B. 
REPORT OF THE 
COMMITTEE ON PRACTICAL MEDICINE. 
The Committee on Practical Medicine, appointed by the American 
Medical Association, at Philadelphia, in May, 1847, respectfully 
beg leave to submit the following 
REPORT. 
The duty with which the committee are charged divides itself into 
two parts. 1st. To report on the more important improvements 
effected in this country in the management of individual diseases; 
and 2dly. To report on the progress of epidemics; referring as oc- 
casion requires to medical topography, and to the character of 
prevailing diseases in special localities, or in the United States 
generally, during the term of their service. 
In respect to the first part of their duty, the committee regret 
that circumstances, not under their control, have prevented them 
from fulfilling it in a manner which is satisfactory to themselves; 
and consequently they can scarcely hope, in what they may offer, 
to meet the expectations of the Association. 
It is rare that any signal improvements in practical medicine are 
introduced and established in the brief space of a year. Improve- 
ments in the treatment of individual diseases are effected only, or, 
for the most part, by careful and reiterated observation and experi- 
ment, and cautious and rigorous induction. The medical journals 
and periodical retrospects are replete with announcements of novel 
methods of managing various diseases. Many of these methods 
disclose, in their narratives, evidence of their hypothetical origin; 
while others seem to betray a disregard of well established princi- 
ples and rules of practice, and are mere crude substitutes for accre- 102 
dited plans of treatment. The results attained by enlightened 
empiricism are sometimes received with acclamation; and not unfre- 
quently take the highest rank among the improvements in practical 
medicine. But there are comparatively few minds possessing the 
qualities requisite to originate, either empirically or by the process 
of induction, improved methods of treating individual diseases. It 
is for this reason that the publications of a year, periodic and mono- 
graphic, though richly stored with the products of scientific research 
in animal chemistry, physiology, hygiene, and general pathology, 
present so meagre an account of substantial improvements in the art 
of healing, strictly so called. 
The tests of improvements in practical medicine, are the benefits 
derivable from means, new or old, applied in certain forms or con- 
ditions of disease in which they had not been previously employed, 
or not employed in the usual methods,—benefits not obtainable, or, 
if so, not so readily, or to the same extent, by the treatment ordi- 
narily prescribed in the same affections. To decide by these tests 
what are real improvements is, in many instances, a task not only 
of magnitude but of great delicacy; it demands time and a patient 
interrogation of nature,—a scrutinous comparison of the effects pro- 
duced by the old and established methods of treatment with the 
effects produced by the new. To what results an examination of 
the recent innovations in the management of certain diseases, con- 
ducted in the mode now referred to, would lead, the committee are 
not prepared to report. 
But though unable, at this time, to express any opinions on the 
subjects which might come under their remark or criticism in this 
department of their duty, the committee beg leave to submit a com- 
munication obligingly furnished them by Dr. Gurdon Buck, one of 
the Surgeons of the New York Hospital, relating to a remedy inge- 
niously conceived and successfully employed by that gentleman, in 
cases of oedematous laryngitis in its suffocative stage. Though the 
remedy referred to is surgical, the disease to which it is applicable 
is strictly medical, and, for this reason, it may not inappropriately 
be introduced to the notice of the Association by the Committee on 
Practical Medicine. On examining the record of cases treated by 
Dr. Buck, and his reflections upon them, together with the beautiful 
pictorial illustrations of the forms of the disease, and the mode of 
applying the means of relief, we cannot but express the belief that 
a most valuable improvement has been made in the treatment of a 
formidable disease. The practice consists in scarifying the oedema- 103 
tous parts; and thus relieving the respiration to a degree which gains 
time for the favourable operation of other remedies, and which may 
obviate the necessity of resorting to tracheotomy. But we will allow 
the memoir drawn up by Dr. Buck, and herewith presented, as a 
supplement to this report, to speak for itself.—(B. 1.) 
In entering on the second part of their report, or that relating to 
the progress of epidemics, &c., during the term of their service, the 
committee lament that circumstances, before alluded to, have pre- 
vented them from collecting the materials necessary to enable them 
to give a full circumspective view of the subject. Indeed, it maybe 
questioned whether the topics now referred to, comprehending in 
their range the nature and effects of the endemic, epidemic, contingent 
and climatic influences which are operative in producing and modi- 
fying popular diseases in the United States, do not collectively form 
a theme too extensive in its details to be examined and reported upon 
by a central committee within the time allotted for the accomplish- 
ment of the task. In the case of your present committee, it is felt, 
that, had there been no impediment to the prosecution of their duty, 
their utmost diligence would scarcely have enabled them to compass 
even an outline of the subject. 
In the observations to which the committee invite the attention of 
the Association, epidemics are regarded as arising from three general 
sources, to wit, contagion, infection, and meteoration; and in ac- 
cordance with this view of their etiology, they may be divided into 
contagious, infectious, and meteoratious, and defined as follows: 
1. Contagious Epidemics are those distempers which arise from 
poisons, generated by specific morbid actions in the human body, and 
which are communicable from the sick to the healthy by mediate and 
immediate contact. To this division belong scarlet fever, measles, 
small-pox, and a few other diseases. 
2. Infectious Epidemics are those diseases which originate from 
the emanations or miasmata from decomposing organic substances, 
including the excrementitious or effete animal matters thrown out of 
the body in health and disease. The disorders referable to this 
class are intermittent and remittent fevers, yellow fever, typhus, 
malignant puerperal fever, and some varieties of dysentery and ery- 
sipelas. 
3. Meteoratious Epidemics are those wide-spreading maladies 
which arise from certain latent influences of the general atmosphere, 
and which have no special relations or connections with seasons, 104 
localities and climates. The most notable examples of this kind are 
influenza and cholera. 
In respect to these three kinds of epidemics, the following laws 
are well ascertained:—1. That their prevalence is periodical. 2. 
That no two of them, belonging respectively to different classes, 
and the same is generally true of such as belong to the same 
class, occur to the same extent, in the same place, at the same 
time. 3. That whenever any of the diseases belonging to the several 
classes prevail together in the same place, they become involved in 
each other in the order we have arranged them, the first being modi- 
fied by the second, and both of these by the third, so that one is 
always predominant, and compels the others to wear its livery. 4. 
That the same epidemic varies in its character in different years, the 
modifications depending mostly upon the diversities of the seasons, 
and the varying influences of the prevailing insensible meteoration, 
or, as it is called, the epidemic constitution of the atmosphere. 
It might not be unprofitable to exhibit the facts and reasonings 
on which the above classification of epidemics is based; and to illus- 
trate, by examples, the operation of the laws just stated. But re- 
strained from this by the need of brevity, we proceed to observe, that 
we are not aware that any well characterized meteoratious epidemic 
has occurred within the United States during the last year. Whilst 
the influenza and cholera have prevailed in some parts of the Old 
World, neither of them has appeared in the New. The only diseases 
which, on account of their prevalence, have attracted general atten- 
tion, in the period referred to, are a few of those arranged in the 
divisions of contagious and infectious epidemics. 
In respect to contagious epidemics, the committee are not able to 
state the extent of their occurrence in the various cities and states 
of the Union. There are, however, in our possession some facts re- 
lating to the epidemic history of scarlet fever, measles, and small- 
pox, as they have prevailed in the city of New York, during a long 
series of years, which are, perhaps, worthy of recital. 
The New York hills of mortality are, for the most part, complete 
from the commencement of 1805 to the end of 1847. For several 
years, so far as is known, prior to 1805, and from this period for- 
ward to the close of 1822, scarlet fever was very rarely met with, 
and measles and small-pox were comparatively infrequent. Between 
these two epochs, that is, during eighteen years, there were reported 
only 43 deaths from scarlet fever, 339 from measles, and 719 from 
small-pox. After 1822, these diseases slowly assumed an epidemic character; and, in the course of twenty-five years, that is, from the 
beginning of that year to the end of 1847, there were 4,874 deaths 
from scarlet fever, 3,124 from measles, and 3,740 from small-pox. 
The progressive, though somewhat irregular, increase and decline of 
the annual numbers of the deaths from these disorders, is shown in the 
following table. 
Table of the annual numbers of deaths from Scarlet Fever, Measles, and Small-Pox in the city 
of New York, from the beginning of 1805 to the end of 1847. 
Years. 
Scarlet 
fever. 
Measles. 
Small-pox. 
Total. 
Years. 
Scarlet 
fever. 
Measles. 
Small-pox. 
Total. 
1805 
4 
_ 
62 
66 
1827 
4 
172 
149 
325 
1806 
4 
— 
48 
52 
1828 
11 
28 
93 
132 
1807 
2 
1 
29 
32 
1829 
188 
91 
16 
295 
1808 
4 
64 
62 
130 
1830 
246 
22 
176 
444 
1809 
9 
2 
66 
77 
1831 
258 
39 
224 
521 
1810 
1 
2 
4 
7 
1832 
221 
290 
89 
600 
1811 
2 
117 
119 
1833 
179 
38 
25 
242 
1812 
9 
21 
30 
1834 
418 
212 
233 
863 
1813 
1 
35 
2 
38 
1835 
174 
82 
351 
607 
1814 
1 
15 
2 
18 
1836 
202 
443 
173 
818 
1815 
18 
94 
112 
1837 
579 
238 
164 
981 
1816 
19 
179 
198 
1838 
257 
79 
91 
427 
1817 
3 
20 
14 
37 
1839 
158 
133 
68 
359 
1818 
18 
19 
37 
1840 
391 
186 
232 
809 
1819 
5 
10 
— 
15 
1841 
366 
113 
209 
688 
1820 
5 
74 
— 
79 
1842 
416 
60 
181 
657 
1821 
3 
109 
— 
112 
1843 
223 
118 
117 
458 
1822 
1 
1 
— 
2 
1844 
225 
51 
20 
296 
1823 
2 
117 
18 
137 
1845 
63 
136 
425 
624 
1824 
3 
100 
394 
497 
1846 
114 
17 
141 
272 
1825 
10 
53 
40 
103 
1847 
142 
275 
53 
470 
1826 
24 
31 
58 
113 
The great increase of the population of the city of New York, oi 
late years, affords no explanation of these epidemic phenomena. 
The facts stated distinctly show that there arose, in 1823, that pe- 
culiar variety of epidemic meteoration which favours the diffusion of 
the contagious exanthemata, and especially of scarlet fever; and 
which, gradually augmenting in force, reached its height of intensity 
in 183T, in which year 579 died of scarlet fever, 238 of measles, and 
164 of small-pox, making a total of 981 deaths from these diseases. 
Since 1837, the prevalence of the exanthemata has been slowly abat- 
ing. In 1846 the deaths were reduced to 272; and in the following 
or last year, 1847, the number, though greater than in the preceding 
year, amounted to only 473. 106 
It thus appears, that in the first twenty of the last forty-three 
years, scarlet fever was nearly extinct in the city of New York; and 
that measles and small-pox were sporadic; and further, that in the 
last twenty-three years, these fevers have prevailed to an extent and 
in a mode which characterize epidemics. In contemplating the gra- 
dual decrease of the exanthemata since 1837, may we not infer that, 
at a period not very distant, they will become as rare, in proportion 
to the population, as they were from 1805 to 1823 ? 
In connection with these facts, we would notice a circumstance in 
the history of an infectious epidemic disease, which is deemed worthy 
the attention of those engaged in researches concerning the pheno- 
mena and laws of popular diseases. It is this; whilst the scarlet 
fever, measles, and small-pox were of infrequent occurrence in New 
York, the yellow fever prevailed several times epidemically in that 
city, and the fear of its annual visitation was never absent from the 
public mind. Since 1822, or, in other words, since the exanthemata 
have been prevalent, the yellow fever has not appeared as an epide- 
mic in New York, or in any place north of Charleston. 
From these facts it seems that yellow fever and the exanthemata 
owe their prevalence to very different varieties of epidemic me- 
teoration. If this be true, is there not reason to apprehend that 
when the prevalence of scarlet fever, measles and small-pox shall 
have further declined or ceased, yellow fever will reappear epi- 
demically in our great northern emporium and the neighbouring 
cities? The fact is remarkable, that the years, from 1804 to 1823, 
'in which yelloAV fever prevailed in New York, are among those in 
which the fewest deaths are recorded from the exanthemata. The 
years referred to are 1805, 1809, 1813, 1819 and 1822. In the 
last of these years the yellow fever was more extensively epidemic 
than it had been since 1805; and there was but one death reported 
from scarlet fever, one from measles, and none from small-pox. 
It must not be supposed, from what has been said, that the pro- 
gressive development, duration, and transition of the meteoratious 
influences which have favoured the prevalence of yellow fever and 
the contagious exanthemata in. New York, are attributable to the 
operation of a general principle which everywhere governs and 
establishes a uniformity in the succession of epidemics, or, in other 
words, which illustrate the order of the epidemic prevalence of the 
diseases in question, as they occur in other localities, or in a different 
series of years in the same place. There appears to be no such 107 
principle regulating the rise, progress, decline, and consecutive 
development of epidemics. 
In cases in which a special form of epidemic meteoration reigns 
over many years, there are not unfrequently seasons in which its 
peculiar agency is for a time suspended, or so broken up as to allow 
of the intercurrence of other varieties of meteoration which, after 
prevailing for a period of a longer or shorter duration, totally dis- 
appear. Such intercurrences happened in New York in 1832 and 
1834. In the warm months of these years the atmospheric condi- 
tion, which had so long and actively promoted the prevalence of the 
exanthemata, temporarily gave way, and in its place was developed 
that peculiar meteoratious influence to which are referable the 
ravages of the epidemic cholera. Of this disease 3513 persons 
perished in that city in 1832, and 971 in 1834. 
Of the diseases arranged in the second class of epidemics, or those 
denominated infectious, the committee must limit their observations 
to those which have attracted most attention in the United States 
during the past year. But before passing to the notice of these 
diseases, it may be observed, that though intermittents, remittents, 
and dysentery, arising from the mild species of koino-miasma, have, 
as in former years, prevailed more or less extensively in the districts 
of country in which the atmospheric temperature and the geological 
formation and qualities of the earth’s surface favour the generation 
of that poison, there is nothing in their history, known to the com- 
mittee, worthy of being specially recorded. These disorders in 
their types, general characters and febrile phenomena appear to be 
essentially the same in every year, while in the extent of their pre- 
valence and their diathesis they are strikingly influenced by the 
varying latent properties of the general atmosphere. 
From the ravages of epidemic yellow fever, produced by the second 
or malignant species of icoino-miasma, our country, with the exception 
of the cities of New Orleans, Lafayette and Mobile, has been exempt 
during the year 1847. The frequent though irregular periodical 
occurrence of that form of pestilence in our southern cities, and its 
occasional prevalence in our northern maritime towns, render every- 
thing concerning it peculiarly interesting to American physicians. 
Its epidemic relations to climate and soil, temperature and humidity, 
the source and composition of its infectious principle, the nature of 
the epidemic meteoratious influence which favours its prevalence, its 
modifications, diagnostic phenomena, anatomical characters and 
treatment, are topics which challenge the researches of philosophical 108 
minds; and as time only is required for their investigation, it is 
hoped that they will hereafter receive elucidation from inquiries 
conducted under the auspices of this Association. 
In respect to the yellow fever of New Orleans of the last year, 
your committee are unable to make any original presentation of 
facts. In a communication received on the 28th ult., from a mem- 
ber of the committee, Dr. Harrison, residing in that city, we are 
referred for information on the subject to the New Orleans Medical 
and Surgical Journal. It appears from the last November number 
of that periodical, that it was estimated that between 20 and 25,000 
cases of the disease occurred in New Orleans, and the neighbouring 
city of Lafayette, from the 3d of July to the 18th of October 1847, 
and that the number of deaths was 2,739. The greatest mortality 
occurred in September, in which month the deaths amounted to 
1,044. In the number of the Journal now referred to, and also in 
that for January, 1848, are interesting articles on the subject; and 
as these are before the public, we shall only add that Dr. Harrison 
states, that the epidemic did not differ from others he had witnessed: 
“Except,” he says, “in this: sulph. quinise was more liberally used 
than formerly, and generally with the best results, according to the 
information I have been able to obtain from those in whom I have 
confidence.” 
During the year in which this yellow fever epidemic occurred in 
New Orleans, or rather from the 19th December, 1846, to 18th 
December, 1847, there were, in that city, but few deaths from the 
contagious exanthemata, there being only 15 from scarlet fever, 38 
from measles, and 27 from smallpox.* These facts are conformable 
to the general laws which govern the prevalence of these diseases, 
and to which we have before had occasion to advert. 
In Mobile, the yellow fever prevailed in the summer and autumn 
of 1847 to a very limited extent. From an abstract, in Wood's 
American Quarterly Retrospect,f of Dr. Nott’s paper on the subject, 
published in the Charleston Medical Journal, we learn that “ the 
summer up to Aug. 1st, was the most temperate and rainy he had 
seen for 12 years, the thermometer but once reaching 89° F. It 
rained half the days in June, and 25 days in July, often in torrents; 
in the midst of these incessant rains the yellow fever commenced. 
From the first case (18th July) until the 1st September, the disease 
progressed very slowly, only about 60 cases occurring, 9 of which 
* New Orleans Med. and Surg. Jour., Jan. 1848. 
f April 1848. 109 
were fatal, and several of the latter were from vessels coming from 
New Orleans. Here we have evidence of the extraordinary mildness 
of the epidemic, and its extremely mild type in its incipiency. 
About Sept. 1st the disease began to spread rapidly, and during 
that month there were 37 deaths. In October only 22, the deaths 
probably not exceeding 1 in 15.” 
But of all the forms of infectious diseases, the one from which the 
greatest amount of mortality has occurred in most of the larger 
Atlantic cities of the North-eastern and Middle States, during the 
committee’s term of service, is typhus, or, as it has been generally 
called, ship fever. 
Though typhus is not perhaps as strictly entitled to the term epi- 
demic as some other distempers, being never equally rife in the 
different classes of society, but mostly confined to persons dwelling 
in confined situations, in the midst of human filth, yet its prevalence 
is sometimes so extensive, and its diffusion so clearly owing to the 
agency of a peculiar atmospheric influence, that there is no sufficient 
reason for not considering it as occurring epidemically. That it 
conforms to the law of periodicity, which determines the recurrence 
and spread of certain other maladies, is shown by its history in vari- 
ous countries. Pursuant to that law, though it may never he absent 
from a city or district, it increases at times, and after raging for a 
season, declines like other epidemics. Dr. Alison says, in speaking 
of the contagious fever of Edinburgh, that “ there have been three 
great epidemics of that disease in the last twenty-two years, begin- 
ning in 1817, 1826, and 1836, (the last of which has now nearly 
subsided,) each lasting nearly three years, and each of the last two 
affecting, I believe, nearly ten thousand persons.”* Of the typhus 
of Glasgow, Dr. Davidson remarks “that a severe epidemic of one 
or two years’ duration, is never succeeded by another until several 
years have elapsed. ”f Similar facts illustrate the epidemic cha- 
racter of typhus in European cities. 
On examining the records of deaths from typhus;}; for the last 
thirty-five years in the city of New York, it is found that the dis- 
ease was epidemic in that period four times, viz.: in 1818, 1827-28, 
1837, and 1846-47. In these years the increase of the disease was 
so remarkable, that there is no hesitation in pronouncing them epi- 
* British and Foreign Medical Review, No. xxi. p. 27. 
f Thackeray Prize Essay, p. 55. 
J In enumerating the deaths from typhus, we include the deaths from what is called 
in the bills of mortality typhoid fever. 110 
demic typhus periods. The fact now referred to wras strikingly 
exemplified in 1837. In that year the mortality from typhus was 
338, while that of the preceding year was but 117, and that of the 
following only 104. From this time, though the amount of mor- 
tality annually varied, there was no notable increase of deaths from 
typhus until 1846, when the number rose to 256; and the disease 
continuing to prevail and with increasing severity, the deaths in 1847 
reached the frightful sum of 1396, to which should be added very 
many of 657 deaths from dysentery, a disease wdiich, in a large 
proportion of the cases in the hospitals, was typhus fever. 
The foregoing facts fully warrant the inference that the diffusion 
of typhus is favoured by a peculiar aerial influence which occurs 
periodically. Such an influence is sometimes very widely extended. 
It is said by Barker and Cheyne, in speaking of the epidemic typhus 
period of 1817-18, as quoted by Ur. Davidson,* that “it must be 
acknowledged that the simultaneous increase of the disease in Ire- 
land, and on the Continent, leads to the inference, that whatever 
may have been its origin, an epidemic constitution prevailed over a 
great part of Europe during a series of years past.” Now such an 
epidemic constitution has manifestly prevailed over the British Isles 
during the years 1846-47; and its influence, in its western direction, 
appears to have extended across the Atlantic ocean to the shores of 
our North-eastern States and the adjacent British Provinces. 
But coincident with this wide-spread epidemic meteoration, were 
other causes more immediately influential in predisposing to typhus on 
both sides of the Atlantic. The more efficient of these causes, espe- 
cially in Ireland, were famine, and the evils physical and moral, 
attendant upon it. Whilst starvation and disease were destroying 
thousands of the poor in that ill-fated land, multitudes of them, to 
escape from calamities so fearful, sought to ameliorate their con- 
dition by a removal to this continent. In no annual period in the 
history of emigration, has the number of foreigners, added to our 
population, equalled that of the last year. It has been estimated 
that about a quarter of a million of emigrants arrived in the United 
States in 1847.f Of this number, 160,134 landed at New York, 
and the remainder mostly at Boston, Philadelphia, Baltimore, and 
New Orleans. Thousands also entered our country by the way of 
* Thackeray Prize Essay. 
f It appears from the report of the Secretary of State to the House of Representatives, 
that the whole number of passengers who arrived in the United States during the year 
ending Sept. 30th, 1847, was 239, 480. Canada and New Brunswick. A very large majority of those who 
landed at New York were Germans and Irish. It is stated by the 
New York Commissioners of emigration, that of the 129,062 passen- 
gers arrived at that port, from May 5th to December 31st, 1847, 
53,180 were from Germany, and 52,946 from Ireland, thus showing 
that the emigration from the former country exceeded that from the 
latter. 
The condition of the German and Irish emigrants prior to their 
embarkation, and during their transit of the ocean, was in most in- 
stances conspicuously different. Whilst the former were generally 
robust, and well provided on the passage with the means of subsist- 
ence, and observant of cleanliness and ventilation,—the latter were 
in most cases enfeebled from the want of sustenance, and on ship- 
board, destitute of supplies of wholesome food, depressed in mind, 
clothed in filthy garments, and crowded and confined in air rendered 
pestiferous by the excrementitious matters eliminated from their own 
bodies. In contrasting the hygienic circumstances in which the two 
classes of emigrants were placed, it is easy to account for the greater 
amount of sickness and mortality which occurred in one class than 
in the other. It is said, that of the admissions of emigrants into 
the hospitals and almshouse of New York, the Irish exceeded the 
German in the proportion of about one to nine or ten; and we are 
told, that the Irish in British ships suffered more than those in 
American. 
The amount of disease and number of deaths which occurred in 
emigrant ships, while crossing the Atlantic, are appalling to contem- 
plate. Many thousands perished on the voyage to the United States 
and Canada. In some ships bound to New York, from 20 to 30 
died on the passage; and in many vessels destined to Canada, the 
deaths were from 30 to upwards of 100. From one ship, the Vir- 
ginia, bound from Liverpool to Quebec, with 470 passengers, 158 of 
the number were buried at sea. 
The Montreal Immigrant Committee, in their report for 1847, 
state, that “ in no year since the conquest has Canada presented 
such fearful scenes of destitution and suffering.” “The year 1847 
has been unparalleled for the amount of immigration to Canada; near 
100,000 souls have left the British isles for these provinces the past 
year,—over 5,000 of these died on their passage out, 3,389 at Grosse 
Isle, 1,137 at Quebec, 3,862 at Montreal, 130 at Lachine, and 39 
at St. Johns, making in all at these several places 13,815. Ilow 
many have died in other sections in Canada East cannot now be 112 
knowm, nor, indeed, how many have perished in Canada West; but 
coupling all those who have perished with those who have passed 
into the United States, Canada cannot now number 50,000 souls of 
the 90 odd thousands which landed upon our shores. In sketching 
a retrospect of these terrific scenes, the Montreal committee forcibly 
remark—“From Grosse Isle, the great charnel house for victimized 
humanity, up to Port Sarnia—along the borders of our magnificent 
river, upon the shores of Lakes Ontario and Erie, and wherever the 
tide of immigration has extended, are to be found the final resting- 
places of the sons and daughters of Erin—one unbroken chain of 
graves, where repose fathers and mothers, sisters and brothers, in 
one commingled heap, without a tear bedewing the soil, or stone to 
mark the spot. Twenty thousand and upward have gone to their 
graves, and the whole appears, to one not immediately interested, 
‘like a tale that is told.’ ” 
The disease of which the emigrant passengers, and in many in- 
stances, the officers and crews of ships, perished at sea, and of which 
a great number were ill on their arrival in the United States and 
Canada, was typhus in its genuine form. In some ships dysentery, 
small-pox and measles swelled the amount of mortality, and added to 
the number of sick that reached the ports of destination. From some 
ships upwards of 100 ill were landed at the New York quarantine 
station; and so great was the influx of sick and destitute emigrants, 
during the summer of the last year, that the public and private hos- 
pitals and almshouse were filled to overflowing, and sheds and 
tents were erected for their accommodation. In stating these things 
we cannot withhold the grateful remark that, in providing these 
accommodations, and furnishing other means of comfort, the same 
spirit of benevolence was manifested, which animated our country- 
men in sending ships laden with supplies of food to the famishing in 
Ireland. 
The number of persons admitted into the marine hospital at Staten 
Island, in the year 1847, was 6,932. Of this number, 5,277 were sick 
with fever, and 662 died. In that hospital, 2,229 cases were registered 
as typhus fever, of which 457 died, and 3,020 as remittent and 
typhus remittent fever, of which 205 died. There is reason to be- 
lieve that many of these latter cases, landed from emigrant ships, 
were typhus; but excluding these, the total number of deaths from 
typhus at the quarantine hospital and within the city of New York, 
wras scarcely less than 2,000. 
But besides those admitted into the hospitals immediately after 113 
their arrival, or who sickened in the city and were sent to the hos- 
pitals, there were many who became victims of the disease at places, 
more or less distant, in the countries over which they were dis- 
persed. 
The effect of introducing so great a multitude of persons affected 
with typhus, or imbued with the fomes of the disease, into the midst 
of the resident population, could not be otherwise than to excite 
alarm, and, in fact, to extend the disease. Wherever the emigrant 
sick were congregated in masses, or collected in small numbers, or 
wherever individual cases were confined in small, unclean, and ill- 
ventilated apartments, the disease frequently attacked those who 
were in constant or occasional communication with them. From 
such communications nurses, physicians, friends, and transient visitors 
to the sick, have suffered in numerous instances. Of the medical 
officers in the New York and neighbouring hospitals and almshouses, 
not less than eight, mostly in the vigour of early manhood, and 
while engaged in active duties, giving promise of future distinction 
in the ranks of the profession, have, during the epidemic, been num- 
bered with the dead.* 
But though the disease among residents has, in most instances, 
been traceable to exposure to the poison emanating from the persons 
and effects of emigrants, there is reason to believe that it has, in 
some instances, originated de novo in the close and sordid dwellings 
of the poor in our large sea-port towns; and that the mortality from 
the disease has been augmented from such sources. This statement 
derives support from the circumstance, that the diseases prevalent 
in our northern Atlantic cities for the last two or three years, and 
especially in New York, have manifested a decided adynamic diathe- 
sis, a circumstance indicating, it is believed, the existence of a me- 
teoratious influence, which not only develops a predisposition to 
typhus, but favours the production of the poison of the disease. 
As to the mode in which the late typhus, or ship fever, has been 
propagated, the committee are not disposed to enter into an elabo- 
rate disquisition. The question whether typhus is diffused by a spe- 
cific contagious principle, or by a vitiated human effluvium, may be 
* Dr. Harrison states, in his letter before referred to, that!i with regard to the ship fever, 
(at New Orleans,) it has not been complicated with or modified in any way by the yel- 
low fever. It has been entirely confined to the hospitals, no persons that I have heard 
of being attacked out of doors. Several of the visiting physicians, Sisters of Charity, stu- 
dents, and others of the Charity Hospital, have been attacked, and some have died j bufc 
the disease has been confined to the cases I have now mentioned.” 114 
regarded as theoretical, and therefore affords grounds for a diversity 
of opinion. The fact that patients affected with the disease, in 
certain conditions, are foci of the typhus poison, must be granted by 
all observers. But the admission of this fact does not necessarily 
impose the obligation to consider the poison a specific virus, analo- 
gous in its origin and distinctive properties to that of small-pox or 
measles; and that it is not so, is the view taken of it in this report. 
As here contemplated, it is the product of the chemical changes 
which take place in the excretions or debris of the body in health 
and disease, accumulated in close apartments,—a poison more fre- 
quently and readily generated by the exhalations and other excre- 
tive matters of typhus patients, than by those of persons suffering 
under other forms of disease, or in the state of health,—a subtle 
aeriform principle, appropriately denominated idio-miasma, one of 
the generic forms of infection; and hence, typhus, instead of being 
classed among the contagious epidemics, is arranged among the in- 
fectious. In this theory is found a ready explanation of the origin 
and prevalence of typhus in jails, hospitals, ships, and the houses of 
the poor; and, also, of the mode in which cleanliness and ventilation 
arrest and exterminate the disease. These hygienic means, so effect- 
ive against the general propagation of the disease in the upper classes 
of society, seem clearly to intimate the true nature and source of the 
typhus poison. 
So entirely were the symptoms and course of the ship fever, as it 
occurred in New York, correspondent with the descriptions given of 
typhus in the standard works on Practical Medicine, that nothing in 
detail need be said in respect to them. It is sufficient to observe, 
that among the emigrants the malady was marked by great prostra- 
tion at an early period of its development, requiring liberal ad- 
ministrations of the most efficient means of stimulation and support. 
Petechise were more general than in some former years. Though 
sometimes running to a fatal issue under a simple form, the disease, 
in its graver varieties, was generally attended with cerebral, thora- 
cic, or abdominal complications. Erysipelas, often assuming a 
phlegmonous character, occurred in many cases, and frequently re- 
sulted in extensive sero-purulent deposits. Fluid collections of this 
kind were most common in the parotid glands, eyelids, and scalp. 
Secondary attacks happened in a few instances; and among the 
sequelae was noticed an affection of the eyes of an amaurotic form. 
As to the rate of mortality among the sick in the various hospitals 
of the United States and of Canada, there has been a great disparity; 115 
the differences depending on circumstances, in many cases, beyond 
the reach of control. In the New York hospital, as it is stated in 
the last annual report of the governors of that institution, “the num- 
ber of typhus fever cases treated during the year, was 1,034; very 
many of them cases of the severest form of the disease, and demand- 
ing far more than the ordinary assistance of physicians and nurses. 
Of this number 136, or a little more than thirteen in the hundred, 
have died. This result, though it appears to be a large proportion, 
bears a very favourable comparison with the statistics of any other 
sanitary establishment under similar circumstances of disease, and 
affords a very striking contrast to the terrible mortality from the 
same cause among the recent emigrants from Europe in other parts 
of the continent.” But though the amount of mortality has been in- 
fluenced by the circumstances in which the sick in hospitals were 
placed, it is to be noticed that the proportion of deaths has been 
greater among those in the higher than among those in the lower 
ranks of life, a fact generally observed in the typhus epidemics of 
Europe. 
With these remarks on the typhus or ship fever of the last year, 
we might close our report, were it not that a question of more than 
ordinary interest, relating to this subject, demands from us a care- 
ful examination,—a question on which the profession in this country 
and in Europe are divided, and which, it is thought, the phenomena 
of the recent typhus epidemic, added to the facts afforded by former 
prevalences of the disease, have largely contributed to elucidate. It 
needs hardly to be stated that we refer to the question of the identity 
or non-identity of typhus, and a form of disease entitled typhoid 
fever. That there are two forms of fever, bearing these names, 
which closely resemble each other, and yet which are essentially dis- 
tinct in their nature, is alleged by some of the most renowned patholo- 
gists of the age. The leading distinctive features of the two diseases 
are, it is affirmed, intumescence and generally ulceration of Peyer’s 
glands, and certain other morbid conditions, in one of them, and the 
total absence of these phenomena in the other. 
Now if, in fact, two such diseases exist in nature, the committee, 
in what they have submitted concerning epidemic typhus, have omit- 
ted to distinguish them, or, in other words, have committed an error 
in confounding distempers specifically dissimilar; for everywhere 
have the two forms of disease been associated and looked upon as 
one and the same malady. The attempt to rectify such an error, if 
such have been made, would involve the necessity of giving the history 116 
of two epidemics, occurring contemporaneously in the same localities, 
one to bear the title of typhus, and the other of typhoid fever, and of 
sustaining the distinction between them,—a labour not achievable 
in the hands of your committee. 
But it is believed that no such distinctive disorders can be recog- 
nized in nature; that the two forms of disease have not respectively 
a development which is peculiar or sui generis; that the disorders in 
question do not, as distinct specific affections, occur promiscuously, 
or side by side, in the same circumstances, from the same causes, 
among the same class of persons, in the same hospitals, ships, jails, 
and private dwellings of the poor. The grounds on which we ven- 
ture to express these opinions we beg leave respectfully to state to 
the Association; and we do this with the more freedom, as the ques- 
tion of the identity or non-identity of typhus and typhoid fever 
should and will continue to attract attention until a unanimity in 
regard to it is attained among the great body of enlightened phy- 
sicians. 
As the two forms of disease in question are fevers, and as the 
problem to be solved is, whether they are, or are not, one and the 
same malady, it will not be improper to glance at the means by 
which fevers are distinguished. It is much to be deplored that the 
distempers comprised in the class febres have not been more per- 
fectly disentangled, and their specific relations to one another de- 
finitively settled. That this has not been done, is owing, not to any 
want of labour or talent devoted to the work, but to the difficulties 
and obscurities inherent in the subject. 
The means of diagnosis in fevers are threefold; 1st, their efficient 
causes; 2dly, their symptoms; and 8dly, the alterations produced in 
the organism discovered after death. 
In regard to the efficient causes of fevers, it is evident that a 
knowledge of them, for the purposes of diagnosis, is of the highest 
value; for were they in all cases ascertainable, they would furnish 
not only a ready and correct diagnosis, but a solid basis on which 
to rest a natural classification of fevers. 
In respect to the symptoms, in the absence of a knowledge of 
the causes of fevers, it is clear that they are the only means by 
which, during life, one kind of fever can be distinguished from an- 
other. But in forming a diagnosis by these means, the mode of 
proceeding is in some respects peculiar. Whilst the acute phleg- 
masia} and most other violent local diseases are generally cognizable, 
by their rational and physical phenomena, immediately, or at an 117 
early period after their development, it is frequently otherwise in 
the case of essential fevers. These diseases are not so commonly 
distinguishable at first sight. In order to collect the facts from 
which their differential diagnosis may be deduced, it is often neces- 
sary to observe them carefully, sometimes in more than single cases, 
during the space of several successive days. Moreover in the phleg- 
masise, the diagnostic phenomena are for the most part local, being 
confined to the organs immediately affected. In fevers it is not so; 
the diagnostic signs are spread throughout the economy, and are 
slowly and successively developed, and not until a certain number 
or variety of them have come fully into view, can a specific fever be 
recognized. 
Of the anatomical alterations produced by fevers, it may be said 
that such of them as occur in the internal organs, and which are 
discoverable only after death, have no absolute claim to the character 
of diagnostic phenomena, since none of them are invariably present 
in the same specific fever, and many of them are found in different 
kinds of fever. There are, however, in some fevers, Gertain altera- 
tions in the organism so frequently revealed by autopsic examinations, 
that they may not improperly be admitted among the accessory 
means of diagnosis, especially in cases in which neither the causes 
nor the symptoms during life are sufficient to elucidate their dis- 
tinctive nature. 
From these general observations, we proceed to the question of 
the identity or non-identity of typhus and typhoid fever. And in 
doing so, leaving out of view for the present the history of their 
causes, we shall inquire: 
1st. Whether these diseases differ so much in their symptomatology 
as to enable us to characterize them as distinct distempers? 
2dly. Whether the morbid anatomy, and particularly the intestinal 
follicular lesions observed after death, indicate the diseases to be 
specifically different? 
1. Of the Symptomatology of Typhus and Typhoid Fever.—In 
essential fevers there are a few symptoms which are common to 
them all; and to these symptoms are added, in particular fevers, 
certain phenomena which arise in the progress of the morbid move- 
ments that mark their special form and character. Now among the 
leading symptoms, mostly of the latter description, observable in 
typhus and typhoid fever, are the following: great prostration of the 
sensorial and muscular energies, cephalalgia, disagreeable dreams, 118 
somnolence, delirium, coma-vigil, deafness, aphonia, stupor, subsultus 
tendinum, picking of the bedclothes, and at imaginary objects in the 
air, small, frequent and feeble pulse, pungent heat of skin, petechial 
eruptions, sudamina, dry and brown or black fur on the tongue, 
accumulations of dark sordes on the teeth and gums, epigastric pain, 
tenderness of the abdomen, gurgling in the intestines, diarrhoea, 
meteorism, hemorrhage from the nose and bowels, and retention of 
urine. 
Though such are the phenomena which occur in typhus and typhoid 
fever, yet all of them may not present themselves in every case; but 
it is observable that many of them, and especially those attendant on 
the last stage of fatal cases, are developed consecutively and in various 
degrees of force, in every individual example of both diseases. 
Now it is among the phenomena enumerated, that we must seek 
for the diagnostic symptoms of the two diseases, if any such phe- 
nomena exist. If the diseases be specifically different, they should 
respectively present certain pathognomonic or characteristic symp- 
toms. If they possess no such symptoms, nor any other diagnostic 
phenomena, they are obviously not distinct disorders. But let us 
examine the symptoms with a view to ascertain how far they indi- 
cate diseases different in their nature. 
It is generally admitted that there is much variety in the symp- 
toms of the premonitory and successive stages of typhus; and a 
similar variety, it is acknowledged, occurs in the corresponding 
stages of what is called typhoid fever. The incipient symptoms are 
often, for the most part, precisely the same in both maladies; and in 
whatever subsequent parallel stages we examine the two disorders, 
we find no signs by which to distinguish them as different species of 
fever. If in the several periods or stages of typhus we observe par- 
ticular combinations of symptoms, we find the same combinations in 
the several periods of typhoid fever. Phenomena which are usually 
present in typhus are sometimes absent, or but slightly developed; 
and the same is true in typhoid fever. The constitutional phenomena 
in the latter disease are grouped, and transformed in the same man- 
ner as are those which occur in the former. So far then as the general 
symptomatology of these diseases enables us to form a judgment, 
they are essentially the same. This conclusion, it is believed, might 
be sustained by an appeal to numerous cases recorded as genuine 
examples of typhus and typhoid fever. 
The phenomena on which the advocates for the distinctive nature 
of typhoid fever mainly rely in forming their diagnosis, are, it ap- 119 
pears to us, totally insufficient to establish the specific character of 
the disease. The more important of these phenomena are lenticular 
rose-coloured spots on the trunk, chiefly on the anterior part of the 
abdomen and chest, sudamina, gurgling in the right iliac region, ten- 
derness of the abdomen, diarrhoea, meteorism, enlargement of the 
spleen, and epistaxis. But which of these phenomena does not occur in 
typhus ? In regard to the size, colour, situation, and time of appear- 
ance of the eruption, there is nothing remarkable in the one disease 
which is not equally so in the other. The eruption in typhus, though 
among the characteristics of the disorder, is variable in size and 
colour; sometimes it is of a rose hue, but frequently violet or purple, 
at one time persistent under pressure, and at another evanescent. 
Such were the varieties of the eruption in the cases of typhus, treated 
under the direction of one of your committee, in the New York Hos- 
pital in June, 1840, and at various times in subsequent years,—cases 
of the identical nature of which there was not the slightest doubt, 
all of them having originated from the same source; namely, the 
fever poison idio-miasma, generated in crowded emigrant ships. In 
no respect did the eruption differ essentially from that which occurs 
in dothinenteritis or typhoid fever. As to sudamina, they are common 
to various states and kinds of disease. 
It is well known that age, constitution and modes of life, climate, 
season, and especially epidemic influences exert a powerful agency 
in modifying the symptoms of diseases; and there is good reason to 
believe that to such causes, the varying forms and character of the 
eruptions in essential fevers are in a great degree attributable. In 
some seasons the eruption in typhus is absent in very many cases; 
and moreover, it is sometimes wanting in cases in which the Peyerian 
glands are extensively diseased. Dr. Elliot, one of the physicians 
of the Bellevue Hospital, reports an instance in which “Pever’s 
plates were much enlarged and deeply ulcerated,” and in which 
“there was no eruption, nor any diarrhoea, during the whole progress 
of the case.”* Are not the rose-coloured spots of typhoid fever, the 
primary forms or conditions of the petechiae or maculae of typhus? 
Professor Clark, one of the physicians of the hospital just named, 
says, that “in the proportion of about one-half of the typhus fever 
patients, a rose-coloured eruption occurs on the body, which fre- 
quently in the progress of the fever assumes a petechial appearance.f 
* Annalist, vol. ii. p. 249; edited by William C. Roberts, M. D., New York, 
f Transactions of the Medical Society of the State of New York, vol. vii. p. 59, 1848. 120 
To elevate the shades of colour, and the varieties of form of the 
eruption to the rank of diagnostic phenomena, indicative of distinct 
diseases, when the more striking and important phenomena are 
unequivocally expressive of an identity of disease, is a refinement 
which, it appears to us, no clinical observer can regard with favour. 
Nor are the diarrhoea and gurgling in the right iliac region worthy 
of consideration, as signs by which the affection called typhoid fever 
may be distinguished as a specific disease, or one different from 
typhus. These phenomena occur in cases in which the general symp- 
toms of the two forms of disease, arising from disturbance of the 
nervous, vascular, and secretory functions, are the same, and which 
therefore indicate the affections to be one and the same. Gurgling 
in the bowels is common to many diseases; and as to diarrhoea it 
frequently occurs in fevers in which there is no follicular disorder 
of the intestines; and though it is generally present in dothinenteritis, 
it is sometimes absent. Dr. Swett, late President of the New York 
Medical and Surgical Society, so well known for his devotion to 
pathological studies, in discoursing on the cases of ship fever, treated 
at the New York Hospital, at a meeting of that society on May 1st, 
1847, stated that “in the case in which the ulceration was most exten- 
sive, there had been no diarrhoea; in the other case with ulceration 
less in amount, though still considerable, the diarrhoea had been pro- 
fuse.”* Similar remarks are applicable to the meteorism and ten- 
derness of the bowels; they frequently occur in disorders different in 
their character, and are occasionally wanting in typhus and typhoid 
fever. With respect to epistaxis and delirium, they are totally des- 
titute of any claim to the character of signs denoting a specific 
difference between the two forms of disease in question. 
But though the rose-coloured spots, the diarrhoea, and gurgling in 
the bowels, the meteorism, tenderness of the abdomen, epistaxis, and 
delirium, taken severally, or any two or three of these phenomena 
combined, do not enable us to distinguish typhus fever from the 
typhoid affection of Louis, still, it may be asked, do they not, when 
collectively present, that is, when grouped together in the same case, 
indicate these diseases to be essentially different ? In regard to this 
question it is to be observed, that, in discriminating fevers, the ablest 
clinical physicians place more reliance upon the uniform constitu- 
tional phenomena, as manifested in the morbid conditions of the ner- 
vous, vascular, and secretory organs, than upon those phenomena 
* Annalist, vol. i. p. 389. 121 
which are local and contingent. The former are esteemed the effi- 
cient, and the latter the accessory means of diagnosis. Are not in- 
termittent and remittent fevers known and distinguished by their 
types and general phenomena, and particularly by the modes in 
which the phenomena are combined or succeed each other ? In these 
forms of fever there is often inflammation or engorgement of parti- 
cular organs, and yet, notwithstanding such complications, each of 
these diseases is readily recognized and distinguished. Even in 
yellow fever, the course and form of the general symptoms, spring- 
ing from derangement of the nervous and vascular systems, are 
vastly more important as indications of the specific nature and dis- 
tinctive character of the disease, than the symptoms immediately 
connected with the gastro-intestinal lesions. These latter, it is true, 
are sometimes valuable subsidiary means of diagnosis; and, indeed, 
are occasionally essential aids in deciding in doubtful cases; but, 
aside from the general phenomena, they would scarcely suggest the 
idea of yellow fever; whereas, the constitutional symptoms are, of 
themselves, sufficient, especially when the disease is epidemic, to 
show the true character of the malady. The same remarks, in regard 
to the symptoms depending on special organic lesions, are applicable 
to every other essential fever. In the contagious exanthemata it is 
otherwise. In these, the eruption is, with very few or no exceptions, 
a constant occurrence, and is therefore regarded as one of their lead- 
ing diagnostic phenomena. 
Now if we examine the phenomena of typhus as described by Eng- 
lish writers, and compare them with those of typhoid fever as de- 
scribed by M. Louis and others, are we not warranted in giving to 
the general symptoms a higher value as diagnostics of the special 
nature of these diseases, than to those which indicate an affection of 
the glands of Peyer ? Is not typhus distinguished in all cases by the 
character and train of the general symptoms, rather than by any 
disturbance of the abdominal organs, indicated by tenderness under 
pressure, diarrhoea, gurgling in the right iliac region and meteorism ? 
And is not the same true of typhoid fever? That such is the fact, 
in respect to the latter disease, there can be no question; for Louis 
and others have recorded cases as typhoid fever in which the symp- 
toms of follicular disease of the bowels were obscure or not conspi- 
cuous. 
Idiopathic fevers, then, are distinguished by the kind and charac- 
ter of their general symptoms, and by the mode in which these are 
grouped and successively developed. In comparing fevers with one 122 
another, the order of the occurrence, as well as the peculiarity of all 
the phenomena, should be observed. When this is carefully done, 
there is generally no difficulty in discriminating particular fevers. All 
cases of fever are to be considered of the same nature in which the 
constitutional symptoms occur in the same order, and agree in their 
general features. The local, contingent, and minor symptoms, as 
well as the variations in the mode of attack, violence and duration 
of the morbid phenomena, indicate modifications of the disease, and 
nothing more. A physician practically versed in the diagnosis of 
fevers, on visiting the wards of a hospital in which the various spe- 
cies of essential fevers are assembled, will distinguish each particular 
kind of fever, not by tenderness of the abdomen, gurgling in the 
bowels, diarrhoea, and epistaxis—for these phenomena may or may 
not be present in fevers unlike each other—he will found his diag- 
nosis on the type, and general course and peculiarity of the pheno- 
mena manifested in the nervous, vascular, and secretory functions. 
In individual cases, in which the type and characteristic symptoms 
of a special form of fever are not as fully and clearly developed as 
is necessary to settle the diagnosis, he will await their occurrence, 
inquire into the etiology of the disease, and avail himself of the light 
thrown on the nature of the malady by the occasional or contingent 
symptoms. Thus, in yellow fever—a disease usually well marked 
and distinguishable by a train of general symptoms, cases occur in 
respect to which a doubt may exist as to their true nature, until the 
appearance of black vomit, an event in itself of no value as a diag- 
nostic of a specific form of fever, except when it concurs with certain 
diagnostics presented by the general system. 
Now in typhus and the typhoid fever of Louis, the morbid 
phenomena are so correspondent in the sensorial, vascular and other 
functions, and are so similarly catenated or related to one another 
from their accession to their termination, that the attempt to assort 
and group them, so as to make them express two different diseases, 
is a labour which, it appears to us, must fail to show any distinction 
which is found in nature and cognizable by practical minds. 
If such be a just view of the subject, in what light are we to regard 
the phenomena considered by Louis and others, as establishing a spe- 
cific difference between the two forms of disease in question ? To say 
nothing of the rose-coloured spots, delirium and epistaxis, are not the 
meteorism, tenderness of the abdomen, gurgling in the intestines 
and diarrhoea, occurring in fever, simply indicative of abdominal 
derangement, in the same manner as cough, expectoration, and cer- 123 
tain auscultatory signs denote a pulmonary complication, or as injec- 
tion of the adnata, intolerance of light, headache and delirium, show 
encephalic disorder? The principal anatomical lesions in typhus are 
found in the three great cavities; and there are no reasons that 
would warrant the forming of a special disease of those cases in 
which abdominal symptoms are prominently developed, which would 
not equally justify the creation of new diseases of cases in which 
pneumonic and cerebral symptoms are predominant. If the term 
abdominal typhus, applied by the German physicians to dothinen- 
teritis, be appropriate, it may not be improper to apply the terms 
thoracic and cerebral typhus to those varieties of the disease in which 
the lungs and brain are the organs that chiefly suffer organic changes. 
These terms, so used, import special complications of typhus, but 
not distinct diseases. 
That every case described by Louis as typhoid fever was genuine 
typhus is, perhaps, doubtful; but that most of his cases in which he 
found, after death, follicular ulceration of the bowels were not that 
disease, he has, we think, failed to show by any diagnostic pheno- 
mena. Had no autopsies been made, the cases would have been 
considered, by every pathologist, as simple modifications of the 
typhus of England and other countries. In searching for novelties 
in pathological anatomy, it should be borne in mind that the evi- 
dence for and against the theory of the essential nature of fever 
vastly preponderates on the side of the former; and, consequently, 
all anatomical lesions are to be considered contingent or secondary. 
The anatomical alterations in typhus and other kinds of fever some- 
times vary so much in different cases, that were one called upon to 
decide on the nature of the disease in a particular case, by inspec- 
tion of the body after death, it would frequently be difficult, and 
sometimes impossible, to say of what species of fever the patient 
died. Now such an embarrassment, in forming a diagnosis, rarely 
occurs in cases in which the symptoms, during the normal course of 
the disease, are carefully observed. In the plilegmasiae proper, a 
post-mortem diognosis is, in general, not left in doubt, but is promptly 
and certainly attained. 
Upon the whole, it seems to us, that the ingenious attempts which 
have been made to establish a specific distinction between typhus 
and typhoid fever, by an analysis of the symptoms, have yielded no 
other profitable result than a lucid exhibition of the modifications 
which genuine typhus assumes under different circumstances of tem- 
perament, habits and modes of life, climate, &c. In no other light 124 
can we regard the able researches on the subject, by Louis and 
numerous other pathologists, in Europe and America. 
2. Of the Morbid Anatomy of Typhus and Typhoid Fever.—As, 
then, the vital phenomena, observed during the progress of the two 
forms of disease in question, lead to the conclusion that they are not 
specifically distinct in their nature, it seems that the opinion, that 
they are so, has arisen from the discovery of dothinenteric lesions 
in one form of the malady and not in the other. The theory which 
localizes the cause of fever in the stomach and intestines, so fashion- 
able in the last thirty years, is obviously the source to which may 
be traced the distinction which is made between typhus and typhoid 
fever. Stated in a brief form, the theory, in relation to these dis- 
eases, is explicitly this; a fever with ataxic or adynamic symptoms 
in which the glands of Peyer and Brunner are tumefied and ulcerated 
is typhoid fever; and that a fever attended with similar constitutional 
phenomena, and in which those glands are not diseased, is not 
typhoid, but some other species of fever. That Louis employs the 
fact of the non-existence of dothinenteric lesions in febrile cases, to 
prove that the disease is not typhoid fever, is shown in his work on 
yellow fever, in giving the diagnosis of which he specially distin- 
guishes the two diseases anatomically, by the normal condition of 
the intestinal glands in one of them, and the constant alteration of 
them in the other. 
That there is a great and fundamental error in the doctrine 
which makes a specific difference between the diseases to which our 
inquiries relate, may, we think, be shown by adverting to a few of 
the anatomical facts and general arguments which bear directly on 
the subject. 
If a diseased state of the agminated and isolated glands of the 
bowels constitute the peculiar and essential anatomical character of 
typhoid fever, then certain other maladies considered by every ob- 
server as different in their nature, should be regarded as identical 
with that disease; for there is abundant evidence to show that in 
many instances of the disorders referred to, those glands are inflamed, 
tumefied or ulcerated. 
It must here he noticed that by the term anatomical character of 
a disease is meant, according to Louis, a morbid condition of organic 
lesion which invariably occurs in the same disease, and which, with 
certain other phenomena, distinguishes the disease from all others. 
Thus, in speaking of yellow fever, he says, “The red or black mat- 125 
ter found in the stomach and intestines, not having been found in 
all the cases, it cannot be considered an anatomical character of that 
disease.” But he adds, “it is not so with the alteration of the liver 
which was more or less exactly the same in all the cases, and which 
for that reason ought to be considered as the essential anatomical 
character of the yellow fever of Gibraltar of 1828.” 
Now, if we use the term anatomical character in the rigorous 
sense in which it is employed by Louis, are we not bound to consider 
every fever in which Peyer’s glands are diseased or ulcerated as 
typhoid fever? No special form of lesion of the intestinal glands, 
analogous to the special form of lesion of the skin in small-pox, is 
described as distinctive of the typhoid affection, for every morbid 
condition of them, except perhaps the tuberculous, is recognized in 
the disease. 
The truth is, disease of the glands of Peyer and Brunner, is in 
none of its forms, in the strict sense of Louis, an anatomical character 
of any one species of fever. It occurs in disorders unlike in their 
causes, and dissimilar in their character. It occurs occasionally in 
the different kinds of Jcoino-miasmatic fevers, and also, now and then, 
in the contagious exanthemata. It occurs especially and most fre- 
quently in idio-miasmatic or genuine typhus, and in febrile maladies 
which, in their progress become adynamic, or, as it is usually and 
properly said, typhoid. It occurs more generally in typhus, in some 
years, and in some localities, and countries than in others; and when 
it occurs it is an effect or complication, and not the cause of the 
febrile disturbance of the system. 
If these statements be correct, and that they are so, might, we 
think, be established by abundant testimony, there are no solid rea- 
sons for considering the affection of Peyer’s glands a feature distin- 
guishing the typhoid fever of Louis from the typhus of England and 
other countries. We have already shown that these diseases are so 
similar in their symptoms, that they cannot by these means be 
rationally characterized as different species. Whatever variety of 
forms they exhibit in their general or local phenomena, they scarcely 
ever fail to manifest a unity of type and character; and consequently 
they should be regarded as the same disease. Indeed, as we have 
said before, were it not that post-mortem examinations had revealed 
a lesion of Peyer’s glands, there never would have been a question 
as to their identity. 
With all the light which modern pathological anatomy has shed 
on the nature and complications of fever, and with all the aid afforded 126 
by researches, directed to the elucidation of the connections between 
the symptoms of fevers, and the structural alterations which occur 
in this class of diseases, can it be determined with a degree of cer- 
tainty, approaching the exactness with which we are able to an- 
nounce the existence of a pulmonary or cerebral complication, that 
the glands of Peyer are diseased in a given case of fever? A high 
degree of probability that they are affected may be inferred from par- 
ticular symptoms; but after all, nothing but an autopsy can establish 
the fact. 
That dothinenteritis occurs in genuine typhus is proved by the 
concurrent testimony of many physicians, who have enjoyed the 
most extensive opportunities of studying the disease, in all its forms 
and varieties of complication, and whose learning and talent for 
observation entitle their opinions to implicit confidence. While, on 
the other hand, it is shown by their inquiries that the intestinal 
glands are frequently affected in typhus; it, is on the other, demon- 
strated that in the form of fever denominated typhoid, the follicular 
disease of the bowels is sometimes wanting. To cite all the proofs 
which might be adduced in support of these remarks, would require 
wider limits than the present occasion affords. The statement of a 
few facts, bearing on the points in question, will sustain what a 
greater number could not render more evident. And first, let us 
advert to the evidence of some European authorities. 
In no country is typhus more prevalent than in Ireland. The 
disease is there seen in all its varieties, symptomatic and anatomical; 
and it is to the enlightened physicians of that country that we are 
indebted for much valuable information in relation to the nature of 
the disease. Dr. Kennedy, in giving an account of the typhus which 
prevailed in Dublin in 1837-38, says: “The only post-mortem ap- 
pearance that was at all constant, was congestion of the vessels of 
the membranes of the brain.”—“But if this epidemic typhus was 
not characterized by any uniform or constant pathological changes, 
it was very remarkable for the almost total absence of those abdomi- 
nal lesions which have been regarded by some as the invariable 
attendants of typhus fever. Indeed, in this respect, this epidemic 
affords a striking and conclusive refutation of the false and hasty 
generalizations of the French pathologists on this subject. In this 
respect, also, it differs altogether from the epidemic fever of 1826 
(which the writer had an ample opportunity of investigating while 
in charge of fever patients, supported at the expense of the govern- 
ment, at the Meath Hospital that year), in which in a large proportion 127 
of the post-mortem examinations made by him, more or less disease 
of the glands of Peyer was found.”* The typhus epidemics here 
brought into contrast by Dr. Kennedy, happily illustrate a well 
known law of epidemics, namely, that the same popular disease 
varies in its form and anatomical lesions in different years and sea- 
sons. There can be no question that the two epidemics of which 
he speaks were essentially the same in their nature, and the differ- 
ence in the condition of the intestinal canal in the two epidemics 
was incidental, certain influences in 1826 operating to produce “in 
a large proportion” of the cases, “more or less disease of the glands 
of Peyer;” whereas, in 1837-38, the analogous modifying influences 
occasioned scarcely any organic changes in the bowels, but chiefly 
a different complication, “a congestion of the vessels of the mem- 
branes of the brain.” 
Dr. M’Cormac, of Belfast, who evinces in his work on fever great 
familiarity with the diseases of Ireland, after minutely describing 
the various changes which take place in the aggregated and solitary 
follicles of the intestines, remarks: “This exanthem, if we may call 
it so, does not present the regular phases seen in small-pox; it may 
exist during the greater portion of the disease, and even after the 
fever has terminated.” And he adds, “after what I have said, I 
need hardly repeat again, that together with its results, it is only 
an occasional contingency in fever, and seemingly more frequent on 
the continent than in this country—from what cause, however, if it 
be this, I do not pretend to say.” 
Dr. Stokes, of Dublin, than whom there are few physicians more 
capable of arriving at correct conclusions on pathological subjects, 
regards “typhus as an essential fever which affects in an especial 
manner in different cases, and during different epidemics, either the 
head, the chest, or the abdomen.” He alleges that “the ulcerations 
of the intestines so much insisted upon by the French pathologists, 
are neither of constant occurrence, nor are they characteristic of the 
disease; in one epidemic they are found on dissection, much more 
frequently than in another. ”f Dr. Graves, the able colleague of 
Dr. Stokes at the Meath Hospital, entertains the same view of the 
nature of typhus. 
In accordance with these opinions, are the extensive observations 
* Medical Report of the House of Recovery and Fever Hospital, Cork Street, Dublin. 
By G. A. Kennedy, A.M , M.D., Dublin, 1839. 
f Medico-Chirurgical Review, No. 81, p. 71, 128 
made in England, recorded in the writings of Drs. Hewet, Tweedie, 
Copland, Southwood Smith, Marshall Hall and others. All these 
concur that the glands of Peyer are frequently the seat of anatomical 
changes in typhus. 
Similar investigations in Scotland have established the same facts 
in regard to the pathological anatomy of the disease in that country. 
Dr. Davidson in his Thackeray Prize Essay on typhus fever, gives 
a table showing the number and kinds of lesions observed in the 
post-mortem examinations of sixty-three eruptive cases admitted into 
the Glasgow Fever Hospital, from May 1st to November 1st, 1839, 
from which it appears, that enlargement of Peyer’s glands and 
ulceration of the intestines were present in many cases. 
These are but a few of the evidences of the occurrence of dothin- 
enterite lesions in the typhus of Great Britain and Ireland. But 
it may be said that the pathologists of these countries confound dis- 
eases which are specifically different; and that this is owing to their 
mode of studying the phenomena not being so minute and philo- 
sophical as the method pursued by the physicians of France. If the 
French make distinctions where the English do not, are we to accord 
to the former superior powers of discrimination? The English, 
Scotch, and Irish physicians have given evidence of talent and in- 
dustry in the investigation of febrile pathology not surpassed, we 
think, by the medical men of any country. They have patiently 
examined the grounds upon which their continental brethren have 
drawn a line of distinction between typhus and typhoid fever; and, 
having done so, they deny that there is any foundation in nature for 
it. Dr. Davidson who, it is believed, expresses the general opinion 
of British physicians, says, “ would it not, therefore, be refining our 
classification beyond all precedent, to separate typhus and typhoid 
fever with two species, where it has been shown that the symptoms 
in both are the same, or very nearly so, that they have nearly the 
same laws, as far as these have been ascertained; that the severity 
of the symptoms in both is not in proportion to the lesions of the 
intestinal follicles; and that the other complications of both are simi- 
lar, although various in the same place at different periods, while 
the only characteristic in dispute has been acknowledged not a con- 
stant, and therefore not a necessary element for the existence of the 
disease.”* 
Such, then, being the opinions of physicians practising in the 
Thackeray Prize Essay, p. 80. Appendix, British and Foreign Review, No. 22. 129 
British Islands, it becomes a question of curious interest, if nothing 
more, to learn what impressions have been produced on the minds 
of those who, conversant with the typhoid fever of Paris and other 
continental cities, have personally compared this disease with the 
British typhus. Dr. Lombard, of Geneva, so often quoted on this 
subject, during his visit to England, Scotland, and Ireland in 1836, 
examined several cases of typhus, two in Dublin, and one in Glas- 
gow, and finding the symptoms similar to those of the typhoid fever 
of the Continent, with which he was familiar, expected to find after 
death the usual dothinenteric lesions; hut, on examination, to his 
great astonishment, no such lesions were found. He says, “ in the 
whole course of my experience I have met with nothing which has 
surprised me more than this occurrence; I had been for years en- 
gaged in the study of typhus fever, and for years my almost daily 
experience in the dead-room led me to associate certain lesions of the 
alimentary canal with the symptoms of this disease, when suddenly 
I find myself assailed by a new experience exactly contradictory of 
my former; nor was my new experience unconfirmed by that of the 
Glasgow or Dublin physicians.” With such facts before him, to the 
question, “whether the two diseases are different or the same?” he 
answers: “I cannot allow that they are specifically distinct, and con- 
sequently I am almost forced to give up the opinion that the local 
changes of structure are of paramount importance in causing or pro- 
ducing the symptoms that accompany this type of fever.”* Though 
Dr. Lombard subsequently resumed the opinion that the two diseases 
are different, it appears to us he did so without sufficient reasons.f 
In the following year, 1837, Hr. Staberoh, of Berlin, made a visit 
to Great Britain and Ireland, and for six months devoted himself to 
the study of the fevers of those countries. His intimate acquaint- 
ance with the typhoid fever of Paris especially qualified him to com- 
pare the diseases in question; and, after doing so, he concluded, that 
though in many cases the British typhus wanted the follicular lesion 
of the bowels, the disease was the same as the typhoid affection of 
the continent.! 
To the above authorities in favour of the identity of the two forms 
of disease, we must not omit to add that of M. de Claubry, whose 
able and elaborate investigations of the subject were published in 
Paris in 1844. His assemblage of facts, and the inferences he draws 
from them, seem scarcely to admit of being rationally controverted. 
* Dublin Journal of Med. Science, vol. x., p. 19, 22, 23. 
J Ibid., vol. xiii., p. 426. 
t Ibid., p. 101. 130 
It thus appears that there are many of the more eminent patholo- 
gists of Great Britain, Ireland, and other European countries who 
concur in the opinion that no essential difference exists between 
typhus and typhoid fever. Their observations, however, establish 
the fact, that dothinenteritis frequently modifies the character of 
typhus; and that this complication is more common in some seasons 
and some countries than in others—a circumstance referable to 
causes which, though obscure, are clearly adventitious. 
The necroscopic researches in this country have afforded no satis- 
factory evidence of there being a specific difference between the forms 
of malady under consideration. On the contrary, the facts already 
spread before the public, as well as those daily accumulating in our 
hospital registers, when carefully analyzed and compared with the 
phenomena of the typhus and typhoid epidemics of other countries, 
show that these diseases are one and the same. Cases presenting 
the same general features, the same nervous, vascular, eruptive, and 
other phenomena, and springing from the same efficient cause, are 
found to differ merely in their complications, one case exhibiting 
after death various anatomical changes, particularly alterations of 
the glands of Peyer and Brunner, and others showing no such 
alterations. 
The strongest testimony, as it appears to us, yet adduced on this 
side of the Atlantic in favour of the opinion of the non-identity of 
typhus and typhoid fever, is that furnished by Dr. Gerhard of Phi- 
ladelphia. This gentleman has described in the American Journal 
of the Medical Sciences for 1837, two epidemics, occurring in that 
city in different years, one of which lie designated typhus, and the 
other typhoid fever. In speaking of the former (typhus), he says, 
“In this large number of autopsies, amounting to about fifty, there 
was but in one case, and that doubtful in its diagnosis, the slightest 
deviation from the natural appearance of the glands of Peyer.” In 
the epidemic which he denominated typhoid fever, it appears that 
Peyer’s glands were generally affected, and hence he inferred that, 
notwithstanding the similarity of the general symptoms to those of 
typhus, that the malady was not typhus. Now, if what has been 
said of the variety of complications which the same epidemic disease 
assumes in different years, be true, is it not fair to conclude that the 
differences in the morbid anatomy of the two epidemics described by 
Dr. Gerhard were due to incidental causes; and that the two epide- 
mics were the same disease modified in different seasons, as in the 131 
instances mentioned by Dr. Kennedy, and adverted to by Drs. Stokes 
and Davidson? 
The post-mortem examinations made at the New York Hospitals, 
during the last year, might be deemed sufficient, apart from all other 
testimony, to establish the identity of typhus and typhoid fever. In 
the cases of ship fever, a pure form of typhus, a disease unquestion- 
ably originating in every instance from the same poison, follicular 
disease of the intestines was found after death in some cases, and not 
in others. Dr. Stone tells us, in the New York Annalist,* that, in 
four weeks, ending May 12th, 1847, there were admitted into the 
Bellevue Hospital about four hundred and sixty-six cases, sick of 
typhus; and he says that “the most constant anatomical lesion which 
I have found in the examination of about twenty-five of those who 
have died, is an enlargement and softening of the spleen. Peyer’s 
glands were found more or less diseased in about one-fourth of these 
cases, and the heart more or less softened in a somewhat larger pro- 
portion. ’ ’ The same gentleman, in another communication, published 
in the New York Journal of Medicine,f relating to the same fever, 
gives the following among his other conclusions, drawn from observa- 
tions of the disease in New York and New England: “ That typhus 
and typhoid fever, so called, are identical.” Professor Clark, in 
illustrating the morbid anatomy of typhus, at a meeting of the New 
York Pathological Society, Feb. 28, 1848, stated, in reference to a 
particular hospital case, that “ the usual old typhoid lesion affected 
the intestines with the common appearance of the present epidemic.” 
“ This case,” he said, “ allies the present epidemic with the typhoid 
fever. At a meeting of the same society, held March 8, 1848, 
Dr. Swett made the following interesting statement. He said, “ that 
fever had occurred at the Bloomingdale Lunatic Asylum, carried 
thither by an insane emigrant, and fifteen persons had been attacked 
with it. Nine or ten had come to the hospital, and two had been 
examined post-mortem. In the first there were no lesions of any 
kind: in the second, there were ulcerations of the small intestines.” 
“ Where the ulcers existed, instead of attacking Peyer’s glands in 
the middle, they attacked the edges, extending two or three feet up 
the intestine, and then disappearing. Some had cicatrized, and 
some were cicatrizing. Both cases originated from ship fever in a 
very cleanly and healthy set of men ; so that it seems as if the same 
* Vol. i. p. 383, No. for May ] 5, 1847. 
f Vol. x. p. 176, No. for March, 1848. 
I Annalist, Vol. ii. p. 249. 132 
poison might communicate to one ulceration, and to the other none.” 
Dr. Swett ingenuously added, “that his belief in the non-identity of 
the diseases lessened daily, and he could not discriminate between 
cases presenting intestinal lesions (typhoid), and those which did not 
(typhus).”* Dr. Griscom, one of the physicians of the New York 
Hospital, states, that in ten autopsies of patients dying of ship fever 
in that Institution, in July, August, and September, 1847, six pre- 
sented follicular disease of the intestines. Peyer’s plates were pro- 
minent in four, and ulcerated in two. Facts of this kind are so fre- 
quently observed in the New York Hospitals that they have, in a 
measure, ceased to attract the attention of many physicians once 
deeply interested in their investigation, in reference to the question 
of the identity of typhus and typhoid fever. 
To the same conclusion tend the inquiries, relating to this subject, 
in other quarters of our country. A writer in the American Jour- 
nal of the Medical Sciences,f in speaking, it is presumed, of the ship 
fever in Philadelphia, says: “We have lately seen a great number of 
cases of fever in recently arrived Irish emigrants—the majority of 
the cases were of well-marked typhus fever; a few were of equally 
well-marked typhoid fever; while, in a third class of cases, the cha- 
racteristics of these two fevers were so completely blended that it 
was very difficult to determine which of the two predominated.” 
And he adds, “ here, then, we have persons who have been exposed 
to precisely the same morbific causes, attacked with fever of a simi- 
lar type, bearing the characters in some of the typhoid fever, in 
others of the typhus, and in others again a union, as it were, of the 
characteristics of both. This fact would seem to prove, that the 
typhoid is a mere form or variety of the typhus fever.” He also 
remarks, that “ in the present state of our knowledge on this subject 
it is, we conceive, much safer to consider the typhoid as one of the 
forms of typhus fever.” 
In view of the facts which have been stated, it seems to the com- 
mittee that no reasonable doubt can remain that typhus and typhoid 
fever are identical. Were medical men united in this conclusion, 
might we not hope, that with undivided attention, and a union of 
effort, more rapid advances would be made in determining the causes 
of the morbid condition of the Peyerian glands and other organs 
which occur in some cases of typhus and not in others ? On this sub- 
* Annalist, vol. ii. p. 265, No. for April 15, 1848. 
f No. xxix. p. 202, January, 1848. ject we would, in conclusion, remark, that it appears to us, that the 
deposit of typhus matter, so called, occurs not only in the intestinal 
follicles and mesenteric glands, hut also in and beneath the mucous 
membranes, in the lungs, spleen, and probably in the kidneys; that 
in some cases this form of epigenesis shows itself mostly, if not exclu- 
sively, in the intestines, in others in a different part, and in others 
again in various tissues; that in some instances it is not discovera- 
ble in any organ; that in the typhus of some seasons and countries 
it is generally present in the intestines, and in others, absent in 
many or a large majority of cases. 
JOSEPH M. SMITH, Chairman.