a  half of  an inch broad.   Throughout  the upper
  portion of  the  intestine  the   patches  were quite
  distinct,  and  healthy;  a  few  of  them, however,
 appearing to be softened before becoming otherwise
 diseased.   The  solitary glands  in the last nine feet
 of the  intestine  were very numerous; and in some
 cases, so  much enlarged, that it was difficult to dis-
 tinguish them from the small irregular  patches  of
 Peyer's glands.  The mucous  membrane generally
 throughout  the  intestine was  well, except  for its
 deep red  color in lower portion.  Large intestines,
 moderately   distended  with  gas;  solitary   glands
 numerous and enlarged, mouths  patulous,  and in
 many apparently ulcerated; just within  the  ccecal
 valve were two ulcers, about a third of an  inch in
 diameter,  dark colored,  edges  red,  penetrating to
 the  muscular coat.   Mucous membrane  generally
 appeared well.                                   J
   The Mesenteric glands corresponding to the lower
portion of small intestine were  enlarged, quite red,
soft,—so as  to break down  easily under pressure, 
OF NEW  ENGLAND.
27
much infiltrated with serum, but containing no pus.
The glands in the mesocolon were somewhat in the
same state.   The rest of the mesenteric glands were
healthy.   The Liver was healthy; the gall bladder
containing an  average  quantity of yellowish, quite
liquid bile.
   The Spleen was  large :  length  seven  inches,
breadth five inches, thickness two  and a half inches ;
of a  deep red  color, readily breaking down  under
pressure.
   The Pancreas, Kidneys and Bladder were healthy.


                    CASE  II.

 Typhoid fever, with  pulmonary  apoplexy: death about
   2Ath day.   Pleura and lungs much diseased; Peyer's
   glands extensively idccrated; ulcers in large intestine;
   spleen large; mesenteric glands enlarged, softened, and
   infiltrated.

   October 13,  1836.   L.  W., aged 28, teamster:
 has  been unwell six months; present illness of three
 weeks standing.  This patient was  brought to the
 Hospital  in  a very advanced  stage  of disease;  his
 previous history not much known.   He reported that
 he was  taken  with chills, and pain in  the chest.
 He  now  complained  of very  little pain,  but  had
 evident marks  of fever, complicated with pneumo-
 nia;  abdomen tympanitic,  pulse 124.
   Oct.  14.   Did not  sleep;   delirious  all  night;
 countenance  wild;  great muscular  tremor of  the
               5 
28
THE  TYPHOID FEVER
whole  body;  tongue moist, pale, tremulous,  pulse
144.
   Oct. 15.  No sleep ; countenance  rather sunken ;
skin dry, warm ; respirations 48, thoracic; muscular
system much agitated, trembling of arms, picking of
bed clothes;  tongue  dry, tremulous,  with  a whitish
coat.   He died the same evening.

                   EXAMINATION.
   Head. — Membranes,  and brain, healthy.
   Thorax.—Pleura of left side covered with lymph,
adherent at upper lobe, cavity containing 55 ounces
of turbid  serum.   Left  lung,  upper  lobe, emphy-
sematous ; in lower lobe, pulmonary apoplexy, a dark
red mass  occupying  a considerable  portion of the
lobe, evidently formed by the  effusion of blood into
the pulmonary  tissue.  In  the  right  pleura  were
some  old  adhesions.   The  upper lobe of the  right
lung was emphysematous, the lower lobe condensed,
somewhat friable, no  effusion of blood.
   Air  passages. — The  thyroid  and  cricoid car-
tilages were considerably  ossified.  There was  a
deep ulcer in the larynx, just  below the posterior
extremity   of the  right   vocal  chord.   Pharynx,
epiglottis and glottis  healthy;  pericardium contained
six ounces of serum.
   Abdomen. — Stomach  healthy. — Small  intestines
slightly distended, contained  a considerable quan-
tity of mucous secretions ;  mucous membrane  much
discolored  by secretions,  no  where red, except round
two  of the  ulcers;  softened  in  lower part of the 
OF NEW  ENGLAND.
29
ileum, thickness natural.  Peyer's glands, 21 patches
counted,—the  first, eight feet from  the  pylorus.
Several were examined particularly, and found to be
considerably thickened, and rather softened.   In a
few, the greyish points were  numerous but not very
distinct; none were at all red, nor was there  any
redness about them.  Seventeen  ulcers were count-
ed in the lower part of the  ileum, all within less than
five  feet of its termination.  Two of them occupied
but a part of the patches in which they were situated,
leaving the remaining portions but little affected.
In the others, the structure of the  glands was nearly
destroyed, so that  there was  little evidence of  the
ulcers having been formed  in them except from their
shape and situation, and  from  the circumstance, that
there  was  no  other appearance of glands.   The
cellular texture remained, being  slightly  thickened,
and opaque,  and  showing distinctly the outline ot
what had  been a patch.  Some of the ulcers were
distinct, others were  in  groups, so that many small
ulcers  were  counted as a  single diseased  patch.
One, situated two feet from the ccecum, was an inch
and three-quarters long, and an inch broad ;  another,
three inches from the ccecum, measured two and a
half inches by one  and  a  half inches.   There was
an irregular ulcer at  the  valve.   The  form  of the
ulcers was  generally  regular,  oval, or round; edges
well defined,  in a few somewhat thickened, firm and
rounded.  The muscular coat of the intestine formed
the  base of the ulcer in  nearly all; the cellular coat
in a  few only ; and in one, half an inch in diameter, 
30
THE  TYPHOID  FEVER
situated 18 inches from the ccecal valve, full half of
the base was formed  by the peritoneum alone,  the
muscular  coat  having been ulcerated  away, and
leaving  the peritoneum  extremely  thin, perfectly
transparent, and apparently just ready  to break
through.  The  base of two, and  the mucous mem-
brane immediately around them, was red; the mucous
membrane around two others had a decidedly bluish
grey color.  The  rest were of  the  natural  color
of the tissues in which they were situated.
   The Solitary glands  were not at all  enlarged.
Mesenteric glands enlarged, softened, friable, and
infiltrated with serum, throughout, getting  more so
from the upper to the lower part of the intestine;
the color whitish in the  upper part,  becoming dark
red in the lower; and in  several  of these last  were
found rounded  opaque tuberculous-looking masses,
from the size of  a turnip-seed, to that of a pepper-
corn ; no proper suppuration.
   The Large intestines were considerably distended,
and contained a  large quantity of very dark brown-
ish,  almost black  substance,  of a  homogeneous
appearance, and soft solid consistence ; in the rectum,
having a reddish tinge as from blood.   There were a
great number of ulcerations in the mucous membrane
in the first four inches, too numerous to be counted,
of a regular form,  more  of them oval than round,
averaging from four  to  six lines long.  In one or
two places, two or three had united  to form one
large ulcer; edges   of ulcers well defined;  no red-
ness about  them,   but  around   some was  a bluish 
OF NEW  ENGLAND.
31
grey color;  the base  was  formed by  the  muscular
coat,  which, as  well as  the  mucous,  was  much
thickened in this part of the intestine.   Beyond this
part, 25 or 30 ulcers were scattered, in appearance
much like those described.
   The Spleen was  five inches eight lines long, four
inches  wide, and  one inch and a quarter thick;
weight seven and a half ounces ;  dark brownish red
color, very soft  and  moist, breaking  readily under
pressure.   Liver  nothing  remarkable;  Pancreas,
Kidneys and Bladder healthy.


                    CASE  III.

 Typhoid fever, complicated with pleuro-pneumonia: death
   klst day.  Pleura, lungs, and portion of liver inflamed;
   Peyer's glands partially cicatrized ; spleen large.

   G. W., aged  22, shoemaker,  was admitted  into
 the Massachusetts  General  Hospital, Nov. 2,  1833,
 on the fourth day of fever.  He had  been attacked
 with  chills, pain in the head, back and  limbs, loss of
 appetite, &c.  On the 5th  day  from attack, he had
 diarrhoea, which lasted several days ; and on the 7th,
 rose spots  appeared  on the abdomen, and  continued
 until the 12th.   On the 8th, he became  delirious.
 By the 18th, he became decidedly convalescent.  His
 pain  was  gone,  diarrhoea had ceased, countenance
 good, his delirium was gone, and he began to regain
 an appetite for food.  He continued nearly station-
 ary for a few days, and then relapsed.  On the 28th 
32
THE  TYPHOID FEVER
 day, delirium returned ; and on the 30th he had pain
 in the chest, which resulted in pneumonia.   He died
 the 41st day.

                    EXAMINATION.
   The head was not examined.
   Thorax.—The  left pleura and lung bore marks
 of very  extensive  and violent inflammation;  some
 pneumonia of right lung;  between three  and four
 ounces of serum in the pericardium.
   Abdomen.—Stomach, healthy.   The small intes-
 tines contained  a considerable quantity of  mucus,
 colored with  bile.   Peyer's glands appeared to have
 been, at a former period, the seat  of extensive ulcer-
 ation.  The  patches  at their margins were  bluish,
 greyish, or slate-colored ; and in many the color was
 diffused over the  surface.   The  margins  of some
 were thickened  irregularly.  In a few, all  the  pro-
 cesses  were seen, from the  open ulcer to  the smooth
 shining delicate  cicatrix, and from  this to a mem-
 brane  closely resembling  the surrounding  mucous
 membrane, with  which it seemed  to be directly-
 continuous.   About these parts there was no redness.
 Towards the ccecal valve  the  patches were  more
 healed  than higher up the intestine.   These appear-
 ances were confined to a space of about 20  inches
 from the valve.   The solitary glands were somewhat
affected  in  the   lower part  of  the  ileum.   The
 mucous membrane,  generally,  well.   The  Large
intestines were healthy.  The  extreme  portion of
the  left  lobe of the Liver bore marks of  recent 
OF NEW  ENGLAND.
33
inflammation, and adhered to the  diaphragm.  The
gall  bladder was very large, partly filled  with bile,
otherwise healthy.   The  Spleen was twice its usual
size; considerable effusion of lymph on its  surface,
its internal structure a  part  firm, and a  part much
softened,  and  contained  a small  diseased mass.
Some serum was found  in the peritoneum, and a
little pus in the pelvis.   The other organs healthy.


                    CASE   IV.

Typhoid fever, fatal 32d day.  Peyer's glands ulcerated;
  peritoneum perforated ;  inflammation of  peritoneum;
  solitary glands enlarged; mesenteric glands enlarged,
  suppurated; spleen  large.

   Sept. 14, 1835.   H.  G., carpenter, aged  22, was
admitted into the  Hospital in the  11th day of fever.
He had had much pain in head and dizziness, and at
times some delirium;  some  diarrhoea,  which  still
continued.  His countenance was dull, face flushed ;
tongue very dry,  red at tip and edges, with  a very
thick coat on  middle; teeth  dry, and covered with
sordes ; skin hot and dry ; pulse 84; manner slow ;
memory imperfect;  some deafness ; throat sore, and
parched;  great  thirst;  abdomen  tense,  tympanitic,
tenderness on pressure, greatest at epigastrium and
in right  hypochondrium ;  some   faint  rose spots.
These  symptoms   continued,  without   any  very
remarkable change,  until October 14th.   The diar- 
34
THE  TYPHOID  FEVER
rhcea continued throughout the disease, causing four
to six dejections daily ; delirium was occasional only,
and  not violent.   The pulse varied from 72 to 96.
An  eruption resembling acne took the place of the
rose  spots.  In the  last two or  three days of this
period, there were some rather decisive  indications
of approaching   convalescence.   His countenance
was  brighter, he  took more  notice of things about
him,  deafness less, and had some disposition for food.
At 2, P. M., Oct. 4th, the  31st day of the  disease,
he had a severe rigor which lasted three  quarters of
an hour,  followed by heat  and  profuse sweating.
He  appeared to  be  in great  pain;  talked incohe-
rently ;  pulse 120.  He died  at five o'clock  the
following morning.

        EXAMINATION--FOUR HOURS AFTER  DEATH.
  Externally.—Numerous  sudamina  on  abdomen,
which was moderately full.
  Head.—Some  effusion  of serum  in  cavity  of
arachnoid, and some  in  pia mater; a large quantity
at base of brain, and more  than usual   in  lateral
ventricles.  Longitudinal   sinus  and  veins of  pia
mater moderately full; glands  of Pacchioni very
large; brain firm, bloody  points  rather  numerous;
two or three small serous cysts in plexus  choroides.
  Thorax.—Left Pleura healthy, right Pleura  con-
tained about five  ounces serum ;  a portion of recent
lymph  hanging from  lower lobe  of lung.  Lungs,
lower lobes engorged, friable, and showing through- 
OF NEW  ENGLAND.
35
out the cut surfaces, dark red, almost  ecchymosed
spots;  otherwise healthy.  Pericardium and Heart
healthy.   Epiglottis, Larynx and Trachea healthy.
   Peritoneum, almost  every  where marks of acute
inflammation; 38 ounces  limpid serum in peritoneal
cavity.  The  small intestines  were glued together
by interposed layers  of recent lymph,  which was
most  abundant  towards the right  side, where also
was effused much of the contents of the  intestines.
A large quantity of lymph on convex surface of the
liver, and corresponding surface of diaphragm ;  none
on the stomach, except towards the small curvature,
and generally none on the small intestines opposite
the mesentery, although  there  was  considerable
redness of the surface of  the mesentery.  Stomach,
distended  with  flatus, contained  four  ounces of
bright yellow  liquid  ;  mucous membrane  healthy.
Small intestines contained much  light yellow, thin
fluid, at upper part, and a soft  solid  matter of  same
color.   The matter found in  the  peritoneal  cavity
was like this.   Peyer's glands, in  upper portion of
intestine, quite healthy; disease below not increasing
so remarkably towards the termination  of the ileum
as is often the  case.    Seventeen  patches in a state
of ulceration  were counted.   The ulcers averaged
two or three  lines in diameter, were well  defined,
edges red and considerably raised from thickening of
the subjacent  cellular coat.   They generally exposed
the muscular fibres.  One ulcer penetrated  through
the peritoneum.  It was  situated  seven and a half
feet from the ccecum;  was more than  half an inch
             6 
36
THE  TYPHOID  FEVER
 long, and  from one  to  two  lines  broad,  and  ran
 transversely to the intestine.   The perforation was
 circular, about one and  a half lines in diameter;
 edges very sharp,  and  peritoneal surface, for  some
 distance around, covered with lymph.   Some of  the
 patches were quite  healthy, except for the ulceration;
 but  they  were generally more or less thickened
 irregularly, red and softened.   Many  other smaller
 ulcerations were  found, which were not in  Peyer's
 glands, being  generally more  superficial, much less
 thickened; the edges of some very  dark, almost
 black.  A few, however, were more  recent,  con-
 siderably thickened, and of a bright red color.  One
 of these, being the first  ulcer that was met  with,
 was situated  12 feet  from the  pylorus.  The  Soli-
 tary glands were visible  throughout  the  last  eight
 feet of the intestine, numerous, especially  towards
 the ccecum, where  they were transparent, and about
 the size of a  turnip-seed.  The  Mesenteric  glands,
 opposite the  lower end of the  ileum, were greatly
 diseased.   Several  were as large as a filbert, soft, of
 a mixed whitish and deep red color externally;  and,
 being cut,  were found to be extensively suppurated.
 Those corresponding to the upper part of the canal,
 gradually became  healthy.  Large intestines, much
 contracted, containing very little healthy secretion;
 five or six small dark-colored ulcers in  the  ccecum,
 most of them  not  thickened,  quite superficial, but
 two  or three  penetrating  to  the  muscular  coat.
 Otherwise, mucous membrane  well.  Liver, toler-
ably natural;  Pancreas, healthy.   Spleen, six inches 
OF NEW  ENGLAND.
37
long, four and a half inches broad, soft and of a deep
red color.   Kidneys, dark-colored,  congested, and
rather friable.  Bladder, not contracted, many small
red spots on its inner surface towards the neck.

   We  come now to the inquiry, to  what extent the
same morbid changes are produced by other acute
diseases ?  I have already remarked, that the appear-
ances in the head are not characteristic of typhoid
fever.   The appearances not only vary in the differ-
ent cases, or  are entirely wanting, but precisely the
same are found in other diseases.   This last remark
I am not able to verify by a very full  collection  of
cases.   Of the 159 cases of  acute diseases, other
than  typhoid fever, occurring  at the Massachusetts
General Hospital, that I  have analyzed for the pur-
pose  of comparison, 18  were fatal;  and  in  15,
examinations were allowed.   But in the earlier por-
 tion of  the  time, only those parts of the body were
 examined which were of more immediate interest in
 the particular disease;  or, if  examined, the other
 parts  received only a general  notice that they were
 healthy.  In  eight cases, the state of the head  is
 noticed.  In four, there was  an  effusion of serum,
 three  in the  arachnoid, one in the pia mater also,
 and one in the ventricles.  Pacchioni's glands were
 very large in one, and numerous bloody points in the
 medullary substance, in one.
    The state of  the  lungs  and   heart  cannot  be
 brought into  this  comparison, because in 14 of the
 15 cases, those organs or their investing membranes,
 were  the chief seat of local disease. 
38
THE  TYPHOID  FEVER
  The stomach was declared to be healthy, or nearly
so,  in seven  cases;  the  mucous membrane was
mamelonnated in three, and in five, its condition was
not particularly described.
  The state of Peyer's glands is particularly referred
to in 11 cases, in all  of  which they were healthy;
and in two other cases  there is  a general  remark,
that the  organs  in  the  abdomen were healthy; in
two, no reference is  made to them.   To  these I
may add six cases  of similar diseases, that  I  have
observed  elsewhere,  in  all  of  which  they  were
healthy.   I  know of  no  case of  any acute  disease,
besides typhoid fever, in the adult patient, in which
these  glands have been found diseased.   In phthisis,
they are  often the  seat of ulceration, and of tuber-
cular  deposits ;  but  the appearances do not  very
nearly resemble  the thickening and  consequent
ulceration peculiar to  typhoid fever.
  There  is, however,  another  class of cases, in
which these glands  are affected in a manner precise-
ly similar  to  the affection in that disease.   This
occurs in young  children, in the diseases of  the first
dentition.   My  observations  are  not  sufficiently
numerous to determine  with what  degree of con-
stancy this  affection occurs  in  teething  children.
But they are sufficient to show, that it is not exclu-
sively confined  to  typhoid  fever,  even  in  acute
diseases.
  The  first case in which 1  noticed  this affection
was in a child 14 months old, who died suddenly in
convulsions, May 28th, 1836.  He had suffered from 
OF NEW  ENGLAND.
39
the irritation of teething for several months previous,
but without diarrhoea; and had undergone an occa-
sional attack of convulsions,  which had  been mild,
and had ceased to produce alarm.  But now a severe
fit, without  any preceding  indication  of danger,
suddenly destroyed life.  On opening the abdomen,
red patches were visible through  the coats  of  the
intestines.  The intestines were opened throughout,
and  nearly  thirty  patches   were  counted, quite
distinct,  extending  from   the ccecum  almost to
the  duodenum.   Many  of  them  were  obviously
diseased;  and, as in typhoid  fever, the disease in-
creased  towards the lower  part of  the intestine.
They were thickened, and red ; and the surface of
some of them was  covered with a soft whitish  sub-
stance resembling  lymph.   The corresponding me-
senteric glands were enlarged and red.   The solitary
 glands  were distinctly visible.  A  portion of  the
 ileum and of the mesentery was removed and shown
 to several gentlemen, who  recognised  the appear-
 ances,  as precisely resembling those  observed  in
 fever.
    In the second case, a child, 10 months old, died of
 cholera infantum, after a week's sickness.   Twenty-
 five patches of diseased glands were counted in the
 small intestine.  They were thickened  and red, but
 not ulcerated.   The mesenteric glands were swollen
 and red ;  the solitary glands not visible.  In a third
 case, a child of  18 months,  died after suffering  three
 or four weeks with diarrhoea, which terminated in
 cholera infantum.   Thirty patches of Peyer's glands 
40
THE  TYPHOID  FEVER
were  counted, elevated and  red ;  and  six  were
ulcerated;  these  last all within nine inches of the
ccecum.  No solitary glands were visible ; but there
were numerous little excavations, penetrating through
the mucous membrane,  scattered over the whole
internal surface of the ileum for the distance of 18
or 20 inches from the ccecum.   It seemed as if they
might  be  ulcerations of the solitary glands; their
edges  were  not  thickened,  and  they  contained
nothing.   The mesenteric  glands  large and  red.
A fourth case, was  presented in a child 18 months
old, who died, during  the period of  dentition, of
dropsy in  the  head.  Peyer's glands in the lower
part  of the  ileum were thickened  and red,  and
several  were  ulcerated.  In  a fifth case, similar
appearances were  observed, but without ulceration,
in a child  that  died of inflammation of the lungs,
after having been previously enfeebled by the irrita-
tion of teething.   The sixth was somewhat different.
The child had suffered  severely from  cholera infan-
tum, and during  convalescence, was  attacked with
hooping-cough, which  was  fatal  to him.   I  was
permitted  to make only a hasty examination, under
circumstances  that neither  allowed a careful inspec-
tion of the organs, nor opportunity to remove them.
Peyer's glands exhibited obvious marks of having
been diseased  and cicatrized.
   These are  all the observations I have had oppor-
tunity to make on this  point; and I do not know
that  the attention of  any other person  has  been
directed to it.   I  must  be  permitted  to repeat, that 
OF NEW  ENGLAND.              41
I do not regard them as sufficient to  establish any
general pathological fact, except,  as I  have already
stated, that of an exception to the general exemption
of Peyer's glands from any morbid affection in  acute
diseases other  than typhoid fever.  It  might  have
been better to have abstained from publishing them,
until a more extended  series  of cases should be
collected  to verify and  illustrate  them.  But  their
direct bearing  upon the  present subject seemed  to
call for some notice of them here.
   In four of the  15 cases of acute disease, before
referred to, the solitary glands in the small intestines
are noticed as  enlarged; and in one, in the ccecum,
 they were ulcerated.  In the remaining 11, they are
 not mentioned,  probably  because  no  disease was
 observed  in them.   The spleen is mentioned  in  10
 cases :  in three, it was large ; in four, small; and in
 three,  of natural  size,  or  healthy.  In  one  case,
 where  it was  large, and  in two, in  which it was
 small, its  texture was soft.   The Liver was examined
 in all the  15 cases.   It was healthy in seven; and
 somewhat softened, or friable, in eight.   In three, it
 was large ; in  three, small;  and in nine, its size was
 not noticed  as unnatural.   The other organs furnish
 no points of comparison to demand our attention.
    It will  readily  be  perceived, that the disease of
 which  we  have  spoken, bears  a very strong resem-
 blance to  the  "Typhoid  Affection"  of  Paris,  so
 fully described by M. Louis.  This has  already been
 shown, by the History  of  our Typhoid Fever, as
 reported  by Dr. Jackson.  It will  be very fully 
42              THE TYPHOID FEVER
confirmed  by a  comparison  of  the physical  and
anatomical appearances.  The " Researches" of M.
Louis, and  Dr. Jackson's Report, are both in  the
hands of the  members of the  Society; and  they are
so familiar with them, that  any detailed  comparison
of the disease of the two countries, on this occasion,
would be quite superfluous.
   The  principal difference  between  them is seen in
the greater frequency  of diarrhoea  in the  fever of
Paris than  in our  own.   Of 128 cases, under  the
observation of Louis, diarrhoea occurred in 104,* or,
81 per  cent.   In  the  Massachusetts  General  Hos-
pital, from 1824 to 1835, this symptom  appeared in
167  out of 297 cases, 56  per  cent.  In the cases
since Oct. 1,  1833, the proportion is still less, being
49 per cent.; or 96 cases out  of 197.
   The  same  difference in regard  to the prevalence
of diarrhoea is found in other acute diseases.  Louis
reports  81  cases of diarrhoea  in 273 acute  diseases
other than typhoid fever,  which is  30  per  cent.,
nearly.   In  159  cases of  similar diseases, in  the
Massachusetts General Hospital, the  diarrhoea occur-
red in 18, being only 11 per cent.f  From these facts,
it  would appear that  the  more  frequent  occurrence

  * Louis's Researches, Vol. II, pp. 14, 19, 22.  No more than 104 cases of
diarrhoea are enumerated; although it would seem from other passages that
the proportion is actually much greater than this, and that some are omitted
in this enumeration.
  t I have omitted M. Louis's enumeration of " pulmonary catarrh," and
" urticaria," &c, in this comparison, because I have no account of similar
diseases to be compared with them.  Those included in the comparison are
of the same general character, and of a similar degree of severity. 
OF NEW  ENGLAND.
43
of diarrhoea in  the fever of  Paris, is not  to  be
attributed  to any peculiarity in  the  character  of
the disease  itself, as  compared with  the  typhoid
fever  of New  England, but to  some more general
cause, affecting in an equal proportion  other acute
diseases.
   The fevers on the continent of Europe appear to
be of the  same  character, generally,  or at  least
extensively, as in Paris.  Dr.  Lombard  says, that
he always  saw  the  same morbid appearances  in
examinations at  Geneva;* Dr.  Staberoh witnessed
the same  in "about  50  cases" in Vienna;f Dr.
Grossheim, in 20 cases, in the  Imperial  Grenadier
Regiment ;J and Dr.  Stannius, in 20 out of  23
cases, in Berlin.  In  one of  Dr.  Stannius's three
remaining  cases there  was  softening of the  lining
membrane  of the intestine;  in a second, the  ulcers
had cicatrized ;  and the third, was a case of petechial
typhus.^
   The  comparison of our fever with the fevers  of
Great Britain,  is of  greater  practical  importance
than with those of France; and, at the same time,
is  much more  difficult.   A very large  proportion of
our medical literature is  received from  England;
and the greater part of our instruction in pathology
and therapeutics  is derived from  English authors.
If diseases of a different  character  are  known by a
* Dublin Journal of Medical Science, Vol. X, p. 18.
t Idem., Vol. XIII, p. 429.
t Edinburgh Medical and Surgical Journal, Vol. XLVIII, p. 177.
§ Ibid., p. 169.
             7 
44
THE  TYPHOID  FEVER
similar name; and the knowledge applicable to one,
is  applied  indiscriminately to another, it is  obvious
that we are liable to be  greatly misled, both  in  our
pathology and treatment.  There is much reason to
apprehend, that this has  already been done to a con-
siderable extent.  A judicious  practice,  in some of
our diseases, has  required an independence of  the
text-books and authorities put into the hands of our
pupils, and a departure  from  their  precepts, hardly
to  be  acquired  or  ventured upon, by  the  young
practitioner,  but at the expense of  much painful
experience.
  The comparison is difficult, because the authorities
upon which it should rest are few and unsatisfactory.
I know of no English physician who has investigated
the fevers  of his country with  any thing  like  the
patient diligence of the French pathologists.  We
could hardly expect, indeed, to meet again, in  the
same  age,  the  laborious minuteness  and  care  of
Louis.  But we might  hope,  from  some  of  the
numerous and  well-appointed hospitals, with which
England is supplied, a  more  full  and satisfactory
account of the phenomena of their diseases than we
have been able to obtain.
   Several of the ablest  of the late British  medical
writers seem  not to  have suspected  any difference
of character, between  the fevers  of  Great Britain
and those  that prevail  on the continent  of Europe.
Dr. Tweedie* alludes to the fact, that the  affection

  *  Cyclopaedia of Practical Medicine, Vol. II, Article, Fever, pp. 161,181 
OF  NEW ENGLAND.
45
of Peyer's glands  is more common in the fevers of
France than in those of England, but without any
intimation that there is any  other  ground  of dis-
tinction between  them.  Dr.  Graves,* although he
has published much on  the fevers of Ireland, scarcely
alludes to any observations made on  the continent.
Dr. Stokes,f and Dr. Copland,! make  use of the  ob-
servations of Andral and Louis, indiscriminately with
those of Tweedie and other English  authorities, in
their pathological remarks on  Fever.  Dr. Marshall
Hall§  speaks, indeed, of the distinction between ty-
phus and typhoid fever  ; but he mistakes for the only
typhus, the severer forms of jail, hospital, and ship
fevers, and confounds the ordinary typhus of England
with the fever of France, as if it were of course  the
same disease.
   The remark has often been made,  however, that
the  typhus  of  Great  Britain  does not afford  the
same anatomical appearances, at least not with the
same constancy, as that of France  and  other parts
of the continent;  and,  at length, the distrust of  the
accuracy  of the  observations, which  at  first  pre-
vailed, although still followed by many a  hint that
the  French  pathologists  attach vastly  too  much
importance to them, has in  some  degree, given place
to a disposition to inquire into  the character of their
  * Clinical Lectures; and various papers in the Dublin Journal of Medical
Science.
  t Lectures on the Theory and Practice of Medicine.
  t Medical Dictionary, Article, Fever.
  § Lectures in the Lancet for July, 1838. 
46
THE TYPHOID FEVER
own  disease.   The  obvious method of  doing  this
effectually would  be, to investigate  the  phenomena
as they are exhibited in their hospitals.   Opportuni-
ties  for  observations  upon fever  are  exceedingly
abundant  and highly  favorable,  in  every  part  of
Great Britain;  not  only because the  hospitals are
numerous ;  but  because,  in consequence  of  the
prevalence of  an  opinion that fever  is a contagious
disease, the number of patients gathered  into the
hospitals is very great, amounting in  some to several
thousands annually.*
   Yet the number of careful observations, of which
I have  been able to obtain any notice, is exceedingly
small.   I  find hospital reports in abundance, giving
accounts of the admission  and  discharge  of many
thousands of  patients, with a considerable  amount
of statistical information in regard to the  prevalence
and  mortality  of fever, and on various other subjects,
often of no  small  value; but I  meet with compara-
tively few notices  of the phenomena of  the disease
as they were  presented  during its progress,  and still
  * The number of cases admitted into the Fever Hospital, Cork street, Dub-
lin, in one year, from April 1, 1834, to March 31, 1835, was 4,524;' and
the number in twenty-five years, was 77,866.2  The number admitted into
the Belfast Fever  Hospital, in seventeen  years, from May, 1818, to May,
1835, was 9,849.3 In St. John's Fever and Locke Hospital, Limerick, the
fever cases in twenty years, from 1816 to 1836, were 30,942; and in the
latter year alone, there were 3,227.4

  1 Dr. Eustace's Report, Lancet for Sept., 1835, Vol. XXXI, p. 724.
  * Dublin Journal of Medical Science, Vol. X, p. 103.
  3 Statistics of Fever, by Wm. Mateer, M. D., Dublin Journal, Vol. X, p. 33.
  * Dr. W. J. Geart's Report, Dublin Journal, Vol. XI, p. 384. 
OF NEW  ENGLAND.
47
fewer  descriptions  of the  anatomical  appearances
discovered by examination after death.
  In  1836,  Dr. H. C. Lombard, of Geneva, visited
England,  Scotland  and Ireland, for the purpose of
investigating this question.  He had been more than
six years engaged in close  attention to this subject,
and having witnessed the examination of  many who
had died of  typhoid fever, in  Paris and Geneva, he
was  quite  familiar with the affection of Peyer's
glands, as it is  found  in  the  fever  of those cities;
although  he describes it incorrectly in saying,  that
"in fatal  cases, it always ends in  ulceration of the
mucous membrane."   His investigation was not very
thorough.   He saw three cases examined after death
(one  in  Glasgow,  and  two  in Dublin), in which,
from the  similarity of the symptoms, he  had confi-
dently predicted the  same changes of structure  that
he had witnessed on the continent.  There was no
affection  of  Peyer's  glands in either.  Being  dis-
appointed in the  result in  these  three  cases,—
and  it does not appear that  he  saw  any other
examinations  in  Great  Britain,—he  immediately
abandons his previous opinions,  founded  upon  the
investigations of more than six years, and comes to
the conclusion, not that the  typhus of Great Britain
is different from that of Paris and Geneva, but "that
typhus fever is more a general disease,  affecting the
whole constitution, than a malady depending on any
local inflammation or any local change of structure."*
* Dublin Journal of Medical Science, Vol. X, p. 23. 
48
THE  TYPHOID FEVER
He is not wholly  unmindful of  the difference in
some  of the symptoms; but he considers  the  differ-
ences unimportant, and, in answer to the question,
"whether  the  two diseases  are  different,  or the
same,"  he expresses  strongly the conviction,  that
they  are  not "specifically distinct."
   In  a subsequent  paper, Dr. Lombard takes a dif-
ferent view of this  question; although it does not
appear that his  second opinion is founded upon any
new  observation of  the  disease.  He now  avows
the opinion, that two distinct diseases were prevalent
at the same time;  one the typhoid fever of the con-
tinent, the other a contagious typhus, which  origi-
nated in Ireland, and from there  spread  over Great
Britain.*   The suggestion, of the twofold character
of the epidemic, might have been of some value,
if  it had been accompanied  by any  satisfactory
explanation  of  the difference between them, or of
the phenomena which they  severally exhibit.   But,
 as a  mere speculation, having no other basis than the
 single  difference of  appearances in regard  to the
 affection  of  Peyer's glands, and with  no other object
 than to escape  from a difficulty, it is entitled  to very
 little consideration.
    In 1837, Dr. Staberoh, of Berlin, visited  Ireland
 and  Scotland,  for  a similar  purpose.  He, too, was
 familiar  with the  typhoid fever of  the continent;
 and  had  formed his  opinions in the same excellent
 school of observation at Paris.   His opportunities
* Dublin Journal of Medical Science, Vol. X, p. 
OF NEW  ENGLAND.
49
for  witnessing  the disease  in  Great  Britain  were
much more extensive than those of  Dr. Lombard.
I know not what account of his observations he may
have published, in his own  country, after his return.
His paper written at Glasgow, after  a residence of
six  months in that city and in Dublin, read before
the College of Physicians  in  Ireland, contains very
few facts of interest to  the general  question.  Its
leading object appears  to  be  to  gratify his  Irish
friends, by proving that the epidemic had not  origi-
nated peculiarly in their country, as had been asserted
by  Dr.  Lombard, but was as truly a Scottish, as an
Irish, fever.   In  doing this, he incidentally describes
some of its phenomena.  He  evidently regards the
fever of Great Britain as the same disease as the
fever of the Parisian hospitals, although, in  a very
large proportion  of cases, it wanted  the character-
istic affection of  Peyer's  glands.
   I have  been  thus particular in  speaking of the
statements and  views of these gentlemen, because,
having been trained to  accurate investigation, and
having come to the examination, with very strong
anticipations of  a different result from  that which
 they  ultimately  adopted, they were peculiarly well
situated to observe carefully, and  to judge correctly;
and their opinions might seem to claim an importance
from  the  circumstances under  which  they  were
formed, to which they were not  entitled, from any
intrinsic value.   But we  are  not  called  upon to
receive the opinion of any  one, however qualified he
 mav be to form  it correctly,  any farther than  it is 
50
THE TYPHOID FEVER
supported  by  the observations on which it rests.
We  proceed,  therefore, to an examination for our-
selves  of  the characteristics of the  fever  of Great
Britain, as they are exhibited in the best descriptions
that we can obtain.
  The earliest notice that I can find, by any English
physician, of affection of the glands of the ileum in fever,
is by Dr. Bright, in his Report of Medical Cases.*  He
gives a brief history of ten fatal cases, with  dissec-
tions, and figured illustrations of the morbid anatomy,
of the several stages of disease, from  simple enlarge-
ment of the  glands, to ulceration, and  cicatrization,
and  perforation  of  the  intestine.  Eleven  other
cases are added as examples of a proper treatment.
It is manifest, that  both  the local  affection, and the
general disease, are  identical in  character with the
typhoid fever  of which  we  have spoken.    These
cases occurred in  Guy's Hospital, ten in  1826, six  in
1825,  three in  1827, and of two the  date  is not
given.  Dr.  Bright does not speak of the local
affection, as universal in fever; but he expresses the
opinion, that "the intestinal  canal  is almost  always
irritated,  and  that  this irritation  keeps  up  all the
bad symptoms."f   Dr. Bright's observations appear
to have attracted very little  attention.  Some  of
them were made, as we have seen, as early as 1825,
and they were published in 1827.   Yet I have found
  * Reports of Medical Case3, selected with a view of illustrating the symp-
toms and cure of diseases, by a reference to morbid anatomy.  By Richard
Bright, M. D., F. R. S., &c, Lecturer on the Practice of Medicine, and
one of the physicians to Guy's Hospital, Vol. I, p. 178.
  t Ibid. 
OF NEW  ENGLAND.
51
only  two or three very slight references to them, in
any of the authorities I have consulted on this sub-
ject ;  and so late as in 1830, it was not the practice,
even  in Guy's Hospital, to open the intestines in  the
examinations of patients who had died of  fever.
   In  1830,  Dr.  Tweedie published his  "Clinical
Illustrations  of Fever;"  containing  the  history of
73 fatal  cases of  disease that  had occurred  at  the
London  Fever  Hospital, in 1828  and 1829.   In 54
of these cases, examinations were made.  The result,
as stated by himself is, that  in 16 cases only, out of
the 54, were ulcerations found in the mucous mem-
brane of  the  small intestines, answering  to  the
affection  of Peyer's  glands.*  But  this  statement
should  not  be  received  as  authority,  although it
has often been quoted as such, without some scrutiny.
   The London  Fever Hospital, under the  medical
care  of  Dr. Southwood  Smith, and Dr.  Tweedie,
receives all cases of febrile disease, including inflam-
mations and the exanthemata, with the exception of
small pox and  measles.  Dr. Tweedie's definition of
simple  fever is, "increased  heat, accelerated pulse,
thirst, general functional  disorder."!  A  large pro-
portion of the patients are the parish poor;  and, in
consequence of a  regulation  that each  parish shall
pay something for the support of its patients, many
of them are received at a very late stage of disease,
and  under circumstances  that  render it impossible,

   * Cyclopaedia of Practical Medicine, article, Fever. By Dr. Tweedie,
Vol. II, p. 181.
   t Clinical Illustrations of Fever, p. 282, Boston edition. 
52
THE  TVPHOID  I'EYEK
without great care and trouble, to obtain any thing
like  a satisfactory  history of  its  earlier  progress.
Doubtless many of these  difficulties might  be obvi-
ated, by  a sufficient degree  of attention;  but they
furnish reason  for  us  to  look beyond the general
statement of the cases, that  we may see with what
degree of  accuracy they have been  observed and
recorded.
   On making such an  examination, we find that the
histories  of the greater part of  the  cases are so
incomplete, as to render it quite impossible  to form
any  opinion of the character  of  the  disease, inde-
pendently  of the  examination after death; and in
some, the uncertainty  is not  removed by the exami-
nation.  Several patients were brought to the hospital
in a dying state, and  no account is  given of their
previous history.   In regard to a part of these cases,
no reason appears why they should be called fever,
unless it be the  accident  that  they were brought to
a fever hospital, and died  there.
   I have  made  a  somewhat careful analysis  of the
54 cases;  and, so far as the materials given afford
ground for classification,  the following appears to
me to be a fair result.   No  more  than 19  of them
are cases of fever; eight  are clearly cases of pneu-
monia, with extensive  hepatization  of one, and
sometimes both lungs,—two of them  with pleurisy
superadded; one is  pleurisy  with  little or no pneu-
monia ;  four are phthisis, with extensive tubercular
disease in  both lungs,—two in a softened state, one
with  numerous  cavities, and one  with ulceration of 
OF NEW  ENGLAND.
53
the intestines,—in  the other  two, the surrounding
portions of lung consolidated  by inflammation ;  one
is pulmonary apoplexy ; one, gangrene of the lungs ;
four, inflammation of  the brain, one of these should
rather, perhaps, be regarded  as hypertrophy of the
brain; two, erysipelas;  one probably scarlatina, though
the history begins too  late to make it certain ;  five,
peritonitis, not caused  by perforation of the intestine,
of which there  are two  examples  in the  19  fever
cases ;  one, internal  strangulation of  the  intes-
tine from intussusception, producing sphacelus ;  one,
inflammation of  the  ccecum;  and  six, are too
imperfectly  recorded  to  warrant  any conjecture  in
regard to them.
   Three or  four of  the  cases that I  have classed
as fever, are somewhat  doubtful,  but  I prefer  to
enumerate in this class, all that  can with  the least
 propriety be called fever,  in any specific sense of the
 term.  Two of these were  complicated by inflam-
 mation of the  lungs.   In 13 out of the 19 cases,
 there were  ulcerations  in the lower part of the
 ileum.  In  five  others, there is described inflamma-
 tion  of the  mucous  membrane of  the  same  part,
 sometimes   in   patches.  These  appearances were
 doubtless caused by  thickening  of Peyer's glands,
 which are  never  mentioned in the  examinations.
 In the  remaining case,  the  abdominal  viscera are
 said  to be healthy, "excepting the mesenteric glands,
 which were enlarged, and  partially  affected  with
 suppurations of a  scrofulous  character."   Now it is
 well  known that  enlargement  of the  mesenteric 
54
THE  TYPHOID  FEVER
glands, especially with suppuration, is rarely, if ever
found, without some disease  in the part of intestine
to which they correspond ;  and it is more reasonable
to suppose, that an affection of that organ was over-
looked in  the general survey of  the "abdominal
viscera,"  than that  so unusual an  exception  to a
general fact existed in  this  case.
   Nearly at the same time with  Dr. Tweedie's
publication, a  treatise on Fever was also  issued  by
his colleague, at the  London Fever  Hospital, Dr.
South wood Smith.   In this are given the narratives
of 104 fatal cases of disease, with the  results of
examination  after  death.    Twenty-seven of  the
cases are the same, in each work.   In 43 of the
remaining 77 cases, there is  notice of ulceration or
other affection in the mucous membrane of  the
ileum.  I have not thought  it worth while to make
an analysis of these 77 cases, like that to which we
have subjected Dr. Tweedie's.  They were selected
from the  same Hospital Records, and are, of course,
subject to  the same imperfections; and they have,
besides, the additional disadvantage of having  been
selected in the illustration and support of a particular
theory of fever.   I think we are  fully  warranted in
saying, both of Dr.  Smith's  and  Dr. Tweedie's
cases, that, instead of establishing any difference of
character between the  true fever  of London, of the
period in which they occurred, and the  typhoid fever
of Paris  and of  New  England,  they  go as  far
towards proving its identity with  them, as cases so
imperfectly  observed  ever  can go  towards proving
any thing. 
OF NEW  ENGLAND.
55
  It is to be  regretted, that  Dr. Tweedie has not
extended  his observations, by  an  examination  of
additional  cases.   In  the  article, Fever,  in  the
Cyclopasdia of  Practical  Medicine,  published  in
1833, we find him referring to the same 54 cases of
his  Clinical  Illustrations,  without  any allusion  to
later  observations, although, in  the mean time, the
publications of Louis, and other French pathologists,
had drawn the attention of the whole medical world
to this most interesting subject.   With an experience
of seventeen or eighteen years as physician to a well-
appointed hospital, that supports 500 or 600 fever pa-
tients, or what is called fever, annually, and with his
attention  sufficiently drawn to  the  subject to have
twice  published elaborate  essays upon it, he might
reasonably have been expected to produce something
more decisive of its character than the reports we have
now examined.   And yet I believe Dr. Tweedie is
fairly entitled to the distinction  of having done more
towards the elucidation of  this subject, by the publi-
cation of facts in  regard to it, than any other English
physician.
  In the last eight or nine years, fever has prevailed
in Great Britain,  much more than for  several years
before.   This new epidemic,  as it may with propri-
ety  be regarded,  began in  Ireland and  Scotland,
chiefly in the larger  cities and manufacturing towns,
and  soon  after  made  its appearance in London.
There can be  no  doubt, that in a large  proportion of
cases, it is destitute  of the characteristic affection of
Pever's glands, which, as we  have seen, is universal 
56
THE  TYPHOID FEVER
 in  the typhoid fevers of Paris  and New England;
 and common, if not  universal, in the earlier fever of
 London.   Whether it differs,  also, in other respects,
 so as to constitute it  essentially a different  disease,
 or  whether the difference exists only  in  regard to
 that affection, bespeaking rather an exception to the
 otherwise  universal  prevalence  of it in  a  specific
 disease, is a question of great pathological interest.
   That this affection  is generally not found in the
 present epidemic, is  confidently stated  in  general
 terms  in   many   accounts  of the  disease,  and  in
 reviews and  various  other   papers,  although  the
 detailed evidence of its absence is not  so precise
 and accurate as we could wish.  Dr. Perry, of Glas-
 gow, states, as "the result of  careful  observation in
 upwards of 4000 cases" (1145 in  the first seven
 months of  1831,  and 3203, between  November 1,
 1833,  and  the end of 1835), "and  300 necroscopic
 inspections," that  enlargement of the solitary glands,
 and  ulceration of Peyer's glands, were  found  in
 about  one-sixth of those who died, of what lie, in
 common with  most of the British  medical writers,
 denominates contagious typhus.*  But he gives us
 no  particulars, either of his 4000 cases, or his  300
 inspections, to enable us to judge how far he might
 be  influenced in  his observations by his theoretical
 views,  or with what degree of care and thoroughness
 his   examinations  were  made.   Dr.  Craigie,  of

  * Observations on Continued Fever, as it occurs in the City of Glasgow
Hospitals.  By Robert Perry, M. D., Physician to the Glasgow Fever Hos-
pital.  Edinburgh Medical  and Surgical Journal,  Vol. XLV, p. 64, Jan., 1836. 
OF  NEW ENGLAND.
57
Edinburgh,  has  published three  Reports  on  the
fever, as  it  came under  his  observation  in  a part
of the  Royal  Infirmary of that city.   In the  first,
embracing the  period from December 15, 1832 to
August 1, 1833, he  reports 104 cases of  fever, and
16 examinations  after  death; in the second, for the
year  from  October  25, 1834 to October  24, 1835,
174 cases, 24 deaths, and 12 examinations; and in
the third,  for  the period from June 28, 1836 to
February 12, 1837, 169  cases, 23  deaths, and 13
examinations.   Some  of  the cases  are  given in
detail,  others are only stated  in general terms.   The
 three reports contain  notices  of 41  examinations.
 Peyer's glands were  found  to  be affected in  seven
 cases; in three of these  there were ulcerations;  in
 three,  the intestines were not opened, and in 31, no
 morbid appearance  was discovered in the  ileum.*
    In the  winter of  1837-38, Dr.  Charles  West
 made  some observations upon  the  fever  of  Lon-
 don,  in  St.  Bartholomew's  Hospital.f    He had
 studied  the  typhoid  fever  of  the continent,  in
 Germany,  and  at   Paris, and  he carried  out his
 observations  in  London, with  a  minuteness and
 care  not often  found in recent English pathological

    x In this last number, several cases  are included, in which nothing is
 expressly said of the condition of the intestines; but it appears from other
 circumstances stated, that they were examined.  Edinburgh Med.ca and Sur-
 gical Journal, Vol. XLI, p.  257. Vol. XLVI, p. 1, and Vol. \L\ II, p. 28o.
    tSome account of the Typhus Exanthematicus, as observed ,„ St Bar-
 tholomew's Hospital, London, in 1837-38.  By Chari.es West M. D
 Graduate in Medicine and Surgery of the  Univers.ty of Berhn.  Edinburgh
 Medical and Surgical Journal, No.  136, for July, 1S3S. Vol. L, p. 118. 
58             THE  TYPHOID FEVER

investigations.  He  followed 60 cases through their
whole  history.   Of  these,  14  were  fatal; and
examinations were made in 10.   The mucous  mem-
brane of the small intestines wras more than usually
vascular in  five ;  the vascularity,  in  one,  being
extreme, but generally not intense ; it was in patches
corresponding  to the situation of Peyer's glands, or
near  the ccecal valve.  In  one case, these glands
were enlarged, and the solitary glands in two;  but
he never saw them ulcerated.
   I am permitted also to refer to several observations
of a young gentleman of this city,* who, after spend-
ing nearly three years in attending  the  hospitals in
Paris, visited the  London  Fever  Hospital, the last
year, for the purpose of investigating the  character
of this disease.  He observed ten fatal cases  carefully
through, and examined  the appearances  after death.
Peyer's glands were  affected  in but one case.
   In  a paper  by Dr.  Stokes,  of Dublin, "On the
State of the Heart, and the use of Wine in Typhus
Fever,"f I  find notices of examinations of  four fatal
cases; in one of which  there was enlargement, with
some ulcerations of Peyer's glands.   If  to  all  these
we add the  three cases witnessed by Dr. Lombard,
in which there was  no affection  of the ileum, we
have  an aggregate of  65 cases of  examination  of
  * G. C Shattuck, Jr., M. D.
  t Researches on the State of the Heart, and the use of Wine in Typhus
Fever.  By William Stokes, M. D., M. R. I. A. Dublin Journal of
Medical Science, for March, 1839, republished in Dungliuson's American
Medical Library, Vol. Ill, No. 2.  1 Monograph A, p. 1. 
OF NEW  ENGLAND.
59
the small intestines, in ten of which, Peyer's glands
were found  diseased,  and  in  55, they  were  not
affected ; corresponding very nearly to the proportion
stated by Dr. Perry, as  the result of his observations
at Glasgow.*
   The state of  the spleen is noticed in but a few of
the reports that I  have  examined.   Dr. West found
it enlarged and  softened in six cases,  and healthy in
four.   Dr. Craigie notices its enlargement five times
in his third report, out of thirteen  cases, and in the
second, in  three  out of  twelve.   But it does not
appear  whether it was  healthy  in   the remaining
cases, or whether its condition was overlooked.
   The  morbid  changes in the other organs are not
uniform nor constant enough in either form of fever,
to enable us  to institute a satisfactory comparison
between them.    In  general, affections of the  head
and those of  the  stomach  are both  more frequent
and more severe,  in the later fever of Great Britain
than  in  that  of France  and of this  country.  But
there is  no one  affection that is not occasionally
wanting.   Indeed, Dr. Stokes  gives one  case  in
which all  were  absent  in  the same case.   "No
organic lesion of any kind  could  be  discovered in
any part of  the  body."   Dr. Stokes found the heart
softened in  three  of  his four cases, in  two very
remarkably.   But the  object  of  his  paper had  a
particular reference to the  state of that organ, and

  * Dr. Staberoh saw the  glands of the ileum affected five times, in Glasgow;
but he  omits to  mention the  number of cases in which they were found
healthy.
              9 
60
THE  TYPHOID  FEVER
it is not improbable, that the cases selected to illustrate
it, exhibited  that  affection in more than  the  usual
proportion.   Softening of the heart is not mentioned
in other reports, as a frequent occurrence.
   The symptoms  of fever in its several forms have
so many  things that  are  common to all,  or that
differ only in their degree of intensity, that it  is not
easy, by any description of them, to distinguish its
various modifications with  clearness.  It is impossi-
ble  to read the  reports of  the  typhus  of  Great
Britain without perceiving  that it is  a  much  more
grave  disease than the typhoid fever either of Paris
or New  England.  Its course  is  more  violent and
rapid ; the prostration, not only of the strength, but
of the faculties, is more sudden and complete ;  the
cerebral  symptoms are more severe,  or severe in  a
larger proportion of cases; the complications are more
numerous  and more  severe,  and it  would  seem,
though the evidence is not, perhaps, very conclusive,
that the  mortality is greater.   There are also some
other marked differences of character;  the eruption,
especially, is widely  different; and  the derange-
ments of  the abdominal organs have more  respect
in general to the  condition of the stomach, than to
that of the  intestines.  Diarrhoea  is much less fre-
quent.  Some  of  these symptoms we must  notice
more particularly.
   Duration.—Dr. Mateer reports,* that the  average
term of residence  in the Belfast Fever  Hospital, of
* Dublin Journal of Medical Science, Vol. X, p. 32. 
OF NEW  ENGLAND.
61
11,209 patients in 17 years previous to May, 1835,
was 22 days;  and by another  table he  shows that
the average duration of  fever before admission was
about seven  days, making the whole  duration  29
days; and he estimates that one half of this term
was  occupied by the disease while  on  its increase,
and  the  other half on its  decline.  It is worthy of
remark, that the term of residence was  three or four
days shorter in the  last  three of the 17 years than
in several of the  earlier years, and somewhat less
than the average, or  than in any of the  others.  The
average  duration  of 170  cases in the Edinburgh
Infirmary, in  1834 and  1835, counting the days of
illness previous to admission, and the  residence in
the Hospital,  was 31 days,* and of 165 cases in the
same institution, in 1836 and  1837, 25 days.f  The
average  duration, ascertained in the same  manner,
of 186 cases of typhoid  fever in the Massachusetts
General  Hospital, from  October 1, 1833 to May 1,
1839, was 39 days.   Of the five fatal cases reported
by Dr.  Stokes,  the  mean  time of death  was the
 17th day of the  disease;   that of  Dr. West's  14
cases, the 18th;  that of 20 cases in  Dr. Craigie's
Report  for  1833  and 1834, the 16th, and of 29 of
those in 1836 and 1837, the  14th day.   The  dura-
tion of the fatal  cases  reported in this  paper was
ascertained  in 21, and of  these, the mean fatal day
was  the  33d.  It thus appears that  the  fever of

  * Dr. Craigie's Report.  Edinburgh Medical and Surgical Journal, Vol.
XLVI, p. 1.
  t Ibid., Vol. XLVII, p. 285. 
62             THE  TYPHOID  FEVER
Great  Britain is much more rapid than our own,
both in the earlier termination of the fatal cases,
and in the more rapid  convalescence of the greater
number who recover.
   Cerebral affections.—The severity of the affection
of the head is manifested by pain, stupor and con-
fusion of mind, and delirium.  All these  appear as
frequent symptoms of  the typhus of Great  Britain,
but the number of each is not particularly mentioned
in most of the  reports.  Dr. Craigie, in his second
report, enumerates  99  out of 174  cases, as compli-
cated with affection of  the head, but without specify-
ing the nature of the affection.  Dr. West states that
there was headache in  all the 60 cases observed  by
him, where it was not masked by delirium or stupor;
and there was delirium in 33, including all the fatal
cases.   Dr. Stokes reports delirium in 11 of his 19
cases.   Of  the  197   cases  in  the Massachusetts
General  Hospital,  since October  1, 1833,  delirium
is recorded in 41, and headache in 164; 33 of these
are included in each enumeration.
   Mortality.—I have not data enough  on this point
to authorize a very confident  conclusion in regard to
it.   Dr. Craigie,  in his second report,  records  24
deaths out of 174 cases, or one to every 7i; and in
his third report,  the proportion is nearly the same.
Dr. West reports 14 deaths out of  60 cases; one to
4£.  Dr.  Jackson  reports   in  the Massachusetts
General Hospital, 42  deaths in 343 cases, making
one  to  eight.   Since  October 1, 1833, the propor-
tion  has been still less,  22 in 197 cases; one to nine. 
OF NEW  ENGLAND.
63
  Diarrhoea.—This  symptom is not reported, so as
to be available for the purpose of comparison, except
by Dr. Stokes and Dr. West.   The former reports
six cases of diarrhoea in 19, and the latter 10  in 60.
In general the  diarrhoea was slight and continued
but two or three days.  It occurred in only three of
Dr.  West's fatal cases.   Thirteen of the 60 were
affected  by constipation.   In the  typhoid  fever of
Paris, diarrhoea  occurs in almost every case; and, as
we have already seen, in  our own fever, in 96 out of
197 cases.  In  the  earlier  English fever, 17  of Dr.
Bright's 21 cases  had diarrhoea; three of the others
were admitted so  short a time  before death that the
state of the   bowels was not ascertained.   Ten of
Dr. Tweedie's  19 cases,  which I recognise as  fever,
had diarrhoea,—three others probably,—and most of
the  remaining six either were free  from it, or it had
ceased before admission.
   Eruption.—There  is  scarcely  any  resemblance
 between the  little bright red rose spot of the typhoid
 fever, scattered  thinly and sparingly over the front of
 the abdomen, and  the abundant eruption of the typhus
 of   England.   This eruption, indeed, is not  always
 uniform.  Three  varieties are described.  One is the
 true rose spot; it  seems not  to  be often if at all
 found alone,  but  to be occasionally met with, inter-
 spersed with  the  other forms.    The second  is of a
 papular form, somewhat confluent,  and very generally
 spoken  of, as resembling the  eruption of measles.
 This is  the  prevailing form, the  others apparently
 being little  more than accidental.  The third form 
64
THE  TYPHOID  FEVER
 is petechia.   The term petechial  is often  applied
 to the eruption generally, though  somewhat  inaccu-
 rately.   Dr. Stokes, for  example, speaks of petechial
 or maculated fever, indiscriminately.  True petechia?,
 however, are  not unfrequently met with, generally,
 if not always, in connection with the papular form.
   The eruption is  abundant over the body, quite as
 much upon the  back as in front, some reports say
 more, and presents itself as a prominent  feature of
 the  disease;  insomuch  that  some writers  call  it
 typhus exanthematicus;  others use  the term eruptive
 fever, and one  at  least regards the  eruption as of
 itself a sufficient diagnostic mark to distinguish  this
 from  other fevers.   It  generally appears from  the
 6th to the 8th day, often  as early  as the 4th,  and
 never later than  the  10th.   Whereas  rose spots in
 the typhoid  fever  never begin earlier  than the  6th
 day, rarely before the 7th or 8th, quite often as late
 as the  12th or 15th, and sometimes later than  the
 30th.  Its manner of going off is  also different.   It
 fades in  two or three days, but  dies away slowly,
 leaving a stain behind, which sometimes is visible  a
 fortnight or more.*   The appearance of the eruption
 brings with  it no appreciable  change of  the other
 symptoms;  and  its abundance or  scarcity  has no
obvious  relation to the  severity of the   individual
cases.  Even  the  appearance of  petechias  is  not
particularly unfavorable.
  I am not able  to state very fully in what propor-
* Dr. West on Typhus Exanthematicus, p. 140 
OF NEW  ENGLAND.
65
tion  of cases  the eruption is observed.   Dr. Cowan
found  at  Glasgow,  in one  year,  from November,
1835, to October,  1836, that of 2257 patients, 1669
had  eruption,  and  580  were  without it.*   Dr.
Staberoh reports 1103 cases in the same city, in five
months, in  1836,  of which 844 had  eruption, and
259  were without.   Dr. Craigie mentions it numeri-
cally only in his third report, in which it is said that
79  out of  169 had  eruptions.  Of  Dr. West's 60
cases, 42 had the " measles-like" eruption, and in five
there  were petechias also.   All  of Dr.  Stokes's 19
cases were  "petechial," or "maculated;" but, as  I
have before remarked, these cases  were selected to
illustrate the effect of a particular remedy, and not
as examples of the usual state  of the malady.
   But  while it thus appears  that the two diseases
differ much from each other, in many of their general
features, it  is no less true that in individual cases, it
is sometimes  impossible to distinguish them, by the
phenomena during life.   Both Dr. Lombard and Dr.
Staberoh acknowledge  the surprise they felt at not
finding in the intestines the appearances of typhoid
fever,  such as  they had seen on  the  continent, in
cases in which the previous symptoms had  led them
to  expect  them  confidently.    The  gentleman, to
whom  I  have  before  referred,  has  more  recently
made  the comparison under favorable circumstances ;
and although  he  could commonly predict in what
  * Review of Cowan's Vital Statistics of Glasgow.  Edinburgh Medical and
Surgical Journal, Vol. LI, p. 537. 
66
THE  TYPHOID  FEVER
 cases  these  appearances  would  or would not  be
 found, it was not always so.  Of the cases reported,
 very few are given in sufficient detail to furnish data
 for any opinion  on this question.   It would seem,
 that, excepting perhaps some more prominent symp-
 toms  of abdominal derangement, differing more  in
 degree  than in character, the cases in which  Peyer's
 glands have been found enlarged or  ulcerated, were
 not essentially unlike others in which no such affec-
 tion was discovered.   This point, however, has not
 received much general attention.  It is by no means
 certain  that further and more careful  observation may
 not discover  marks  of distinction  which  shall be
 appreciable in all cases during life.   If  it should be
 otherwise, it is no more than what happens occasion-
 ally  in  regard to  other diseases,  of  a  character
 obviously distinct in their nature and origin.
   It is not impossible,  perhaps  not  improbable, that
 further investigations may discover a common origin
 for all the forms of fever, and distinguish the several
 modifications that occur, as varieties of the  same
 general  disease.   But  in  the  actual state of know-
 ledge, which is the only sound basis for our opinions,
 for the time being, it seems more reasonable to regard
 as distinct diseases those which are characterized by
 a marked difference of phenomena, and of pathologi-
cal appearances.  In this point of view, I think we
 are warranted, in considering the recent typhus  fever
of Great  Britain  as a  different disease  from the
typhoid  fever of France and New England, and of
England itself. 
OF NEW  ENGLAND.
67
  Our information  is  not sufficiently full and com-
plete, to authorize a very confident opinion on the
subject, still  less  to explain all  the difficulties that
attend it.  There is little room  to doubt that the
earlier fever  of England,  as seen by Dr. Bright and
Dr. Tweedie, was the  true typhoid ; and  it is by no
means  improbable  that  some cases  of   the  same
disease still occur, in the  midst of the other, while
many more, perhaps, are in a greater or less degree
modified by a complication of the two.
  We have  the  example in  this country, of the
prevalence  of  two  fevers  of essentially  different
characters,  in  the  same places, and  at the  same
periods of time.  The prevailing, but not the  sole,
fever of New England, is the typhoid.   In the more
southern and western parts of the country, other forms
of fever prevail; while the  typhoid is only occasionally
witnessed.  In  the Middle States, the several classes
of fever are more equally  met with, either indiscrim-
inately, or in different  epidemics.   This  point has
been very fully and satisfactorily established in regard
to the fevers of Philadelphia, by Dr. Gerhard.*  He
has  often  observed in  that  city  the  true  typhoid
fever, with its characteristic affection of the intestinal
glands.  But in the remitting and bilious  fevers from
the southern coast,  this affection is entirely wanting.
It was also  absent in  an epidemic which prevailed
extensively among the poor of Philadelphia, in the

  * On the Typhus Fever which occurred at Philadelphia in the spring and
summer of 1836.  By W. W. Gerhard, M. D.  American Journal of the
Medical Sciences, Vol. XIX, p. 289, and Vol. XX, p. 281).
                10 
68
THE TYPHOID  FEVER
spring and summer of 1836, of which  Dr. Gerhard
has given a full and able account.   His observations
in that epidemic extended to nearly  250  cases,  and
to about 50 examinations after death.  In one case
only were Peyer's glands at all affected; and in that
the symptoms had been of a doubtful character.
   This disease Dr. Gerhard proposes to call  typhus
fever,  in  contradistinction  from  the typhoid fever,
which has formerly been included in the same desig-
nation.  It differs from that, not only in wanting the
characteristic affection of Peyer's glands, but also  in
the violence and nature of its  symptoms, and in more
frequent and severe affections of the  stomach  and
liver, and  perhaps the spleen,  as  well as in being
liable  to  graver  and  more frequent complications,
with diseases of the head, and of the heart and lungs.
The character of the eruption is different, resembling,
so far as  it is possible to compare it by  description
alone, that of  the typhus of Great Britain.  Indeed,
the disease is, in all its most important  features, the
same with that,  and as such it is rightly regarded by
Dr. Gerhard.*   It was less frequently complicated
with typhoid fever.  Dr.  Gerhard, as we have seen,
found but one  case of this complication  in  50; while
about one  sixth of the recorded cases in Great Britain
  * Since the publication of his papers in the American Journal of the Medical
Sciences, Dr. Gerhard has  had opportunity to establish, still more fully, the
identity of the typhus of Philadelphia with that of Ireland, by the observation
of a considerable number of cases, in emigrants recently arrived from Ireland.
More than 30 cases of this sort came under his care in the summer of 1837;
and they presented all the distinguishing features of the disease before described
by him. 
OF NEW  ENGLAND.
69
exhibited  it.  There may perhaps be a reason for
this difference  in  the  greater  tendency to typhoid
fever in the latter country in ordinary seasons.  But
we have not facts enough on this subject to make  it
expedient to pursue the inquiry here.
   I have  already intimated that  fever occasionally
occurs in New England, of quite a different character
from the typhoid.   Such  fevers  have  recently been
seen among us only in  sporadic cases, except perhaps
in a  few localities;  and  most  frequently in persons
who have just returned from a more southern climate.
In the  hottest season of the year, a  few cases are
sometimes produced  by  indigenous causes.  They
are easily distinguished from the typhoid fever during
life; and the examinations after death  show as  great
a difference in the anatomical appearances, as exists
between the English and French fevers.  Five or six
such  cases came  under my own observation during
the last summer.   They were  all mild, and as the
patients recovered,  there was  no  opportunity for
anatomical investigation.  But  the nature  and course
of the symptoms marked it as a different disease from
our ordinary fever, with a clearness  not to be mis-
taken.  Whether this  fever is to be regarded as the
same as the typhus of Philadelphia  and of Great
Britain, or whether it  is still another  form of fever,
allied to, or identical with,  the bilious fever of more
southern  climates, and   distinct  from  typhus, are
questions upon which I  am not disposed  at present
to enter.
   A single case, much more  nearly resembling the 
70
THE  TYPHOID FEVER
English  typhus,  occurred  at the  Massachusetts
General  Hospital, in  December,  1836, in  a young
man who had recently come from England, and was
attacked with fever about the  time of his  arrival  in
America.  He had been ill four weeks  when  admit-
ted, and  was then delirious.   His delirium was more
violent than is common in typhoid fever; and con-
tinued till  his death.  He had  no diarrhoea, not
much  apparent  tenderness  of  the  abdomen,  no
meteorism ;  no sudamina,  nor rose spots; but a red
eruption  over the abdomen of  a different character.
He died the 13th day from his admission.   There
was  some effusion of serum in the arachnoid; the
lungs and  the heart were healthy;  the  mucous
membrane of the stomach was softened, apparently
cadaveric, that  of the small intestines stained at the
lower part, and a little softened ; Peyer's glands, not
diseased, except that one or two patches were a very
little  softened; large intestines healthy; liver and
spleen of natural size  and  healthy.
   We may, I  think, now regard it as established,
that the true typhoid  fever is  marked  by rose spots
on the abdomen, and the  affection of Peyer's glands
in the  intestines.  As  diagnostic signs,  therefore,
these appearances are of the highest  value; since
they  enable us, generally during life, and always
after death,  to ascertain with  entire confidence, the
character of the disease in which  they  are observed.
   The question next arises, What degree of import-
ance  shall  be  attached  to them in a pathological
point of view ?  What influence have these affections, 
OF NEW  ENGLAND.
71
or  either  of them,  in  producing  or  modifying
the general symptoms  of fever.    In England, the
affection of  Peyer's  glands  is  almost universally
regarded merely as an  accidental complication of
fever, of no more consequence to its general character
than inflammation of  the lungs or the stomach.  In
France, on the contrary, especially by many of the
pupils of Louis,  it is considered as the chief cause of
all  the  phenomena, without which they cannot be
produced.   I do not perceive that M. Louis himself
has  any where  distinctly  expressed this  opinion.
But the manner in which he uniformly speaks of the
affection as  the essential  characteristic of  typhoid
fever, certainly  countenances it.   The  truth doubt-
less, as in many other cases, lies between.
   That the affection  is  something more than an
accidental  occurrence,  is  apparent from  the  mere
fact of its  universal  prevalence.   This prevalence,
indeed, has  been denied by the English physicians;
but, as  I think  we have sufficiently  shown, a  more
full examination of their own diseases  would  prove
that  they  are  in  error; and that the affection  is
found,  whenever it is  properly  looked for, in true
typhoid fever.
   On the  other hand,  it is not easy to believe that
an inflammation in the  ileum, of  so small  an extent
as is often observed, should be capable  of giving rise
to all the variety of  symptoms  that are frequently
seen in that fever.   At  a  later stage, when the
disease of  the intestine has proceeded  to ulceration,
it is not difficult to account  for its influence.  In 
72
THE  TYPHOID  FEVER
regard to perforation, there can  be no  doubt of its
agency;  and independently of  that, there is much
ground for the opinion suggested by Dr. Bright, that
many of the leading symptoms  are  kept up by the
irritation of  the  intestine, either directly, or by its
sympathetic  effects.  But  ulceration  rarely  if ever
is found before the twelfth day, while  many of the
most active symptoms of disease, headache, dizziness,
general pain, &c, are often  present  at  the very
beginning.   In  a large proportion of cases, especially
those  in which there is no delirium,  the  general
symptoms are on  the decline, at  the  period when it
should seem, from  anatomical researches, that  the
affection of the glands is constantly advancing.
   These glands are also  affected in  other diseases:
and, although those diseases have so  little  affinity
with typhoid fever, that the fact of a kindred affection
causes no  embarrassment  in diagnosis,  we might
reasonably expect to see some  analogous effects in
them, if its influence  in  this were so  important as
has been  supposed.  It  is true that in phthisis the
appearance of the ulcerations is  somewhat different,
but the organ affected is the same, and the immediate
consequence, diarrhoea, is often  the  same, and  yet
the symptoms  that accompany it  in  the general
system are  most unlike.  In the affection of teething
children, the case  is still stronger, for both are acute
diseases, and  the course and appearances of the local
derangement are perfectly similar.
   We  are  not  therefore to regard the affection of
Peyer's glands as  the cause of the other  symptoms 
OF NEW ENGLAND.
73
of typhoid fever, but as an effect with them of some
common cause, the true character of which remains
still to be discovered.   It  will  facilitate the investi-
gation of that cause, to keep in mind a right view of
what  has been already done.  If we prematurely
imagine  the  whole question  to  be settled, we of
course take away the inducements to further inquiry.
It is  much  to have  advanced so far, as  to  have
obtained some fixed points, resting upon indisputable
facts,  that are not liable to  be removed  by  any
successive change of opinion.  The influence will be
highly important in all future pathological  investiga-
tions, in respect to other diseases  as well as to fever.
   The question remains, Of what  avail is the know-
ledge  of the  disease of  Peyer's  glands,  in  the
treatment of typhoid  fever ?   It certainly does not
bring  us  information  of any  sure method  of cure.
The local inflammation and ulceration are  no more
under our control, than  are  the other symptoms.
This  knowledge,  however, does  serve  to explain
many  phenomena of the disease, and many effects of
remedies  which  could not be so well  understood
before.  It  serves  to guard  us   especially against
inappropriate, irritating   medicines, such  as were
formerly in use, in  the expectation of  arresting the
progress of  fever.   So long ago as 1827, Dr. Bright
said he had  " almost  always  found that  the small
doses of antimonial remedies usually administered as
a  part of the diaphoretic plan in fever, do harm,
where  any decided  tendency to irritation  of the 
74
THE  TYPHOID FEVER
 bowels  exists."*   Up to  a very recent  period, if it
 be  not so in some  places even now, it was a common
 practice  to give  not only  antimonials,  but irritating
 cathartics, not occasionally to evacuate the intestines,
 but daily, and several times a day, to  "break up," or
 arrest the progress of the disease, or to cure diarrhoea,

  *  Report of Medical Cases, Vol. I, p. 185.  The recommendation of anti-
 monials in Dr. Jackson's Report on Typhoid Fever, is limited with so much
 care, as scarcely to bring them within the  implied prohibition of Dr.  Bright's
 remarks.  He does, however, recommend  their use, and suggests the  inquiry,
 whether the omission of them, with that of other active treatment, might not
 have been the cause of the greater mortality and increased duration of the
 disease in the two or  three last years  of the period, to which the report ap-
 plies.1  The suggestion was certainly a natural one, founded upon the facts as
 they  stood at the time.  But a continuance of the report  to the end of 1838
 would  materially change the  aspect of the facts.  It must be observed, that
 the apparent comparative want of success from the less  active practice was
 not fully known at the time.  Consequently, the treatment has continued  up
 to the  present time, to be  quite as mild  certainly, as  at any former period,
 perhaps even more so; not  from  any particular concert between the several
 physicians, but in consequence of the opinion entertained by each, that a very
 active treatment, beyond a proper  attention to the state of the stomach  and
 bowels, and  to local inflammation, when  that exists, is not well  adapted to
cure  the disease.  The number of deaths in 343 cases, prior to the end of
 1835, was 43,—nearly one in eight;  or,  taking the numbers  in which the
character of the  disease  was  more strictly ascertained, which  is the fairest
for the present comparison,  it was as follows, viz.:
Year	Cases.	Deaths.	One death in	Year.	Cases. ~25~	Deaths.	One death in
1822	1	0		1829		1	25
1823	5	0		1830	14	4	14* 5|
1824	15	3	5	1831	29	2	
1825	18	2	9	1832	23	4	
1826	26	3	Sh	1833	37	6	56
1827	19	3	6J	1834	34	6	
1828	22	2	11	1835	35	6	fi5
  In 14 years, 303 cases and 42 deaths, one in  7£, very nearly; and in the
last four years, one in six.
  1 Report on the Typhoid Fever.  Massachusetts Medical Communications, Vol. VI,
p. 111. 
OF  NEW  ExNGLAND.
75
by   removing  the   supposed  cause  of  irritation.
Surely a knowledge  that this cause was  inflamma-
tion in the intestines, would do something to improve
such treatment.   It  teaches, too, and  enforces, the
necessity of  a mild and unstimulating diet, during a
long convalescence, as well as during the more active
period of  the disease.
   But perhaps the  most  important  practical  lesson
derived from this knowledge, consists in  the caution
which it  imposes to abstain from  attempting  too
much by active treatment,   inflammation, it is  well
known, after  it  has  become established, must  go
through a certain process, before it can terminate in
health.  If  typhoid  fever, therefore, be  inseparablv
connected, as it  assuredly is, with a process of this
sort, so that  the  patient cannot be restored until that
process is completed, it is apparent, that violent, per-
severing  efforts  to  arrest the  disease, after  it  has
The three succeeding years exhibit the following result, viz.:			
Year.	Cases.	Deaths. 6 0 1	|One in
1836 1837 1838	59 29 20		10 nearly. 0 20
Total,	ldS	7	15
  In the two years, from November, 1836, to November, 1838, there was a
succession of 55 cases of the typhoid fever, without a single death; and the
case in which death then occurred (and there has been no death since) was in
so advanced a stage at the time of admission, that the result, strictly speaking,
could have no bearing upon the  question of treatment.  It is manifest, there-
fore, that  the greater mortality  in the years  1832—1835, must  have been
produced  by some other cause than the difference of practice.  The true
cause of difference is, doubtless, the difference in severity of the same disease
in different periods.
                1 1 
76
THE  TVPHOID  FEVER
fairly begun its course, cannot be successful.   They
may do much harm, by increasing the irritation and
inflammation; but it is  scarcely possible that they
can do good.   We may allay the general irritability of
the system,  we may watch against the attack of
unfavorable  symptoms, we may soothe  the irritated
state of the intestinal canal, and sometimes, perhaps,
moderate the severity of its local inflammation; and
thus contribute greatly, both to the comfort and the
restoration  of  our patient.   In the  beginning of
disease, before the process of inflammation is fully
established,  we may, perhaps, do more, and by early
removing the causes of irritation, prevent its forma-
tion, and cut short its course.  It is only then that
active  remedies can  be  used with benefit, or even
with safety.   If persevered in at a later period, they
may exhaust the  patient, but they will  not subdue
his disease.

   Suffer me, in  conclusion, Mr. President, to con-
gratulate you, and  the  Society, on  the  continued
advancement  of  our Institution in  prosperity  and
usefulness.
   The  number  of members who have  connected
themselves with the  Society, during  the past year, is
60, being,  with  one exception, more than  have
joined it in  any previous  year of its history.  The
present number of  Fellows, is  678, including;  62
retired  members,  who  retain all the privileges of
fellowship, although  released  from some of its obli-
gations.   The number who have  died during the 
OF  NEW  ENGLAND.
/ /
year, so far as I  have been able to ascertain, is but
six.   Two  of them  were  retired  members, at  the
ages  respectively of  86 and 74 years; four were at
the  active  period of life, two of them respectively
at the ages of 32, and two at 38 years.*   Our pro-
fession cannot claim  for its members, any more than
for its patrons, an  exemption  from  the general  law
of  humanity.  But  it  is  a striking  proof of  the
general healthfulness of our pursuits, notwithstand-
ing all the fatigue, and care, and responsibility which
attend them,  that in  a whole class of adult men, the
annual proportion of deaths should  be no more than
one  in 113.  A few  are taken away, to remind the
many who remain,  to  renew their activity in the
fulfilment of  the duties of  their station here, and in
preparation for the  enjoyments of  a higher station
hereafter.
* John Stone, M. D.,        Springfield,   Sept., 1S38,  74
  Joseph W.Valentine, M.D., Charlestown,  Nov., "    32
  Edward Frost, M. D.,     Wayland,    Nov., "    38
  Martin Phelps,          Chester,     Dec, "    86
  Charles Walker, M. D.,   Framingham,  Jan., 1839,  32
  Joseph W. McKean, M. D.,  Boston,      April, "    38