679

of the medulla spinalis, for we find, in the same authority on can-cer, that" inflammation has not been noticed, either in the ner-vous substance or its membranes, nor have the structures everbeen distinctly found to have become cancerous by continuity.The condition of the urine, which in this case presented abun-dant pliosphatic deposits, has been noticed both in Mr.Hawkins’ case of cancer of the spine, and in Sir B. Brodie’s,as quoted by Dr Walshe ; the latter surgeon’s patient sufferedfrom inflammation of the urinary organs, and it will be per-ceived, that in Dr. Leeson’s case the urinary apparatus was

igreatly disorganized. ____

KING’S COLLEGE HOSPITAL.Ticnaour of the Face.—A case, which excited a great deal of

interest, was operated upon last Saturday, 15th instant, byMr. Fergusson; both the size of the tumour and its situationwere well c.1lulated to attract a large share of attention. Thecase runs as follows:-James B-, aged forty-six, a nativeand resident of Reading, unmarried, is an ostler, and has gene-rally enjoyed good health, admitted, December 8, into theLondon ward, under the care of Mr. Fergusson. lie states,that thirty years ago, he first perceived a swelling in theneck behind the annle of the jaw, which continued increasingin size at a slow rate, and without pain, till about two or threemonths ago, since which time it has been increasing rapidly,giving the patient great pain at intervals. He says that hecan remember no cause for its appearance, and that he hasnever submitted it to medical treatment. The tumour is ofan irregular lobulated shape, and projects three or fourinches from the side of the head and face. It extends fromthe mastoid process to the malar bone, and from a little abovethe zygoma to the level of the body of the lower jaw. It ap-pears inflamed and softened at its most projecting point. OnDecember 11, Mr. Fergusson punctured the tumour in the last-named situation, and squeezed out some of the softened con-tents ; heisofopinion that the tumour is non-malignant, and thatit has no connexion with the lower jaw. When the patient ap-peared in the theatre, the tumour looked very much like thehead of a foetus projecting from the side of the face, but thefeatures were not distorted, and the general appearance of theman was satisfactory. Chloroform was administered by Dr.Snow, the patient being in a recumbent posture, and Mr.Fergusson proceeded to the removal of this enormous growthin the following manner:—Two incisions, meeting at rightangles, were made across the tumour, producing four flaps,which were carefully dissected back, to lay bare the bulk ofthe swelling; a good deal of dark blood escaped whilst theseparts were being divided. When the operator reached thelower part of the tumour, he was noticed to proceed verycautiously in dividing its cellular connexions with the vesselsand nerves which abound between the jaw and the sterno-mastoid muscle, and when the diseased mass was removed, aconsiderable cavity appeared, in which the external carotidartery could be seen beating. The masseter muscle was

quite bare, but no distinct trace of the parotid couldbe distinguished. Indeed, the knife must have passed veryclose to the carotid, and it was certainly no easy task to keepclear of it. The numerous arterial branches, as the auricular,ex-ternal maxillary, &c. &.c., did not bleed profusely, and the ha3-morrhage was soon commanded by a few ligatures. Points ofsuture were placed towards the base of the angular flaps, a fewshreds of diseased growth removed, and the wound dressedwith compresses. The patient was kept continuously underthe influence of chloroform, and experienced no pain. Mr.Fergusson, in addressing the pupils, remarked, that this casepresented unusual interest, both from the size of the tumour,and the locality where it had grown. Here was a tumourwhich had existed thirty years, involving the right parotidgland; it caused great disfigurement, but the patient hadhitherto been unwilling to allow of any surgical interference.Three months ago, however, the tumour increased rapidly,and for the first time began to give pain, and now the sufferer’was anxious to have this diseased mass removed. Still it wasa nice question, at present, whether the knife should be used,for it was evident that a new action had now set up in the tu-mour. It was plain that the growth was originally non-malig-nant ; but it was not certain whether it had not latterly becomeso; as there are plenty of facts in the history of tumours showingthat such changes take place. If malignant, interference wasnot justifiable; but the tumour was distinctly superficial; it hadno connexion with the jaw, or other important parts, and on apuncture being made on the inflamed part, cerebrifrom matterescaped. Such consideratious led Mr. Fergusson to consentto an operation, which, however, would have been much less

hazardous, had the patient applied only twelve months ago,for now the tumour is three times the size which it then was.The dissection, continued Mr. Fergusson, was carried very nearthe carotid artery; and it is very probable that the portio duranerve has been cut, for the patient, on leaving the theatre, al-ready exhibited some signs of paralysis of the face. The patientmust of course now run the risk of the casualties which mayattend such extensive and deep division of parts. Still it ievery probable that the disease will not return; and the ope-rator had seen smaller tumours of the kind, in the samelocality, which, after excision, did not return. On a sectionof the tumour, it was found that the anterior part was formedof a hard, fibrous substance, which had formed around a cyst,the remains of which were still visible. Three-fourths of thegrowth presented the aspect of highly-injected, cerebriformmatter; and it is Mr. Fergusson’s opinion, that this latterportion was fibrous originally, but has broken down by inflam-mation. The microscope will decide the true nature of thetumour; but even that instrument does not always give asatisfactory solution; and Mr. Fergusson is inclined to putsome faith in the old-fashioned way of deciding these ques-tions. It is evident, however, that the growth was at first ofa fibro-cystic character, whatever the subsequent changes mayhave been. The haemorrhage was far less than expected, andmatters are in as favourable a state as the case will allow.Mr. Fergusson had good reason for congratulating himself onthe small amount of bleeding, since, in operations of thiskind, " the haemorrhage is sometimes so profuse, from themain branches of the external carotid, and mere pressure souncertain of always commanding the flow of blood, that thepatient may actually die from sudden loss of blood." (Cooper’sDiet.) Mr. Goodlad, of Bury, many years ago, tied the carotidprevious to the operation. Mr. Carmichael, of Dublin, mentioned,after he had performed such a removal, that in a similar casehe would pass a ligature under the vessel, to be ready for anyaccident. But the present case shows that so great an amountof caution is not always necessary, and that a steady handcan surmount the difficulty. In Mr. Carmichael’s case, pa-ralysis of the face occurred, from the division of the trunk ofthe portio dura. Mr. South mentions a case, where, in theremoval of such a tumour, the external carotid was so per-fectly exposed, that he could raise it with his fingers; yet hesucceeded in not injuring the vessel. From all appearance, agreat portion of the parotid gland must have been absorbedin the present case, as generally happens when tumours growin this locality.Whilst we were witnessing the different steps of this ope-

ration, we were forcibly reminded of a passage in Mr. Fer-gusson’s book on " Operative Surgery," with the quotation ofwhich we shall close our notice :-

" Operations for the removal of tumours may be among themost simple in surgery, or among the most difficult and dan-gerous which the surgeon is ever called on to perform: thesmallest possible amount of skill may be necessary, in one

. instance; whilst in another, anatomical knowledge, facility in

. the use of instruments, judgment to plan, and courage toexecute, all the steps of the operation, are indispensable :’

Medical Societies.

ROYAL MEDICAL AND CHIRURGICAL SOCIETY.TUESDAY, DECEMBER 11, 1849.—DR. BURROWS IN THE CHAIR.ONE fellow was elected.

ON THE IDENTITY OR NON-IDENTITY OF THE SPECIFIC CAUSE OFTYPHOID FEVER, TYPHUS FEVER, AND RELAPSING FEVER. ByWILLIAM JENNER, M.D. Lond., Professor of PathologicalAnatomy in University College, London, and Assistant-Physician to University College Hospital.

(Communicated by DR. SHARPEY.)The author, at the commencement of his paper, remarks,

that for many years small-pox, measles, and scarlet fever wereconfounded under one name, and that it was only after thepublication of Dr. Withering’s essay, that measles and scarletfever were regarded as distinct affections-i. e., distinct as totheir course, their symptoms, their lesions, and their causes.Typhus fever, typhoid fever, and relapsing fever, are yet bymany looked on but as varieties of one disease. But thewritings of Dr. Gerhard, M. Valleix, and Dr. A. P. Stewart,.have rendered it highly probable that typhoid fever andtyphus fever are absolutely distinct from each other-twospecies of disease, and not varieties of one affection. In the

680

Monthly Journal of Medicine of the present year, the authorhas analyzed the course, symptoms, and lesions of structurefound after death in a certain number of cases of fever, andthis analysis, he thinks, proves that, as regards their course,symptoms, and lesions, no two diseases can be more distinctthan typhus and typhoid fever. But small-pox, measles, andscarlet fever differ also in respect of their exciting cause,which, in the case of each of these diseases, is specific. Inlike manner, typhoid fever, typhus fever, and relapsing fever,must require for their production the application of distinctspecific causes, if they be distinct diseases. To inquire whetherthe specific cause of each of these diseases is distinct, orwhether the cause of all these is the same, is the author’s ob-ject in the present paper. He first describes the peculiaritiesof the course and symptoms of relapsing fever, and of the skineruption of typhoid fever and of that of typhus fever, on whichthe diagnosis of these diseases rests. He then gives threetables, showing all the instances in which two or more cases offever were admitted from one house into the London FeverHospital in the years 1847,1848, and 1849 ; the age, sex, anddegree of intimacy of the individuals, as well as the, natureof the disease under which they laboured; and for the years1848 and 1849, the number of all cases of fever admitted intothe Fever Hospital during the separate months, with therash of typhoid fever and that of typhus fever respectively.The results exhibited in these tables are,—1st. That, in 1847,there were five instances of the admission of two or morecases of typhus fever from the same house, two instancesof the admission of two cases of typhoid fever from thesame house, and five instances of the admission of two casesof relapsing fever from the same house, and not a singleinstance of cases of the three diseases, or even of two of them,coming from the same locality. 2nd. That in 1848, two ormore cases of typhus fever were admitted from each of thirty-three houses; and two cases of typhoid fever from each offour houses; while there was only one instance of a case oftyphus and one of typhoid fever being admitted from onehouse; and in this exceptional instance there is reason tobelieve the patients received their diseases from differentsources. 3rd. That in 1849, two or more cases of typhus feverwere admitted from each of eighteen separate localities; andtwo or more cases of typhoid fever from each of four locali-ties ; while in not a single instance was a case of typhoid feverand a case of typhus fever admitted from the same house.4th. That in 1847, the relapsing fever, typhoid fever, andtyphus fever, and in 1848 and 1849, the typhus and typhoidfevers, prevailed simultaneously in the metropolis; and never-theless, that the cases of these several diseases came to thehospital from distinct localities. In 1848, there were receivedinto the fever hospital 118 cases of fever with the rash oftyphoid fever, and 390 with the rash of typhus fever; in 1849,118 with the rash of typhoid fever, and 143 with the rash oftyphus fever. As, therefore, about one-fourth of all the casesof fever admitted in 1848, and nearly half of those admittedin 1849, were cases of typhoid fever, the author argues, thatin the numerous instances in which two or more cases wereadmitted from one locality, cases of typhoid fever ought tohave been mingled indifferently with cases of typhus fever,in about their proportion in the two years, if the cause of thetwo diseases were identical; while, as has been shown, fromall the localities which yielded cases of typhus, there camebut one case of typhoid fever. He remarks, moreover, thatan increase of the epidemic prevalence of one of these kindsof fevers had no influence in increasing or diminishing theabsolute number of cases of the other kind of fever; that notransition-cases were observed, marking the passage of oneepidemic constitution into another; that the rash of typhoidfever and that of typhus fever were not modified in their cha-racters by variations in the prevalence of other kinds of fever;and that the absence or presence of lesion of Peyer’s patchesand the mesenteric glands always corresponded with thesymptoms of the particular cases during life, and did notdepend on the epidemic constitution. The author then ad-duces some particular instances, in which a succession of cases,coming from the same locality, or apparently arising from thesame cause, all presented the same characters. And in con-clusion, he remarks, that the facts contained in this paperappear to him to prove incontestably, that the specific causesof typhus and typhoid fevers are absolutely different fromeach other; and to render it in the highest degree probable,that the specific cause of relapsing fever is different from thatof either of the two former.

Dr. BARCLAY made inquiry of Dr. Jenner, whether he re-garded all cases in which there was no eruption as relapsing

fever, or whether there were cases of continued fever withoutspots, which were liable to relapse ?

Dr. JENNER said, certainly there were cases of continuedfever without eruption; in one-fourth of the cases admittedunder fifteen years of age there was no eruption; from fifteento twenty-two, in three out of twenty-one cases there was noeruption, but in every case beyond that age eruption was pre-sent. In one-fourth of Louis’s cases there were no spots.

Dr. A. P. STEWART was pleased to see that the opinions hehad published several years ago on the subject before theSociety were borne out so completely by the author of thepaper. He was satisfied at the time, that future experienceand observation would verify the correctness of his assertion,that the eruption of typhus and typhoid fevers were invariablyof a different character, and on no occasion passed from oneinto the other. One point, however, which he had dwelt onhad not been investigated sufficiently-he alluded to the re-lapses which took place in typhoid fever after convalescencehad been apparently established, the second attack runningin every respect the course of the former, with also the pro-duction of renewed lesions in the intestinal canal. This kindof phenomenon was never observed in typhus; sequelse mightoccur in typhus, but relapses never. It was said, by somewho contended for the identity of the two fevers, that in casesof typhus, in which no lesion of the intestines ever occurs,the disease progressed too rapidly to allow of such a change;but the truth was, that in typhoid fever the structuralchange had reached its full height on the third or fourth day,after which, disintegration commenced. The facts advancedby Dr. Jenner regarding locality were of much importance;and it now became necessary to ascertain whether an attackof one form of fever protected the sufferer from the other. Itwas not really true, that one attack of typhus with eruptionalways prevented a second attack in the same person, as hadbeen proved by many published cases, one of the most re-markable of which was that of Dr. Christison, who had sufferedthree times from typhus fever.

Dr. BARCLAY could not feel satisfied with the answer to hisquestions; for in his own experience fever without spots wasvery common; with spots, uncommon. Out of 111 cases offever admitted into St. George’s Hospital, fifty-nine onlywere spotted; and this number included all kinds of spots.He had found great difficulty in distinguishing the variouskinds of spots mentioned in the paper as diagnostic of typhusand typhoid fever, as in some cases the rose-coloured spotschanged to the mulberry hue; whilst in other instances nosuch change took place. Indeed, the actual appearance of theskin did not enable him to distinguish between typhus andtyphoid fevers: his diagnosis was founded on the state of thetongue and abdomen,the dejections, and other symptomswhichwere sufficiently easy. The state of the eruption enabled himto draw this conclusion, that where it was of a dark hue,ulceration of the intestines was very uncommon; whilst it wasalways present when the spots were rose-coloured. Thesefacts he had verified in numerous instances.Mr. SANKEY had at one time the same confused ideas re-

garding fever as the gentleman who had just spoken. Bookshad not enabled him to arrive at a more definite opinion; foreven in the latest works on the practice of physic the erup-tions were evidently confounded one with the other. Thisconfusion had been cleared up since Dr. Jenner and himselfhad perused the last edition of Louis’ work on Fever. Whenonce the two kinds of rashes were thoroughly understood, nomistake in diagnosis would be made. It would doubtless,however, require some well-marked cases, placed side byside, to arrive at a just knowledge of the eruption : thenurses of the Fever Hospital could distinguish the differ-ence. Out of the 300 fatal cases which had since occurred inthe hospital no error in diagnosis had been made, the post-mortem revealing the disease in Peyer’s glands where theeruption indicated the nature of the affection. For two orthree years past, the majority of cases admitted had beentyphus fever; no typhoid fever had been present, and, conse-quently, no ulceration of the intestines. Whilst typhus wasthen so prevalent, some Irish paupers were admitted, from St.Margaret’s Workhouse, with typhus; and before the epidemiewas on the decline, two female servants were admitted, fromthe house of one of the prebendaries of Westminster: thesewere undoubted cases of typhoid fever. It was supposed atfirst that the disease had spread from the workhouse, but, be-ing so different from the fever there prevalent, some distinctlocal cause was believed to exist; and this was proved to bethe case, for a foul and obstructed drain was discovered at theback of all the houses in which the fever had broken out. He

681

could corroborate the remark of Dr. Stewart respecting thechange which occurred in the intestine in distinct cases oftyphoid fever being often very early developed. In one case,a woman who was washing on the Friday, died of fever on thefollowing Monday, and both sets of glands were completelyhypertrophied. Mr. Sankey then made some remarks on thenecessity of observing a number of cases of fever before wecould arrive at a just knowledge of the exact nature of thedisease, from the eruption, and said, that cases were con-stantly admitted into the Fever Hospital, certified, too, bymedical men as cases of " fever," which turned out to be bron-chitis, pleurisy, or some other local affection.

Dr. BALY observed, that if the statements made by Dr.Jenner respecting the connexion of certain kinds of eruptionwith distinct kinds of fever, were admitted to be correct, thenthe additional facts, that cases of typhoid and typhus wererarely sent from the same house would go far to prove thatthese fevers depended on different and distinct causes. Hisexperience in some measure corroborated this; for in 1848 and1849, 117 cases of fever occurred in the Millbank Penitentiaryat the time that typhus and typhoid fever were epidemic with-out. Twenty of these were fatal, and in all the mesentericand Peyer’s glands were affected; they were all cases of typhoidfever. His experience regarding the presence and nature ofthe eruptions present in fever agreed, in the main, with thatof Dr. Barclay: many cases might occur without any kind oferuption whatever..Dr. WEST remarked that the remittent fever of children had

not been alluded to in the discussion. This fever amongst thepoor was often fatal, and his observations had led him to thesame conclusion as Barthez, that it was of the same nature asthe typhoid fever of Louis. The same appearances, allowancebeing made for age, were observed during life, and when fatal,the same appearances after death; the characteristic erup-tion, however, was often wanting. He recollected no case ofremittent fever in a child in which typhus fever was presentin the same house, and the converse of this also obtained.These facts, so far as they went, bore on the difference betweentyphus and typhoid fevers, and confirmed the view advancedin the paper by Dr. Jenner.Mr. SANKEY, in answer to a question from Dr. Webster,

said, that in speaking of cases being admitted into the hospitalunder certificate from medical men as cases of" fever," hemeant they were not instances of fever, according to the views of himself and Dr. Jenner. The question as to what is fever, Iwas an open question. The hospital admitted all cases offebrile disturbance of a contagious nature, or likely to becomeso. Thus small-pox, rheumatism, and acute inflammatory dis-eases of the chest, had been lately admitted.Dr. HEELE said that he recollected the time when it was

said that fever could not exist without some acute lesion ofthe internal organs being present. He did not thereforethink it very disparaging to the profession to occasionally con-found cases of pneumonia, bronchitis, &c., with cases of genuinefever.

Dr. WEBSTER inquired whether Dr. Jenner regarded typhusand typhoid fevers as contagious. Other causes, as overcrowd-ing, might produce fevers.

Dr. BARCLAY had drawn up a table specifying the propor-tion in which the two kinds of eruption occurred at differentages. From ten to twenty years there were five of the floridand three of the dark; from twenty to thirty, there wereseven florid, and three dark; from thirty to forty, five andthree, and from forty to fifty,five and five. The age and con-stitution of the patient influenced the colour of the eruption,which he regarded as independent of the specific contagion,and dependent on casual and other causes.

Dr. MERVYN CRAWFORD regarded the difference of opinionexpressed by the physicians to St. George’s and the FeverHospital as depending on the different circumstances in whichthey saw cases of fever,-in one, crowded together, and ofcourse exposed to the more condensed poison of the disease;whilst in the other the cases of fever were placed in variousparts of a common ward, and the poison thus mitigated. Hehad the same difficulty as Dr. Barclay in recognising theexanthem. He regarded the eruption as an accidental phe-nomenon, modified and determined by the state of ventilation,and by locality.Dr. JENNER, like others, had seen cases of typhoid fever in

which there was no eruption; and he spoke now of the spots,when present, only as a means of diagnosis. It must be re-membered, that in scarlet fever and measles the exanthemwas occasionally absent; and this would serve to point out theinconsistency of those who sought to associate typhus and

typhoid fevers, because occasionally there was no eruption.The mulberry spots in typhus, at first, in many cases, bore aclose resemblance to the rose-coloured spots of typhoid fever;so that in a few cases they might be regarded as exactlysimilar. His experience, however, fortified by 2000 cases,enabled him to assert, that if by the eighth day of the diseasethe eruption presented the true typhous character, then, ifdeath ensued, intestinal lesions would not be discovered.Dr. Baly’s cases, to be of any service in determiningthe diagnostic value of the eruption must be confined tothe fatal cases, where the after-death appearances were de--scribed : and these appearances had not been mentioned byhim. With regard to the opinions of Dr. Crawford, respect-ing the influence of impurity of the atmosphere and locality-on the eruption, he might state, that the Fever Hospital re-ceived patients from all parts of London, and its neighbour--hood. Personal observation of houses, in these various localities,-had not enabled him to observe any difference in their hygie-nic conditions. It must be self-evident, that no very great im--purity of atmosphere existed in the Fever Hospital, when nosuch change as that mentioned by Dr. Crawford, he, Dr.Jenner, could distinctly deny, ever occurred. He agreed withDr. West, that infantile remittent fever was really typhoid,and never gave rise to typhus. He reminded Dr. tewart,,that, in his published essays, he had described a ftttal case oftyphoid fever from relapse, in which the eruption appearedfor the second time. The fact of Dr. Christison having sufferedthree times from typhus fever, was no evidence that typhus.fever occurred more frequently than typhoid fever in the sameperson: because lie might have had the three different formsof fever under discussion, all of which Dr. Christison mightregard as simple continued fever. After some remarks on theconcurring testimony of Dr. Gerhard, Dr. Shutruck, Dr.Stewart, and himself, respecting these fevers, he observed,.that it was a frequent occurrence in the Fever Hospital, forpatients affected with typhus and typhoid fevers to lie side byside in the same ward, each disease preserving its own pecu--liar symptoms.

Dr. P. M. STEWART, in answer to Dr. Crawford, respectingthe influence of impurity of the atmosphere on the intensityof the fever poison, said it was not so attributable, accordingto the evidence of the experience of the Edinburgh Infirmary.He had frequently visited that hospital along with the late-Dr. Reid, and the patients were there distributed as they werein St. George’s and the Middlesex Hospitals, and yet the samesymptoms were there observed as in the Fever Hospital,in London, which now was well ventilated with pure air.Although Dr. Crawford had not found typhoid fever at Munich,.he (Dr. Stewart) had found typhus and typhoid fever in thehospital at Stuttgard; in Paris, where no cases of typhusfever had yet been seen, there was a strong impression thatthe two fevers were essentially different. In no other greatcity of the world were the two fevers so nearly allied innumbers as in London, and hence the facilities for studying,their essential characters were great.

Correspondence.

MEDICAL FEES AT ASSURANCE OFFICES.

"Audi alteram partem.11

To the Editor of THE LANCET.

SIR,—Some few weeks since I forgot my usual quiet habits,so far as to send you a correspondence between myself and the-Temperance Provident Institution, 31, Moorgate-street, whichyou were pleased to review in a very unmistakable way.I feel unwilling to intrude in your valuable periodical again,but the letter of " Fiat Justitia" (or as it should have been,Fy Justice, I know ye not) in your last number, roused my in-dignation, as it must that of every honourable man.As regards his puny attempts to show that the medical

attendant should be paid by his patient, if paid at all ! I have-nothing to say, as you, Sir, have long settled that questiontheoretically, and we, Sir, are now in a fair way to settle itpractically. I am sorry to agree with " Fiat Justitia," that wehave rogues in our profession, but at the same time am proudto say they are rare exceptions. But when he is so baretacedas to state openly in the first periodical connected with ourprofession, that we ought to give our services to assurance-offices for nothing, my indignation attains the boiling point;and I can only suppose that he is some official connected with