i V"1' ' ■HT-ttTf\K— '.V ,-V1^: .!■'!; .■.','•. •'*$3 K T y+. Surgeon General's Office a** . ' « * yvi' fa «# 'AiW ,N< SsS^rf* ^CQjQ^.gQOaCjQQO'?0" -^ .-^ - v. *. *■*■ ^ • * - " « *. -,:V ■ *, * t g§£ J *' •-* to ?.-\ •;^ti "» -- «s -:;,::•&' ** ^y$n<: V ;.,. ■'a.>-.. /• V* '.......- / A TREATISE ON THE NATURE, CAUSE, AND TREATMENT CONTAGIOUS TYPHUS. iFrom the ©fermam OF J. VAL. DE HILDENBRAND, IMPERIAL AND ROYAL COUNSELLOR, PROFESSOR OF THE PRACTICE OF MEDICINE IN THE UNIVERSITY OF VIENNA, CORRESPONDING MEMBER OP THE ROYAL SOCIETY OF GOTTINGEN, OF THE SYDENHAMIC SOCIETY OF HALLE, AND HONORARY MEMBER OF THE PHYSICO- MEDICAL SOCIETY OF ERLANGEN. <. ^ ^.LIBRARY. :- By S. D. GROSS, M. D. " ------—7------ NEW-YORK : ELAM BLISS, NO. Ill BROADWAY. PHILADELPHIA : JOHN GRIGG, NO. 9 NORTH FOURTH-STREET. 1829. w c x SOUTHERN DISTRICT OF NEW-YORK, SS. BE IT REMEMBERED, That on the eleventh day of March, A. D. 1829, in the fifty-third year of the Independence of the United States of America, Elam Bliss, of the said district, has deposited in this office the title of a book, the right whereof he claims as proprietor, in the words following, to wit: "A Treatise on the Nature, Cause, and Treatment of Contagious Typhus. From the German of J. Val. de Hildenbrand, Imperial and Royal Counsellor, Professor of the Practice of Medicine in the University of Vienna, Corresponding Member of the Royal Society of Gottingen, of the Sydenhamic Society of Halle, and Honorary Member of the Physico-Medical Society of Erlangen. By S. D. Gross, M. D." In conformity to the Act of Congress of the United States, entitled " An Act for the en- couragement of learning, by securing the copies of Maps, Charts, and Books, to the Authors and Proprietors of such copies, during the time therein mentioned." And also to an Act, entitled " An Act supplementary to an Act, entitled an Act for the Encouragement of Learning, by securing the copies of Maps, Charts, and Books, to the Authors and Proprietors of such copies, during the times therein mentioned, and extending the benefits thereof to the arts of Designing, Engraving, and Etching Historical and other Prints-" FRED. J. BETTS, Clerk of the Southern District of New-York. Printed by Gray & Bunce, 224 Cherry-st ZUM WOHL DER MENSCHHEIT. Ego vero, et cujusmodi fuerit dicam; et quae sibi quisque ob oculos proponens, si quando rursus etiam hie morbus ingruat, jam praedoctus aliquid habeat, ex quo preecipue eum cognoscat, haec declarabo; turn quia ego ipse hoc morbo laboravi, turn etiam quia alios hoc laborantes ipse vidi.— Thucyd. de Peste, L. 11. Ed. Oxoni. Shel. p. 111. PREFACE, Although we have a number of works on Ty- phus Fever, yet it is to be presumed, that the Trea- tise of Professor Hildenbrand, in an English dress, will not prove altogether unacceptable to the mem- bers of the profession, or entirely unworthy of their perusal. Germany, France, and England, have al- ready acknowledged its merit; and almost every Eu- ropean writer of eminence, has considered its author as one of the most able writers upon the disease before us, as well as one of the most excellent and skilful practitioners of the present age. The observations which it contains are the result of an experience of more than twenty years, during which the author had frequently charge of large hospitals, and lazarettoes, and had an opportunity of wit- nessing the most extensive and deplorable ravages of the disease. During the late continental wars which convulsed Europe, and carried havoc and destruction amongst her armies, Hildenbrand was faithfully engaged in combatting the ravages of Typhus Fever, and re- stored to his country, by the interference of his VI PREFACE. skill, many a useful and valiant soldier. It cannot be justly supposed, therefore, that the work which we here present to the public, and which is the re- sult of such extensive experience and profound ob- servation, should be entirely destitute of useful matter. Whether Typhus Fever is a very common dis- ease in this country, is, perhaps, a matter of doubt; yet it cannot be denied that it often makes its ap- pearance in many of our states, especially in New- York, New-England, and in the interior of Penn- sylvania. Nor is it, perhaps, precisely of the same nature and characterized by the same symptoms as the Typhus of Europe; yet it does not necessarily follow from this, that we are to neglect its study, or pay no attention to the observations and opinions of foreign writers ; because the disease may, from a variety of causes, soon become as common in the United States as it is abroad, and, perhaps, assume a similar character. S. D. GROSS. Philadelphia, Dec. 1828. CONTENTS. ■~»»q<»i. Page SECTION I. On the Definition of Contagious Typhus ... 1 SECTION II. Of the Antiquity and History of Typhus, and of its Effects upon the Human Race . . ■ . • • • 13 SECTION III. Of the Preliminary Division of Contagious Typhus . 19 SECTION IV. Of the Simple Regular Typhus, communicated by Contagion, 22 SECTION V. Description of the Regular Typhus, communicated by Con- tagion ......... 56 SECTION VI. Of the Causes and Modes of Development of Typhus 73 SECTION VII. Of the Terminations of the Disease .... 93 SECTION VIII. Of the Prognosis of Typhus.....105 SECTION IX. Of the Treatment of Regular Typhus . Ill SECTION X. Of the Treatment of Irregular Typhus . . 146 SECTION XI. Of the Regimen in Typhus .....158 SECTION XII. General Observations on the Originary Typhus . . 168 CONTAGIOUS TYPHUS. —@©©— SECTION FIRST. OF THE DEFINITION OF CONTAGIOUS TYPHUS. The word typhus is derived from the Greek Tttyas, or according to some, from Tv$*h, and owes'its origin to the an- cient Greek physicians. It properly signifies stupor; and febris typhoides, Tv$a$n<; Tv^trtq, therefore, when taken in this sense, denotes nothing else than a fever, in which stupor is the most prominent symptom. In the writings of Hippocrates, typhus signifies insensibility, or coma. Foesius says: (1) To$e« apud Hippocratem dici- tur stupor attonitus, cum quis mutus aut attonitus considet. This observation he has confirmed by several passages from the works of Hippocrates. In the books of Hippocrates, (2) however, there are no less than five kinds of fever, described under the name of ty- phus. The first kind appears to he our common bilious fever ; the second, a pituitary nervous fever; the third, a dysenteric ; the fourth, a rheumatic, and the fifth, a hectic fever. Although these books cannot be classed amongst the legiti- mate works of the Father of Medicine, yet they show, in a satisfactory manner, that the notions of the ancients, with regard to typhus fever, were neither clear nor comprehensive, and that the word typhus was employed rather to designate a single symptom of the disease than the whole assemblage of phenomena by which it is characterized. (1) (Economia Hippocratis. (2) De Internis Affectionibus, Sect. III. 2 Galen, who was not contented with a mere empirical view of diseases, regarded the liver, the bile and the mucus, as hav- ing a powerful influence upon the production of typhus fever. He considered it in an arbitrary manner, and without any re- gard to the previous signification of the term, as a continued and inflammatory fever, symptomatic of, and excited by, erysi- pelatous inflammation of the liver. (1) In taking this view of typhus fever, Galen did not neglect to take into consideration the phrenetic stupor, which is the most essential symptom of the disease, (2) and which has chiefly given rise to its name, when he observes : Typhomania, affectus ex phrenitide et le- thargo mixtus, in quo delirant aegri et somniculoso torquentur comate, ex bilis et pituitae permixtione. (3) In the mean time, as these theoretical ideas of Galen became disseminated, they had such an influence upon the minds of physicians, that the empirical view of the disease was so much neglected, that the stupor, the most apparent and prominent symptom, scarcely received any morfe attention; while the liver and the bile were regarded as the principal objects in the study of typhus fevers. The Arabian physicians, who embraced the doctrines of Galen, united all their influence in support of this opinion, and the doctrine of these fevers, instead of receiving additional strength, was so much neglected, that its principal characters were almost forgotten. Avicenna, in fact, is the only one who mentions typhomania, under the name of sohara subeth; but without differing from Galen in any point whatever. The excellent practitioners of the sixteenth century, who shook off with so much boldness the yoke which Galen had imposed upon them, during a period of more than one thou- sand years, fell into the same error as the ancient Greeks, in applying to typhus the same, and sometimes even a more limit- ed signification. Petrus Forestus (4) relates the history of an (1) Comment, in Aphor.42. 1. 7. (2) Thcstupida insania of Hippocrates. (3) Comment. 1. in Prorrhat. (4) Ob3erva. Medic. Lib. 11. Observa. 37. 3 ordinary inflammation of the liver, under the name of typhus, which terminated in suppuration; and he considers as such, every kind of erysipelatous fever ; although Galen, and sub- sequently Aetius, described the inflammatory fevers, attended with erysipelas of the stomach, under the name of lipyrias, those with erysipelas of the lungs, under the name of crimo- des, and those only which were attended with erysipelas of the liver, under the name of typhoides. But this expression of erysipelas plainly indicates, that, in the sense of this doctrine, a typhus fever could not have been an inflammatory fever, properly so called; and that the inflam- mation which accompanied it never presented a true plegmo- nous character. In taking this view of the disease, however, physicians lost sight of its characteristic symptom—the stupor. Prosper Alpinus gives a similar, though a somewhat more arbitrary view of these fevers, when he observes: (1) Febres exterius mites, intus conturbantes Graeci typhodes appellant. The humoral pathologists of the last two centuries, totally abandoned this denomination, and comprehended amongst the typhus fevers those which had a tendency to produce an alter- ation in the fluids. They confounded typhus also with the bilious, the putrid and petechial fevers ; though, according to their origin, these fevers, as well as the hospital, prison and camp fevers, should only have been considered as so many va- rieties, and the useful views which might have been deduced from the peculiar character of typhus, were, by this manner of considering the disease, every day more and more neglected. Notwithstanding this, the learned Sauvages, who appears to have attentively observed an epidemic typhus, which prevailed along the frontiers of Spain in 1761, laying aside every theore- tical notion, gave a masterly description of this disease, and a°-ain pointed out its peculiar and characteristic symptoms. According to him, typhus is a fever which has a course of from two to three weeks, and differs but little from synoehus during the first few days, but may be readily distinguished from it, by its having less intensity and heat, by the almost natural state of (1) De Praesag. Vita et Morte. Lib. 1. cap. X. 4 the pulse and of the urinary secretions, and particularly by an insidious character susceptible of contagion ; all of which may give rise to coma, delirium, exanthematous eruptions, swellings of the parotid glands, convulsions and other symptoms. In consequence of these views of the disease, its characteristic symptom was again perfectly re-established. Sauvages. also believes that the first and third typhus of Hippocrates, as well as his cacoethis, (1) were the same kinds of fever. The physicians who believed that the solids were the seat of every morbid derangement, and particularly those who attribu- ted every thing to the nerves, were contended by including typhus, properly so called, amongst the nervous fevers. But in the different views which they took of this disease, they fell into the same error as the humoral pathologists, by neglecting to take into consideration the peculiar nature of typhus. The slow nervous fever, so admirably described by Huxam, was no- thing else than a typhus, which generally ran its course in four- teen days. . Dr. Cullen, in giving the definition of typhus, after Sauvages, observes: (2) " I think that the limits between the synochus and typhus will be with difficulty assigned ; and I am disposed to believe that the synochus arises from the same causes as the typhus, and is, therefore, only a variety of it. The typhus seems to be a, genus comprehending several species. These, however, are not yet well ascertained by observation; and in the mean time we can perceive that many of the different cases observed, do not imply any specific difference, but seem to be merely varieties arising from a different degree of power in the cause, from different circumstances of the climate or season in which they happen, or from different circumstances in the con- stitutions of the persons affected." Such is the explanation of this great nosologist, who has left us undetermined as to what meaning we ought to attach to the word typhus, which he has used in too general a sense. (1) Coac. Praenot. (2) Synopsis Nosologic Methodicse. 5 This was no doubt the reason why most of the modern phy- sicians have endeavoured to re-establish the ancient denomination of typhus; but, being guided by the authority of a great phy- sician, who had given in an arbitrary manner, and contrary to the opinions of the ancients, too general a definition of the word typhus, (1) they regarded as such, not only every fever in general, but every stage of the disease in which there was some predominant symptom of nervous irritation, or some de- gree of debility. In this manner, the sense of the ancient denomination, and the idea that should have been attached to it, were not only perverted, and the peculiar nature of typhus entirely neglect- ed; but there resulted this logical error, that instead of divi- ding typhus into species, and considering it as a genus of ner- vous fevers, they comprised every nervous fever under the general description of typhus. Peter Frank is the only one who has avoided this error, and who has conciliated the sentiments of the ancients (at least that of Galen,) with the opinions of the moderns, when he observes: (2) Non aliter cum Typhode, etc. veterum rem se habere observamus, quae vix non semper ad nervosam aut ma- lignam febrem pertinet, cum abdominalium viscerum inflam- matione non nunquam conjunctam. W. G, Plouquet (3) appears to have justly appreciated the peculiar nature of a species of typhus ; but in another place, he takes this word also in a general sense, and regards the ner- vous and malignant fevers as synonymous with typhus. J. C. Reil (4) denominates the typhus fevers those in which the vital energy of the organs is depressed and attended with an increase of irritability, and arising most frequently from a malignant and remote cause. He thus hypothetically associ- ates with the idea of the stupor, which ordinarily accompanies (1) L. C. § 67. He avows that he cares but little what meaning the ancients attached to this word. (2) Epitome De Curand. Horn. Morb. T. 1. § 90. (3) Delin. System. Nosol. T. 1. p. 183. (4) Fieberlehre, § 300. etc. G the typhus fever, a sort of irritability which is in direct opposi- tion to it; but he confesses that he was obliged to extend the dominion ?of typhus beyond the limits that are assigned to it by the sense of the term. The partisans of the doctrine of excitement, classify the ty- phus amongst the asthenic fevers; or they comprehend under the name of typhus, every fever arising from debility. Even the celebrated Hufeland, (1) understands by typhus, nothing else than a fever which is dependent upon a diminu- tion of the vital powers; and C. F. Harles (2) refers the na- ture of this disease to a diminution of the vital energy, either of the whole system, or only of a single organ. Sprengel, who has given such an admirable description of this disease, under the name of Febris Hungarica, nosocomia- lis, navalis, carceralis, castrensis, &c, has entirely avoided the denomination of typhus; (3) and the same thing is done by Pinel, (4) who includes the typhus in the order'of fevers, which he has so ingeniously called ataxia?. From this general doctrine, and from the opinions of the writers on typhus, which we have just related, it appears: 1. That all physicians are agreed that a state of debility is the general and essential character of typhus. • 2. That the bilious, the nervous, the malignant, the putrid, the petechial, the nosocomial, the prison, the camp and the ty- phus fevers, were confounded under the same name, and al- most without the slightest difference, by the physicians of the sixteenth century; that all these fevers have been classed by the modern physicians amongst the asthenic fevers, though the word typhus, previously used to designate a species, was im- properly employed to denote a genus—a" circumstance which has been a source of much injury to the diagnosis and treat- ment of this disease. (1) System, der Pract. Heilk. 2 Th. (2) Neue untersuchungen ttber das Fieber fiberhaupt und uberdie Typhusarten insbesondere. (3) Handbuch der Patholog. 1. B. (4) Nosographie Philosoph. 7 3. And finally, That typhus has not been considered as an essential and special disease, or as a peculiar kind of asthenic fever accompanied by the predominant symptom of a kind of stupor of the senses, or an affection of the liver ; and that no physician has justly appreciated the primitive meaning of the word which has been so arbitrarily employed. We cannot, however, consider every nervous or asthenic fe- ver as a typhus, without too great a departure from the sense of the ancient denomination, and consequently from the proper use of language. 1. Because many fevers, which have not the slightest appear- ance of nervous disturbance, or any remarkable symptoms of true debility, have been described by the modern physicians as nervous or asthenic fevers; and because they have been more anxious to ascertain the causes of asthenic, than even the characters of debility itself. It is in this manner that physi- cians have often regarded a simple depression of the vital pow- ers as a true debility, when, in fact, it was perfectly fallacious. 2. Because, although the true vital debility consists in the state which has been designated by the name of status nervo- sus, and in the asthenia properly so called, and which author- izes the denomination of nervous and asthenic fever, we should only comprehend under the name of typhus such a kind of fe- ver, which is essentially characterized, according to the ancient and original denomination, by the attonic stupor and the ty- phomania. In the new doctrines of this disease, physicians have paid too little attention to its peculiar character, and have contented themselves with a generic denomination and a gene- ral mode of treatment. 3. Because, in general, we have as yet no clear and precise ideas of asthenic fevers ; for the debility, or diminution of the vital activity and excitement, are rarely or perhaps never the cause, but simply the effect of the fever; and because we can- not by any debilitating means, artificially produce any kind of fever, as may always be readily done by stimuli; and, as has been beautifully remarked by Plouquet, (1) none of these fe- ci) Exposit. Nosol. Typh. Tubing. 1800. 8 vers arise from a diminution of excitement or of the vital pow- ers, but they come on simply with debility ; and, in a word, the most malignant asthenic fever is always preceded by another febrile character, however short it may be, which is the reason that the asthenic character is always a secondary symptom, and never the disease itself. 4. And finally, because the typhus is an essential and primi- tive disease, and is therefore justly entitled to this name, from first to last; and because the simple character of the symptom- atic debility, which may accompany every kind of fever and arise simply from the effects of bad treatment, does not merit the appellation of typhus. The denomination of typhus, moreover, having been once taken arbitrarily, and given rise to very erroneous ideas, it is easily to conceive why some physicians have regarded typhus fever as contagious, and others as non-contagious; and why most of them have defended their contrary opinions with so much warmth, and even with some degree of truth; for the de- nomination .was not only too vague, but the different cases of the disease were too undetermined. The words typhus, asthenic fever, nervous fever, putrid fever, bilious fever, pituitary fever, hectic fever, &c. have frequently been confounded, and the ideas that should have been attached to them have been so in- distinct that many physicians appear to have been ignorant what kind of disease they should designate by these terms. The essential typhus was often taken for another fever, as cer- tain fevers were falsely taken for the typhus. In order, however, to avoid every ulterior dispute concerning the denomination of a disease, the original sense of which has been lost by an abuse of language, I shall treat in this work exclusively of the contagious typhus—a disease which developes its peculiar miasm in the human body, so as to be capable of being communicated to other individuals, and which is always perfectly similar and of the same essential nature, arising from a miasm sui generis and always the same ; and which, in a word, should alone bear the name of typhus, since it possesses the peculiar characters which are expressed by this word. 9 The contagious typhus is an essential fever which presents a constant uniformity in its progress. It is a disease of a peculiar kind, and like the small pox, it is of a contagious * nature; since, by means of a peculiar matter, which is de- veloped during the disease, it may be transmitted and com- municated to those who are predisposed to it. It has a pecu- liar exanthema, by reason of which it belongs to the family of exanthematous fevers, amongst which the contagious fevers are ordinarily arranged. It has a definite course, as well as differ- ent characters in its proper stages, and a constant and uniform ^ symptom of stupor, with delirium or typhomania. In its nature also, the contagious typhus, as has been in- geniously remarked by Galen,. presents more or less evident biliary derangement; in a word, it is a fever which is in itself, sometimes inflammatory, sometimes nervous or putiid, and which may at all times assume these characters. The typhus is distinguished from the malignant fever, by the fact, that the malignity, even when it causes a sudden depres- sion of the vital powers as the meaning of the term indicates, is not necessarily contagious, and that it is in general only a symptom which may accompany every kind of fever, and even the typhus itself, when it has an anomalous course. It is distinguished from the pure nervous and asthenic fevers, properly so called, in this, that, although these fevers are ushered in with true vital debility and the ordinary nervous symptoms, they are not contagious; and the affected nervous system manifests only some particular signs of this contagion, as for instance, the stupor and some others which we shall hereafter describe when speaking of the course of typhus. The exan- thema, perhaps, also establishes some difference, as well as the periodical exacerbations, which are more peculiar to the sim- ple nervous fevers. It is distinguished from the putrid fevers, by the fact, that the character of putridity of these fevers is only symptomatic, and occurs during the course of every kind of fever, and is even sometimes, in anomalous cases of contagious typhus, a symptom of this disease. As long, however, as it is not typhus, 3 10 it is not of a contagious character, and appears to be, in every respect, an acute scorbutic disease. It is distinguished from the inflammatory bilious fevers, which, so long as they are simple and unconnected with any other dis- ease, are riot only destitute of contagion, but they are distin- guished by their characteristic phenomena, and especially by the absence of nervous symptoms. They manifest also, in general, rather a state of oppression of the vital powers than any real debility. Typhus, in a word, is distinguished from all the fevers which we have just enumerated, and from all those which have any resemblance to it, by certain essential and predominant symp- toms, and by a peculiar and determinate course. These phe- nomena will be more fully described in another section, where they will be distinguished as much as possible from the other accidental phenomena. By this method, I believe it possible to avoid every mistake, and to point out in a clear and satisfactory manner, the dis- tinction between the symptomatic and asthenic debility of fe- vers, and the typhus, properly so called ; and I believe, more over, that with these two words—contagious typhus—I shall be able to say enough to be intelligible and clear upon a subject which has hitherto been represented, in the writings of Cartheu- ser, (1) Reil, (2) Meier (3) and others, either in an insufficient manner, or under improper points of view. I am far from misconceiving the merits which some modern authors, such as Mayer, (4) Frank, (5) Sternberg (6) and others, have acquired in the explanation of this disease, and in its distinction from other asthenic fevers ; but their observations are by no means satisfactory. The English, in general, and particularly Campbell, (1) Stephenson, (2) Jearne (3) and Bu- chanan, (4) appear to have already had some clear ideas of typhus, at the time that the school of Brown enforced, with so (1) De Typhomania. Fr. 1750. (2) Pathologia Typhi ficuti, Hal. 1792. (3) Disser. de Typho. WurC. 1804. (4) Specimen Pract. deRemed.in Morb. Contag. Vind. 1806. (5) Reisen. 11. Th. (f>) E. Horn'* Archiv/furmodiz. Erfahr. vii- B. 1. H. 11 much pretention, that every contagious fever might be explain- ed by the doctrine of excitement.—A complete monograph upon this disease will perhaps excite more attention, and lead to more perfect and satisfactory results. I have retained the denomination of typhus, because this term is, in reality, the most proper and convenient; and be- cause it was employed by the most ancient Greek physicians, and expresses the most constant phenomenon of this disease. This expression does not lead to any erroneous theory, nor to any hypothetical mode of cure, as the names of putrid fever, nervous fever, bilious fever, and others are apt to do. In a word, it has in itself no particular relation to the different symptoms which occur during the course of the disease, but it is applicable to each stage and to each character of this fever, which are, ordinarily different in the different stages of the disease. In order to give a more correct idea of the general character of typhus, and to penetrate into the intimate nature of this dis- ease, it is absolutely necessary to pay particular attention to the difference which appears to exist in the contagious matter. This contagious matter, independently of the variations and the accidental modifications which are sometimes observed in its effects, is not only more or less malignant, but it is likewise characterized by different and essential properties. The typhus may be properly divided, according to the differ- ent degrees of intensity, and the modifications of this contagious matter, into malignant and ordinary. The pestilential, or Oriental typhus, or the common plague, and perhaps also the occidental typhus, or the yellow fever of America, belong to the first division. Both these diseases are strongly characterized by malignity, and the climate appears to modify the contagious matter, which produces them, in such a manner, that some of the symptoms, and especially the exan- thematous eruption, which is the most invariable symptom of the typhus fevers, are different from the ordinary symptoms of the European typhus. The typhomania and the affection of the liver, are, however, invariably present, and constitute the most common symptoms of the disease. 12 The ordinary typhus, which is peculiar to Europe, is com- monly less malignant in its progress, nor are its symptoms so violent, so acute, or dangerous. Under this ought also to be comprehended, though only as so many varieties, the typhus which occurs in hospitals or lazarettos, in prisons and camps, the typhus of ships and besieged cities, and that which is develop- ed originally in small communities, from whence it is exten- sively communicated, either so as to become endemic, like the fever of Hungary, or epidemic, like some malignant, putrid and petechial fevers. When these fevers are spread by contagion, they are nothing else than an ordinary typhus, and then, they are also contagious. Fracastor already observed of these dis- eases : (1) Sunt febres mediae quodammodo inter vere pestilen- tes, et non pestilentes—majoribus etiam nostris cognitae. The consumption of horned-cattle or the plague of these animals, may, in every respect be comprised in the one or the 'other of these divisions which we have just indicated, because it is nothing but a typhus, communicated by contagion, and cha- racterized by peculiar modifications. I woukHnvite, therefore, the veterinary physicians, to pay particular attention to what we shall say upon typhus fever, as it affects the human subject, in order that they may draw such conclusions as may be appli- cable to the resources of their art. I have treated the pestilential typhus, for several years, but having had but a few cases of this disease on the frontiers of Turkey, I have not been able to make any precise and satisfac- tory observations. The remarks which I shall make upon the ordinary typhus, are founded upon a great number of careful observations, which every physician may compare with his own, since this disease is not of rare occurrence in practice. I have selected them, in fact, for the most part, from the observations on the typhus which occurs in hospitals and prisons, because I have seen it more fre- quently than any other, while those which I have collected upon the other varieties of typhus are comparatively few. But I am disposed to believe that the remarks which I shall make upon the first, maybe readily applied to all the modifications of this disease. (1) De Morb. Contag. Lib. 2, Cap. 6. SECTION SECOND. OF THE ANTIQUITY AND HISTORY OF TYPHUS, AND OF ITS EFFECTS UPON THE HUMAN RACE. If we compare the observations that have been made in the preceding Section, upon the nature of this disease, with the word typhus, taken in the sense which the ancients attached to it, it will be obvious, that this disease, which is here designated under the name of contagious typhus, and which it is our main object to distinguish, in a diagnostic and therapentic point of view, from other analogous fevers, was already known to the ancient Greek physicians, and that its intimate nature had en- gaged their particular attention. There prevails, in fact, in the writings of Hippocrates (1) a striking confusion with regard to the five species of typhus which are there recorded; but the description of the first, of the second, and the third typhus, and especially the faithful de- scription of a disease, which is found in the legitimate works of Hippocrates, under the title of " Popular Diseases," (2) prove that the contagious typhus, with all its different and essential symptoms, and its particular course, has been known and ob- served from the earliest ages to the present day. If we take also into consideration the causes which produce this disease, and which must have been the same in all ages of the world, there can be no ground for doubt, that typhus is as ancient as the human race, or at least as ancient as the first traces of civilization or the formation of society. And as this disease is contagious, and as the principles and species of contagion have always been the same, there can be no doubt that typhus often made its appearance, especially in (1) De Intern. Affect, Sect 3. (2) De Morbis Popular, Lib. II et HI. 14 hot climates, under the form of a prevalent popular disease. And if the ancients have said nothing of the contagious pro- perty of this disease, it is probably because they were still ig- norant of it; for it must be remarked, that during many ages, and even in modern times, physicians have uniformly sought in the air the causes of the Oriental plague, though they had al- ready employed, with the greatest success, establishments for the prevention of infection. This being the case, contagious typhus might easily have exercised its ravages, for several centuries, either as a sporadic, an endemic or an epidemic disease, accompanied by its differ- ent modifications, and conformably to the denominations and ideas that had been received at those periods. And this, in fact, has been the case. Many of the contagious diseases which have desolated the human race', and which have been described under the name of the plague, belonged neither to the plague of the East, nor to the other popular epidemic diseases, and were nothing else than an ordinary prevalent contagious typhus. Without pretending to make a parade of erudition, either in history or literature, and without taking the trouble to give an account of all the plagues that have been described, and which were nothing else than the ordinary typhus, I shall only cite that, which in the year 1528, ravaged all Italy, and carried off no less than twenty-one thousand of the French troops, (1) and which, according to its description and origin, was merely a typhus camp fever. The disease, which prevailed in the army of the emperor Charles V. in the year 1552, during the siege of Metz, described also under the name of the plague ; (2) the plague which appeared in Hungary, in 1566, and which spread, under the name febris Hungarica or pannonica, over a great part of Europe ; (3) the plague of Misnia, in 1574, that of Den- (1) Math. Unzer. Catoptron Loimodes S. de lue pestefera, Lib. 3. Hall. 1615. Item Fracastor. de Morbo Contag. (2) And. Gratioli. Commentarii de Peste. Venet, 1576. (3) Dan. Sennert, de Morbo Hungarico. 15 mark, in 1613 and 1652 ; (1) that of Leyden, in 1669, (2) and several others, were nothing but an ordinary prevalent contagi- ous typhus. The innumerable multitude of epidemics that have been ob- served under different modifications, and which have been de- signated, according to their different and predominant symp- toms, under the names of putrid, malignant, dysenteric, and other fevers, were nothing else than the ordinary typhus. For the proof of this, let us take a glance at the fevers that have prevailed in modern times. The epidemic putrid fever which prevailed in and about Vi- enna, from 1757 to 1759, and which has been so admirably de- scribed by Hasenoehrl, (3) was a contagious typhus ; as well as the epidemic of 1771 and 1772, which caused so much mor- tality throughout Germany and in Vienna, and which has been described by Fauken, Langsvert, Jagemann, Huther, Melch, (Et- tinger, Mayer, Bcehmer, Kesler, Schebelt, Opitz, and others. I shall prove in a subsequent part of this work, that every violent epidemic may finally degenerate into contagious typhus. From this fact, it is evident that the famine and the calamities, which are the usual consequences of war, may draw after them a great mortality, either arising from contagious diseases, or, as it is vulgarly called, from the plague. Under such circum- stances, the sufferings of man are at their highest pitch of in- tensity. The mortality which arose from the contagious diseases that prevailed during the late wars, is still fresh in the memory. After the campaigns of 1793 and 1794, the contagious diseases desolated all Germany, (4) and again appeared in 1796 and 1797. After the campaign of 1805, a destructive contagion ravaged all Galicia, Moravia, Bohemia, Hungary and Austria, (1) Ad. Lebenwald Chronik Aller denkwtirdigen Pesten. Ntirnb. 1615. (2) Sylvii de le Boe, Prax. Med. Tract. 10. (3) Hist. Med. Morbi epidemici S. febris petechialis, quae 1757 usque 1759. Vienna? grassata est. Vindob. 1763. (4) H. Rennebaum Hist. Morbi Epid. Contag. anni 1793 et 1794 a Franco- gallis captivis Culmbacium delati. Erl. 1796. id* I. C. G. Schafer uber das 1793 in und um Regensburg Herschende Ner- venficber. 16 and penetrated into Germany and Russia. A similar disease made its appearance in the suburbs of Warsaw, and in a great part of Prussia; it directed its course towards the north, as has been asserted by Hecker, (1) and produced almost as great ravages as the plague in the Levant, and in the East Indies. These diseases, and particularly those of a prevalent character, are in fact, almost always the consequences of wars, and hu- man calamities. While I was writing this work, during the summer of 1809, at the commencement of the war, a prevalent and similar con- tagion had already made its appearance, and threatened the most dangerous consequences. The germs of this disease were partly developed in consequence of the crowded apartments of the soldiers, partly in consequence of the unwholesome situa- tion of the camps, and partly also in the hospitals, whence it spread, after the evacuation of the convalescent, and followed their different routes, so as to produce the most extensive ra- vages. The direction of this disease could be easily traced, by following the route of the infected soldiers. These contagious diseases, which are the consequences of the calamities of war, and which occasion so great a depopula- tion, have been justly denominated by Hufeland, the " Pest of War." They are always produced by the contagious typhus; and what is still worse and more to be regretted, they frequently display their most horrible and destructive effects long after the establishment of peace between the contending nations. An excellent description of the typhus camp fever which carried havoc and destruction into the Carthagenian army at the siege of Syracuse, may he found in the writings of Diodo- rus, (2) the historian.] Similar contagious typhus diseases, however, may often pre- vail to a very great extent, and may occasion considerable mor- tality, without the consequences of war or the influence of that dreadful scourge of humanity. If we take into consideration all the remarks which we have made, and if we take a glance at the by-passed ages of the (1) Uber die Nervenfieber, Welche in Berlin 1807 hcrrschten. (2) Biblioth. Hist. Lib. 14. Cap. 70-71. 17 world, and the millions of people that have been the victims of contagious typhus, it will be seen that this disease has more contributed to the depopulation of the human race, than even the plague, which, though it is more malignant in itself, is never- theless of more rare occurrence. Like the small-pox, scarlatina, croup, epidemic catarrh, phthisis pulmonalis and the plague, contagious typhus is one of the seven heads of the cruel Hydra which devours the human race, which threatens incessantly the inhabitants of Europe with calamities and death, and which in general causes the greatest mortality throughout the world. Powerful means have already been discovered for the pre- vention of the small-pox, and experience has proved that man- kind have but little to fear in future from this disease. The Oriental plague is no longer so dangerous as formerly; the means of keeping it off are already known, and of preventing it when it makes its appearance in the West. It is true we can never perfectly destroy the typhus, because it may every day be reproduced upon our soil, but it is in our power to arrest its propagation. This, however, has hitherto been but imperfectly done ; and it is high time to lay aside the unhallowed idea that we have done enough for humanity, when our attention has been occupied with the preservation of single individuals. It is a duty enjoined upon us by the sacred ties of nature to prevent the propagation of such diseases, and to free, as far as lies in our power, mankind from its horrible effects. The efforts of physicians in preventing contagious diseases, may, in general, be regarded as of the highest importance, be- cause, to preserve the health of thousands is certainly a much greater blessing than to be able to treat the disease of a single individual since it is proved, that the contagious diseases, which might cause almost a total destruction of the human race, are not only its greatest scourge, and the most extensive cause of its de- population ; but what is stilly more dreadful and distressing than any other circumstance, is the^ct^-that by means of this dis- ease, the contagion may be reciprocally communicated from one individual to another, from brother to brother, from the 4 18 father to his children, and from the children to their parents, and that the fraternal and charitable reception of those who are affected with typhus, the most sincere pity, and the most tender cares are too frequently involuntarily recompensed by the con- tagion, the disease and death of the benefactor. These reflections have induced me to persevere in making indefatigable researches upon the contagious diseases, and I may be permitted to hope that my efforts will not be altogether without benefit to the human race, especially so far as they re- late to the contagious disease of which we are treating. SECTION THIRD. OF THE PRELIMINARY DIVISION OF CONTAGIOUS TYPHUS. In order to give a correct description of the contagious typhus, and to avoid every confusion in the classification, the etiology and treatment of this disease, it will be necessary in the first place to give an exact division, andthen to treat of each of these divisions in particular. In the first place then, typhus may be divided into commu- nicated contagious typhus and into originary typhus. The communicated typhus is that which attacks a person in health, or one who has already been suffering from previous disease, but which, in this case, has no dependence upon, or re- lation with, that disease, and which results solely from the com- munication of a peculiar contagious matter, which, during the course of the disease, is regenerated and strengthened in the human body, in such a manner as to be able to communicate itself to other individuals. In this respect, the communicated typhus may be accidentally connected with another disease, without, however, its being essentially dependent upon it. It may be either simple or complicated, but in relation to its ori- gin it is always a primary disease produced by contagion. The. originary typhus, on the contrary, is that which is deve- loped spontaneously by means of some other disease, and by means of certain requisite conditions, without being produced by any previous contagion, but which may afterwards be com- municated to other individuals by a subsequent contagion. The originary typhus, therefore, is always in itself a secondary dis- ease, which is not only produced by another disease, but which can never appear in a healthy individual. 20 Although it cannot be confirmed by experience, yet reason teaches us, that every communicated contagious matter must have its peculiar and primitive origin. The contagious miasm of typhus, which is perhaps better understood than that of any other disease, is developed in consequence of other fevers, in such a mariner that we can describe and explain its progress ; and by means of certain requisite circumstances, it may, as we have already said, be daily reproduced. Notwithstanding this, it is of the greatest importance to dis- tinguish the symptomatic debility, and the nervous state of the originary typhus, in which the danger of the contagion is of a purely chimerical nature, while it is of a directly opposite cha- racter in the communicated typhus. I shall hereafter have occasion to point out the circumstances which give rise to the developement of the matter of contagion, during the state of debility, as well as the characteristic signs, by means of which this fever may be readily distinguished from the nervous putrid fevers, so called, and which are of a non- contagious character. Finally, contagious typhus may be divided into regular and irregular. As the typhus, especially when it is communicated by con- tagion, is an essential disease, arising from a constantly uni- form miasm ; so it also presents in its natural course, when un- interrupted by any extraordinary cause, a constant uniformity in its symptoms and its stages, like the small-pox, and all the essential exanthematous fevers, which, by their contagious character, may give rise to similar diseases. If, however, there be any unusual causes which act upon this disease so as to disturb its ordinary course, it then changes its nature, like the other contagious exanthematous fevers, and becomes irregular or anomalous. In describing the contagious typhus, we shall enter into a minute detail of all the different forms in which it can possibly occur ; but before this, can be done, we must necessarily give an account of the primitive and natural state of the simple and regular typhus which is communicated by contagion ; in doing 21 which, we shall be obliged to defer our description of the ex- _ ceptions and complications of this disease for another section, where they will be more readily understood ; and in the last place, we shall make some general observations upon the ori- ginary typhus. I shall not admit the division of typhus into acute and chro- nic, because I regard this disease in another sense, that is, in the sense of its contagious character ; and because the slow nervous fever, which is very often nothing but the pituitary or catarrhal fever of the humoral pathologists, with nervous symptoms or debility, is not contagious ; while the contagious typhus, on the contrary, is always acute, even when the symp- toms which accompany it are moderate. SECTION FOURTH, —&&&— OF THE SIMPLE REGULAR TYPHUS, COMMUNICATED BY CONTAGION. The contagious typhus, like all the contagious exanthema- tous fevers, such as small-pox, rubeola, scarlatina, and the pes- tilential fever, has its regular course which is determined by the nature of the contagious matter, and its accidental symp- toms, which, although they are few, nevertheless predominate over all the other characteristic and general phenomena of the fever, and are in relation with the modus operandi of the con- tagious matter. This regular progress of the characteristic symptoms of each period, may be particularly observed and demonstrated in ty- phus, as in all the other essential contagious fevers: 1. When this disease attacks a person who has been previ- ously in the enjoyment of health. 2. When it is produced by contagion. 3. When it is simple in its course and uncomplicated with other diseases. 4. When the constitution is not of a particular epidemic character, so as to hold it under its influence. 5. When it is left to itself, or when the regularity of its course is not interrupted by any powerful remedies. 6. When it is not deranged by any violent method of treat- ment, and when we avoid all such means as have a tendency 23 to increase its intensity and to give it an unnatural and impro- per direction. I am enabled, from a great number of careful and repeated observations on the regular contagious typhus, to give a descrip- tion of this disease, which is not gleaned from books, but founded upon correct and repeated observations upon the dis- ease itself. This description, however, agrees with those which have been transmitted, under other denominations, by some ex- cellent observers, particularly by Huxam, Sauvages, Pringle, Hasencehrl and Sprengel. From its commencement to the perfect reestablishment of health, the simple contagious typhus runs through eight periods or stages ; but if it terminate in the death of the individual, it is evident that the number of these periods may diminish. Each of them has its peculiar character, according to the cir- cumstances of the disease, as well as its determinate limits. For this season, therefore, I shall examine each in particular. FIRST PERIOD. Of the Stage of Infection.* This stage probably lasts but a moment, during which the contagious poison is conveyed into the healthy human body, in such a manner as to take root and to manifest, sooner or later, its injurious effects. There is no striking sign by which we can ascertain the ac- tion of the contagious miasm upon the animal economy at the moment of the infection. Some physicians have advanced the idea that they could determine the instant that the contagious poison is taken into the system, by certain peculiar sensations, by a kind of electrical commotion, by the impression of a me- phitic vapour, &c. But these notions appear to be only the result of a vivid imagination; and I am inclined to believe that in these cases the infection had already terminated, and that * Stadium der Ansteckung. 24 these sensations depended upon the alteration of the irritability, and constituted the precursors of the disease. I have always paid particular attention to the sensations which took place in my own person while sitting at the bed- side of my patients who were affected with the typhus, fever, in order to ascertain whether I could perceive any particular feel- ing arising from the contagion. I have contracted the disease, and knew the patient who communicated it to me, without be- ing able to distinguish or feel any peculiar impression depend- ent on the contagious poison. The analogy of the phenomena of other contagions also shows, that the human body experiences no sensible impres- sion at the moment the contagious matter is conveyed into the system. A person, therefore, never knows the time when the infection takes place, however important and desirable it might be so to do. It appears to me, however, though it is merely a conjecture, that the vivid and peculiar sensation of heat which is experi- enced by the patient, and which seems to increase under the hands of those who touch him, may have some relation with the contagion by immediate contact. Be this, however, as it may, this sensation is not owing to a real increase of heat, since the application of the thermometer, as has been justly remarked by Sprengel, indicates, in fact, a diminution of heat. This sensation cannot be perceived by immediate contact, but the patient appears to experience an agreeable sensation in the part which was the original seat of the contagion. SECOND PERIOD. Of the Forming Stage. Under the title of forming stage, I comprehend, according to the common acceptation of the term by modern authors, that state, in which the precursors of the disease are observed, while the person still enjoys some degree of health. 25 These precursors of typhus are not characterized by any peculiar symptoms, but they consist solely, as in all fevers, in certain general phenomena of indisposition, such, for example, as a feeling of lassitude, indifference, loss of appetite, fatigue after exercise, want of sleep, &c. The fetid breath, the tre- mour of the hands, frequent vertigo, a painful and sudden commotion of the limbs, as if it were produced by an electrical shock, severe pain in the loins, and oppression in the epigas- tric region, are perhaps the most constant symptoms in this stage of the disease. How long this prodromal state, between the contagion and the invasion, properly so called, may continue, or how long it generally does, it is not possible precisely to determine, because we never know the exact time when the infection takes place. Nor can we ascertain the limits which separate this stage from the natural contagion, by artificial inoculation, any better than in the disease called small-pox; yet I am disposed to be- lieve, from repeated observations, that this stage never lasts less than three, nor longer than seven days. We are still ignorant also, whether the contagious virus of typhus remains for a certain time inactive in the human body, as is the case, for instance, with the hydrophobic virus, and then suddenly displays its injurious effects, or whether it ac- quires intensity in a slow and progressive manner. It seems to me, however, that the symptoms of the forming stage are more apparent towards the latter days which precede the in- vasion of the disease. THIRD PERIOD. Of the Stage of Invasion, or the Commencement of the Fever. The stage of invasion commences, like every other kind of fever, with a painful and unpleasant tension in the head, horri- pilations in the back, slight- chills, alternated with flushes of heat, and with the other concomitant symptoms, such as a pale 5 26 and dejected countenance, a constricted skin, tremours, thirst, great anxiety, &c. The patient loses his gayety, and repairs to his bed in order to seek warmth and repose. As the chills of the contagious typhus attacked me at a public entertainment, where I was obliged to stay during the greater part of the night, I had an opportunity of observing the powerful influence of the mind in preventing the dejection which is one of the ordinary symptoms of this stage of the disease. The horripilations are extremely severe, as they are gene- rally at the commencement of every violent fever. They pre- side over the invasion of typhus—a disease which never leaves the patient before the occurrence of a crisis. They generally last from six to twelve hours. FOURTH PERIOD. Of the Inflammatory Stage. This might with equal propriety be called the inflammatory catarrhal or exanthematous stage, the stage of irritation, or according to the expression of the ancient physicians, the stage of ebullition. But as I am satisfied with an empiric view of this disease, I purposely avoid every denomination which has any reference to hypothetical theories, and which might lead to arbitrary "methods of treatment, and content myself with such denominations only as shall designate the prominent and constant characters of the disease, and which shall indi- cate the proper method of treatment. With this view of the subject, therefore, I shall call this the inflammatory stage of the disease. This stage lasts seven days, and forms the first septenary of this disease. General Observations upon this Period. To this septenary stage I shall apply the name of inflamma- tory, because the disease is really characterized by symptoms 27 of inflammation, as we shall prove by the following observa- tions : 1. In this stage of the disease, there is no real debility of the vital powers ; but on the contrary, they enjoy a higher de- gree of activity and energy, or at all events, they are only in a state of depression. The symptoms which are usually present in the inflammatory fevers, and, in general, in the diseases of this kind, are also developed in the stage of which we are speaking. These symptoms are : a frequent, strong, full, and oppressed pulse ; loss of muscular power; a general tumes- cence, with redness ; a white and humid tongue ; oppression at the chest; a moist skin; scanty, red and scalding urine; constipation of the bowels; continual exacerbations without any apparent remissions; and, as has been demonstrated by Lind and Milman, even a buffy appearance of the blood. 2. The antecedent cause—the contagious miasm—which must necessarily act upon the human body as a violent and fo- reign stimulus, produces a real state of irritation or inflamma- tion at the commencement, and which, however short it may be, is nevertheless inevitable. The truth of this assertion is perfectly confirmed by analogy. All the contagious fevers, as well as every contagious disease without exception, as for in- stance, the small-pox, rubeola, scarlatina, pertussis, syphilis, gonorrhoea, hydrophobia, and even the pestilential fever, are characterized at their commencement, by symptoms of inflam- mation. 3. This fact, is moreover, satisfactorily proved by the mode of treatment which is applicable to this stage of the disease ; which, though not strictly antiphlogistic, is always of the great- est efficacy. In fact, in the septenary stage of the contagi- ous typhus,' every thing of a stimulating nature is injurious to the patient, and the. mild or refrigerating means are so useful, that his welfare, during the subsequent stages of the disease, and during the crisis, appears, in a great measure, to depend upon them. Reason and experience, therefore, have always confirmed the utility of a moderately antiphlogistic mode of treatment in this stage of the disease, and the modern physi- 28 cians, notwithstanding their limited views on this subject, have decided in favour of this practice. (1) Finally, the examination of the inflammatory character of this stage, can alone perfectly terminate the numerous disputes which exist amongst the empiric physicians, with respect to the debility and the irritation which occur in these diseases ; for each of the opposite methods of treatment may have its value, if we take into consideration the different stages of the disease and its prominent characters. The inflammatory character in the first stage of typhus, " moreover, is intimately connected with a peculiar exanthema, which is analogous to that which occurs in every other exan- thematous contagious fever. The inflammatory state, however, always occurs before the exanthematous irruption makes its ap- pearance. Although the inflammatory character w a constant and uniform symptom of the first stage of every exanthema- tous contagious fever, as well as of the contagious typhus, at least in its ordinary course, it never has the symptoms, of a real simple inflammatory fever; but is generally so much compli- cated with symptoms of catarrh or gastric irritation, that it is not of unfrequent occurrence that one or the other of these predominant forms of the disease, renders the diagnosis ex- ceedingly difficult and perplexing to the physician. This cir- cumstance, therefore, deserves particular attention, in as much as it has already given rise to numerous errors in the treatment of these kinds of fever. The catarrhal symptoms in this stage of typhus, are charac- terized by redness, a slight inflammation, and a watery dis- charge from the eyes, by engorgement of the nasal fossae, which are at first filled with a limpid mucus, which becomes gradually dry and inspissated, and blocks up the nose ; by similar pheno- mena in the mouth, the fauces, the oesophagus, and even the traehea, attended with a slight cough, and oppression at the chest, and consequently a slight degree of peripneumonia. These symptoms, together with the frequent bleedings from the (1) See J. A. Marcus Entwurfeiner Specielen Therapie, Nurab. 1807. 29 nose, and the slight or superficial inflammation of the fauces, clearly show how much the mucus organs of these parts are usually affected in this stage of the disease. These symptoms are an immediate effect of the contagious typhus, both in the human subject and in horned-cattle. Man, however, is more subject to the ordinary catarrhal affections, which consist in disagreeable and painful sensations through- out every part of the body, and particularly in the extremities. The typhus, like every other contagious fever, is character- ized by an inflammatory catarrhal stage which precedes the ap- pearance of the exanthematous irruption, and like every ani- mal contagion, has a peculiar effect upon the mucus mem- branes of the nose and of the fauces. The gastric symptoms in typhus, are always, except in case of accidental gastric complication, owing to the catarrhal affec- tion, with which they are so intimately connected that they are probably nothing else than this affection itself, in which the derangement of the secretory and absorbent functions of the primae viae causes an accumulation of mucus, which gives rise to gastric irritation, to nausea and vomiting, to the white- ness and foulness of the tongue, to loss of appetite, to disturb- ance and irregularities of the intestinal excretions, and other affections. How far the state of irritation of the liver, considered either in a proximate or remote point of view, and the alteration of the bile which it secretes, contribute to the increase of the gas- tric symptoms, we shall take an opportunity of pointing out in a subsequent part of this work. I have given this general view of the phenomena which characterize this stage of typhus, in order that I may hereafter be able to examine more carefully each symptom in particular, which I shall lay down from the most careful and attentive ob- servations ; and in order that I may be able also by this means to furnish the proof, that this stage of typhus is characterized by febrile irritation, and by catarrhal and exanthematous affec- tions, without being accompanied by any symptoms of debility or of nervous disturbance. 30 It appears evident from the preceding observations, that this stage of the disease, by the inflammatory character which dis- tinguishes it, indicates that the lymphatic system is affected in a very sensible manner; and it is to this state that we may, with propriety, refer the nervous symptoms. From this fact, we may also learn the reason, why aged and debilitated subjects some- times suffer so little from the catarrhal and inflammatory symp- toms. Description of the Symptoms which occur in this Stage of the Disease. After the chills have disappeared, and the fever is properly developed, the patient experiences a remarkable febrile heat, which is sensible to the touch, and extremely distressing to his feelings, and which has this peculiarity, that every part which is uncovered is affected with chills, while those, on the contrary, which are carefully covered, occasion great anxiety, and an unpleasant and extremely distressing warmth. Great thirst, and a longing after cold and acid drinks, invariably accompany this stage of the disease. In this stage of the disease, the external senses are ordinarily but little affected, excepting perhaps, the sense of touch. The faculties of .the mind are also but slightly affected ; and the de- sires, though guided by a certain instinct, become gradually more depressed, and, although the nervous system does not appear at this moment to be affected in any particular manner, yet the encephalic symptoms are already numerous, and ex- tremely characteristic. The head is affected with vertigo, be- comes extremely heavy, and feels, as it were, rather a sense of intoxication than of real pain. Under these circumstances, the nausea and frequent vomit- ings, which generally take place, even when the tongue is per- fectly clean and unfurred, appear to be rather a consequence of the vertigo, which accompanies this stage of the disease, than the effect of the contagious irritation upon the stomach. The irritation of the liver may also contribute to produce these 31 affections. These symptoms never owe their origin to the irri- tation of the stomach, except in those cases where this organ has been over-distended, either before or during the develop- ment of the disease, with too great a quantity of fluids, taken with a view to allay the great and parching thirst. The other phenomena which are developed in this stage of the disease, are the ordinary and general symptoms of an in- flammatory fever, unaccompanied by any local affection, ex- cept the catarrhal symptoms. The countenance is red and animated; the tongue rather white than furred ; the skin moist and clammy; the urine scanty, red and sometimes scalding ; the feces almost natural; the pulse full, frequent and oppress- ed, accompanied by a remarkable dilatation, and an evident want of contraction of the artery,—a kind of orgasm, consist- ing in a great expansion and a feeble contraction. Such is the state of the patient during the first day after the invasion of the disease. On the second day of the disease, after a night of restless anxiety, some of the first symptoms slightly abate, and give way to others. The nausea and vomiting either disappear or di- minish ; the heat increases, and the precursors of delirium al- ready begin to make their appearance. Under these circum- stances, the patient sometimes appears to enjoy sleep, when, in fact, he experiences the most severe internal agitations. The heaviness in his head gradually increases, so as to amount to stupor; there is a ringing noise in the ears, with a derangement of the functions of hearing; the vertigo increases in a very re- markable manner, and the patient cannot assume the erect posture without experiencing great debility, or sickness at the stomach. The eyes become more red ; the 'catarrhal symp- toms in the fauces and the nasal fossae gradually augment; the mucus membranes of the tongue and of the posterior part of the mouth are more engorged than in the healthy state ; deglu- tition is more painful; the oppression at the chest becomes more alarming, and approaches to peripneumonia ; the cough is often distressing; the hypochondric regions, especially the right, become tense and painful, and the tension and uneasi- 32 ness in the extremities, and particularly in the calves of the legs, and in the articulations of the fingers, gradually augment in intensity and pain. The same unpleasant sensation is expe- rienced in the lumbar and dorsal regions; and although the vital powers are still in a moderate state, the morbific pheno- mena of the cutaneous organ, of the excretions, and of the pulse, as well as the fever in general, become more exalted than during the preceding day. On the third day, the disease is still characterized by the same symptoms, which augment in an almost imperceptible manner. Until now, however, there have been no well mark- ed alternate remissions and exacerbations, except those which generally take place at evening. To the. characteristic and pathognomonic symptoms, which occur during the first three days of the disease, and which serve, amongst a host of other variable phenomena, to point out the diagnosis of contagious typhus, belong the remarkable stupor and vertigo, which are, in every respect, similar to the intoxication which is produced from the effects of inebriating liquors, or from the narcotic poisons. The redness of the eyes, the catarrhal and peripneumonic symptoms, the affection of the liver, the disagreeable and painful tension in the extremities, and particularly in the calves of the legs, and the articulations of the fingers, are the cause that the contagious typhus has been considered and treated by some physicians, who have dis- regarded every other phenomenon of the disease, as a rheuma- tic fever. These symptoms, it is true, are sometimes so slight, that an inexperienced physician may not be able to distinguish what kind of fever he has to combat. Besides the essential symptoms, which we have just enume- rated, there is not only in this, but in every other stage of the disease, an invincible repugnance on the part of the patient to perform the least motion, which is so much the more remark- able, because his muscular powers are neither so much depress- ed nor debilitated as we might at first sight be disposed to be- lieve. In this stage of the disease, the patient also begins to experience difficulty in speaking, and observes the most perfect 33 silence, unless he is interrupted by his friends or attendants ; he answers slowly and incoherently, and puts out his tongue with difficulty. From these observations upon the symptoms of the conta- gious typhus, it is evident that it may be distinguished, even during the first days, from every other kind of fever. On the fourth day, which forms the moiety of the first sep- tenary, are already developed some of the precursors of a crisis, which are, however, extremely imperfect, and produce only some slight relief, or rather a remission of the fever, with- out a decided termination. On the fourth day there is generally a slight degree of hemorrhage from the nose, which is always accompanied by a temporary relief of the encephalic symptoms. The blood, which is discharged, is generally thick and consistent. There appears also, about the same time, an extraordinary redness upon the whole surface of the body, that is, upon the external tegumentary membrane, which forms what is called the exanthema of this disease. This exanthematous irruption, and the nasal hemorrhage, probably arise from the same cause, and are, no doubt, owing to the plethoric state of the small capillary vessels, which gives rise not only to the dilatation and redness of the cutaneous ves- sels, but also to the slight effusions into the cellular tissue, which are nothing else than an internal hemorrhage of these small vessels. The absence of analogous symptoms in the internal organs, which are affected in a similar manner, permits us to presume, that this turgescence is less prominent in the internal parts and the viscera, except perhaps, in the lungs and the intestines, than upon the external tegumentary membrane. In the first case, when there is a simple dilatation and tur- gescence of the cutaneous vessels, with an imperfect distribu- tion of the fluids, there will be a mere red-spotted exanthema- tous irruption. We may remark, however, that the tegumen- tary membrane of the healthy subject, sometimes presents a red, and if we may be allowed the expression, a marble-like 6 34 colour, which is unequally diffused, and is particularly observ- able when the skin is somewhat cold or chilly. It is in this manner that the red-spotted exanthematous irruption of typhus sometimes makes its appearance ; an irruption, which is very easily succeeded by small vesicles, called sudamina, and by small red pustular elevations, which are not unlike the purple pustules which occur in the malignant fevers. This exanthema, which has all the properties of the purpura rubra, is observed on the surface of the body, the face, and es- pecially on those parts which are subject to warmth, as the back, the breast, the upper part of the thighs, and the anus. This irruption, which is more conspicuous in proportion as the eyes are more red and affected, has often been confounded by physicians with the true purple irruption ; and there have not been wanting some who have regarded the purpura rubra as a typhus fever : and to this fact, no doubt, are owing the disputes that have arisen concerning the contagious and non-contagious nature of the purple fevers. The cutaneous exhalation which takes place during the ex- anthematous irruption, and which is interposed between the epidermis and the skin, is unquestionably the cause of the se- paration of the epidermis, and contributes, when this matter becomes dry, at a more advanced period of the disease, to the disquamation of the cuticle and to the falling off of the hairs during the period of convalescence. But in the second case, when there are small effusions of blood between the epidermis and the skin, with a general tur- gescence of the cutaneous organ, they form what are called petechial irruptions, either with or without the red purple efflo- rescence. These petechial irruptions, which, in this period of the disease, are only very small red ecchymoses, do not belong to the essential phenomena of typhus, and are developed only in consequence of certain requisite conditions. They are not always found in cases of typhus ; and in case they do oc- cur, when the patient is suffering from the bites of the flea, they may be easily confounded with them. It often happens, also, that they are not at all remarked, unless the patient is examined with great care. 35 In this stage of the disease, these irruptions do not, as has been erroneously supposed by some physicians, present any signs of a contagious character, (for the typhus itself, is scarcely contagious in this stage ;) but at a more advanced period, when they become larger, and of a red colour, their contagious cha- racter becomes somewhat more suspicious. The matter, which they contain, is neither fit for inoculation, nor for the artificial propagation of the disease; and it appears to be a general law of nature, that the animal mucus, the pus and the lymph, are the vehicles of the contagious miasmata, particularly of those which form analogous fluids in the exanthematous ir- ruptions which they produce. z Finally, it remains to be remarked, that the exanthematous | irruptions, which are peculiar to typhus, and which were al- ready alluded to by Sauvages, occur either under the form of spots, or under the form of glandulous or tuberculous specks ; and that, as the carbuncles and the pestilential boils are the pe- culiar exanthemata of the plague, so are the inflammatory af- fections of the parotid glands more peculiar to the typhus, and have a certain connexion with the exanthematous irruption, to which we have just alluded, especially by reason of the inti- mate connexion which exists between the functions of the lymphatic system and the cutaneous organs. The sympto- matic affections of the parotid glands, or at least the germ which produces them, exists simultaneously with the spotted exanthe- ma of typhus. It is true, these affections of the parotid glands are not met with in every case of typhus, but because they are not percep- tible in a moderate degree of the disease, or because they are not very conspicuous, we ought not to conclude that they do not really exist; for it has been found, by the most careful observation, that these, as well as some other lymphatic glands, are really tumefied and affected with a peculiar painful tension, as is satisfactorily proved by the difficulty which the patient ex- periences in opening his mouth, by the derangement in the functions of hearing, by the noise in the ears, and in some cases, even where the disagreeable and painful swelling of these J 36 glands is not perceptible, by the profuse discharge from the ears during the stage of convalescence. After the irruption of the one or the other of these exanthe- mata, the typhus and its predominant character remain, for se- veral days, almost entirely stationary. On the fifth, the sixth, and the seventh day of the disease, the exanthematous irruption not only remains the same, but the other symptoms of the dis- ease are apparently unchanged, and the fever is still character- ized by an inflammatory type. It should be observed, how- ever, that the peripneumonic symptoms always begin to abate as soon as the exanthema makes its appearance, and that, al- though these affections exist simultaneously, they have an in- verse relation. The catarrhal symptoms also entirely disappear in this stage of the disease. The general progress of this septenary period deserves par- ticular attention. In this period, the typhus generally presents an inflam- matory type, and observes, independently of the exacerba- tions which take place during the night, a somewhat conti- nuous course ; and if there be any regular exacerbations and remissions, they happen only accidentally, and in consequence of peculiar circumstances. The critical exacerbations, how- ever, take place exactly at the end of the third and at the com- mencement of the seventh day ; and subsequently, at the end of the tenth and at the beginning of the fourteenth day, and are followed by remissions. Typhus is distinguished from every continuous and non- contagious nervous fever, by the fact that it is not subject to any periodical exacerbations of a quotidian, a tertian, or double tertian form. FIFTH PERIOD. Of the Nervous Stage. Towards the end of the seventh day, there is a very remarka- ble exacerbation, which is succeeded by an imperfect crisis, and 37 by an apparent remission of some of the symptoms, which often lasts, however, but a few hours, and forms the fifth stage of this disease. At this time also, there arises a new febrile heat, without any previous chills, or rather, there is an increase of heat, during the development of which the antecedent inflam- matory character, as well as the exanthematous symptoms en- tirely disappear. This stage, which in the regular and ordinary course of typhus, lasts until the fourteenth day, constitutes what may be called the nervous stage, and embraces the second septenary of this disease. All the circumstances which can authorize the terms nervous fever or nervous character, are presented in this stage of the disease, in a manner to justify us in using the denomination which we have deemed proper to apply to it. In the fifth period of the disease the nervous system is principally affected, and the general debility which had previously been only fallacious now becomes real, and so well marked that it cannot be mistaken: this, however, does not always take place. The prominent symptoms of this stage are evidently of a nervous character, though the disease still retains its constant and specific character, which readily distinguishes it from every other non-contagious nervous fever. Every nervous state, which occurs in the continued fevers, and which has been so emphatically represented by the parti- sans of the celebrated Brown as being produced by debility, is generally nothing else than this nervous stage of typhus. General Observations upon this Stage. The peculiar character of this stage of the disease is owing to the derangement of the nervous system, and may be easily understood from the following observations: 1. The inflammatory symptoms or the phenomena of irritation gradually disappear, as well as the concomitant catarrhal, or exanthematous symptoms, without however, there being a ter- mination of the fever itself or any melioration in the state of the 38 vital powers. This fact is clearly proved by the development of the new symptoms, which are directly opposed to those of the preceding stage of the disease, and which arise from the de- rangement of the nervous system. The turgescence of the external and internal organs gradually disappears; the muscular debility increases; the pulse becomes more feeble and generally less frequent; the skin and the tongue become dry ; the urine more pale and limpid, and the alvine evacuations more frequent and colliquative. The type of the fever also changes, in as much as it becomes somewhat more characteristic, though the exacer- bations and remissions are not more frequent than in the pre- ceding stages. 2. In explaining this passage to the nervous state which characterizes this stage of the disease, we may be aided by the analogy which exists between typhus and some other fevers. In fact, all the exanthematous fevers, and especially those of a contagious character, have a particular tendency, at an advan- ced period, to run into a low nervous state. 3. A debilitating plan of treatment, in this stage, is evidently prejudicial and dangerous; while, on the other hand, every thing of a moderately stimulating nature, though not indispensably necessary, is less hurtful, and may even be favourable to a salu- tary crisis. 4. Almost all the symptoms of this stage of the disease, at least the predominant ones, indicate a special affection of the nervous system. This state of typhus, however, has a peculiar character which distinguishes it from the nervous character, taken in its ordinary sense, and which, whatever it may be, I would rather denominate the nervous state than the state of debility. The disorder of the intellectual faculties and the delirium which accompanies it, the coma, the disturbance of the sensi- bility, and of the muscular irritability, the tremours, the twitch- ings of the tendons, the convulsions, the cramps, the spasms and the other symptoms which occur in this stage of the disease, are the certain indications of a deranged state of the nervous sys- tem. These symptoms are generally developed in a slight de- 39 £ree when the disease observes a mild and regular course; but if we should believe that these depended uniformly upon a real debilitated state of the nervous system, and that we should combat them by a stimulating plan of treatment, we should no doubt be led into error and to erroneous and, consequently, hurtful indications. Nor is it less fortunate, when, during the state of the nervous symptoms, we employ a stimulat- ing and empiric mode of treatment, founded upon the de- lusive names of nervous remedies, and upon the favourite ideas of a pretended debility of the nerves and of the general excitement of the body. For it must be understood, that the true nature of these symptoms does not consist in a real debili- ty, and in this case, therefore, as in hysteria and in the other nervous diseases, a passive, and sometimes even a debili- tating mode of treatment, are best adapted to the removal of the disease. We see striking examples of this kind of nervous symptoms in cases of mania a potu, in the affections arising from the narcotic poisons, in sanguineous apoplexy and the paralysis which accompanies it, and in the numerous cases of convulsions which occur in robust and plethoric persons. I am of opinion, however, that the nervous symptoms which accompany these different states, or even the debility which is developed in every case during this stage of typhus, do not de- pend upon a real debility, but rather upon a fallacious state of debility, which is generally observed in fevers in consequence of a depression of the vital powers. Such, in fact, is the case with typhus, in which the apparent debility is owing to an op- pression of the vital energy, occasioned by the contagious virus, while the nervous symptoms have an entirely different source. To confirm the truth of this assertion, it will be sufficient to make the following observations: 1. In the ordinary course of this disease, the favourable crises contribute much more to the cure than any of the reme- dies that are employed; and, consequently, nature ought to have sufficient power to produce these crises which can only take place by the reaction of the vital powers, a fact which per- 40 mits us to presume that they are not affected, and that there is no real debility. 2. The salutary crises sometimes take place, notwithstanding the employment of a debilitating mode of treatment, as may be observed in the practice of some physicians, who consider this disease as a bilious fever, and treat it, from its commencement to its termination, by mild evacuant remedies, and are not al- ways unsuccessful in their treatment. 3. The vital energy, and particularly the power of the volunta- ry muscles, are not more debilitated in this stage of the disease than they are, for instance, in drunkards, where there is a want of energy which is difficult to be overcome, but which is not altogether insurmountable. In both cases, the vital powers are impeded in their exercise and are merely in a state of de- pression. 4. In a moderate course of typhus, we may sometimes ob- serve, during this stage, a certain fulness of the pulse, as if there were a real increase of vital energy,and which Sauvages regards, after Hippocrates, as a characteristic symptom of the disease. This, moreover, is the period when the powers of nature act with the greatest energy to combat and remove the contagious matter, as well as to free the body of the humours which have become altered, and have already arrived at the highest degree of elaboration by the process of irritation, which marks the preceding stage of the disease. It is, in fact, like the devouring flame which succeeds a smothered fire ; and it can scarcely be denied that the chemico-animal process performs as important a character as that which takes place in the phenomena depend- ing upon the vital powers. We may perhaps be permitted to remark that the contagious miasm, being inflamed and spread throughout every part of the body during the preceding stage of the disease, now becomes more confined to the periphery, from which it is conveyed and communicated to other individuals. For it is in this period that the power of the contagious matter is more energetic and more perfectly developed. 11 Description of the Symptoms ichich occur in this Stage of the Disease. This stage, as we have already said, commences about the eighth day of the disease, and is preceded by a short and remark- able change, and by an evident relief in the symptoms of the disease. The new scene opens with an increase of heat, which is ap- preciable to the touch, and highly distressing to the patient. It is this heat, or the intensity of the fever, which is the cause of the development of the new symptoms. The tongue and the whole surface of the body become dry; the skin no longer executes its functions, and forms a focus where the heat accumulates and augments under the hands of those who touch the patient. The thermometer, however, scarcely indicates any increase of heat, which appears to be the same as in the preceding stage, and never ranges above 32 de- grees of Reaumur's thermometer, nor below 102° of Fahren- heit's, a fact which proves, that the communication of caloric exercises a peculiar influence upon the actual state of the skin. The cutaneous exanthema now disappears, while the pe- techial irruptions either continue to augment, or begin to make their appearance.—In the regular course of typhus, however, this occurrence is extremely rare. As soon as the exanthematous irruption disappears, the epidermis separates, becomes dry and rugose, and impedes the cutaneous transpiration and absorption. This separation of the cuticle is attended with the formation of a new one, and is not completed until the occurrence of critical sweats, and the complete restoration of the functions of the skin. The heat and dryness of the skin increase, and the thirst be- comes more intense and distressing; the appetite is generally lost, and the intellectual faculties are obliterated, so that the pa- tient seldom takes any drink, unless he is solicited so to do by the nurse: the state of his mouth, however, and the dryness of his tongue, plainly indicate his scorching thirst. 7 42 The deglutition now becomes difficult, partly on account of the dryness of the mouth, and partly also on account of the in- activity of the muscles of deglutition; but, by a careful examina- tion, these organs will be found to present no remarkable change, though they are more dry, and, owing to the previous symptoms of the disease, they have lost their natural fulness. The catarrhal symptoms which mark this stage of the disease are also dissipated; but the nasal cavities are still obstructed by dry inspissated mucus, or by the remains of a sanguineous effu- sion, which gives these cavities a fuliginous appearance. The oppression at the chest also disappears, and the respira- tion becomes more free, and somewhat accelerated. The cough also ceases, but there is a convulsive movement of the diaphragm, which gives rise to hiccough. This symptom is rarely wanting in this stage of typhus, even in the most moderate course of the disease. There are also remarkable changes in the intestinal canal, which has always a very great sympathetic relation with the skin. The intestines, in fact, appear to be exceedingly slug- gish, thovgh I believe that they are really in a state of excite- ment, and perform the suppressed functions of the skin. The fecal evacuations are frequently of a liquid nature, extremely fetid, and sometimes even putrid. The patient often experi- ences, also, a slight degree of pain in his bowels, which is aggra- vated by pressure. This pain, which is owing to an inflammatory state of the intestines, forms one of the most constant symptoms of this period of the disease, being almost invariably present, and of which traces may always be found upon post mortem exami- nation. It is to it, rather than to the accumulation of the fecal matter in the intestines, that is owing the swelling of the lower part of the abdomen, or the tympanitic affection, which con- stitutes as invariable a symptom of this stage of typhus as the inflammation to which we have just alluded. It is to it, in fact, that must be attributed that disposition to dysentery which is so frequent in this stage of typhus fever. It is possible also that the mobific state of the liver and the altered bile, which it secretes, may contribute to this state of the intes- tines. 43 In this, as in the ordinary nervous state, the urine is more abundant than in the inflammatory fevers, and instead of being red and acrid, it is pale, limpid, or somewhat turbid, and very seldom sedimentous. The nature of the urinary secretion is so extremely variable in this stage of the disease, that it is impos- sible to determine whether it indicates an inflammatory state.' This character of variability is in every respect similar to that of the pulse, which varies in respect to its force, its fulness and its quickness. So much is this the case in every stage of the disease, that we may remark a different pulse similar to that which is observed when the vital powers are in a state of depres- sion or exhaustion. Notwithstanding this, it is never so uniform- ly weak, so quick, nor so small and tremulous as it is observed to be in cases of real vital debility. In the regular and mode- rate course of this stage of typhus, on the contrary, it is very frequently moderately strong, tolerably full and open, never small nor extremely soft, and what is more astonishing, it is in no relation with the debility of the vital energy. What is still more remarkable than this, however, is that the quickness of the pulse, or rather its slowness, (in consequence of which Visone has denied the typhus a place amongst fevers,) does not ap- pear to have any relation with the increase of the heat of the body. Notwithstanding this, the pulse always presents some- thing peculiar and almost indiscribable : it is commonly varia- ble in respect to the force of the arterial pulsations, and the ca- liber of the artery has no free and perfect contraction, being rather, if we may be allowed the expression, in a constant state of dilatation, so much so, in fact, that the pulse appears to be in a state of depression. In the blood itself, however, there seems to be an irregular agitation which resembles the action of ebullition, or the peculiar noise which is observed in cer- tain cases of aneurism. By a careful examination, this phe- nomenon may generally be observed, during this stage of the disease. The most important morbific phenomena of this stage of typhus, are unquestionably those which constitute the nervous state; and though they should have been described first, I have reserv- u ed them lor the latter part of this section, in order to give a more detailed account of them. This nervous state, which is invariably present, constitutes one of the essential symptoms of typhus and depends upon the nature of the contagious virus, which exercises a peculiar influ- ence upon the brain during the whole course of the disease. In the preceding stage, this affection consisted principally in the depression of the external senses, in the stupor and disorder of the intellectual faculties, in insomnolency and in a slight de- rangement of the voluntary muscles. In this stage, however, all these symptoms become more aggravated and assume vari- ous modifications. The vital powers become apparently very much depressed; but, as I have already said, this apparent debihty is merely a want of activity, which, as in cases of inebriation, it is difficult to overcome, but which may, notwithstanding, be surmounted by proper and well-directed efforts. The involuntary movements of the muscles appear to increase in proportion to the debility of the voluntary movement; and hence arise a number of dis- tressing symptoms, such as tremours, twitchings of the tendons, slight convulsive motions and different kinds of spasms, particu- larly in the muscles of the neck and in those of the bladder. These symptoms by no means always depend upon an increas- ed erethism of the system, as is proved by the fact, that they are generally present when the nervous system is in a state of depression—a state, which is generally peculiar to this disease. In this state of the disease, the external senses become more unequally depressed, the difficulty of hearing augments, the sight becomes dim, and the sense of smell, of taste, and of touch, as well as every kind of feeling, is almost completely obliterated. Thus, the impressions of the external senses being imper- fectly received by the sensorium, the patient, instead of sleep- ing, experiences nothing but distressing dreams, and when in a semi-dormant state, he makes incessant gesticulations, and talks in the most singular and incoherent manner, concerning the ob- jects which surround him and which he is unable to distinguish from his internal impressions. 45 It is singular how a striking impression, and the fixed and fantastic idea which it creates, will incessantly torment the pa- tient during the whole period of the fever, and frequently cause the most dreadful anxiety. During the septenary stage of an attack of typhus, my mind was constantly engaged in removing an awkward ornament from my stove, which stood directly oppo- site to me, and, being of course unable to remove it, it tor- mented me in the most cruel manner. One of my pupils, who, having been taken with an attack of typhus a short time previ- ously, had assisted at the opera, called the Mirror of Arcadia, performed, during the whole septenary of the nervous stage of typhus, the character of viper-catcher ; and as he was obliged to swallow these disgusting reptiles, he experienced the most inexpressible anxiety. Another laboured under the painful and fantastic idea, during the whole course of his disease, that he was not only suffering for himself, but for all his comrades in the clinical ward. It is by this that we are enabled readily to distinguish the state of the phrenetic stupor of typhus from every other state that has any resemblance to stupor or inebriation, in the latter of which there is seldom that fixed and distressing idea. It is remarkable also, that, even when this distressing idea is not present, the patient never, or at least very seldom, recollects when he gets well, what has happened during the disease, and especially during the nervous stage. It would appear reason- able, however, to suppose, from some of his symptoms, that the patient had still some knowledge of what was going on, or at all events that he enjoyed some lucid intervals ; but, notwithstanding this, he is in a constant state of deli- rium, and whenever he does any thing of a rational nature, it is during his sleep. I believe, therefore, that I may justly compare this to a state of somnambulism, and that the con- tinual insomnolency, or the unrefreshing sleep, added to the stupor of the patient, is the principal, cause of this and of many other phenomena. I was informed that when I was in a state of delirium, ^1 had some lucid intervals, and that I conversed rationally with my physician, concerning the nature of my dis- 46 ease, but of these circumstances, I have not the least recollec- tion. Generally speaking, the patient in this stage of the dis- ease, will converse rationally, and give proper answers to such questions as are put to him—a fact, which is not usually re- marked in other febrile deliria, and especially in that which arises from inflammation of the substance of the brain. Amongst the numerous facts of this kind that might be re- lated, I will merely mention that of a Galician Jewess, of whose case I have always had a striking recollection. This woman had a very great desire, during her attack of delirium, to see her son. Upon his arrival, she received him with the greatest tenderness, and bathed him with her tears: during the rest of her fever, she took nothing but what came from his hands ; and, when she got rid of her delirium, she was as- tonished at his presence, asked the reason that had induced him to come, and felt, for the first time, the real joy of a mother, in an agreeable state of surprise. Besides, although in this stage the delirium is considerably greater than during the preceding, it is worthy of remark, and of the particular attention of the psychologist, that, even in this confused state, the most noble faculties of the mind are often but slightly affected, and the patient is more capable of forming a correct judgment, in proportion as his memory is weaker. Finally, what concerns the desires, or the direction of the will, depends here, as in every other case, upon the state of the mind ; the movements of which, are, unquestionably, more in accordance with the interior, than with the exterior impres- sions. Notwithstanding this, however, the mind is generally depressed, and the desires are in a state of inertia, analogous to that of the muscular powers. Both these affections, are caused by the contagious miasm, and in every state of the disease, by the continual stupor, or probably by the state of compression of the sensorium commune. This indifference of the patient, suffering from typhus fever, to every surrounding object, is so remarkable, that he is per- fectly regardless of his own situation, having no anxiety for his 47 recovery, nor attending to those duties which he is called to perform by the instincts of nature. There is, therefore, perhaps no disease, except apoplexy and phrenites, in which the patient is less sensible to pain, and so truly indolent, and in which he dies with less pain and regret, than in typhus. He is, as it were, a mass without desire and volition, being occupied only with the present, without any re- flection on the past, or any anticipation of the future. His at- tendants, moreover, are constantly obliged to urge him to take such things as may be useful, and to abstain from such as may be injurious. The stupor, then, in all its different degrees, is, generally, the most essential, the most characteristic and constant symp- tom in every stage of this disease. It is, as we have already said, perfectly analogous to intoxication; and upon it appear to depend all the other symptoms of the disease which distinguish the affection of the nervous system. This stupor, which is very clearly manifested by the indiffe- rence of the patient to surrounding objects as well as by his carelessness and want of motion, establishes at first sight, even in the eye of the empiric, a certain diagnosis of typhus, which is frequently distinguished in the hospitals by this symptom alone, amongst a host of other diseases. These symptoms which we have now enumerated constitute the characteristic signs of the fifth stage of typhus, and remain the same at the eighth, the ninth and the tenth day, nor are there any other remissions than those which follow the slight evening exacerbations. At the end of the tenth day, there is a very strong exacerba- tion. The febrile heat, as well as the nervous symptoms in- crease in a very remarkable manner, and are succeeded, after a slight perspiration, a copious alvine evacuation, or a discharge of urine, by a remarkable remission, which is more sensible on the eleventh day, and is manifested by a renewal of the febrile heat and a considerable degree of nervous affection. There are cases, however, of the moderate and regular course of typhus, where the symptoms of this stage are much milder 48 than we have here described them. I have seen patients, who could sit up during almost the whole period of the disease, or at least, several hours a day. Their stupor was extremely slight, notwithstanding which, they were in a constant state of re- very—which justifies what we have already said concerning the state of the sensorium commune. In these cases, the slight de- gree of febrile heat and the derangement of the vital energy, are, however, in fact, the only symptoms by which they can be distinguished from the most severe cases of typhus. SIXTH PERIOD. Of the Critical Stage. The disease which, during the seven days of the preceding stage, had arrived at a certain degree of intensity, now very ra- pidly declines; and undergoes, without the resources of the healing art, a change which decides the fate of the patient, and which, in the regular and moderate course of typhus, leads, un- less impeded by some obstacle at the moment .that the crisis is about to take place, to the perfect reestablishment of health. At the end of the thirteenth day, there is generally a violent exacerbation. The fever evidently increases, the heat becomes more acrid, the pulse more strong, the brain is apparently more affected, and there supervenes a peculiar soporous affection. Towards the twelfth hour of this day, however, or the fourteenth day of the disease, the skin which was before dry, becomes moist, and all the exhalent vessels on the superficial parts of the body appear to open, and to become free from their spasmodic constriction: it is at this moment that the critical stage com- mences. Under these circumstances the patient sometimes experiences a slight degree of hemorrhage, which affords great relief to his cerebral affections. When there is no bleeding, however, which is generally the case, the nose, which before was dry, now be- gins to become moist; and the black, inspissated crusts which line the anterior and posterior nasal cavities, as well as the mu- 49 cous substance, which is sometimes united in a very com- pact manner so as to fill these cavities, become detached by means of the new secretions. This seldom happens without sneezing, so that it has frequently been remarked by the vulgar that this affection is a precursor of health. The tongue also becomes moist, and more natural and red, first towards its point, and subsequently towards its base. In some cases, the patient has a copious expectoration, espe- cially if the chest has been affected at an early period of the dis- ease, and if it has been surcharged with mucus; in most instan- ces, however, there are sputa which are derived from the poste- rior cavities of the nose and from the fauces, when the tenacious mucus, which was collected during the disease, now becomes detached. In all these cases, the whole surface of the skin becomes covered with a salutary perspiration, and even with a universal sweat. And although this sweat is not always the cause of the general melioration of the symptoms of the disease, it is, never- theless, unquestionably, one of the most powerful means; for by it the skin resumes its natural relations with the atmosphere, and recovers the functions which are necessary to the integrity and reestablishment of health, and which have been most im- paired by the contagious virus. This sweat, when it is truly critical and of a salutary nature, is generally diffused over the whole body, and is of a soft and gaseous consistence; in some parts, however, such as the fore- head and the anterior part of the neck, it makes its appearance under the form of distinct drops. Its odour is of a peculiar kind, being neither very strong, nor of a very disagreeable nature. The urine, which, during the nervous stage of the disease, was pale and transparent, and passed with much difficulty, is now evacuated with ease, becomes turbid, high coloured and more abundant, and frequently affords a great quantity of a whitish, or black, mucous deposition. Notwithstanding this, the urine deserves less consideration than any other critical evacuation. 8 50 Next to the sweats, the alvine evacuations afford the greatest and most frequent relief in the symptoms of this disease. No- thing is more erroneous than to suppose that this evacuation is peculiar to the gastric fevers ; for it is well known that the in- testines have the most intimate relation with the skin, which performs so important a character in typhus, and that they perspire, if we may be allowed the expression, as frequently as the skin itself. f A diarrhoea, however, is not always strictly necessary to the production of a salutary crisis, for the same effect is often pro- duced by the discharge of fetid and aqueous evacuations. The patient is generally able to determine the degree of re- lief afforded by these evacuations, or at all events, he is able to distinguish those which are of a salutary nature, and which con- stitute, as it were, the last stroke of the disease. A physician, whom I attended while suffering from an attack of typhus, and who was extremely pusillanimous during his delirium, an- nounced to me his cure as certain during an evacuation in which he perceived that all his symptoms began to disappear. The same thing obtains in the pestilential typhus, where the al- vine discharges are also frequently of a critical nature. The celebrated Dr. Valli, one of the professors at the university at Mantua, who suffered from an attack of the plague while at Constantinople, assured me that as soon as he experienced his diarrhceal affection, the symptoms of his disease began to abate, and by degrees to disappear. The crises, which take place in consequence of the salutary evacuations, and in which the powers of nature have more ef- fect than the efforts of the healing art, preserve all their rights in typhus, though these have frequently been disputed, especially in cases of considerable debility. The critical evacuations, in typhus, whether they be the cause or merely the effect of the relief that is experienced by the patient, manifest their happy effects by a striking and almost instantaneous relief. This relief is so very remarkable that it cannot be denied by any one who has ever seen or observed this disease. These sudden and salu- tary changes can be best observed in those cases where the 51 patient is in extreme danger, and where he has received no beneficial effects from the resources of the healing art. These decisive crises, in the contagious typhus, when it ob- serves a mild and regular course, generally take place about the fourteenth day ; and are of such a nature that they either speedily restore the patient to health, or produce his death. It sometimes happens, though extremely seldom, that the salutary crisis takes place on the seventh day of the disease ; in these cases, however, it is not so decisive, notwithstanding it is fol- lowed by a sensible relief on the fourteenth day. It is proba- ble also, that in these cases, there are peculiar circumstances which interrupt and retard the crises, which would otherwise supervene on the fourteenth day, which is the period when every typhus terminates when it has not been interrupted in its ordinary course. SEVENTH PERIOD. Of the Stage of Remission. The critical stage, like the stage of invasion, lasts but a few hours. When it is salutary, the stage of remission, which suc- ceeds it, is generally observable in about twelve hours; the transition, however, from the critical stage to the reestablish- ment of health, is by no means so sudden. This passage takes place by means of a successive remission, which is very distinct from the convalescence itself, and which has not the least ana- logy to the forming stage of the disease : for in the remission we meet always with some of the essential symptoms of the preceding disease, though they are less numerous and of a less distinct character. In the convalescent stage, however, these symptoms disappear, andthere remain none but the general symp- toms of a common indisposition. This stage, therefore, which forms the immediate passage from disease to health, may be justly compared to the forming stage, which serves as the pas- sage from health to disease. It may be presumed, though it cannot be confirmed by ob- 52 servation, that there are in this stage of the remission, slight and insensible crises, which gradually dissipate the rest of the disease, even after there shall have been a perfect and instan- taneous crisis at the ordinary period. Notwithstanding this, it is by means of this crisis that the symptoms of the disease experience so striking and rapid an abatement; and upon it, moreover, depend the remission of the disease, and the abatement of the most intense and dangerous symptoms, as well as the fate of the patient. The first striking symptom that disappears, is the delirium. The patient awakes, as it were from a dream, or a fit of intox- ication, his head becomes free, and in some instances, he has an instantaneous and perfect recovery of his former knowledge. The memory, however, is still peculiarly affected, so much so, that the patient has great difficulty in recalling to mind the cir- cumstances that passed before and during his illness. His astonishment is always great when he discovers his delusion. The mind also experiences a considerable change, and the indifference which was previously observed in the patient, now begins to disappear. The eye becomes more attentive and ex- pressive ; the surrounding objects begin to excite an interest, and the patient takes more notice of what is going on ; the in- sensibility of the soul is dissipated, and the feelings of grati- tude, of love and of friendship, as well as every other sentiment of the soul, are gradually awakened and displayed in the most exalted degree. The organs of the external senses resume their former acti- vity, and awake, as it were, from a profound dream. The or- gan of hearing, however, is still as obstinately affected as dur- ing the preceding stages of the disease. While the nervous system resumes its ordinary functions, and the locomotive powers become more energetic, the func- tions of the circulation are reestablished, and the pulse be- comes calm, regular, and open, though it is frequently weaker than in the preceding stages of the disease; the heat and per- spiration of the body become mild and uniform ; the thirst com- pletely disappears, and the drinks which formerly afforded so 53 much comfort to the patient, now become disgusting ; the ip- petite becomes developed, and the sleep, though not so sound as in the healthy state, becomes more refreshing, and adds much to the comfort of the patient. To the phenomena of this stage of the disease appertain also, a sense of debility and loss of power which is more distressing than even during the most severe stupor ; a depression of bo. dily strength, especially of the extremities, which indicates tha; the stupor is about to disappear, and may, therefore, be hailed as a happy precursor ; fatigue after every movement and effort on the part of the patient; a pale and hollow countenance, which indicates-the disappearance of the turgescence ; vertigo, and heaviness of the head, continual difficulty of hearing, and noise in the ears; debility of the intellectual faculties ; fre- quent drowsiness and unrefreshing sleep; a white or furred tongue, with depraved and unnatural appetite ; a peculiar irri- tability, and a disposition to costiveness and perspiration. Such is the state which generally lasts about seven days after the formation of the critical stage, though every day dispels a new symptom, and the disease gradually disappears. The pa- tient by degrees regains his strength, so that he is soon able, and, in fact, glad, to leave his bed; his sleep becomes more re- freshing ; his appetite improves ;"and in this manner he each day acquires'more strength and spirits, and experiences a de- sire to resume his usual occupations. The difficulty of hearing, and the noise in the ears, are the most obstinate symptoms ; these, however, are gradually dissi- pated, though in some instances they persist for a considerable time. EIGHTH PERIOD. Of the Convalescent Stage. In this stage, which follows the stage of remission, all the symptoms of the disease are dissipated, and the patient is re- stored to the enjoyment of health. 54 The vital powers, however, are not yet sufficiently strong, nor firmly reestablished ; the body is weak and emaciated, the muscles soft and flabby, the skin is withered, and the epidermis separates under the form of scales ; the hairs gradually fall off, and the nails are reproduced, which proves that they undergo some alteration during the disease, in the same as the separation of the epidermis proves the existence of a previous exanthe- matous irruption. The pleasures of the senses and the desires are not only augmented, but they are greatly enlarged, so much so, indeed, that when they are gratified, they afford the most pleasing and inexpressible delight. The desire of eating amounts to a vora- cious appetite ; and bread is the kind of food that is generally preferred. The venereal appetite is in a state of morbid ex- citement ; and the patient who was previously like an animated mass, now becomes extremely sensible to the pleasures of the senses. We may almost assert it as a fact, that no one has ever experienced the plenitude of sensual enjoyment, who has not felt it in the convalescent stage of this disease. These de- sires, however, are so unnatural that they must always be at- tributed to a morbid state of the sensibility and irritability of the system. Besides these phenomena, which characterize this stage of the disease, there is generally a great irregularity in the excre- tions, constipation of the bowels, and in the female, a suppres- sion of the menstrual discharge. As soon as the assimilative functions, and the vital powers are restored, the excretions are reestablished, nor can the pa- tient be considered as perfectly well until this has taken place. It must be observed, however, that this requires several weeks ; because the convalescence after an attack of this fever does not take place so rapidly as in others. When the patient has perfectly recovered from an attack of typhus, his health is frequently better, and more permanent than it was before the disease ; nor is he in so much danger of contracting the same disease, or other kinds of fevers. 55 Before we conclude our description of the regular course of typhus, it will be proper to observe, that cases are not unfre- q\ient where persons who have suffered from obstinate and dan- gerous chronic diseases, have been perfectly cured by an at- tack of this disease. Doctors Vaidy and Roux, two experi- enced military physicians, have informed me that they have seen a case of hydrothorax and chronic gout perfectly disap- pear in consequence of an attack of typhus. SECTION FIFTH. DESCRIPTION OF THE IRREGULAR TYPHUS, COMMUNICATED • BY CONTAGION. * As the small-pox, rubeola, scarlatina, the pestilential, and all other kinds of contagious fevers, do not always observe a regu- lar and natural course, but may, in consequence of various causes, present many anomalies, notwithstanding the contagi- ous miasm has, naturally, the property of producing the same diseases with their ordinary phenomena; so the contagious ty- phus is not always so regular, nor so natural as it has been de- scribed in the preceding section. Hitherto we have only seen the normal state of the disease; but it is susceptible of presenting a great number of variations in which we may remark symptoms which are entirely foreign to the disease, and which establish a certain confusion in its ordi- nary course. In this class, therefore, I shall include the whole assemblage of the characters or forms of the disease that can be denominated complications. The same contagious matter may, according to a great num- ber of causes, produce different phenomena in different individu- als, and give rise to the anomalies of which we are speaking. The most remarkable and common of these causes are: 1. The predisposition of the subject.—The disease, although always produced by a uniform contagious matter, experiences various modifications and anomalies, according as the sub- ject is young or old, of a sanguineous or lymphatic habit, weak or strong, of a lax-or rigid fibre, more or less irritable or sensi- 57 ble, predisposed to disease in one Or more organs, or already affected with some other disease, differently influenced by diffe- rent modes of living, &c. 2. The prevailing constitution.-2-All diseases, and especially those of a febrile character, receive from the prevailing con- stitution, as may be proved by the most conclusive observations, peculiar modifications which impress upon them the chief cha- racters of that constitution; but of all these, the contagious fevers are much more subject to this influence than those of a sporadic nature. According as this constitution is inflamma- tory, or bilious, or of the nature of intermittent fevers, the pe- culiar character of typhus, especially in certain periods, is so much influenced by these circumstances, that the type of the disease is completely changed, and the physician is obliged to have recourse to other remedies, or to those of a more energetic nature. Every epidemic, whether it be owing to the season and temperature of the year, or to any other cause, likewise holds under its dominion not only the contagious typhus, but all other diseases which are developed during the same time ; when the prevailing diseases, however, present nothing peculiar in their character, the typhus generally remains more or less simple and regular. 3. Unfavourable influence.—This may result from the habits and regimen of the patient, as well as from the accidental phe- nomena which arise from various causes and actions, and modi- fy or alter the character of the contagion or even of the typhus itself when already developed. Under these circumstances it is not difficult to lose sight of the influence of these peculiar causes, and to have recourse to an improper mode of treatment. If these causes act separately, or as is most commonly the case, simultaneously with the contagion, which is the principal cause, the disease will assume as many anomalies, as the diffe- rent causes may exert upon it. In order, therefore, to give a correct idea of the anomalies which occur in the different stages of typhus, and to point out the diagnosis of this disease, considered in respect to its 9 58 different forms, I shall endeavour to give a succinct description of those which are of the most usual occurrence. Of the Anomalies in the Forming Stage, and in the Stage of Invasion. In these two stages of typhus, the symptoms differ but little from those of the ordinary and regular course of the disease, and instead of presenting any thing peculiar, they merely indi- cate a general febrile affection. In the forming stage, particularly, where we can scarcely determine the ordinary and primary symptoms of the disease, as well as their duration, the anomalies can hardly be said to exist. During the stage of invasion, however, there is generally, an increase in the chills or in the febrile heat; though it sometimes happens that the chills do not last longer than in the ordinary course, or they are so slight that the disease is characterized from its commencement by a remarkable febrile heat; while in other cases again the chills last several days or return at inter- vals, as in cases of intermittents. Of the Anomalies in the Inflammatory Stage. The anomalies in this stage of typhus are so numerous and striking, that the disease is frequently changed, so that it is ex- tremely difficult to establish its diagnosis. The modifications which it presents, are almost innumerable; and the essential characters of the disease, by which we are enabled to determine the mode of cure, can only be remarked in the earliest part of this stage. 1. The inflammatory character is sometimes unusually intense.__ The fever, which is developed in the early part of this stage, under the form of an inflammatory catarrh, appears subsequent- ly in the form of a severe synocha. This synocha consists in an excitement of the vital powers, in 59 a kind of general plethora, and in an inflammatory disposition of the mass of the blood, unaccompanied by any predominant local affection. In some cases, however, there are violent local inflammations, in which are concentrated, as it were, the suuerings of the pa- tient and the peculiar phenomena of typhus. In the head, this inflammatory state is frequently so intense that the delirium assumes a phrenetic character, and the stupor is converted into apoplexy. I have seen cases also in which the inflammation of the fauees and of the parotid glands has amounted to a very high degree of intensity. In the chest, the symptoms are often distressing; the lungs are in a state of severe inflammation, accompanied with stitch- ing pains, spitting of blood, considerable oppression and all the severe symptoms which usually occur in that local affection. In the cavity of the abdomen also it is not very rare to find the liver, the intestines, the peritoneum, the bladder and some of the other organs in a state of inflammation. In all these cases, the physician may easily be led into error, and take typhus for an essential inflammatory fever, accompa- nied with local inflammation. Many of the cases of inflamma- tory fever, which assume a nervous or putrid character, in consequence of improper treatment, as well as certain symp- toms arising from a stimulating plan of treatment, have their origin in this error and in the careless observation of the disease. In this stage of the disease, the anomalous symptoms are sometimes so complicated that the most experienced practition- er may misunderstand the true diagnosis. The signs of typhus, in fact, are so obscured by the predominant symptoms of the inflammation, that it is not only difficult but almost impossible to distinguish it, especially when the physician is only guided by a mere superficial knowledge of the semeiosis. Typhus, thus misunderstood, is designated under the erroneous denomination of inflammation of the bladder, of the lungs, the liver, the intes- tines, and other organs. The suspicion of the existence of a contagion, the unusual length of the forming stage, the stupor and vertigo, the noise in the 60 ears, the essential exanthema, and the other symptoms which it is not easy to describe, and which can only be distinguished by a careful and attentive examination, are the peculiar and cha- racteristic signs of this disease. After the seventh day, these signs are always more distinct, in consequence of the diminu- tion of the inflammatory symptoms. The causes of this anomaly, then, consist, in great measure, in a plethoric disposition of the patient, and in local inflammations, or in a prevailing inflammatory constitution, in the actual exist- ence of an inflammatory fever, in a stimulating plan of treat- ment, and in the immoderate degree of heat of the apart- ment. 2. The symptoms of the disease are frequently owing to a pro- minent gastric character.—The continual nausea, and repeated vomitings, the bitter taste in the mouth, a furred tongue, op- pression in the epigastric region, constipation and pain in the bowels, fetid alvine evacuations, and other symptoms, not un- frequently give to typhus, in this stage, the appearance of a bilious fever : so fallacious, in fact, are these symptoms, that the most experienced physicians are sometimes led into error. The passage of the bilious fevers to the nervous or putrid state, is owing to the absorption of the bile, to the debility of the system, as well as to other causes, and should not by any means be attributed to a contagious property. By a careful reflexion upon the essential characters of ty- phus, it will be easy to distinguish it, even in the midst of the gastric symptoms to which we have just alluded. In some cases, however, the diagnosis is difficult, and cannot be render- ed clear until the seventh day of the disease, when the nervous character begins to predominate. The causes of this anomaly are, a state of irritation of the gastric system, occasioned by the contagious matter ; a kind of sympathy between the stomach and the head, which, in this case, is principally affected ; a considerable degree of irritation of the liver, which performs so important a part in this disease ; the influence of a prevailing bilious epidemic ; and, in short, a gastric complication, which is developed during the forming 61 stage of the disease, or even during the disease itself, whether it be occasioned by some irregularity in diet, or by overloading the stomach with medicines or drinks. 3. The exanthema is either entirely absent, or it is altered in dif- ferent ways.—There is, generally speaking, no symptom which is so variable and subject to so many irregularities as the exan- thema. This, therefore, will, probably, always present a great obstacle to the classification and systematic arrangement of the exanthematous fevers ; for it is well known that the exanthe- matous irruption in typhus presents as many varieties and mo- difications as there are species. In typhus, the peculiar exanthema of this stage, is some- times entirely absent, or it is so concealed by the skin, that it can only be perceived by the most careful examination. In some instances, it makes it appearance under the form of a miliary petechial irruption, &c. and soon disappears. It never continues beyond the seventh day, and when it is dissipated, it does not always afford the relief which is the usual consequence in the regular course of the disease. The causes of this anomaly in the exanthematous irruption, in fact, consist most frequently in the irregularities in diet, in the suppression of the perspiration, or in any other derange- ment of the functions of the skin, occasioned by cold, mois- ture, &c. Most of the other functions of the body, and espe- cially those of the digestive canal, have the most intimate con- nexion with the skin; so great, in fact, is this connexion, that, when the skin is interrupted in the exercise of its functions, the partial crises, which succeed to the exacerbations, may be dis- turbed—a circumstance which does not ordinarily take place when the skin is in the full exercise of its functions. 4. The nervous character is sometimes developed in this stage, to which it does not essentially belong.—It presents more or less in- tensity from the slightest to the highest degree of vital debility, which gives rise to the premature dissolution of the body. Notwithstanding this, however, the nervous state in this stage of typhus, is sometimes extremely slight, and consists more par- ticularly in the absence of the inflammatory symptoms. We do 62 not, moreover, meet with that intensity in the vital powers whicn is usually observed in this stage, and which is so salutary to the future state of the patient. The tongue and the skin become dry, and, instead of the hulammatory symptoms, there is some- times a nervous state, which is characterized by typhomania, subsultus tendinum, convulsions, spasms, partial paralyses, hic- cough, and other distressing symptoms. In this state of the disease, the already existing local inflam- mations may be altered, so as to assume an unnatural charac- ter. It sometimes happens also, that there is so great a degree of real debility, that the disease presents the greatest malignity, and suddenly proves fatal. This nervous state soon assumes a putrid character, even in this stage, or under'the influence of a general debility, and of the relaxation of the soft parts ; the fluids become impoverish- ed, and the blood is extravasated both internally and externally. At the same time that these symptoms take place, there are black petechial irruptions, hemorrhages, a disposition to gan- grene, diarrhoea, a putrid fetor, and all the other unhappy pre- cursors of a speedy dissolution. Under these circumstances, the disease always approaches to the character of the plague, in as much as we may sometimes observe blotches and pesti- lential carbuncles, the sure precursors of the extinction of life, which always takes place before the seventh day of the dis- ease. The causes which give rise, at so early a period, to this ano- malous state, and to the nervous character, may be owing either to a peculiar disposition of the subject previously to his contracting the disease, to a stimulating plan of treatment at the commencement of his illness, or, on the contrary, to the employment of too debilitating means, such as copious bleed- ings, and powerful purgatives ; at other times, to the exhaustion occasioned by debilitating evacuations, such as hemorrhages and diarrhoeas; or, in short, to the irregularities of diet, the want of cleanliness, moisture, heat, and cold, but principally to a close and stagnant atmosphere, to bad and unwholesome food, and to the influence of the moral affections. 63 The character of the prevailing epidemic and the constitution of the air, may greatly contribute to the premature development of the nervous state. But the most common of all the debilita- ting causes consists in the fever, and in the alteration of the vital powers which, after having been for a long time in a state of depression, finally pass into a state of real debility, as is proved by the fact, that the vital energy which is beyond the power of development, finally sinks into a state of exhaustion, as happens in typhus fever and in fevers in general, where the debility is al- ways fallacious from fhe commencement of the attack. This circumstance is frequently the source of the malignity which is either sought for in causes entirely unconnected with the patient, or is attributed to some unhappy and foreign influ- ence which has no existence, and cannot, consequently, be detected. The causes, however, which in fevers, give rise to the acute scurvy, or to the state of putridity which distinguishes it essen- tially from the nervous character, are as yet unknown and shut up in the bosom of the Creator. The phenomena of the putrid state do not depend upon the debility alone, and have scarcely any connexion with it. For in some cases, the patient may pass through all the grades of de- bility, without contracting the state of putridity; and even in some of the most remarkable cases of scurvy or of putridity, the vital powers of the patient are neither sensibly depressed, nor is he obliged to confine.himself to his bed. Do the symptoms of this state depend more upon a relaxation than upon a real de- bility ] In the chronic scurvy this really appears to be the case ; but in the acute, the relaxation,-is probably combined with the debility. Amongst the circumstances which give rise to the debility and favour the development of the putrid state, may be included the crowded and unwholesome air of the apartment, in which the patient is, as it were, immersed for several days in a bath of his own peculiar atmosphere, loaded with the perspiratory and pulmonic vapours, the same corruption of the air when many sick people are confined in a narrow, and unventilated apart- 64 ment; the want of motion, and the passive state to which he is subjected, especially when he is badly attended; the want of internal efforts in the highest degree of debility, the privation of acid drinks, the moral impressions, and a variety of other circumstances. 5. There may be different anomalies in the particular symptoms of the disease.—These may arise not only in this, but in fact, in every stage of the disease, as well as in every kind of fever. These anomalies in the distinct symptoms of the disease, how- ever, seldom, give rise to any essential difference in the peculiar character of this stage, and their whole effect consists in a mere modification of its form. 6, and lastly. This stage may also sometimes present slight anomalies in respect to its course or duration.-—In some instances, for example, the inflammatory character is very short, and soon gives way, as we have already said, to the nervous character; while in other cases again, it continues beyond the seventh, the ninth, or even the eleventh day. Of the Anomalies in the Nervous Stage. This stage of the disease is susceptible of affording as many anomalies as the preceding. The nervous character, in fact, not only amounts to the highest degree of intensity, but it likewise presents a great number of modifications and complications. At first, it is not much unlike the preceding inflammatory character, and the local inflammations, especially those of the chest, which exist during the first stage, may likewise, accord- ing to their peculiar nature, continue for some days. These local inflammations, by their protraction in this stage, frequent- ly change their nature and assume a distinct character of de- bility which augments, in a very singular manner, the tenden- cy to gangrene. At this time it may also give rise to nervous or septic local inflammations, which now make their appearance for the first time, and are extremely subject to variations. The most com- mon of these are, inflammations of the brain, of the lungs, of 65 the liver and the intestines. The last, owing to peculiar cir- cumstances, may frequently assume the character of a putrid dysentery, and the inflammation of the liver, that of typhus icterodes. This affection is sometimes suddenly developed, and, what is still more singular and inexplicable, it often disap- pears of itself. I have seen a case of this kind in which the deep yellow colour of the skin perfectly disappeared in the course of thirty-six hours, and was succeeded by the natural colour of the skin. The gastric symptoms are not only fallacious, but they de- pend, moreover, upon the impurities of the primae viae, pro- duced generally by too great a quantity of medicines adminis- tered during the disease. One of the most ordinary symptoms of this disease is the presence of worms in the alimentary canal. These are generally of the species called ascarides lumbricoides, whose mode of development is so obscure, that it is impossible to say whether they are engendered before, or during the disease. It should not be inferred, however, when only one of these worms is discharged spontaneously, that there exist many others, as has been so frequently done ; for, by the most careful post mor- tem examination, we cannot, in some instances, discover the least trace of the existence of these animals. The diarrhoea, which is so often characterized in this stage of typhus, by frequent, copious and fetid stools, may also, in some degree, be comprised amongst the number of the gastric symptoms of which we are speaking. It appears that this di- arrhoea, is, in great measure produced by the presence of the acrid bile which is secreted during the inflammatory attack of the liver; yet, I believe, as I have already had occasion to state, that a superabundance of the intestinal exhalations, oc- casioned by the diminution of the cutaneous perspiration, also greatly contributes to this exceedingly debilitating affection. The exanthematous irruptions which occur in this stage of the disease, instead of diminishing, as they do in the ordinary course of typhus, present various anomalous appearances. We may observe, for instance, a continuance of the petechiae, 10 66 or they may be seen to increase and to assume a new aspect It is in this stage also, that the parotid glands commonly begin to inflame. To the most frequent irregularities of this stage, belong, moreover, a remarkable increase of the debility and of the nervous character, and the development of the putridity, which is not, however, peculiar to the ordinary course of this disease in any of its stages. The most remarkable nervous symptoms in this stage of the disease, are: a dry and parched tongue ; an inextinguishable thirst, accompanied with dryness and acrid heat of the skin; a disposition to diarrhoea, attended with meteorism and pain in the bowels, which becomes aggravated on pressure ; a uni- versal tremor; different kinds of convulsions, which vary in intensity and duration ; grinding of the teeth; delirium with gesticulation and carphology; a kind of mussitation ; hiccough ; spasms in the muscles of the jaws, the neck, and the bladder ; paralysis in the eye-lids, in the muscles of the tongue, the neck, the anus, &c. &c. I have also, in some instances, observed a kind of rigidity of the fingers and of the extremities, tenesmus, a horror and dread at the sight of water, and many other symp- toms of a hydrophobic character. To the symptoms of putridity belong, moreover, the black- ness of the tongue and the fuliginosity of the teeth, the disa- greeable fetor of the breath, of the alvine evacuations, and of almost every part of the body; the lividity of the skin, the pe- techiae or the large pestilential blotches, the carbuncles, the gangrene of the compressed parts, the passive hemorrhages of every kind, a corrupted state of the urine, the bad appearance of the expectorations, the coldness of the extremities, the clammy sweats, and other highly distressing symptoms. The various complications existing between these different symptoms may give rise to almost innumerable modifications, which have been designated by some physicians under the names of inflammatory typhus, bilious typhus, nervous typhus, putrid typhus, dysenteric typhus, pituitary typhus, &c. The Frusi l.equent anomaly of this stage, however, depends upon 67 the different degrees of the nervous and putrid character, which is frequently attended with more or less inflammation, as well as upon the extremely variable forms of the disease, which give rise to different local affections. But the ordinary course of the fever itself, which, in such anomalies, seldom terminates on the fourteenth day, is protract- ed, when death does not take place at an early period, to the seventeenth, the twenty-first, or even to the twenty-eighth day. I have seen several cases also in which the disease, though it ultimately proved fatal, preserved an uninterrupted course un- til the thirty-fourth day. Of the Anomalies in the Critical Stage. The critical, like every other stage of typhus, has its ano- malies, whether it be considered in respect to its appearance, its critical phenomena, or in relation to its consequences. In the ordinary course of simple typhus, there is a kind of partial crisis, which takes place about the seventh day, and af- fords considerable relief by an abatement of the inflammatory symptoms. After a successive increase of the nervous symp- toms, there is a second crisis, which occurs on the fourteenth day, and which greatly diminishes the disease, whicji now be- gins to disappear. In the anomalous state, however, there may be many irre- gularities in the first crisis, which may either be entirely absent, or it may afford but slight relief, or it may, on the contrary, even produce an increase in the symptoms of the disease. Be- sides these irregularities, there may also be slight anomalies with respect to the critical day itself, which may either be ad- vanced or retarded. With respect to the period of the second crisis, which is ge- nerally decisive, as well as to those which usually appear at the end of a complete septenary, it may be remarked, that in those cases where they do not manifest themselves on the fourteenth day, they may be expected to take place on the twenty-first day. The crises which occur on the seventh, tenth, or the eighteenth 68 day of typhus, are seldom of a decisive nature; while those which take place on the twenty-eighth, and the thirty-fifth day of the disease, though of very rare occurrence, are as decisive as any of those which make their appearance at a more early period. Notwithstanding this, this order of days is always much more definite in the salutary crises than in those which have a fatal tendency. In all kinds of fevers, death may happen at any period of the disease, and especially in that which is not cha- racterized by the appearance of a crisis, which is itself irregu- lar, on account of the fatal crises commonly taking place in a premature or tardy manner. The causes which retard the salutary crises of the fourteenth day,* are extremely numerous. The most remarkable are : first, the different kinds of local affections, especially those of the lungs and of the intestines, which greatly oppress the vital powers, and are more opposed to a salutary reaction than even the different affections of the brain; secondly, a debilitating plan of treatment which gives rise to a real debility, and im- pedes the critical efforts of nature; thirdly, spontaneous eva- cuations, passive hemorrhages, diarrhoea, or other epigenome- nous and debilitating symptoms; fourth, and lastly, a stimu- lating plan of treatment which increases the orgasm of the fluids and their resistance against the action of the vital powers, which are so much depressed, that they become finally exhausted, and are succeeded by the greatest degree of debility, which is in di- rect opposition to every salutary crisis. The physician, therefore, during the inflammatory stage, should never lose sight of a suitable plan of treatment, and of the proper management of the vital powers, upon which de- pends the welfare of his patient during the remaining stages of the disease. For it is well known, that it is extremely difficult to mehorate the vital powers, when the treatment has been of an improper and injurious nature. * In the fevers which are essentially contagious, there are never any example* of a premature crisis. 69 Besides the anomalies which have already been pointed out as belonging to the critical stage of typhus, there are a variety of others, in which the critical evacuations especially hold a conspicuous place. The changes which supervene in the urinary secretions dur- ing the existence of this disease, are perhaps less to be depend- ed upon than any other critical evacuation : for the farther the fever recedes from the inflammatory type, the less, in general, will the urine serve as a characteristic sign. In the critical stage of typhus, therefore, the urine is never seen to differ from its natural state, or if it does, it will be found similar to that which is discharged during the preceding stages of the disease. It sometimes happens also, that the alvine evacuations dur- ing the critical stage of this disease, are neither different in their quantity nor quality, and leave us in doubt as to their critical nature. The critical sweats are also sometimes, though seldom, want- ing ; and though there is no perspiration, and the skin retains its previous dryness, the patient nevertheless begins to get well; and the spasmodic constriction of the cutaneous exhalent ves- sels gradually disappears, without there being, however, any remarkable exhalation. The ordinary critical exacerbations are frequently so imper- ceptible, that the physician is unable to determine to what symptoms he ought to attribute the relief of the patient. The causes of this anomaly are so obscure, that it is ge- nerally impossible to distinguish the critical symptoms. Be this, however, as it may, it is certain that the irregularities in the crises, especially in those of a salutary nature, are rather unfrequent, and that they do, in all probability, often exist only in the mind of the careless and inattentive observer. With respect to the consequences of the crises in typhus fever, all those may be said to be anomalous which have not an immediate bearing upon the health of the patient. The miasm of contagious typhus, like that of the small-pox, the measles, and of other similar diseases, is of such a nature, that it may be easily overcome by the efforts of the vital powers, especially 70 if there be no obstacle. Thus, in the natural course of the disease, when there is no extraordinary alteration in the power* of life, the patient is always restored to the enjoyment a health; and the number of those who get well, is generally much greater than the number of those who succumb. Every unhappy crisis of contagious typhus, whether it ter- minates immediately in death or in any other fatal disease, con- stitutes what is called an anomaly in the effects of the crisis. We shall consider the causes, and the different modes of this unfavourable termination in a subsequent part of this treatise. Of the Anomalies in the Stage of Remission. When there are no irregularities during the preceding stages of the disease, or when there are many when the disease is at its highest degree of intensity, it sometimes happens that the stage of remission is far from being regular. The anomaly may consist either in an extraordinary and protracted course, or in some unusual symptoms. The anomalous course of the remission of the fever is always very protracted, and never short or accelerated. If the vital powers are considerably depressed in the preceding stages, and, if instead of a decisive crisis, there are several slight and imperfect ones, the progress of the remission will necessarily be slow. In general, there is a distinct intermission, between the convalescence, properly so called, and the close of the pre- ceding stages of the disease. If the remission of the fever, however, be premature, and if it be not attended with immediate health, it is liable to terminate in some other disease. The most common symptoms which are observed in this anomalous remission, are, the continual stupor, occasional de- lirium, disturbed sleep, deafness, dryness of the tongue, thirst, want of appetite, the affections of the chest or abdomen, obsti- nate tympanitis, derangement in the excretions, a slow and fee- ble pulse, a slight degree of fever, and loss of muscular power. 71 In this stage of the remission, when the disease does not terminate in health, but in some other disease, we may fre- quently remark a number of new symptoms, especially inter- nal metastases, which always prove fatal, either immediately, or at a subsequent period of the disease.—We shall give a more full account of these symptoms when treating* of the different terminations of typhus. The inflammatory affection of the fauces which is sometimes observed in this stage of the disease, cannot, in my opinion, be considered as metastatic. Finally, there are not wanting cases in which, after the stage of remission, there is a development of a new contagion, which gives rise to a relapse. When this takes place, the new symp- toms are united to the preceding phenomena, and instead of a remission, the disease augments in intensity and danger. Of the Anomalies in the Convalescent Stage. The term convalescent is applied to that stage of the disease in which all the essential symptoms are completely dissipated, and in which the general symptoms of the rest of the disease gradually disappear, until the functions are at length completely reestablished. The convalescence, after an attack of typhus, may be ren- dered difficult and imperfect, and, consequently, anomalous, in a variety of ways. Many patients, during their convalescence, remain for a long time afflicted with that disagreeable state of inebriation which accompanies the disease ; their nights are generally spent in unrefreshing sleep ; their appetite is bad, and their strength so much enfeebled, that they are scarcely able to leave their bed, and can only walk the room when supported on the arm of an attendant; they labour under profuse sweats, and the unplea- sant effects of constipation of the bowels ; and, although the disease is completely dissipated, they are generally impatient, and recover but slowly their ordinary vigour and strength. This does not only happen when the disease presents many 72 anomalies in its different stages, a great degree of debility, and a long duration, but likewise, when typhus observes its ordi- nary course. The least irregularities in the diet of the patient during his convalescence prevent the rapid increase of the vital powers, and I have seen examples also where this was rendered extremely difficult, in consequence of the influence of the mo- ral affections, even after a regular and ordinary course of ty- phus. The ulcers from blisters, and the wounds of the differ- ent parts of the body that have been subjected to pressure, are also not unfrequently a great obstacle to the perfect and speedy recovery of the patient. Having thus given an account of the principal anomalies which aggravate typhus, it only remains to be remarked, that this disease is sometimes so slight and its symptoms so indistinct (typus levissimus,) that the patient is able to sit up during al- most the whole course of the disease, which lasts only about fourteen days, and consists merely in a slight degree of stupor, and in some trifling pains in the abdomen. These singular anomalies to which we have just alluded, are also sometimes observed in the pestilential typhus, as I have myself seen on the frontiers of Turkey, and as I have been informed by other phy- sicians, who witnessed the plague at Constantinople, at Smyr- na and Cairo. When typhus fever is so slight and so imperfectly developed, as we have just described it, it has often been considered and treated by physicians, either as a pituitary, or as a slow and se- vere nervous fever. SECTION SIXTH. —e©©— OF THE CAUSES AND MODES OF DEVELOPMENT OF TYPHUS The typhus to which I have applied the term communicated, is always produced by contagion, that is, by the communica- tion of a matter which, like all other contagious miasmata, occasions in the healthy subject a peculiar fever, during the ex- istence of which is reproduced the germ of a similar disease. Our knowledge of the causes of this disease is extremely li- mited, and in order to be able to give a correct idea of it, is absolutely necessary to treat separately, 1. Of the properties of the contagious matter; 2. Of its mode of communication ; and 3. Of the circumstances under which the contagion and the development of typhus take place. Of the Properties of the Contagious JUatter of Typhus. Every contagious miasm possesses the properties, 1, of pro- ducing a similar virus in the disease which it has occasioned ; and 2, of spreading and extending itself ad infinitum, by virtue of this secondary development, that is, so long as there exists a matter capable of receiving the miasm, and of producing a new one. Both these properties are similar, by their power of reproduction, to the germs of animals and of plants; but the last property is analogous to the matter of fire, since a single atom of the contagious virus, like a spark, is capable of spread- ing itself ad infinitum, and of traversing, when unobstructed in its progress, all bodies that are capable of receiving it. 11 74 The virus of contagious typhus possesses both these pro- perties. Every contagious virus, like the germs of a plant, contains, 1, a principle of invisible power which is not evident to our senses, and which is put into action only under certain condi- tions ; 2, a visible or sensible matter, capable of organization, or which was originally organic, and serves as an envelope to the principle to which we have just alluded. In the contagious virus, this principle of invisible power is set into action by its contact with a peculiar animal principle ; and it not only deranges the vital movements of the healthy body, but is likewise capable of reproduction. The vehicle or the appreciable matter of this principle, is a kind of animal mucus or lymph : consequently pus, mucus, tenacious lymph, and in general all fluids of this kind form the special seat of this contagious principle ; while, on the contrary, the blood, the urine and the fecal matters appear to be but little calculated to receive or to fix it. The analogy between typhus and other contagious diseases, allows us to presume that the contagious matter of typhus has in common with all other contagious matters, the general pro- perties which we have just pointed out. Notwithstanding this, the virus of typhus, like every other virus taken separately, has its peculiar properties. 1. In typhus, as in all other contagious fevers, the new mat- ter is not developed in every stage of the disease, but more probably at the moment of the appearance of the exanthema- tous irruption. It is for this reason, undoubtedly, that in cases of typhus where there are only some exanthematous spots, the miasm is not so visibly enveloped in an animal fluid as in the other contagious diseases; notwithstanding which, the mucus of the nose and the fauces, as well as the secretions of the skin, appear to be well adapted for the communication of the contagious matter of typhus. 2. In the nervous stage of this disease, the constant dryness of the skin, which is particularly favourable to the contagion, allows us to presume, as is also proved by the most careful ob- servations, that the contagious matter of typhus is «not uniform- ly communicated by means of animal mucus, nor by the me- diate or immediate contact of this matter, but that it is effected under the influence of an atmosphere, in which the patients labouring under an attack of the disease, are, as it were, im- mersed. Under these circumstances, the virus is always capa- ble of spreading itself to a certain distance. It must, likewise, be remarked, that the contagious matters possess different kinds of volatility, and that their power of acting, at different distances, is susceptible of numerous varie- ties. The virus of syphilis, for example, of hydrophobia, the cow-pox, and other diseases, is completely destitute of volati- lity, and cannot communicate itself to a certain distance, as is the case with the virus of typhus, of scarlatina, and some other contagious diseases, especially when it is suspended in an animal atmosphere. 3. The miasm of typhus, after having produced its effects, almost always destroys, for a certain time, the susceptibility of the system to a similar contagion. This want of susceptibility, however, lasts seldom throughout the whole period of life, as is the case with that of small-pox, rubeola, and some other dis- eases. In this respect, however, it has, notwithstanding what we have just said, some analogy with the virus of these dis- eases ; while, on the contrary, it is entirely different from the syphilitic virus, which, when once introduced into the human body, always favours the development of a similar contagion. 4. The miasm of typhus appears to possess a mode of ac- tion analogous to that of the narcotic poisons, though its action is much more permanent. The essential and constant symp- toms of the disease are dependant upon the action of the virus, and cannot be explained, from the nature of the chemical pro- perties of the contagious matter, much less indeed, in as much as the chemical analysis of these narcotic poisons cannot ex- plain their mode of action. It is evident, therefore, that our knowledge of the nature and properties of the virus of typhus, like that of every other conta- 76 gious virus, and of the peculiar properties of the different germs, is still extremely obscure and unsatisfactory. Of the Modes of Communication. The communication of the contagious matter of typhus takes place either immediately or mediately. An immediate contagion (contagium vivum) is that which is communicated from a sick to a healthy person, by immediate contact, and, as it were, from hand to hand. This contagion, however, is of much more unfrequent oc- currence than that which is produced by mediate contact; and it commonly requires also, that the communication between the patient and the healthy person should be several times repeat- ed, in order to be able to produce the disease, not only in its ordinary, but even in its pestilential form. As a spark of fire does not always burn, and only catches when the substance is of an inflammable nature ; so the contagion, after one or more communications, only attacks those who have some suscep- tibility. Immediate contact is not, however, always indispensably ne- cessary to the contracting of this contagion. In fact, it may frequently be contracted merely by being in the atmosphere of those who are labouring under the disease ; for it is well known, that the atmospheric air which surrounds living persons and warm blooded animals, is generally warmer and more abun- dant than it is around persons labouring under typhus, and, consequently, more hurtful. The mediate contagion (contagium mortuum) is that which takes place by touching persons that have been in contact or communication with the patient, and who are, by this means, rendered capable of receiving and of spreading the contagious miasm to other individuals. There are, however, many dead substances which are impregnated with contagious matter, and which, although ihey have not the power of communicating the contagion, either 77 consume, destroy, or decompose the contagious matter, or re- tain it so as to be incapable of spreading it to the living subject. These bodies, which are called non-conductors of the conta- gious virus, are the metals, the different kinds of earth, glass, and similar substances. There are other bodies, and especially those to which the animal mucus appears to have the power of obstinately attach- ing itself, which have, in general, the property of communi- cating to a healthy, but predisposed individual, the virus which they contain. These bodies are called conductors of the con- tagious virus, and consist not only of animal substances, espe- cially of skins, hairs, feathers, &c. but likewise of many of the filamentous substances of vegetables, such as cotton, hemp, flax, and all the stuffs into the composition of which they enter, as well as hay, straw, moss, and a variety of other substances. The mediate contagion, then, may be communicated in nu- merous ways ; but most commonly by articles of clothing, such as linen stuffs, furs, dirty bed-clothes, and even by means of the straw or the skins, upon which the patient may be ob- liged to lie during his illness. This fact strongly confirms the remarkable history related by Pringle, by which he proves, in the most clear and satisfactory manner, the contagious nature of the camp fever. -The sick soldiers were lodged in a number of old tents, which served them as beds. These tents were afterwards sent to Ghent to be repaired, and for this purpose twenty-three men were employed, seventeen of whom were attacked with the disease, and died, without having ever had any communication with the sick. The mediate contagion is of much more frequent occurrence, and more capable of spreading the disease, than the immediate; and it is very probable also, that it may, as it is customary to say, develope its effects when received from first, second, and third hand. 78 Of the Contagion itself The immediate contagion takes place only in consequence of certain requisite conditions, which consist in touching or ap- proaching a person labouring under an attack of typhus ; while the mediate contagion, on the contrary, takes place by a third and intermediate body, which communicates the miasm to a healthy individual. The contagious miasm, which is not spread immediately from a sick to a healthy person, frequently remains inactive in the dead body to which it adheres; and, like the germs of plants, it only begins to act, when its internal and hidden power is put into action by the necessary conditions of approach and contact. In case, however, these should not take place, this power to which we have just alluded, is lost, and sooner or later completely destroyed. Experience proves that the pestilential virus preserves for a long time, and according to some, for several years, its conta- gious power, especially when it adheres to substances that are well calculated for its reception. The same observation may also, in some measure, be applied to the small-pox, and even to scarlatina. While visiting a patient, who laboured under an attack of scarlatina, I wore a black coat, which I carried with me, about a year and a half afterwards, from Vienna to Polodia, where it communicated to me that contagious disease, and where it afterwards spread throughout the province, in which it had before been almost entirely unknown. Although the virus of typhus preserves for a long time its contagious property, it is difficult to determine the period in which it is dissipated. From my experience, however, upon this subject, I may venture to assert, that it does not last more than three months, because a typhus epidemic that is dissipated, and completely exhausted in the course of three months, can- not, after that period, easily reproduce itself, unless there is a development of a new contagious matter. This contagious matter, however, as it continues to spread to different individuals, becomes gradually more feeble and in- 79 active, and is finally, according to the opinion of some physi- cians, completely exhausted, which is not, however, confirmed by my own experience. The circumstances which occasion the inertia of this matter, are, like those of every other contagious miasm, entirely un- known. Is it owing to the contagious matter being more or less volatile 1 or to its being more or less readily decomposed ] or is it owing to the vehicle of the contagious matter being de- stroyed 1—These are circumstances of which we are as igno- rant as we are of the causes of the duration of the life of the germ of a plant or of an animal. Finally, in order that this contagious matter may be able to produce the mediate contagion, it is necessary that there should be, besides its presence and powerful action, as in the immedi- ate contagion, a concourse of certain necessary conditions, 1, of heat; 2, of the introduction of the matter into the healthy body ; and 3, the necessary susceptibility of the body to the contagion. If any of these conditions be wanting, it is impos- sible for the contagion to take place. 1. Of the Influence of Heat upon the Contagion. Heat is extremely favourable, and, in fact, indispensably ne- cessary to the development of every contagion ; while cold, on the contrary, is directly in opposition to its production. Heat, which performs so active a part in the development of every germ, is also extremely active in the propagation of the contagious virus. * It generally imparts life and motion to this matter, and spreads it upon other bodies that are disposed to receive it; it disengages the principle, which was before dor- mant and concealed, from its envelope, renders it free and ac- tive, and presides thus over all its effects, which attain, under its influence, the greatest possible degree of extension, at least so far as the susceptibility of the bodies that are affected, will permit. It is by means of heat, then, that is developed the peculiar 80 activity of the contagious matter; it is by heat that this germ takes root in the human body ; it is by it, that the contagion extends its influence upon bodies that are already impregnated ; and it is by heat, in short, that this contagion produces a new matter which has likewise the property of extending itself, or that the first virus is maintained in a state of constant expan- sion and activity. It is for this reason, therefore, that in warm climates, in warm seasons of the year, or whenever the temperature of the air which surrounds those who are affected with contagion is elevated, that the violence of the contagious fever sensibly augments. It i§ for the same reason that the contagion extends itself with more promptitude and activity under similar circum- stances ; and that all bodies which are not conductors of ca- loric, and which are, consequently, susceptible of preserving both the matter of caloric and the contagious virus, are like- wise the most proper for spreading the contagion; and that, on the contrary, the conductors of caloric are improper and unfit for its propagation. Cold, on the other hand, or the absence of a sufficient de- gree of heat, is incapable either of putting the contagious mi- asmata into activity, or of favouring their effects : they are, as it were, in repose under its influence, and slumber for want of proper conductors. Many contagious germs are frequently destroyed in consequence of excessive cold, and are, like some of the germs of plants and of animals, completely frozen. This is, particularly, the case with the miasmata of typhus, which are sometimes so circumscribed and limited in their ac- tion, by the influence of cold, that they lose both their expan- sibility and their power of extension. Cold then is the surest prophylactic mear>3 against every kind of contagion; and when employed to a certain degree it is the most sure and certain means for destroying the conta- gious matter that has hitherto been discovered; it either com- pletely annihilates the virus, or it arrests its effects until it is again exposed to the influence of heat. This fact is so strik- 81 ing, that, if we were sufficiently careful, we might, by this means alone, prevent every contagious disease. It is for the same reason also, that in cold climates and dur-, ing the cold seasons of the year, the propagation of contagions is sensibly diminished, and sometimes completely suspended, especially when it is not, as sometimes happens, promoted by artificial heat, which may easily be avoided in the common con- cerns of life. This being the case, it is obvious, that every contagious fever, as well as the typhus, will be much more be- nefited by a refrigerant than by a stimulating plan of treat- ment. Notwithstanding the observations which we have just made, it is impossible to determine the degree of heat that is neces- sary to put into action the contagious matter of typhus, or of any other disease. It would appear, however, that the ordi- nary degree of animal heat, when it is constant and uniform, is sufficient to put in motion the contagious virus, as it is in general sufficient for the activity of the germs of animals ; and, as on the one hand, a too great a degree of heat impedes its vi- vification, so on the other a too high a degree of cold may com- pletely destroy it. Dr. Campbell, and other physicians, have remarked, that the atmospheric heat under the torrid zone was capable of producing the same effect. With respect to the contagious matter of typhus, however, experience teaches us, that, that which is communicatedby a mediate contagion by means of a moderate degree of heat, is generally developed in its highest degree of activity and exten^ sion. The wearing of clothes that have been impregnated with the contagious matter, or lying in infected beds, or even upon infected straw, is sufficient to develope, in the space of an hour or more of a uniform heat, the contagion in a healthy hi' dividual, especially when he has been asleep. In the immediate contagion, the heat which is evolved by the patient, forms, as it were, the conductor of the contagious mat- ter, and determines its vivification, its expansion and activity, especially when the reaction on the part of the person that is affected with the contagion, is too weak to resist its influence ; 12 82 it is for this reason, therefore, that a feeble person, when he is exposed to a contagious miasm, is in much greater danger than one of a vigorous and active constitution ; the former is always in a disposition adapted to receive, while the latter, by a super- abundance of life, seems to have the power of opposing every cause of destruction. From what we have already said, it is evident that the con- tagious matter can seldom spread from the dead subject, and only in those cases where the circumstances are favourable to its development. Finally, experience proves, though it is not easy to explain the fact upon which it is founded, by any of the principles that have been laid down, that the dryness of the atmosphere is not at all calculated to favour the propagation of the contagious matter, while moisture, on the contrary, is extremely favoura- ble to its development; nor can we explain the cause why the contagion of typhus is more rapidly developed and spread in dark than in lighted places. 2. Of the Introduction or Reception of the Contagious Matter. The contagious matter being conveyed into the body of a predisposed healthy individual by means of heat, produces a contagion, or such a change in the health, that, it gives rise, after s&me determinate symptoms of the disease, to the deve- lopment of a new and analogous matter, or rather, as we have already said, it preserves itself, in a state of constant expan- sion and activity, and multiplies itself in an inexplicable man- ner. In order, however, that this contagious matter may take root and display its effects, it is absolutely necessary that it should be received into the body. This being the case, we shall ne- cessarily be obliged to make some observations upon the mode in which this matter is received, and upon the necessary and in- dispensable dispositions of the healthy body for its reception. The opinions of physicians concerning the manner in which the contagious matter is introduced into the human body, have 83 been extremely various. The absurd hypothesis whieh attri- butes the contagion to a mixture of the virus with the saliva in- troduced into the stomach, where it spreads its effects, ought, as it justly deserves, to be abandoned by every scientific physi- cian ; for the incontestable fact, founded upon repeated expe- riments, that different kinds of virus may be introduced into the stomach without any danger whatever, is in direct contradic- tion to this hypothesis. The opinion, that the contagious mi- asmata may be conveyed into the lungs during the act of in- spiration, is not, however, entirely without foundation, because this passage may really serve for the transmission of the dis- eases of the lungs and of the trachea. It is always with pleasure that we revert to the ancient and well founded opinion, that the cutaneous system is the essential organ of the contagion, as is proved, moreover, by the analogy which exists between artificial and local contagions. The dif- ferent contagious miasmata, however, which affect the skin, exhibit the greatest possible variety of phenomena. Many of the contagious virus will remain inactive if there be no solution of continuity of the cutaneous system, and if the orifices of the inhalent vessels are not denuded. This, for ex- ample,, is the case with the virus of hydrophobia, and probably also with that of psora, of phagedenic ulcers, and of the cow- pox, the effects of which will be extremely slight, if the vessels of the skin have not been denuded, or at least if the epidermis has not been raised. On the other hand, there are many other virus, such as the virus of gonorrhoea and of syphilis, for instance, which do not require that there should be a solution of continuity of the skin or of the epidermis, and which act upon the most delicate and sensible parts, of the skin. There are others again, such as those which belong to the contagious exanthematous diseases, which appear to act upon every part of the cutaneous system, without having any regard either to the denudation or the delicacy of the skin. Notwith- standing, this contagion appears to act in a more certain and striking manner, according to the number of points of contact, 84 in the same manner as fire burns more readily in proportion to the number of points upon which it may have a chance of ex- erting its influence. It is impossible to determine to what degree the hairs, which perform a certain character in the physiological phenomena of the skin, contribute to the transmission of the contagious virus, and to the contagion itself. Be this as it may, it is extremely probable that they have either a positive or a negative influ- ence : for it is well known, that the syphilitic contagion can only take place in those parts that are destitute of hair; while the herpetic contagion, on the contrary, can only occur upon those parts that are well covered, with it, as happens in cases of tinea capitis. In typhus, and in general in the exanthema- tous fevers, the parts which are not covered with hair, or but slightly so, are too unimportant to afford room for such an abun- dant and extensive contagion. It is to be presumed, however, although the hairs are not godd conductors of caloric, that the ordinary contagion of fevers usually operates on the parts that are covered, at least it is by them principally that the virus is received. It should, nevertheless, be remarked, that the mu- cous membrane of the nose and the fauces is extremely well adapted to the reception of a volatile contagious matter, and that these organs themselves may, in typhus, perform an impor- tant character. The manner in which the contagion is com- municated in the typhus of animals, especially in horned-cattle, greatly confirms the suspicion, that the hairs perform an impor- tant character in this disease. But if the contagious matter is always communicated in this or in any other manner, by the cutaneous system which receives it* as well as the first germs of the disease, there ought to be a previous disposition on the part of the body to favour the elec- tive attraction existing between that organ and the contagious virus > and here naturally arises the question, what are the changes which supervene in the organic activity of the skin, as well as in the other parts of the body, and in every part of the vital system 1 or in other words, in what consist the lesion of 85 the vital functions, and the primitive and secondary changes which take place during the contagion itself? If the explanations of the physiological phenomena of the cutaneous organ, are vague and unsatisfactory, its pathologi- cal condition, which arises from an invisible material, is still less comprehensible and explicable. As yet we have no pre- cise theory of contagion, and probably never will have, while physiologists continue to explain the functions of the animal economy, by vain and unmeaning expressions. In fact, they have never given us even a satisfactory explanation of the functions of any individual organ in the body, not even of those of the skin, which can be so easily examined both in its healthy and diseased state. This pathological state, to which we have just alluded, though much involved in obscurity, may, however, at some future period, contribute to throw light upon the phy- siological functions of the skin, and lead to more favourable and satisfactory results. The phenomena of every impression upon the cutaneous or- gan, and, consequently also, the pathological phenomena of the impressions of the contagious matter, may, in general, be con- sidered in two different ways: 1. All the impressions of this kind, and especially the local impressions which are exerted upon the skin, extend to a greater or less distance, in propor- tion as they are superficial, and are sometimes conveyed to the most remote regions. 2. They are carried into the inmost re- cesses of the internal organs which have any physiological rela- tion with the general system of the skin, and from whence they may, by means of their ordinary secondary effects, be conveyed to all the other systems of the body. The properties which are enjoyed by the affections of the cutaneous organ of extending to the superficies, are amply con- firmed by the successive and sometimes unlimited extension of certain diseases, such as erysipelas, herpes, and other affec- tions. The same is also sometimes observed in the common local irritations of the cutaneous system, which extend succes- sively over the whole superficial part of the skin. 86 From these facts, therefore, we may presume that the irrita- tion peculiar to the contagion, may extend in a variable space of time over every part of the skin, and that its first, and per- haps its principal effect, is to pass from the point where the first impression was made, as from a particular centre, to the general surface of the cutaneous organ, in the same manner as the divergent rays of a luminous body are carried towards the periphery of another. The manner in which the morbific changes take place in this case, is still unknown ; yet it would appear that the necessary relation between the atmosphere and the cutaneous organ is de- ranged, and that the equilibrium of the functions of this organ is interrupted. Should it ever be proved that the general system of the skin is the generating organ of animal heat, and that the lungs are the organs producing cold by means of respiration, it will be no longer difficult to explain the changes which supervene in the skin, in consequence of the contagious irritation, or at least the fever which is developed from its effects. The morbific impressions of the skin produced by the ef- fects of the contagion, are communicated to the internal and neighbouring organs, especially to those which have an intimate physiological relation with the cutaneous system, such for in- stance, as the lymphatic vessels, the nerves, and the lymphatic glands. As yet, physicians are ignorant of the changes which super- vene in the organs during the contagion, and of the anomalies which affect the vital powers. It is not necessary, however, to have recourse to a pretended absorption of the matter, or to a septic fermentation, in order to be able to comprehend the de- velopment of the contagion ; for this may take place when the skin is morbificly affected from the effects of a contagious im- pression, and when the perspiration and absorption are either in a state of ingravescence or diminution. All the functions which are either immediately or mediately dependent upon the skin, are consecutively deranged, until all the other systems 87 become affected with disease. The contagious matter is pro- bably distributed through the body, in the same manner as heat and electricity ; so that we are not obliged to seek for its ex- planation in the action of the vessels, or in its volatility : for there is, moreover, a well founded suspicion, that every fever, and especially the typhus, is dependent, in great measure, upon a derangement of the animal electricity. All this, however, is mere conjecture, the farther pursuit of which will necessarily lead the mind into error, and into the dark mazes of an impe- netrable labyrinth. It is of little consequence, therefore, to the practitioner, whether this disease consists, as has been asserted by Hart- mann, (1) in a deoxidation of the skin, or whether it depends upon an alteration of the sensibility and irritability, or whether, in short, it depends, as is most probably the case, upon the de- bility of the animal system, accompanied with a diminution of the muscular and sensorial powers. 3. Of the Necessary Disposition. Besides the circumstances that have already been mention- ed, both as necessary to the morbific action of the contagious matter, and to the contagion itself, it is absolutely necessary that there should be in the healthy human body a certain capa- city or disposition, without which the contagious disease cannot be developed, and which has for this reason, been called the ne- cessary disposition. As in small-pox, rubeola, scarlatina, and even in the venereal contagion, this disposition is indispensable, so it is likewise ab- solutely necessary to the contagion of typhus. This disposi- tion does not, however, exist in all persons, nor is it present at all seasons of the year; yet it may be remarked, that there are some who are at various periods extremely susceptible to the disease. (1) Med. Chir. Zeitung, No. 45, 1807. 88 In what conditions of the body this susceptibility consists, neither reason nor the theories of our art, are capable of ex- plaining. The manner in which the cantagion itself is commu- nicated, is too imperfectly known, to enable us to ascertain the part that is performed by the healthy organs in its production, and consequently, to determine in what manner the whole body participates. Observation and experience, however, have fur- nished us with some interesting results, which it may not be improper to mention. In respect to age, it may be stated, that young or middle- aged persons, are those who are most disposed to the contagion of typhus. It must be remarked, however, that children and small infants, who contract all kinds of contagion with a great degree of ease, are rarely affected with typhus, even when they are constantly with their mothers or nurses, who are suffering with the disease, or have been afflicted with it a short time pre- viously. Are the symptoms and course of typhus in infants so obscure, that they cannot be recognized 1 Old, lean, and wrinkled people are likewise rarely, if ever, attacked with this disease, nor do they appear, according to my own experience, to be at all subject to it. As regards sex, there appears to be no remarkable difference in the susceptibility of contracting typhus, or any other conta- gious disease. It would seem, for reasons that will soon be mentioned, however, that women are more subject to it than men. With respect to the state of the body, it may be remarked, that weak and delicate persons, and those who have a fine and lax skin, are generally the most subject to this contagion ; while those, on the contrary, who are of a robust, plethoric and vi- gorous constitution, are rarely affected. In relation to diet and the mode of living, it may be stated, that all persons who have been weakened by abstemiousness, are particularly subject to the contagious typhus. The priva- tion of strong drinks, the effects of hunger and cold, the moral affections, fear, anxiety, and grief, as well as numerous other affections, are extremely well calculated to give rise to a pecu- 89 liar susceptibility to this contagion. It is, for this reason, there- fore, that persons should never visit patients who labour under an attack of typhus, with an empty stomach, in a cold and hu- mid temperature, and under the fear of taking the contagion ; because it has been proved by ample experience, that such per- sons are exceedingly liable to contract the disease. It is for this reason also, that persons who travel during cold and rainy seasons, are likewise extremely liable to take the disease, es- pecially when they are obliged to sleep in beds that have been infected with the smallest quantity of this contagious matter. Those, on the contrary, who drink wine and brandy, smoke tobacco, are gay, and courageous, are but seldom subject to it; because the body, being in a state of warmth and excite- ment, is capable of reacting upon all such occurrences, as might, under other circumstances, exert an unfavourable influence. From this, it is obvious, that it must be less dangerous to visit patients labouring under an attack of typhus, after having taken something to eat, a glass of wine or brandy, after smoking a cigar or a pipe of tobacco, especially, if with all these, the mind is cheerful and unruffled. It is for this reason that stimu- lating remedies have for a long time been regarded as more sure anti-pestilentials than most other debilitating means, such as the continual spitting at the bed-side of the patient, and even the employment of vinegar; although with respect to the lat- ter, it must be remarked, that it has the power of neutralizing the contagious miasm, and that it cannot be disputed, that it possesses the property of contracting the pores of the skin, and thereby enfeebling its susceptibility to the contagion. The disposition of the skin of a healthy individual, may like- wise, so far as it depends upon the mode of living, and the va- rious functions of the body, present a great influence upon the susceptibility to the contagion ; for it may be greatly favoured both by its roughness, its hardness, and its want of cleanliness : with respect to cleanliness, however, it must be remarked, that filthy persons, such as chimney-sweeps, and those whose skin is impregnated with greasy substances, &c. suffer but seldom 13 90 from the contagion, because the virus is, as it were, repelled. and cannot traverse the filthy substances which surround the skin. From this, it is reasonable to infer, that in order that the whole skin may be rendered susceptible to the impression of the contagion, it will only be necessary to wash it with warm wa- ter ; yet even this, as well as other means of cleanliness, may completely resist an incipient contagion. The susceptibility of the body to contagion, is frequently de- stroyed by previous diseases; yet persons who have been weakened by other diseases, especially by nervous affections, succumb easily under the influence of every contagion, and consequently also under that of typhus; while those, on the other hand, who are subject to chronic affections, suffer in ge- neral, but seldom, from its effects. Amongst the many hun- dred cases of typhus fever, which have come under my treat- ment, there has not been a single instance of persons labouring under phthisis pulmonalis, that were attacked with this disease. Is it possible that a suppuration may have the power of dimi- nishing the susceptibility of the body to the contagion 1 This question will be examined in another part of this work. Be this as it may, the typhus belongs to the class of conta- gious diseases, which, when once dispersed, diminish or even destroy, if not always, at least generally, the susceptibility of the system to the same disease. Hence it follows, that persons who have experienced the disease, may again expose them- selves, without the least danger, to the contagion; while those who have never had typhus, show the greatest susceptibility to the contagion, and speedily contract it: they are sometimes so saturated, that they finally become insensible to its action. This is frequently seen to be the case with physicians, sur- geons, ministers, and nurses, who, after having had an attack of this disease, brave the contagion without the least danger of again contracting it: the same thing obtains with respect to the typhus of horned-cattle. Sometimes, however, the typhus, like the plague, destroys 91 the susceptibility to the same disease, only fop a few months or years; and it is upon this fact, that some physicians have founded the unhappy idea of inoculating these diseases. We shall appreciate, in its proper place, the value of this opinion. It is impossible to explain the manner in which a contagious disease can, for a certain time, destroy the disposition to the same contagion; nor is it possible to tell how it happens, on the contrary, that there remains for a long time, a morbific diathe- sis, and a tendency to a relapse, in certain non-contagious dis- eases ; nor do we know to what must be attributed, in other contagious diseases, as in syphilis, for instance, the develop- ment of that peculiar disposition to a return of the same phe- nomena. If we knew how it happened, that the human body becomes accustomed sooner or later to certain stimulants, so as to be no longer capable of experiencing the least impression, we should then, perhaps, be able also to comprehend how it happens, that certain misasmata, to which nature appears to become soon accustomed, finally lose their effect, so as to be incapable of occasioning any hurtful impression or irritation. This general rule, however, presents many exceptions, espe- cially in typhus; for persons often relapse soon after an at- tack of this disease. I have seen a case, where the patient, who had been affected several times with the same dis- ease, relapsed from the very commencement of her convales- cence, and who, three weeks after her second convalescence, was attacked for the third time, and died on the fifteenth day of her disease. In other cases, however, I have observed, that when the disease was produced by a new contagion, it was much slighter than the first attack. Besides the circumstances which we have related, and which appear to be the principal cause of the susceptibility to the con ta