had uterine pains, since which she has had no return of the spasms, but has regained her accustomed health. Was this a case of partial chorea, or was it a development of one of the many nervous conditions to which pregnant females are subject? I neglected to state that about a month prior she was similarly affected, though in a milder degree. Lectures on the Varieties of Continued Fevers and their Discrimination. Delivered at St. Thomas's Hospital, by THOMAS B. PEACOCK, M.D., Assistant-Physician to St. Thomas's Hospital, etc. Lecture on the Relations of Typhus and Typhoid Fever.-In my last lecture I described to you the general symptoms and morbid appearances of Typhoid fever. In the present, I propose to inquire how far we are justified in adopting the view advanced at the commencement of the course, that typhus and typhoid are not mere varieties of the same disease, but distinct specific forms of fever. I have already mentioned, that with the advancement of Medical science, the tendency has been to limit the so-called essential fevers, and to ascribe the constitutional symptoms to local causes, and especially to lesions of the gastro-enteric mucous membrane. Various writers have at different times described inflammation and ulceration of the mucous membrane of the bowels as occurring in fever, but such appearances were only regarded as acci dental complications, arising from peculiarities of climate or season, or in particular forms of disease. Thus the characters of the typhoid fever of Paris were well described by Petit and Serres, in 1813, under the name of "fièvre entèro-mesentèrique." Broussais, however, ascribed much greater importance to the inflammation of the gastro-enteric mucous membrane, regarding it as existing in all cases of fever, and contended that the febrile symptoms were the direct effects of such local disease. * In 1826, M. Trousseaut gave an account of M. Bretoneau's observations on typhoid, as he had observed it at Tours, under the names of Dothinenterie, or Dothinenterite. In 1827, Dr. Bright‡ published several cases, affording examples of the intestinal disease occurring in the fever of London; while Dr. Alison showed its almost constant absence in the epidemic fever of Edinburgh.§ * Examen de la Doctrine Médicale, Paris, 1816. Archives Genéralés de Médecine, Tome X, 1826, p. 67. Reports of Medical Cases, Vol. I., p. 178. Edinburgh Medical and Surgical Journal, Vol. XXVIII., p. 223. In 1829, the first edition of M. Louis's work appeared, in which he illustrated most fully and philosophically all the features of the typhoid fever of Paris, both during life and after death, and in particular demonstrated the constancy of the intestinal disease. Dr. Tweedie and Dr. Southwood Smith, in 1830, reported, however, that in London, while the intestinal disease generally occurred, it was also very frequently absent; and in 1836, M. Lombard,* who was well acquainted with the morbid appearances of typhoid fever, as he had observed it both in Paris and Geneva, having had an opportunity of witnessing post-mortem examinations of cases of fever both in Glasgow and Dublin, was not a little surprised to find that the intestinal disease, which he had believed to be a constant feature of the disease, did not always exist in the English fevers. The first impression produced by these observations was to raise doubts in Dr. Lombard's mind as to the importance of the intestinal lesion as a constant occurrence in fever, while he still held to the identity of the two forms of fever. Subsequently, however, after he had seen more of the English fevers, he adopted the view that there were here prevalent two distinct forms of diseasetyphus, which he regarded as originating in Ireland, and as propagated by contagion by the Irish laborers; and typhoid, which was an endemic disease, precisely similar to that with which he was previously familiar. In 1836, Dr. Gerhardt published an account of an epidemic of typhus in Philadelphia, in which, while the symptoms and morbid appearances bore entire resemblance to the typhus of this country, they presented very marked distinctions from the typhoid fever, or dothinenterite, which he had before met with in the United States, and which he had found to be in every respect similar to the ty phoid fever which he had studied in France; and he hence inferred the specific difference of the two diseases. Such was the state of the question when, in 1838, the Academy of Medicine proposed for the subject of a prize, the investigation of the analogies and differences between typhus and typhoid fevers. This led to the publication of the Essays of Gauthier de Claubry and Montault, the former of whom contended for the two fevers being one and the same disease, while the latter inferred their specific distinctness. In 1839, M. Valleix entered into an elaborate investigation of the respective features of the two forms of fever, founded upon the reports of fourteen cases collected by Dr. Shattuck, of Boston, at the London Fever Hospital; and he was led to adopt the conclusion that the fevers of this country embraced two distinct speciesone, an essential fever, typhus; the other, typhoid, which is identical with the typhoid fever of Paris. Dublin Journal, Vol. X., pp. 17 and 101. American Journal of Medical Science, Vol. XIX., p. 289. * In 1839, Drs. Henderson and Reid published a report on the typhus fever of Edinburgh, in which they investigated fully and carefully the symptoms of that disease during life, and the appearances of the body after death, and established the almost constant absence of any abdominal symptoms and of the intestinal lesion. On the other hand, they published a communication from Mr. Goodsir, showing that a fever, every way similar to the French typhoid, prevailed endemically in some adjacent districts. In 1840, Dr. Stewart, who had closely studied both typhus and typhoid at the Glasgow Infirmary, and the latter disease in Paris, published an able memoir,† in which he advocated the non-identity of the two diseases; and in the following year, M. Louis, in the second edition of his work, adopted the same view. The peculiarities which distinguish the two diseases, and which have been relied upon as indicating their specific difference, may be briefly stated as follows: 1. The mode of invasion of the two diseases is generally very different. Typhus usually attacks suddenly, and rapidly produces such prostration of strength as to compel the patient to seek medical relief at an early period. Typhoid is usually more gradual in its mode of invasion, and less rapidly advances; so that the time. at which the cases come under treatment is usually much later. 2. Typhus can generally be traced to contagion; the origin of cases of typhoid is often very obscure, and the disease, most probably, generally originates in common causes, or, at least, is very much less contagious. 3. Typhus affects persons at all ages, both those in early and in advanced life, though most common during middle age. Typhoid affects chiefly young persons, and very rarely those more than forty years old. 4. The eruptions which characterize the two diseases are different in their form, mode of appearance, and progress; that of ty phus assumes the form of a rash, is not, except at the very commencement, elevated above the surface, and has a livid-rose color, and subsequently becomes petechial; that of typhoid consists of several spots, few in number, always elevated, and of a pale-rose color. The typhus rash appears at an early period, follows a regular course, and its disappearance is usually succeeded by convalescence at the end of a few days. The typhoid spots come out a few at a time, and continue to make their appearance in successive crops, and their final disappearance may precede for many days the establishment of convalescence. 5, The predominant spmptoms in typhus are ordinarily those of prostration of strength and of cerebral disturbance; while the evidences of gastro-intestinal disorder are of minor importance and *Ed. Med. and Surg. Journal, Vol. LII. Ed. Med. and Surg. Journal, Vol. LIV., p. 289. frequency, and, indeed, are often absent. The symptoms of disorder of the gastro-enteric mucous membrane are, throghout the progress of typhoid, predominant: while the cerebral symptoms are less constant and usually less severe, and the prostration of strength is also generally less. 6. The duration of an attack of typhus is comparatively short, and is limited to a tolerably definite period. Typhoid is usually of longer duration, and is less regular in its course; some cases being short, others very much prolonged. 7. In typhus, when convalescence is once established, the progress of the case to recovery is generally satisfactory, and true relapses seldom, perhaps never occur. In typhoid, relapses are of by no means infrequent occurrence, and inflammatory affections of the viscera and serous membrenes frequently supervene during convalescence. 8. Typhus usually proves fatal during the second week of illness, and rarely after the expiration of the third week. Typhoid, though it may prove fatal at as early a period as typhus, usually destroys life, in from the third to the fifth week, and occasionally death takes place at a much later period. 9. After death from typhus, the only constant pathological condition found in the body, is the altered state of the blood, and the follicles of the intestinal mucous membrane never present any appearances of disease. In fatal cases of typhoid the follicular disease of the intestines is of constant occnrrence. These circumstances certainly afford broad grounds for distinction between the two forms of fever: but it has been contended that they do not prove their specific distinctness. 1st. It has been argued that the absence of the intestinal lesion in typhus is owing to the much earlier period at which death occurs in that disease than in typhoid. This objection does not, however apply; for, though the period of death in typhus be earlier than in typhoid, it is not too early for the intestinal disease to have appeared; while occasionally typhus proves fatal at a late period. Of the cases of typhus to which I have referred in my first lecture, one proved fatal from pneumonia on the thirty-first day from admission, the precise duration of illness not having been ascertained; and I have examined cases which have died on the nineteenth to the twenty first days of illness, without meeting with any evidence of intestinal disease; indeed, after death at the latest period, the solitary and aggregate glands are even less distinct than in cases proving fatal in the earlier stages. Of the cases of typhoid also one died on the seventh or eighth day of serious illness, and yet in that instance the plates were not only greatly enlarged and much inflamed, but in places sloughs had already formed; and I exhibited to you a portion of intestine from a patient who died on the fourteenth day, which exhibited the most extensive and advanced disease. M. Chomel, indeed infers, from the observations collected by M. Louis and himself, amounting to 92 in number, that in typhoid, ulceration commences in the plates from the eighth to the twelfth or fifteenth day at the latest. 2ndly. It has also been contended that the peculiarities of the eruption on the skin, and the presence or absence of the intestinal affection in the two forms of fever, may depend on the relative vigor and age of the subjects attacked;-that typhus is a disease of the young and robust, typhoid of the aged and infirm or debilitated. But this is not the case, typhus appears sufficiently frequently in young subjects to prove its features to be similar in them and in the aged. The disease also may be conveyed by contagion to persons under the most diverse conditions, and yet in all, however its malignity may vary, its general features remain the same. 3rdly. It has been supposed, that the disease of the intestinal follicles is only an accidental complication, superinduced by peculiarities of local climate or epidemic infinence. This argument would possess much force were the two diseases never found to prevail coincidentally in the same localities-if the fever which prevails in one locality were always typhus, as is ordinarily the case in Edinburgh; or always typhoid, as in Paris. It fails, however, entirely to explain, how, in other localities, as in London, for instance, we sometimes meet with one and sometimes with the other form of fever; and each of them, instead of being modified or displaying certain intermediate gradations, is found to present its clearly defined and characteristic features. For the establishment of the latter point we are indebted to Dr. Jenner, who for a period of three years conducted a most elaborate investigation into the history, symptoms, and morbid appearances in the cases of fever treated at the Fever Hospital; and he has conclusively shown that the typhus of London is as distinctly marked as that of Edinburgh, and the typhoid as that of Paris. In this state of the question it must, I think, be admitted, that the argument preponderated in favor of the non-identity of typhus and typhoid; but Dr. Jenner was able to furnish still more conclusive evidence of their distinctness. He has shown, that during the years 1847, 1848, and 1849, in all instances in which two or more cases of fever were admitted into the Fever Hospital from the same house, with one solitary exception, whatever was the character of the case first received, such also was that of the cases subsequently admitted; and he has justly concluded, that if the diseases were not propagated by separate contagions or poisons, there would certainly have been numerous exceptions to this rule, instead of the solitary one I have referred to. This, too, could hardly be regarded as an exception. It was the case of a boy received laboring under typhoid after his father had been previously admitted with typhus; * Medico-Chirurgical Transactions, Second Series, Vol. XV. 1850, page 23. |