to at least one in five of all who were under treatment. He remembers to have found, one morning, that five of his patients, lying side by side in adjoining beds, had been attacked by erysipelas during the preceding night; yet the ward was large and well ventilated-one of the two best in the hospital, and it was not overcrowded. There was, at the time, little or no erysipelas in the hospital out of the fever wards. As the typhus epidemic lost some of its virulence, this secondary accident became less frequent; but under all circumstances, it appears to be not very unfrequently the companion of typhus, as it is known to be of typhoid fever. The occurrence of this accident, as seen at Bellevue, did not seem to increase, in any great degree, the mortality of the fever; indeed, the writer cannot now recall an instance in which a patient died during the continuance of this local inflammation. Occurring almost uniformly in the second or third week of the fever, it may have added its own weight to the agencies that were overwhelming the vital powers, but its immediate and direct effects in increasing the mortality were not very obvious.]

SEC. IV.-General Remarks. The most striking fact in the pathological anatomy of typhus fever consists in the absence of any constant and characteristic lesion. One of the most uniform and probably one of the most important alterations is that of the blood. It seems to me, in the present state of our knowledge, quite idle and useless to attempt to trace any obvious connection between the symptoms and the lesions, or, in other words, to refer the former to the latter. The broad and fundamental difference in the state of Peyer's glands, and the mesenteric glands, in typhus and typhoid fever, will, of course be noticed.

[Many writers, particularly on the continent of Europe, prefer to characterize these affections by terms which imply some affinity between them. Typhus abdominalis is their appellation for the typhoid affection of Louis, and typhus cerebralis, or nervosus, for the typhus of English writers; and it is necessary to admit that the greater severity of the head symptoms, and the greater frequency of the cerebral lesions in the latter disease, compared with the Peyerian lesion of the former, furnishes some ground for the distinction. Yet it is not claimed that the cephalic changes in one are met with as uniformly as the intestinal alterations of the other.]

CHAPTER IV.

CAUSES.

I SHALL enumerate under this head some of the principal circumstances which appear to favor the occurrence and spread of typhus fever. Our knowledge of its efficient causes, excepting that of contagion, is very limited and imperfect.

SEC. I.-Locality. It is very evident that the geographical boundaries within which typhus fever prevails, as a common and more or less constant disease, are much less extensive than those of typhoid fever. The actual extent to which typhus fever has heretofore prevailed in different regions and countries, owing to the imperfect histories which have been left to us of this and of analogous diseases, and the consequent doubtfulness and uncertainty of our diagnosis, is a matter which it is now impossible to determine with any considerable degree of precision. One thing is very certain, and that is that typhus fever has always been of very rare occurrence in New England. Nathan Smith, one of the great observers of New England diseases, says expressly that he never met with any other form of continued fever than that which he has so well described under the then common name of typhus fever, and which was evidently the typhoid fever of this work. Very few of the New England country physicians now living, I presume, have had an opportunity of seeing typhus fever on their own soil, excepting now and then a few instances, in cases of foreigners recently arrived from Britain.

A continued fever, which seems to have been evidently contagious, prevailed in the Boston Almshouse in 1817. The account of it, however, which was published in the New England Journal of Medicine and Surgery, for April, 1818, by Dr. John P. Brown, is not sufficiently detailed and particular to enable us to decide whether it was typhus or typhoid fever. Many cases are annually received into the hospitals of our large cities, especially those of

New York, from the British emigrant vessels. The ship Eutaw arrived at New York March 6, 1842, forty-two days from Liverpool, with about two hundred passengers, mostly Irish, seventy of whom were sick with typhus on her arrival. Amongst these there were eight deaths. The bark Barlow arrived at New York from Greenock May 15, 1842, after a passage of forty days, with nearly fifty typhus patients, there having been three deaths before her arrival. These are instances of what occurs nearly every year.1 In August, 1840, twenty-one cases of typhus were admitted, from a single vessel, into the Boston Almshouse. Four of the cases were fatal. Dr. Butler informs me that the dulness of the mind, deafness, stupor, suffusion of the eyes, and dinginess of the skin, were amongst the most prominent symptoms. The bowels were usually torpid, and there was slight meteorism in only two or three cases. Dr. Doane, physician at the New York quarantine establishment, informs me that amongst the most striking and constant phenomena of the disease, he has noticed the injection of the eyes, the fuliginous aspect of the skin, and deafness. Diarrhoea is rare, and the alvine discharges, when procured by medicine, are dark colored and offensive. The evidences of the contagious character of the disease observed by Dr. Doane are very positive; during his connection with the institution, a period of about three years, no less than fifteen or sixteen individuals connected with the hospital having died with typhus fever, which had been contracted from the emigrant patients.

The disease which was commonly called spotted fever, and which prevailed in many parts of New England, principally between the years 1807 and 1816, is supposed by some writers to have been the true typhus fever. Dr. Gerhard says that it was similar in its nature to the British typhus. Dr. James Jackson thinks that it was a different disease. It is very certain that, in many important particulars, it bore a very striking resemblance to true typhus. This resemblance is noticed by most writers upon the disease. Dr. Elisha North called it a new petechial malignant typhus. Dr. Hale, of Boston, whose description of the disease, as it prevailed at Gardiner, Maine, in the spring of 1814, is the fullest and best that has been published, regards it as a congestive fever. He speaks of the many points of

The number of these cases during the present year, 1847, has been immensely greater than it ever was before. The hospitals of most of the commercial cities from the St. Lawrence to New Orleans have been crowded with typhus patients, coming mostly in emigrant ships from Scotland, England, and Ireland.

resemblance which exist between it and Dr. Armstrong's typhus; but he says, also, that there are many strong points of difference between the two diseases. It is not easy, at the present day, upon such evidence as we possess, to decide with any confidence upon the precise character of the spotted fever of New England. Without going any farther into the consideration of this question here, I will merely observe that an examination of most of the records that have been left us of this disease, has induced me to believe that it belongs to that class of new and more or less temporary epidemics, each having its peculiar character, marked by its peculiar phenomena, and depending upon new and peculiar combinations. of unknown morbific influences-which have always from time to time made their appearance, rather than to the class of established and permanent maladies.

Dr. Gerhard thinks that some of the epidemics which overran the Middle States, between the years 1812 and 1820, were typhus fever; and that it was of this disease that three distinguished professors in the University of Pennsylvania-Rush, Wistar, and Dorsey-died. He says that Dr. Parrish, one of the most experienced physicians of Philadelphia, who practised very extensively amongst all classes of inhabitants in the winter of 1812-13, when he saw some of the cases at the Philadelphia Hospital, in 1836, immediately recognized their identity with those of the former epidemic. A pupil of Dr. Gerhard's, from North Carolina, informed him that he had witnessed a similar fever amongst the negroes. It seemed to be contagious, and, from the absolute disregard of cleanliness and the crowded state of the negro cabins, it frequently spread extensively. It is hardly necessary to say that these and similar opinions are to be received with a good deal of caution; and that the extent and frequency of the prevalence of true typhus fever in the United States can only be determined by the accurate and continued observations of the future. Upon this question, as upon so many others connected with epidemic disease, the past sheds but a confused and uncertain light.

It is very clear that, for the last thirty years, at least, true typhus fever has been almost or entirely unknown in France. In the years 1813 and 1814, there appeared at Paris a severe epidemic fever, which was first noticed amongst the troops who returned from Napoleon's campaigns in Germany, and in the east of France; and which afterwards spread amongst the inhabitants of Paris, and other large cities, and was everywhere extremely fatal. This epi

demic, Dr. Gerhard is disposed to believe was typhus fever; although Louis, Chomel, and other French physicians who observed it, are inclined to regard it as identical with their prevailing typhoid fever, or dothinenteritis.

A writer in the October number of the British and Foreign Medical Review, for 1841, thinks that the fever which devastated Italy in 1816 and 1817 was identical with the typhus of Great Britain.

The fixed and constant residence of typhus fever is to be found in the British Islands. The mud cabins of Ireland, and the damp dark cellars of the cities of Great Britain, are its true habitat. These are its perpetual lurking-places, and here it is always to be found. The terms Irish typhus and British typhus have, indeed, come to be its most distinctive appellations.

The number of deaths in England, except the metropolis, from typhus, in 1841, was 13,795; of these, 6,618 were males, and 7,077 females. The number in 1842, was 15,027; of these, 7,056 were males, and 7,971 females.'

According to the Report of the Registrar-General, there is no marked difference in the mortality from typhus in town and country districts in England; the annual mortality to one million living, in 1841, being for the town districts, nine hundred and eight; and for the country districts, nine hundred and twenty-nine. Dr. John Hunter says he never met with the disease in the West Indies.2

SEC. II.-Season, Weather, &c. Typhus fever prevails at all seasons of the year. Several of the Irish writers have remarked, in general terms, that the disease is found to prevail most extensively during the early part of summer. It seems probable, however, from extensive and accurate researches, that the difference in the extent to which the disease prevails in the different seasons of the year is not very great. Illustrative of this point, so far as a single locality is concerned, I copy the following table from Dr. Mateer's statistics of fever, during a period of eighteen years at the Belfast Fever Hospital. It shows the aggregate number of admissions into. the hospital, arranged according to the four seasons, for this long and continuous series of years, with the average rate of mortality for the several seasons:

1 Rep. Reg. Gen.

2 Hunter's Diseases of the Army, p. 83.