CHAPTER XI.

DEFINITION.

WE may, provisionally at least, adopt the following definition of the disease, the natural history of which has now been given.

Typhoid fever is an acute affection, occurring most frequently between the ages of fifteen and thirty years, sufficiently often previous to the former period, and but rarely after the fortieth year of life, attacking, at least in cities and amongst adults, in a large majority of instances, persons who are recent residents; occasionally, and under certain conditions, capable of transmission from one individual to another; rarely occurring twice in the same person; more common in certain countries than in others, but not confined, so far as is known, to any geographical localities or regions; prevailing at all seasons of the year and in all climates, but more common in the autumn than at other periods, and in temperate and northern than in southern and hot latitudes; sometimes sudden and sometimes gradual in its access; attended at its commencement with chills or rigors, not commonly very severe, and usually repeated, at uncertain intervals, for the first few days; then with more or less feverish heat of the skin; generally with increased quickness of the pulse; somewhat accelerated respiration; slight, dry cough; an extensive sonorous or sibilant rhonchus, with pain in the head, back, and limbs; loss of the vigor, and, in grave cases, perversion of the faculties of the mind; dull expression of the countenance; more or less somnolence or watchfulness; giddiness or dizziness; ringing, roaring, or buzzing in the ears; occasional epistaxis; great loss of muscular strength; in grave cases with spasmodic twitchings of the muscles, especially those of the forearms and hands, with entire loss of appetite, and with thirst; sometimes with nearly a natural appearance of the tongue, and at others with a red, dark, dry, glutinous, cracked, trembling state of this organ; sordes upon the teeth and gums; occasional nausea and vomiting; frequent diarrhoea; abdominal pains and tenderness,

these latter not unfrequently most marked in the right iliac region; dulness on percussion over the spleen; meteoric distension or rigidity of the abdomen; the skin, particularly of the front part of the body, being usually the seat, in the course of the second and third weeks of the disease, of a peculiar eruption, not commonly abundant, consisting of small circular or oval spots of a bright rose color, slightly elevated above the surrounding surface, and readily disappearing under pressure; coming out successively, one after another, for several days, remaining usually for somewhat more than a week, and successively and gradually fading away, and finally disappearing; the blood, when drawn from the body, having its proportion of fibrin diminished in a degree closely corresponding to the gravity of the affection, which symptoms differ very widely in their duration, in their march, in their severity, and in their combinations in different cases, no one of which is invariably met with, and several of which are frequently wanting, but enough of which are almost always present to characterize the disease; which symptoms, furthermore, may either gradually diminish in severity, and finally disappear between the twelfth and the thirtieth day of the disease, or may increase in severity, and terminate in death between the seventh and the fortieth day from their access, the bodies of patients exhibiting, on examination after death, in only a certain proportion of cases, various pathological changes in the brain, heart, lungs, stomach, and liver, but in most cases enlargement or softening, or both, of the spleen, and in all cases thickening or redness, or a morbid deposition in the subcutaneous cellular tissue, or ulceration, or all these changes of the elliptical plates of the ileum, with enlargement, redness, and softening of the mesenteric glands, corresponding in their position to the altered intestinal follicles; which disease, thus characterized and defined, differs essentially from all others in its causes, in its symptoms, in its lesions, and is, in the present state of our knowledge, only to a limited extent under the influence or control of art.

CHAPTER XII.

BIBLIOGRAPHY.

THE bibliography of typhoid fever, as a distinct and specific disease, may properly enough be said to have commenced with the publication of Louis's Researches, in 1829. I do not forget the earlier works of Roederer and Wagler, in Germany; and of Prost, Petit and Serres, and Bretonneau, in France, on the same subject; nor the description of Huxham in England, and of Nathan Smith in America: but these publications, compared with that of Louis, were fragmentary and incomplete. Other continental writers have also given very good general descriptions of the disease, under the names of typhus, adynamic, ataxic fever, and so on. These descriptions are now of but little value, for the reason that no clear distinction was made between true typhus and typhoid fever. It indeed remains to the present moment a question undecided, whether the camp, the jail, and the typhus fevers of the continent of Europe, previous to the thorough study of typhoid fever, were identical with this disease, or constituted a distinct and different species. My own opinion is, as I have already stated, that both parties are partly right and partly wrong. It is probable that both typhoid and true typhus fever made up these diseases; and it is quite impossible to determine now, in many cases, to which of the two any particular epidemic belonged.

Besides the few but very important works which are hereafter briefly mentioned, Andral, Bouillaud, Cruveilhier, and others amongst the French; and Schönlein, Skoda, Rokitansky, and others amongst the Germans, have written more or less extensively and systematically upon this disease. Several important papers have also been published in the French medical journals.

Médecine éclairée par l'observation et l'ouverture des corps. Par P. A. Prost. Paris, 1804. In connection with the history of the researches in relation to typhoid fever, this is a very remarkable book. Prost may be fairly regarded as one of the far forerunners

of Louis.

He seems to have devoted himself for a considerable period of time with great assiduity and faithfulness, and almost exclusively to the observation of disease, in its most extended sense, in the large hospitals of Paris. Before publishing his book, he had made more than four hundred autopsies, many of them requiring an entire day, and none less than several hours. One of the first fruits of his arduous and conscientious study of nature was the discovery that, in the ataxic fevers of Paris, there always existed inflammation, with or without ulceration, of the mucous membrane of the intestines. Bouillaud, in speaking of Prost's work, says: "This fine commencement of a revolution, which ten years later was destined to shake the temple of medicine to its deepest foundations, was suffered to pass almost unnoticed. Truly, Prost might have said of his epoch, as Tacitus said of another: 'Nostra oetas oblivia suorum.'

There is a curious fact in medical literature, connected with this portion of the history of fever. Prost's book, as Grisolle says, fell stillborn from the press. Almost the only one of his contemporaries who took any special notice of it was Broussais; and a singular notice this was, coming as it did from a man whose highest title to glory-subsequently claimed for him, both by his disciples and by himself-consisted in a fuller development of this very doctrine of Prost. Broussais, in the first edition of his History of Chronic Inflammations, after citing the opinion of Post, relative to the influence of inflammation of the digestive mucous membrane in the production of ataxic fever, says: "I have too often found this membrane in good condition after the most malignant typhus; I have seen too many patients improved by the employment of the most energetic stimulants, to share the opinion of this physician on the cause of ataxic fever." And still, the truculent and unscrupu lous reformer, after having thus summarily rejected, as worthless, the materials which had been laboriously quarried from the great primary formation of nature, did not hesitate to make use of them as corner-stones for the temple which he himself strove to build.

Prost's work is in two volumes, and the greater part of it is made up of short histories of disease, with an account of the several organs after death; only a small proportion of these being cases of fever. The preliminary observations are to a great extent speculative and hypothetical.

A Practical Essay on Typhous Fever. By Nathan Smith, M. D. The author of this modest and unpretending essay was an extensive

and distinguished teacher and practitioner of medicine and surgery throughout many portions of the New England States during the first quarter of the present century. He was a remarkable man; and his name stands worthily and fitly by the side of those of Huxham, Pringle, and Blane. My opinion of the value of the essay above mentioned has been already sufficiently attested, by the incorporation into my book of a large portion of its matter. To an American practitioner, it is worth infinitely more than all the modern English treatises on fever put together; for this simple reason, if for no other, that it deals with the form of disease with which he is familiar-which the English treatises do not do. Nathan Smith was a shrewd, clear-headed, patient, and careful student of nature-his vision undazzled and his judgment never perverted by fanciful speculations; and the labor of my book will not be wholly lost if it succeeds in some degree in calling back the attention of my countrymen to his neglected and almost forgotten pages. The essay was published in 1824.

Anatomical, Pathological, and Therapeutical Researches upon the disease known under the names of Gastro-Enteritis; Putrid, Adynamic, Ataxic, and Typhoid Fever. By P. Ch. A. Louis, 2 vols. Paris, 1829. This is the great work of Louis, to which reference has been so constantly made throughout the preceding history. An American edition was published from a translation by Henry J. Bowditch, M. D., in 1836. A second French edition was published in 1841. The work at the time of its first appearance was entirely without a parallel, if we except the Researches on Phthisis, by the same writer. These works of Louis have become the established models for all similar undertakings; they are the standards by which all analogous labors are to be tried. Here and there, a single individual has attempted to depreciate their value and underrate their importance-a value and an importance which every successive year since their appearance has only served to strengthen and confirm. Like new planets added to a solar system, they have quietly but irresistibly wheeled into their orbits, from which they are henceforth no more to be jostled than the planets are from theirs. Leçons de Clinique Médicale, etc. Par A. F. Chomel. Fièvre Typhoide. Paris, 1834, pp. 548. Next to the great work of Louis, this is perhaps the most valuable original treatise on typhoid fever that has been published. It is not so methodical in its plan and arrangement as it might have been, and the anatomical details are somewhat prolix, extending as they do to nearly two hundred and