Letter from Dr. Perry on T~phous Fever. 381

taken in Germany within the last few years; and, in the next place, to describe more exactly the therapeutic value of tile medicinal springs at Weisbaden.

Wiesbaden is by far the most fi'equented medicinal spring in Germany; it generally contains from twelve to fourteen thousand invalids; and from fifteen to eighteen thousand persons make a longer or shorter stay in it, at- tracted by the splendour of the surrounding scenery, and the pleasant and agreeable society it affords. I t is, at pre- sent, the only one in Germany visited during the winter sea- son. Many delicate persons from the north select it as their winter station, its climate being the mildest in Ger- many, (for instance, it is the only place in Germany where the fig bears fruit in the open air,) and its situation pro- tecting it from the north and east winds. The arrange- meats for bathing and drinking the waters during winter are extremely well organized.

ART. XXIr.--Letterfrom Dr. :PERRY on Typhous Fever.

Glasgow Royal Infirmsry# Oct. 1# 1936.

DEAR SIR, I observed in the last Number of the Dub-

lin Journal of Medical Science, a letter from Dr. Lombard of Geneva, giving some account of his observations on Typhous Fever in Glasgow, Dublin, and other places ; in which letter, though not named, reference is made to my statements and opinions on typhous fever. During the meeting of the British Association in Dublin# it will, I believe, be in your remembrance, my having, on the morn- ing I had the honor of breakfasting with you and other members of the Association at the Lying-in Hospital, shewn you a paper on typhus, in the form of propositions, which, I explained to you at the time~ was drawn up at the

VOL. x. NO, 30. 3 D

882 JLetterfrom Dr. Perry on Typhous Fever.

request of a commission appointed by the Glasgow Medi- eal Society, to investigate the facts upon which the state- ments were founded. After looking over this paper, you advised that it should be read that day at the meeting of the medical section, which through your kindness was accordingly done. From my being unfortunately absent at the time the paper was read, it was unaccompanied by those explanatory observations which were necessary to account for the form in which it appeared, and to make it fully intelligible. From this cause, any netice of it which appeared in the periodicals of the day were very incorrect. I, therefore, judged it proper to publish the propositions, with a few explanatory observations, in the Edinburgh :Medical and Surgical Journal, for January, 1836.

When I had the pleasure of seeing Dr. Lombard ill Glasgow, I was delighted with tile interest he took in typhous fever; and during our interview I communicated to him the result of some of my observations on this disease, which appeared to him to be new', and I referred him for others, to the paper above mentioned in the Edinburgh Medical and Surgical Journal. He seemed, from what he heard and saw, to be satisfied--that a considerable dif- ference existed between the same fevers as they appeared on the Continent and in this country; chiefly, in the greater frequency, in the former, of those affections of the bowels, which by some are thought essential to typhous fever. When I was told by him, that he had never seen a ease of typhous fever inspected, in which there was not found extensive disease of the intestinal glands, I was not surprized, because I had heard the same statements repeat- edly made by medical men in this country, who had studied part of their course on the Continent, and whose opportuni- ties of inspecting typhous eases in this country, were neces~ sarily more limited than my own. I have inspected several hundreds of eases, and have not confined my observations to

Letter f~vm Dr. Perry on Typhous Fever. 883

those cases where intestinal disease was suspected, but have, uniformly, had the whole intestinal canal slit up, and the mucous membrane carefully examined; in this way I have often detected intestinal disease, when it was not pre- viously suspected. I was anxious, therefore, to learn the number of cases Dr. Lombard had an opportunity of seeing in the hospital to which he was attached, and the symptoms by which they were characterized. I f I remember rightly, his hospital did not admit of more than forty fever cases, and was not always full, so that from our greater number, about 2000 annually, and the nearly unlimited opportuni- ties we enjoy of inspecting all the fatal cases, (and which, for some years, I have never neglected to do,) I was able to speak more confidently on the subject, than his experience warranted him to do, so 4"ar as the fevers of this part 'of the country were concerned.

I not only explained to :Dr. :Lombard, that this local glandular disease of the mucous surface of the intestines, was, as far as my experience went, not essential to typhus, as supposed by most of the continental pathologists, and by many in this country, but that it frequently existed al- together, independently of contagious typhus, and was easily distinguished from it by the absence of symptoms essential to typhus, and by the presence of others not es- sential to that disease. From the circumstance of this disease of the follicular, or mucous glands of the intestines, being so s found in combination with contagious typhus, or following as a sequela of this disease, the dis- tinctions between this intestinal disease and typhus, have been too frequently overlooked, and the two diseases con- founded ; in the same way that Dr. Armstrong, from seeing the lining membrane of the bronchial tubes so frequently inflamed and thickened, considered these as constant and necessary accompaniments of typhous fever. Dr. Clutter- buck committed a similar mistake, when hc concluded, from

884 Let ter f rom Dr. Perry on Typhous Fever.

seeing the head requently affected, and, on post mortem examination, the brain and its membranes often exhibiting marks of inflammatory action, that typhous fever was caused by inflammation of the brain. It is true, that the doctrines of Broussais, which ascribe all fevers to intestinal affections are now iusistcd on by few: but still, they influence the opinions of many, to a greater extent than facts will war- rant. In the same way, I have myself seen bronchitis, &e. mistaken by experienced practitioners for typhus. I t is hasty conclusions like these, which retard the advance of medical science.

In the paper already referred to, I have mentioned tim symptoms which distinguish the one disease from the other. The distinction is not always so broadly marked as there stated. And, I am inclined to believe, that it has been the compounding of these diseases together, which has given rise to the opinion, that the typhous fever of this country is more contagious than it is on the Continent ; and also, that to this source is to be ascribed the contrariety of opinion which prevails, both in this country and on the Continent, respecting contagious typhus, which, as far as my expe- rience goes, is a contagious disease, while the intestinal affection is not. Dr. Lombard, towards the conclusion of his first letter, approaches near to what I conceive to be the true solution of the difficlflty, when he asks the ques- tion, " I f we may not infer, that various causes serve to im- press upon the general disease (viz. typhus), a tendency to associate itself with, and produce various local ailments ?" Among these he enumerates climate, season, diet, lodging, difference of race, and peculiarity of constitution. In his second letter, where he wishes to make out typhus to be, peculiarly, an Irish disease, he appears to have forgot what he had said in his first letter, and is not, altogether, con- sistent with himself. Nor is it altogether consistent, to call this an Irish disease, and yet call it contagious typhus,

Letter from Dr. Perry on Typhous Fever. 385

the "fi~vre des armes, ou fi~vre des prisons." Dr. Lom- bard, however, is in the fair way of arriving at the truth, and, with so active and intelligent a mind, I have little doubt he will soon arrive at ~ore .just conclusions, respect- ing fever, than he has hitherto arrived at ; and, considering the prejudices and prepossessions under which he laboured, the advance he has lately made is highly creditable to his r judgment, and love of truth.

A notion has been lately broached, and eagerly caught at by those members of the profession, who find, that they can no longer resist the evidence of their senses, and are yet unwilling to admit, that they have hitherto overlooked some of the most striking characters of contagious typhus, viz: tbat the typhus now prevalent is a different disease from that which prevailed some twenty or thirty years ago ; or, at least, that it is not characterized by the same symp- toms, and that it has undergone a modification, or assumed its present character, since the advent of Asiatic cholera. To shew the unsoundness of this opinion, it is only neces- sary to refer to the descriptions of the older authors, and more particularly, to the very excellent descriptions of Drs. Barker and Cheyne of Dublin, in their reports of con- tagious typhus. In these, we find exactly the same symp- toms mentioned, which characterize the typhus of tile pre- sent day ; and we have, at the same time, the testimony of many of the other reporters, who had seen the disease at former periods when epidemic, that it was in all respects the same.

I have, for some years, entertained the opinion, founded upon an extensive series of observations, that contagious typhus is an exanthematous disease, and is subject to aU the laws of the other exanthemata ;~ that, as a general rule, it

* In proof of this, I have often, in cases shewing symptoms of typhus, and

when I learned that they had been exposed to contagion, and had. not been secured

386 Letter from Dr. Perry on Typhous Fever.

is only taken once in a life-time, and that a second attack of typhus does not occur more fi'equently than a second attack of small-pox, and, judging from my own experience, Iess frequently than a second attack of measles, or scarlet fever.

I t is a very generally received opinion, that typhous fever may originate spontaneously, and become contagious from filth, improper diet, impure air, from the confinement and crowding together of human beings, or from some peculiar constitution of the atmosphere, or emanation from the bowels of the earth. Where are the well attested faets to be found, which can warrant any reliance on such fancies-- fancies so contrary to sound philosophy ? To suppose that any of these causes could generate a specific poison, and this always of the same kind and character, capable of pro- pagating itself by contagion, requires stronger faith than [ am possessed of; nothing but the most positive evidence could make me tbr a moment entertain such an opinion. It is, undoubtedly, a matter of great practical importance, to ascertain exactly the period of the disease at which typhous fever becomes contagious. From numerous observations and experiments I am satisfied, that it is not contagious before the ninth day, perhaps not till a later period of the disease. Among many circumstances which establish this opinion~ I may mention one experiment which I made upon a pretty extensive scale. The fever wards of the Glasgow Royal Infirmary are each capable of containing twenty pa- tients. The beds are arranged in two opposite rows, and a r e pretty near each other. While the patients are in the acute wards, they" are not allowed the use of their clothes, though they may be able to sit up ; they are, therefore, al-

against by a previous attack, predicted it with unfailing certainty, tile appearance of

the typhous eruption on the fifth, or at furthest, the sixth day from the commence-

meat of the attack.

Letter from Dr. Perry on Typhous Fe~:er. 387

most constantly confined to bed, excepting when rising to stool; and there is about one close-stool to every three pa- tients. Into the fever house are admitted, cases of measles, scarlet fever, and small-pox; and patients are very fie- quently sent in, labouring under bronchitis, pneumonia, erysipelas, and other local inflammatory affections. I found by experience, that when the latter elass of patients were sent to the convalescent ward, where they necessarily mixed with the'others, almost all those who had not a previous attack of typhous fever were either seized with it before ]eaving the house, or returned soon after their dismissal, ]abouring under it ; the period intervening between the time of their being sent to the convalescent ward, and the attack, never beil:g less than eight days. Although means were taken to keep those recovering fi'om small-pox, searla tina, &e., in a separate room from those convalescent from typhus, the rooms being adjoining, the non-intercourse waa incomplete, and the result was, that these diseases oCea. sionally spread among the typhous convalescents, and the convalescents from small-pox and scarlatina caught typhus. In consequence of these observations, I adopted the practice of not sending, as formerly, to the convalescent wards, those patients affected with inflammatory diseases, unless I ascer- tained that they were secured against the disease by having" had a previous attack of typhus ; butkept them in the acute fever wards, till they were so far recovered as to go to their own houses, and the result was, (and the practice was con- tinued for several months,) that not one of those detained in the acute wards caught the disease while there, or returned with it afterwards. Fl'om the above, and other observations, I have adopted the opinion, that typhus, like measles, small-pox, &e., is chiefly spread during the period of con- valescence. In the paper already noticed, I have men- tioned the desquamation of the cuticle, whieh usually takes place when a patient is convalescent from typhus. Do the

388 Letter from Dr. Perry on Typhous Fever.

fine scales thrown off in this state contain the poison, which, by adhering to the clothes and hair of the patient, are carried about with him, and being rubbed off, are, while floating in the atmosphere, applied to the mucous surface~ or inhaled by a susceptible recipient, in whom it produees~ after a certain time, the specific disease ? Whether this is the way the disease is spread or not, further observa- tions must prove. The practice of shaving the head of every f ever patient admitted into the Glasgow Royal Infir- mary is a good one, and ought to be universally adopted~ as well as the practice of causing every such patient, before dismissal, to be well washed in a tepid or warm bath. I may mention that I am, at present, engaged in preparing statistical tables to illustrate some of the points here ad- verted to, and others connected with fever.

Permit me, in conclusion, to return my sincere thanks to you and the other medical gentlemen of Dublin, for the very kind and friendly manner in which you treated the gentlemen from Glasgow, who attended the meeting of the British Association. All of us remember it with pleasure~ and, for myself, I state it seriously, I think it among the happiest periods of my professional life. I trust the gen- tlemen of Glasgow will soon have an opportunity of return- ing the compliment.

Believe me, my dear Sir,

Yours sincerely,

ROBEnT PERRY, M.D.