|JI3< 1*33 Wi\\ ) ;■$& ®m zm, i jrl -1""W ,U\ 2 ^\,yyy - sSM- v.& irae? ->r«, ■-Vi .•V.'lll1 ' 1 r 1 ? yj# u. 'O^f o^"j o'O >j o.o txi/cO'co a ~' aw u* Surgeon General's Offics ^1 tMiM"1' ejection No. -*-■',--------r/ - 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 OPEN- ING 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. ji'is**. BOSTON: PUBLISHED BY WHIPPLE & DAMRELL, No. 9 Cornhill. 1838. » * '"' . '.V?., »-..,V- , » I ..'■"\s|.V> *\ wci 3l3v 1838 \7fi'< o //) A REPORT ON THE TYPHOID FEVER. INTRODUCTION. The report here offered is derived from cases in the Massachusetts General Hospital. They occurred there between September, 1821, when the hospital was first opened, and December 31, 1835. I have stopped at the period last mentioned, because I ceased to attend there, in the autumn, after that time. Before that time, I had always been the attending physician from the first or middle of October till March or April; so that about half the cases were under my care. It will be seen, that there was not any case of typhoid fever in 1821, one case only in 1822, and five in 1823 ; so that almost all the cases occured in the subsequent twelve years. It has long been my wish to make the records of 2 REPORT ON the hospital useful to the cause of science. A pub- lication of cases merely would not answer this pur- pose ; nor would a hasty report, made quarterly, or annually, do much better. To render cases useful, they must be analyzed, and the results accurately stated; nor would much satisfaction be derived from them, if few in number. In this way, M. Louis has rendered the most important services to medical science. It is his numerical method, which I shall attempt to follow in these reports. It must be observed, however, that in pursuing his method, the first steps are most important. That is, the observations of cases must be accurate, and must be faithfully stated. If this be not done, we shall be led into error, not to truth. How far has this been done in collecting the cases at the Massachusetts General Hospital ? I shall endeavor to answer this question honestly, so as to show where those cases may and where they may not be relied on. Let me premise, that to have made our observa- tions perfect, we ought in every case, first, to have ascertained the previous state of the patient's health; second, to have inquired into the state of all the functions, and to have recorded the results, noting as well what functions were well performed, as what were not; third, to have noted the successive changes in each symptom; and fourth, in examining bodies in the fatal cases, we ought to have noted the state of all the organs, those presenting natural, or healthy ap- pearances, as well as those presenting morbid changes. THE TYPHOID FEVER. 3 It has be$n"the practice at the Massachusetts 'General Hospital, in the medical department, to note „the state of the patient every day, in acute cases, as our records show. It has been our intention to in- quire into the state of all the functions in the begin- ning of each case, and more or less fully from day to day. But we have been willing to diminish the la- bor of our records, by mentioning only the functions which manifested disease, while oftentimes we made no records of those which appeared healthy. Unless it was certain, however, that this course was uni- formly pursued, it is obvious that there must be some uncertainty in any given case, whether something had not been omitted. There is no doubt that our negligences have been so frequent, that our records cannot be entirely relied on, except for what is posi- tively stated. Nor can we say that our inquiries have been sufficiently full originally. We have often failed in learning, and still oftener in stating, the previous histories of our patients. And we have en- tirely, or generally, neglected to inquire accurately into some points. In the first years we were the most deficient; but we have made our observations with more and more care as we have proceeded. After making these concessions, I venture to add that, perhaps, there are not any observers, who have acted up to the strict letter of the excellent rules, which M. Louis has given us on this subject. 1 had thought myself careful in the investigation of cases, and in noting every thing essential; and I find that in some points I have been more so than he is; but 4 REPORT ON on a larger number he has been decidedly the most thorough. This is especially true as to the morbid appearances in fatal cases, previous to 1833. If I have an apology to offer for this, I will not trouble the reader with it; it is the fact only that interests him. Let the reader be apprized, then, that the materi- als, from which this report has been drawn, are not represented as perfect. There are, no doubt, inaccuracies in the observations recorded, and there are deficiencies to be lamented. Having conceded thus much, I think proper to add, that as to every thing which is stated positively, there are probably so few inaccuracies, that they need not be regarded in a general calculation. 1 proceed now to remark on the particular subjects noticed in the report. The number of patients, on whose cases this report is founded, is more than three hundred. During the period embraced by the report, the cases varied in number in the different years. In the early years, patients did not resort freely to the hospital ; but in the last ten years the number of fever cases bore perhaps a fair proportion to the general prevalence of the disease in the city. If this proportion varied much, it was when the fever was most prevalent, and when, accordingly, the hospital could not receive all who applied for admission. Besides those reported, there are sixty-five cases on the records, which were regarded as the same disease, or at least suspected to be so, at the time of THE TYPHOID FEVER. 6 admission. Some few cases, originally entered as continued fever, obviously were not so, as appeared from the histories after admission, and these are not included in the doubtful cases. Some had doubtful claims to be regarded as the same ; but from the late period of admission, when they had become compli- cated with secondary diseases, or from the imperfect histories which the records furnish, it is impossible now to decide positively in regard to them ; though probably more than half of these mii^ht really have been the same disease. There were others, and not very few, where it was impossible to decide even the probable period, at which the disease commenc- ed, and where the details were very imperfectly as- certained, owing to the natural or morbid stupidity of the patients, although there was not any doubt as to the disease. These, however, were placed among the doubtful cases, because they do not admit of any inferences. But these doubtful cases deserve some consideration in calculating the proportion of fatal cases; and under that head they will be referred to. It may be proper to make a few remarks on the name of the fever, which is the subject of this report. All, who have attended to the sub- ject, are aware how vaguely the term, fever, has been used ; and this by medical men, as well as by others. I have always held to the distinction, made by most physicians in my day, between essential, or idiopathic, and secondary, or symptomatic fevers. Among the idiopathic fevers, I have not been able, until within a very few years, to draw very certain 6 REPORT OiN lines of distinction, except those dependent on their type. Nature has drawn a broad line of distinction between intermittent and continued fevers. In re- gard to remittents, there is not so clear a ground for distinction. These have appeared to me to belong to one or the other of the kinds before mentioned; some being intermittents accompanied by secondary, local affections, which prevented perfect intermis- sions. These are the formidable remittents of warm climates. Others have seemed to me to be continued fevers, in which the exacerbations were more thor- oughly marked than in common cases. All other varieties of idiopathic fever seemed to me to be de- pendent on the following circumstances, viz., first, the disproportion in the symptoms, which appertain to the disease, and even the entire absence of some of them in many instances. Thus, in some cases the cerebral symptoms, or those belonging to the an- imal system, and the organic, or those belonging to the organic system, are in a certain due proportion; those of both descriptions being duly developed, and those of one, or the other kind, predominating at different stages of the disease. In other cases, the cerebral symptoms are almost entirely wanting throughout the disease; while in some they predom- inate so much, as to throw into the shade, or actual- ly to mask, all other symptoms. Second, the addi- tion of secondary and local affections, no one of which certainly occurs in the greater number of cases of continued fever, explains much of the diver- sity in cases of this disease. THE TYPHOID FEVER. 7 That a great variety in the phenomena and in the severity of idiopathic fevers maybe explained in this way is, I believe, admitted by all. While holding these views I was not ignorant that physicians of great name, and particularly in France, had endeavored to show that there was an error in calling any fevers idiopathic ; that in all cases fever was dependent on a local affection. As one of these physicians, I may mention Dr. Clutter- buck, of London, who labored early in the present century, and with great ingenuity, to show that in- flammation of the brain, or of its membranes, was the local affection, on which continued fever, at least, is founded. But his work failed to produce conviction in many minds; certainly in mine. I will here add, that he was admirably answered by Dr. Beddoes, in one of his last and best works, that " on the com- bination of fever and inflammation." The work by M. M. Petit and Serres on the entero-mesenteric fever observed at the Hotel Dieu, in Paris, in 1811, 1812, and 1813, arrested my at- tention, when first published. I was led to believe, however, that the fever they described was peculiar to the time and place. In a review of the work, in 1815, I urged my readers to be more attentive in examining all the organs, and especially those of the abdomen, in fatal cases of fever. But it is easier to give advice than to follow it. Had I pursued this course, undoubtedly, I should have found that we were seeing every year the disease described by these French physicians. 8 REPORT ON The work of M. Louis, on continued, or typhoid fever, is now, I trust, well known in this country. It was not till the year 1833, that it received from me the attention it merited. Since it has been known to me, I have found that the continued fever, which is so well known to us in this city, at least, was the same as that which he has described. The symptoms are essentially the same, and the appear- ances discovered in the body, after death, are pre- cisely the same. These appearances had been noticed here before, when the examination was so made as to disclose them. From 1833, our fever has been the same it formerly was, and in every case, where an examination has been made, the morbid changes have been found to be the same as described by M. Louis. In neighboring places, a similar con- firmation of the identity of the disease has been furnished from different sources. I may refer here, particularly, to cases, which occurred in Lowell, and were reported by Dr. Bartlett, the learned professor of pathological anatomy, in the Berkshire Medical Institute. M. Louis did not show, nor did he attempt to show, that the disease he described was dependent on the morbid affection of the small intestines. But he did furnish the means of deciding unequivocally, the anatomical characters of the disease, so that it might be distinguished in other places. Thus he laid the foundation for making further distinctions, if continued fever was not the same in all places. It was almost in vain to look back to descriptions of THE TYPHOID FEVER. 9 fevers previously written. It was for those only, who fully understood the present state of the ques- tion, and who were well acquainted with the obser- vations of M. Louis, on both the living and dead body, to prosecute the inquiry. Viewing the subject in this light, I had a great desire to get observations properly made on the fevers of warm climates. It was, therefore, very grateful to me to receive, in 1835, the observations made by Dr. Gerhard, of Philadelphia, a pupil of Louis, on cases of what has been called bilious re- mittent fever. These observations were very limit- ed in number; but, so far as they went, they showed clearly, that this disease differed essentially from our continued fever. Since that time, the same gentle- man has done still more to settle the question before us. In 1837, he has described the disease, which he calls typhus, and which, in many respects, resem- bles our fever; but which he clearly shows to differ from it, both in its symptoms, in their course and order, and in its anatomical characters. Meanwhile, M. Lombard, a physician of Geneva, and also a pupil of Louis, being on a visit to Great Britain and Ireland, has described the fever he saw in Dublin, principally, but also in England, and has shown that that also differed from the typhoid fever described by Louis. It would seem, indeed, that the disease, described by M. Lombard, is the same as that witnessed in Philadelphia by Dr. Gerhard. It is not my intention to prosecute this subject any farther; nor is it important for my purpose to 10 REPORT ON inquire, whether others have made the same, or any other observations on the subject under consid- eration. It is plain, that there are, at least, two species of continued fever, both in Europe and this country; and further researches may very possibly show more. A necessity now arises for distinguishing these diseases by some proper names. In former years, I have avoided the distinguishing names applied to continued fevers, for two reasons. First, such distinctions between them, as those of synochus, synocha, and typhus, were not shown to exist in nature, and were in truth grounded on men's fancies; and, second, those names were originally significant, not indeed of different qualities in nature, but of men's notions in regard to the different na- tures of diseases. Until, therefore, three different continued fevers were shown to exist, and until it was shown that these had, respectively, the qualities im- plied by these names, it seemed improper to employ such names. But, for a good while, the name, typhus, has been getting into common use, as the most common ap- pellation of the continued fever of England, and of that of this country, or, at least, of New England. And under this, as an arbitrary, and not a significant name, it has been spoken of and described, more or less accurately by many writers. Under these cir- cumstances, I had just become reconciled to adopting the name, as being one so generally received, that it must continue in prevalent use ; and that, as its sig- THE TYPHOID FEVER. 11 nificant character had been dropped, there was no harm in employing it. Now my friend, Dr. Gerhard, proposes to restrict the name, typhus, to the disease which he has recently described, and to leave to the continued fever of Louis the name of typhoid fever. Names, when arbitrary, are of so little importance, that I would not waste a moment on a choice, if only they can be so used, as to avoid mistakes and confusion. But I am truly puzzled, as the matter now stands, which name to adopt. After much hesitation, I have decided to call the disease typhoid fever. Let me add, that as far as my knowledge extends, this is the continued fever of New England, as 1 be- lieve it is that of Old England. But exceptions may occur in both countries. With us it prevails every year, though not equally ; and may be seen in any month of the year. But it is most prevalent in the autumn. In some seasons, it prevails extensively, and may be called epidemic. In others, it is limited to small neighborhoods, and even to a single family, not even the near neighbors being affected. In that case, it will pass slowly through the family, attack- ing new residents, but not often watchers and visit- ers for a day. It will be from three to six months in passing through a large family. I have seen this happen in summer, but oftener in winter. Persons removed from such a family to other houses do not communicate the disease; which seems to disprove the existence of contagious properties. The experi- ment has often been tried under my observation, 3 12 REPORT ON from necessity, and the disease has never been prop- agated by the person removed. In one case, four persons were removed from one diseased family to four different families, and no disease was produced in any of them.* The disease, which prevailed among us in 1808, and for some years after, under the name of petechial fever, was different from our common continued fe- ver. The observations on it were not made, as they would be at the present day, and its characteristics cannot be distinctly stated. Meanwhile, I will re- mark, that I think my friend, Dr. Gerhard, has fallen into an error, in thinking that the disease was the same which he has lately described under the name of typhus, and which he has witnessed in Philadel- phia. The petechial fever seldom had premonitory symptoms ; it was sudden in its attack, and usually short in its course ; often an ephemera, or fever of one paroxysm, and then terminating within forty- eight hours, which is the limitation of an ephemera laid dcwn by Fordyce.f These characters do not surely belong to the disease he has described. The cases, from which this report is made up, were none of them left to themselves. In almost all, active treatment, as the French would term it, was employed at some period, and in most of them during the first and second week of the disease. Hence the natural history of the disease cannot be *See a paper of mine in New England Journal of Medicine, &c, Vol. XI, page 225. + Dissertations on Fever, by George Fordyce. THE TYPHOID FEVER. 13 deduced from them, with the same certainty, as from cases in a Paris hospital, where active treatment is so little employed in many cases. For instance, in almost all our cases, vomiting, or full purging, or both, were induced by medicine, in the first or second week of disease. Hence, perhaps, diarrhoea was a less constant symptom with us than in Paris. It will, however, be sufficiently apparent, I trust, from the symptoms, that our disease was the same as that so well known in that city. But the value of particular symptoms, in relation to the prognosis, may perhaps be more certainly es- timated from our cases, than in relation to diagnosis. The influence of age also, on the result, will likewise be shown, so far as the number of our cases can go to decide it. I am inclined to think, that something will be learnt as to the effects of remedies. This may be relied on, that whatever is stated under this head will be done fairly, with the impartiality of a mere observer. This will be more readily believed, when it is re- membered, that a large share of the treatment was conducted by others, and that I cannot have the feeling of partiality for the remedies employed, which is felt by one who gives an account of his own prac- tice. It will be believed still more fully, if I give a history of my own views and opinions on the treat- ment of fever, and of the changes they have under- gone. There may seem to be too much egotism in this : but it will not appear to be so much, when I add, that the same opinions have been entertained, 14 REPORT ON and that the same changes, or nearly the same, have taken place among a large part of my contemporaries, within the circle of my acquaintance ; and that by giving this history, I shall possess the reader more fully and distinctly with the different methods em- ployed in different cases, which methods are to be the subjects of comparison. In New England, so far as I have been able to learn, it has long been the custom to evacuate the alimentary canal freely at the commencement of acute diseases. The use of cathartics has been so common, that they have been the domestic remedies first resorted to, under any threatening of acute dis- ease, before sending for a physician. Emetics not unfrequently have been used in the same way. I well remember that my professional master did not so much endeavor to prove the utility of these medi- cines in the treatment of typhoid fever, as to decide which should be employed first. The emetic was commonly given first by the physician, in grave cases at least; but he instructed me that, in cases of con- stipation, there was often a benefit in giving the cathartic first. The reason seemed to be that, when the bowels were loaded, and were excited to action by the presence of the emetic substance in the stom- ach, the stomach itself was embarrassed, and could not so easily and so perfectly perform the operation of vomiting ; nor under those circumstances could the rest of the system be so advantageously affected by sympathy, as when the bowels were comparatively at ease. In many cases, the physician combined the THE TYPHOID FEVER. 15 emetic and cathartic medicines, making what was called an emetico-cathartic, leaving it to the disposi- tion of the organs, and to a sort of chance to deter- mine the amount of evacuation in one mode or the other. Blood-letting, at the commencement of continued fever, has been a more rare practice in New England than in many other parts of the world ; and was re- sorted to only when symptoms regarded as highly inflammatory were present, or when vomiting and purging had failed to give relief to the urgent symp- toms of the early period. Preparations of antimony, at least to the extent ad- vised by Cullen, were resorted to very commonly, when my knowledge of the practice here was first acquired ; yet they were not very confidently relied on. Preparations of mercury, especially the submu- riate (calomel), were in much higher esteem, in the treatment of both continued fever and in the phleg- masiae. Calomel almost always made a part of the cathartic administered by the physician at the com- mencement of the disease ; or it was combined with ipecacuanha, or with tartarized antimony, in the emetico-cathartic. After this, the calomel was given in small doses, frequently repeated ; from four to ten grains a day by the most prudent practitioners. This was either combined with antimonials, or with ipe- cacuanha, or alternated with them : and opium was often added, in doses of a sixth to a third of a grain to each dose of calomel, to prevent the too free ope- ration of this article on the bowels. In this way, 16 REPORT ON from half a grain to a grain and a half of opium was often given in a day. It was not thought necessary, however, to prevent all motions of the bowels. On the contrarv, it was considered an object to have dejections from them daily, or, at the least, every other day. Two or three dejections a day were not objected to, unless there was an increasing weakness and obvious exhaustion from them. In the use of calomel, it was thought useful to have a slight sore- ness of the gums, and even a little ptyalism induced. Prudent physicians endeavored to guard against any severe affection of the mouth ; but, if now and then this occurred, it was regarded as the fortune of war, the result, perhaps, of an unforeseen idiosyncrasy in the patient, and an evil, which he ought to bear with patience, rather than to forego the aid of the Herculean remedy. The physician regarded the patient as even more secure as to recovery, though his suffering might be greater when the mouth was decidedly sore ; and he was careful to watch against this effect, more because the patient would be offend- ed, than because he would be injured by it. This mercurial practice in acute disease began, in New England at least, quite as early as the mid- dle of the last century, as I learnt from my master, the venerable Dr. Holyoke, who commenced prac- tice at that period. It was then indeed limited to a few physicians, but had become universal before my studies commenced forty years ago. I was surpris- ed, in attending the hospitals in London in 1799 and 1800, to find this practice, so familiar here, in typhus, THE TYPHOID FEVER. 17 pleurisy, pneumony, &c, as well as in hepatitis and cephalitis, to be unknown there. Inflammation, or rather dropsy of the brain, as it was called, was com- bated by calomel; and Dr. Saunders, on the authority of physicians in Bengal, advised the use of calomel in acute, as well as in chronic inflammation of the liver. But in neither case was the remedy advised on gen- eral grounds, as one adapted to overcome inflamma- tion. The use of it in continued fever would at that day have been regarded, by most physicians in Eng- land, as in the highest degree preposterous. I well remember how much I laughed within me, as young men are wont to do, at the folly of my masters, who could not see what I thought the true principle, on which the calomel proved useful in hepatitis ; so that they were blinded to the extensive use, w hich might be made of it in other inflammations. In these views I was confirmed a few years afterwards, when some English physician, a Dr. Hamilton, I believe, first recommended the extensive use of calomel in acute diseases, such as we had long been accustomed to, and such as many of the British practitioners have since that time adopted. In addition to these remedies there were many oth- ers of minor efficacy. One other, however, not of slight power, was vesication. This was employed sometimes at an early period for severe headache, or other severe pain, when not relieved by evacuations ; and much oftener at a late period, either as a gen- eral stimulant, or with a view to combat grave symp- 18 REPORT ON toms, particularly when these were referred to the brain. Such, substantially, was the practice in this quar- ter, as I learnt it, when I began my professional life, and this I adopted. I looked on bloodletting with great, jealousy, except locally for specific objects; and I felt a firm faith in the potency of mercurials, if so employed as to cleanse the alimentary canal thoroughly and to answer the purpose of alteratives. It was following the idea of Mr. Hunter, that they altered morbid action, not the older notion that they altered the humors of the body. A young physician does not at once have an op- portunity to bring his opinions to the test of experi- ence. In the fifth and sixth years of my practice, typhoid fever, not of the most severe character, pre- vailed extensively in this city. I did not need a case- book, for my mind, intent on the subject, retained every case which I saw, and I think it does not fail me in recalling the results, to which I arrived in a review, at that time, of my experience. My favora- ble opinions of early evacuations were confirmed ; and that of an emetic at a very early period was rendered more favorable than before. Of antimoni- als, used alone, I made no trial, but I employed' them somewhat in combination with calomel and opium. My faith in calomel was shaken, not de- stroyed. I became satisfied that the benefits of this article were not sufficient to justify the risk of a severe ptyalism, or very sore mouth ; and that the THE TYPHOID FEVER. 19 use of it so far as to induce any soreness of the mouth was of very doubtful utility, unless this was done at a very early period; that is, within five, or certainly within seven days from the commencement of the disease. But of the benefits of early care and medication in the disease, there seemed to me to be no doubt. My fatal cases were entirely, or nearly so, among those, who called on me in the second week of the disease, or later. Indeed, I came to the con- clusion, that there must be something peculiar in a case to excuse the physician from censure, if he lost a patient to whom he was called as early as the third or fourth day of the disease. As my observations were made mostly amongst the poor,—for among the rich this disease was then rare, and the poor do not call for early attendance,—I lost my fair proportion of patients; but this I considered as their fault, not as mine. It is from a belief that this represents a change of opinion as to mercurials, which many others among us have undergone during the first quarter of the present century, that I state it thus fully. About 1812,1 learnt, from Odier's Manuel de Medi- cine Pratique, the bolder use of antimony in febrile diseases. The method recommended by him was to exhibit this medicine every two hours, in constantly increasing doses, until it was ascertained how large a dose the patient could bear. Introduced thus gradually, he said, the medicine could be borne in much larger doses, than if given freely at first. To this mode of treatment I gave a trial, during an epi- demic typhoid fever in 1814, and thought it prefera- 4 20 REPORT ON ble to the mercurial practice. Emetics and cathar- tics were first given, and then the tartarized anti- mony (tartar emetic), in the dose of one eighth of a grain ; each succeeding dose was increased by an eighth of a grain. In this way, many persons were brought to take half a grain to a grain at a dose ; some two grains, and a few three and four grains at a dose; and this without any important effect on the stomach, or bowels. I am not aware that the Ital- ians had, at this period, adopted the use of this article, in large doses. Under the use of it, the more grave symptoms seemed to me to subside, and the disease to go on quietly, without secondary affections, and a favorable result to be produced oftener than when the antimony was not employed. But, in some following years, I was led to doubt, whether I had not attributed too much virtue to this medicine, and gradually I used it less and less. It will appear that I resumed it at a later period. At all times, however, I found patients whose stomachs would not bear the medicine, even in small doses. I will add, that those, to whom it seemed most useful, would, after using the full doses for three or more days, express a reluctance, or even a sort of horror, in repeating it, although it produced no nausea, nor any sensible effect on them. If continued after this, the patient would appear to be sunk and very un- comfortable ; so that I soon w7as taught to give up the medicine, or to give it in smaller doses, and at longer intervals, as soon as this feeling was manifest- ed. I will add, that more lately I have learnt an THE TYPHOID FEVER. 21 effect of this article, which requires to be guarded against. This is a vesicular eruption in the fauces, and an inflammation more or less extensive there, analogous to the effect of the same medicine, when applied to the skin. I believe that this evil will not be produced, when the medicine is well diluted; say two ounces of water at least to every grain of the tartarized antimony. When the hospital was opened, the use of mercu- rials had not been relinquished so much by others as by myself; and 1 still employed them occasionally in the first three or four days of the disease, and still more when any important secondary disease, of an inflammatory character, was added. But the faith in them was lessening from year to year ; and they have been given up almost entirely, in typhoid fever, since 1830. In accordance with this statement, I find, on look- ing at the cases, that mercurials were employed effi- ciently among those, who entered in the 1st or 2d week of the disease, in fifty-five cases. The whole number who entered in those weeks was two hundred and twenty-nine. Of these fifty-five cases, fifty- three were admitted prior to the year 1831, two in that year, and one in the year 1833. To see the force of this statement, it must be observed that the whole number of cases, prior to 1831, was one hun- dred and forty-five; and the whole number in 1831 to 1835 inclusive, was one hundred and fifty-eight. In the year 1833, we began to doubt the benefit of active treatment, or at least of any continued active treatment; though few patients were allowed 22 REPORT ON to go without a cathartic. This doubt was sustained by-one of my colleagues, who had the charge of the hospital usually from July to the middle of October, more than by myself. I commonly had the charge for five or six months from the first or middle of Oc- tober till March or April. During the years 1833, 1834 and 1835, I usually employed antimonials, ac- cording to the method of Odier, in cases admitted in the first week of the disease, and occasionally in those admitted later, except where some objection showed itself in the peculiarity of the case, and ex- cept in very slight cases. I also continued the early evacuations, but did not so often employ cathartics after the first days, as I had previously done. These statements must be borne in mind when we come to the comparison of the different modes of treatment. I trust that this full account of the view, or theory, on which each mode was pursued, will enable the reader to comprehend the treatment more perfectly than he would otherwise do. In saying this, I am fully aware that the question in each case is, not by what theory the physician is governed in his treatment of a disease, but what he has actually done. I wish also to add, for myself, that, in whatever course was adopted, I endeavored to judge fairly what support was given by the result to the usefulness of the remedies employed, and to the truth of the theory, by which their application was directed. It was not, however, until I had fin- ished a careful analysis of all our cases, the result of which I shall give, that I felt any strong convic- THE TYPHOID FEVER. 23 tion of the relative advantages of different modes of treatment. Nor do I now profess that any thing more, than an approximation to an estimate of these modes, is to be authorized by these reports. If they are regarded rightly by others, they may serve as a foundation, on which to institute future experiments. Let me also add, that no patient need be alarmed in finding our treatment of him regarded as an ex- periment. Such, probably, must long be the case in medical practice. The patient's assurance should be grounded on this, which ought to be the rule, and will be the rule of every honest physician, viz., that in each case, the physician will try that experiment, which, in the present state of his knowledge, appears most likely to be successful. In relation to this matter, I must add one more re- mark. The numerical method is easily followed in stating the numbers who recover, and the numbers who die of any disease, under various modes of treat- ment ; and likewise the duration of the disease in those who recover. But it is very difficult to state in this way the trouble, or the comfort, occasioned by these different modes. The ancient rule, as to the cure of the sick, was, to do it safely, quickly and pleasantly. This last cannot easily be estimated in numbers. How safely and how quickly the pa- tient is brought to a state of convalescence may be determined with a good degree of precision. REPORT OF CASES OF TYPHOID FEVER MASSACHUSETTS GENERAL HOSPITAL. The whole number of cases, sufficiently well marked to be the subjects of a critical inquiry, was 303. In addition to these, there were 65 cases, which may be regarded as doubtful. In some of these, the details on record are insufficient to be the foundation of a clear diagnosis. In some, there is no doubt, and in others very little, as to their claim to be admitted, as cases of typhoid fever. But the de- tails in these are insufficient to enable one to deter- mine the period, at which disease commenced, and therefore the cases are of little value as to most points. They ought, indeed, to be kept in view, when calculating the proportion of fatal cases. It would be safe to say, that, of these 65 cases, 40 should be admitted as cases of typhoid fever. One only of the 65 cases terminated fatally. Fatality of the disease.—Of the 303 cases, 42 proved fatal; that is (303-^42=7.214) 1 in 7.214 was fatal. But if we add the 40 cases, among REPORT ON THE TYPHOID FEVER. 25 which there was one death, we find (343-^43=7.976) 1 fatal case in 8 nearly. In all future calculations, 303 will be regarded as the whole number of cases. Sex.—The whole number of males was 208 ; and that of females was 95. It would be improper to ground any calculation, as to the relative frequency of the fever in the two sexes, upon this statement. It is probable that females have never resorted to the hospital so readily as men have; it is certain that this was true the first years after its establishment. In 1821, there was not any case. In 1822 to 1826, inclusive, there were 54 male, and 11 female pa- tients ; making the whole number 65, affected w ith typhoid fever; so that 1 in 6 nearly was a female. In 1827 to 1835, inclusive, there were 154 male and 84 female patients; in the whole 238, so that 1 in 3 nearly was a female. Even here, perhaps, the pro- portion of females affected with this disease was less than that, which actually occurs in the whole community. Yet it is true, as I believe, that this disease occurs among men much more frequently than among women. Among the males, there were 28 fatal cases and among the females, 14; so that among the males (208-^28=7.392) 1 in 7.392 cases was fatal. Among the females (95-^14=6.785) 1 in 6.785 was fatal. jo(>.—The age was recorded in 291 cases, and among these the average age was 23.309 years. Among the cases, which terminated favorably, the average age was 22.980. There was a difference between the males and females; for the average age 26 REPORT ON among the males was 22.908; while among the females it was 24.044, being more than a year greater in the females than in the males. The ages were recorded in 27 of the fatal male cases, and among them the average was 24.926. They were recorded in all the 14 fatal cases among the females, and the average was 26.071. In the 41 cases taken together, the average age was 25.317. Thus it appears that the average age was about 2 years more in the fatal cases than in all the cases taken together, and about 2£ years more than in the cases not fatal. A more minute examination into this subject confirms more strongly the influence of age on the event in this disease. In the whole number, whose ages were recorded, viz., 291, there were 16 aged 35 or upwards, and of these, 4 died, or 1 in 4; whereas in all the 303, there died 1 in 7.214. And there were 34 cases where the age was 30 or upwards, and of these 8 died, or 1 in 44, nearly in the same proportion as in those of 35 years or upwards. If we deduct these 34 from 291, we leave 257, who were under 30 years of age. As there were 42 deaths in the whole, and in 1 of the fatal cases the age was not ascertained, and as there were 8 fatal cases in the 34, it appears that there were 33 fatal cases among the 257. Among these, therefore (257-^33=7.787), 1 case in 7.787 was fatal. Again there were 87 cases, in which the ages were 20 or under, and among these there were 8 fatal; so that among these the fatal cases were (87-^8=10.875) in the proportion of 1 in 10.875 cases. THE TYPHOID FEVER. 27 The period of the disease, at which patients entered the hospital, had a manifest influence on the result,* as will appear by the following statement. 90 cases were admitted in the first week of the disease; of these 7 died, or 1 in 12.85. 139 cases were admitted in the second week of the disease; of these 16 died, or 1 in 8.68. 46 cases were admitted in the third week of the disease; of these 10 died, or 1 in 4.60. 21 were admitted in the fourth, or later; of these 5 died, or 1 in 4.20. It will be found, that the same circumstance has a great influence on the period of convalescence, and that perhaps a day is important. I will therefore add the following table, in which the result is shown as to those admitted on each of the first fourteen days of the disease. On the 1st day, 3 entered, of whom none died. 2d u 6 3d l( 10 4th a 11 5th u 22 6th u 18 7th u 20 8th a 47 9th ii 17 10th u 22 Uth u 27 12th a 9 13th u 6 14th « 11 In 229, 1 a —1 in 10. none u 3 (( —1 in 7| 1 u —1 in 18. 2 u ,—1 in JQ. 6 u —1 in 7 5-6 3 u —1 in 5 2-5. 2 a —1 in 11. 2 u ;—1 in 13*. 2 u ;—1 in Ah. none a 1 u ,—1 in 11. 23 d ed; —1 in 9.95. *The same thing was found to be true in regard to cases of pneumonitis in our hospital. See my Appendix to Louis on Blood-letting, translated by Dr. C. G. Putnam. 5 28 REPORT ON It will be seen, that in the first four days of dis- ease, 30 were admitted, of whom one only died ; and in the remaining 11 days, 199 were admitted, of whom 22 died, or 1 in 9. Accidental causes have an influence on the small number admitted on any one day of the disease, but this comparison is be- tween numbers sufficiently large to exclude any great influence from accident. In pointing out this ad- vantage of an early admission to the hospital, in cases of typhoid fever, I state what the facts warrant. Let it not be supposed, that this advantage is set down to the medicinal treatment of the patients. That alone may be conducted as wTell elsewhere. The advantage is to be attributed to the many comforts and immunities, which the patients enjoy there, more than the same class of patients can commonly com- mand at their own places of residence. The following table will show the numbers admit- ted, and the numbers who died, in each year. It also shows those of each month. It should be kept in mind, that patients are not always admitted in the month, in which the fever commences; many are taken sick on the month before admission. It is also obvious, that death often takes place on one of the following months, so that cases are entered on months, in which they neither commenced, nor ter- minated. This is noted, in order to guard against false inferences. CM Table, exhibiting the numbers admitted and the numbers who died in each year and in each month. IN THE YEAR. JANUAHY. FEBRUARY. MARCH. APRIL. MA Y. JUNE. JULY. AUGUST. SEPTEMBER OCTOBER. NOVEMBER. DECEMBER Adm. Died. ldth.in Adm. Died. Adm. Died Adm. Hied Adm. Died. Adm. Died. Adm. Died. Adm. Died. Adm. Died. Adm. Died. Adm. Died. Adm. Died. Adm Died- 1822 1 1 1823 5 2 2 1 1824 15 3 5 1 1 1 1 3 2 1 3 1 4 1825 18 2 9 1 3 2 7 3 1 2 1 1826 26 3 8J- 1 1 3 1 4 4 8 1 2 1 3 1827 19 3 Ci 4 1 5 1 6 1 o 1 1 1828 22 2 11 1 1 1 1 1 1 1 2 4 3 6 2 1829 25 1 25 1 1 1 11 9 3 1830 14 4 3-1 1 1 1 1 3 1 I 4 1 3 1 1831 29 2 14J 1 1 1 7 4 1 6 1 7 1 1 1832 23 4 5J 0 1 1 1 4 7 1 4 1 2 2 1 1833 37 6 61-6 1 1 3 1 2 8 1 17 1 5 0 1 1834 34 6 5 4-0 o 1 2 1 1 1 2 2 7 11 1 6 I 2 1835 35 6 5 5-6 2 1 3 3 3 1 9 2 7 1 4 1 3 1 303 42 10 4 6 1 2 1 1 4 1 10 3 31 4 48 4 62 7 79 7 33 7 17 3 1 death in Id. in 2.50 1 d. in 6 Id. in 2 No death. 1 d Id. in 3.33 1 d. in 7.75 1 d. in 12 Id. in8.85 Id.in 11.28 1 d. i n 4.73 1 d. in 5.6f; 7.21 patients. In the cold months, January, February, March, October, .November and December, there were 147 cases, and 23 deaths j that is, 1 in 6.39. In the warmer months, April, May, June, July, August and September, there were 156 cases, and 19 deaths ; that is, 1 in 8.21. If we take the five months in which the disease prevails most, viz., July, August, September, October and November, we have 253 case*, and 29 deaths; that is, 1 in 8.72. In the other seven months, December, January, February, March, April, May and June, we have 50 cases, and 13 deaths; that is, 1 in 3.84. It appears, then, that at the season when the disease is most prevalent, the mortality is not half so great as at the season when it is least prevalent. 30 REPORT ON Convalescence.—In deciding on the period of con- valescence, the same rule is followed which was adopted by M. Louis, in regard to pneumonitis, in in his work on blood-letting. In some instances, per- haps, the application of this rule is not perfectly sat- isfactory. But in the great majority of cases I think it is so; and I have not been able to fix on other rules, which appear to me as good as this. By this rule, the day of convalescence is that, on which the patient begins to take some solid food, such as bread or rice; the febrile symptoms having abated for two, or three preceding days. By febrile symptoms, in this case, I mean, particularly, heat and acceleration of the pulse. In doubtful cases, however, I have had regard to all the circumstances in noting the day of convalescence. It may not be improper to state, that these rules were not thought of, when the cases were going on and the records made. In many instances, the period of convalescence was delayed by secondary affections; in a few, by causes strictly accidental, that is, not at all growing out of the principal disease ; and in not a few, by errors in diet, or by undue efforts of body or mind. In some few instances, after an unequivocal convalescence in all points, for two, or three, or more days, a secon- dary disease has ensued. In these, I note the first day of convalescence. But, in the few instances, where there has been a relapse into the typhoid fever after a temporary convalescence, I have noted the second convalescence as the true one. As the day of convalescence is numbered from the THE TYPHOID FEVER. 31 day, on which the disease commences, the accuracy of one depends on that of the other. There is more difficulty, perhaps, in ascertaining the commencement in cases of typhoid fever, than in many other acute diseases. The beginning is not indeed well marked, in many cases; and the patient, whose mind has be- come dull, at least, in the progress of the disease, cannot well carry his memory back to the first days. This is more true, as the disease is more advanced. Thus the day of the attack may commonly be settled, with a good degree of certainty, in one who enters in the first week; with less certainty in one, who enters the second week of the disease; and with much less in one, who enters later. It almost always is found, when means occur of correcting the first story of the patient, that he did not date his attack early enough. In one who has been sick many days, there is a disposition to date by weeks. This ex- plains why so many appear to have entered the hos- pital on the 8th and 15th days. They say they have been sick a week or a fortnight before admission; and having said so, many insist upon it; though probably they have, on an average, been sick longer. Among the two hundred and sixty-one patients who recovered, the period of convalescence was as- certained with a tolerable degree of accuracy in two hundred and fifty-five. Among these the average day of convalescence was the 22d, or precisely 22.019. The difTerence between males and.females was very slight as to this day; the average of the former being above one third of a day more than of 32 REPORT ON the latter. Age had a greater influence. In those under twenty-one years of age, the average day of convalescence was 20.27; while in those aged twenty- one years or over, it was 22.23; being nearly one tenth, or 2 days in 20 more in those twenty-one years old or upwards, than in those under twenty-one. The difference as to the day of convalescence in different years was very great, the extremes being nearly eighteen in one year, and nearly twenty-six in another. All this will appear, in the following table. As a matter of convenience, I have included in this table a statement of the number of patients admitted in each year, under the care of the physi- cian, and the proportion of those who had typhoid fever. Table, exhibiting the average day of convalescence among the subjects of typhoid fever in each year, from 1824 to 1835, inclusive; also the pro- portion of the same subjects to the whole number of medical patients in the hospital in each year. Year. Average day of Whole No. of The cases of fever Convalescence. Med. cases. being one in 1824 24. 221. 14.7 1825 19.60 278. 15.4 1826 19.82 392. 15.0 1827 22. 251. 13.2 1828 18.55 357. 16.2 1829 19.91 342. 13.6 1830 22.55 285. 20.3 1831 24.77 326. 11.2 1832 17.73 318. 13.8 1833 22.29 328. 8.5 1834 25.92 336. 9.8 1835 24.93 311. 8.8 It appears, from this table, that the cases of fever were much more numerous, in proportion, in the last three years, than previously. Undoubtedly the THE TYPHOID FEVER. 33 disease was more prevalent than usual in the city and its vicinity in those three years. In those years, likewise, the convalescence was later, and the fatal- ity was greater, than usual. It is a question, wheth- er these unfavorable results should be attributed to the greater severity of the disease, or to the less active treatment adopted in those years. The period of admission had a great influence on the length of the disease, as well as on its fatality. The average day of convalescence among those, who recovered, was, in those who were admitted in the first week of disease, 17.42; in the second week, 21.21; in the third week, 25.52; in the fourth week, or later, 43.93. The proportions will be better seen, if we suppose ten to represent the day of those of the first week ; and then, in proportion, it will be found that the days of the others will be represented by 12.1, 14.6, and 25.2; or, omitting the fractions, they will be ten, twelve, fourteen and twenty-five. There are a few instances, in which the 4th and 5th days are marked as the days of convalescence. Some persons may doubt the accuracy of our diagno- sis in these cases; and perhaps even in those, in which convalescence is noted as early as the 8th or 9th day. On this point, I will remark, that in every fatal case, which we had regarded as typhoid fever, where due examination was made after death, the pathological changes described by M. Louis as essential, w ere found to exist in an unequivocal manner. This is some evidence of the accuracy of our diagnosis. But fur- 34 REPORT ON ther, if several persons are seized at, or about the same time, under similar circumstances, with the same symptoms, and if under judicious management a part of them recover early, while the rest go through the disease, it may be fairly inferred that they would all have gone through the same, if the treatment had been omitted. The following statement respecting cases, which occurred among the nurses and servants of the hospital, will bear on this point. Other evi- dence of the same kind could be offered, but it would require the statement of many details to present it clearly and with advantage. The following admits of comparatively a brief history. In 1829, from the 18th to the 28th of August, there were four persons employed in the hospital at- tacked with typhoid fever. Two of them were nurses, one the porter, and one a woman employed in the kitchen, I believe, as a washerwoman. The last of these is marked on my list as convalescent on the 7th day, and then was so well as to be discharged from the ward. One of the nurses, a healthy woman but never vigorous, was marked convalescent, and indeed free from disease on the 9th day, and per- haps might have been called so earlier. She had however, been treated very actively, was reduced by venesection on the 2d day, and by vomiting and purging ; so that she regained her strength slowly, and on the 20th day from her attack, she was sent into the country to recruit. She was, how- ever, free from disease, from the 9th day. Both of these were of mature age, the washerwoman 41 ; THE TYPHOID FEVER. 35 and both prudent in their general conduct. The other nurse was young and not prudent. She had an emetic, and was cupped, on the 1st day, with re- lief. On the 3d and 4th days, she had calomel and antimonials. On the 8th day, she appeared well, and was discharged from the sick list. There was per- haps an error in trusting her to herself so early. She soon became sick again, but did not return to the care of the physician till the 16th day, when she had severe headache, great derangement of the alimen- tary canal, &c, &c. Cerebral symptoms did not supervene, and on the 22d she was again convales- cent. The absence of cerebral symptoms was notic- ed in almost all the cases of this year. In this case, the benefit of the early treatment was not entirely lost. The porter was evacuated freely on the first day by the house-physician, but did not enter the ward. After two days he returned to his work. On the 11th day, he entered one of the wards with decided symptoms of typhoid fever; he never had grave ce- rebral symptoms. He was convalescent on the 24th day, but not well reestablished on the 30th day, when he was discharged. In four days he returned. It appeared that he had eaten voraciously, and had been exposed to inclement weather. The result was great derangement of the alimentary canal, with prostration of strength. He was not convalescent again till the 44th day, and was not so well as to be discharged till the 63d day from the commence- ment of his disease. He was twenty-three years of 6 36 REPORT ON age. His disease commenced on the same day as that of the nurse first mentioned, viz., the 18th of August. There can be no doubt that one week of careful restraint, after the early evacuations, and com- mon prudence afterwards, would have saved this man from his protracted sufferings. That all these four patients had the same disease there cannot be any doubt, nor any, that that disease was typhoid fever. I shall add one more case in the same season. Oct. 13th, another woman employed in the hos- pital-kitchen, was attacked by the same disease. She had a cathartic on the 2d day, and was received into the ward on the 3d day. On that day she was vomited and purged freely, with decided relief. She was purged again on the 4th day. On the 5th and 6th days, she had slight exacerbations in the after- noon. On the 8th day, she was decidedly convales- cent ; indeed the disease had ceased. A nasal ca- tarrh followed, and a slight cough afterwards, but without serious inconvenience. She was kept under observation till the 20th day, when she was dis- charged quite well. I proceed next to give an account of some of the prominent symptoms, or at least of those which were most uniformly and definitely noted in our records ; and to draw from them such inferences as they may afford in reference to the prognosis. SYMPTOMS. Tongue.—With few exceptions, the tongue was THE TYPHOID FEVER. 37 noted as coated, or furred. The other characteris- tics of the morbid state of the tongue, frequently noted, are dryness, a dark color of the fur or coat, and a denuded state. I believe that these were not uniformly noted when they occurred ; but that the omissions were not numerous after the first four years. In these years, 1822-5, the notes were much less full and precise than afterwards; thus, in that time, the tongue was noted as dry in only six cases. Omitting these years, therefore, I shall state the ap- pearance of the tongue in the years 1826 to 1835, inclusive. In this period, the cases were 177 males and 87 females ; in the whole, 264. Among these the tongue was Dry in 92 males (177-^92=1.92), or in 1 case in 1.92 cases; << u 40 females (87-^40=2.17), or in 1 u a 2.17