Practical illustrations of typhus fever, of the common continued fever, and of inflammatory diseases, &c., &c
'l--^^kf^'i: M ■^x^- .-, , <*■ ■* c--^.. ■ i-'^ *»* •^*»' : PRACTICAL ILLUSTRATIONS OF TYPHUS FEVER, OF TKE COIMIVEON CONTINUED FEVER, AND OF 3[nfiattimatorp ^t^ea^e^, Sfc. Sfc. By JOHN ARMSTRONG, M.D. PHYSICIAN TO THE FEVER INSTITUTION OF LONDON. WITH JsrOTES, CRITICAL AKD EXPL^MHTORY, By NATHANIEL POTTER. M.D. PBOfESSOR OF THE THEORT AND PRACTICE OF MEDICINE IN THE UNIVERSITY OF MARYLAND, &C. 8cC. Human esperience, which is constantly contradicting theory, is the great test or truth. DK. SAMUEL JOHNSON. SECOND AMERICAN, FROM THE THIRD ENGLISH EDITION. WITH CORRECTIONS AND AN APPENDIX. PHILADELPHIA: PUBLISHED BY JAMES WEBSTER. WILLIAM BROWN, PRINTER. 1822. Eastern District of Pennsylvania^ to -wit : BE IT REMEMBERED, That on the thirteenth day of February, m the Forty -fifth year of the Independence of the United States • ««««««« of Afnerica, A.D. 1821, James Websteh, of the said District,y »SEAL.* hath deposited in this Office the title of a Book, the right/ ******** whereof he claims as proprietor, in the words following, to wit : "Practical Illustrations of Typhus Fever, of the Common Continued Fe- ver, and of Inflammatory Diseases, &c. &c. By John Armstrong, M.D. Phy- sician to the Fever Institution of London, with Notes, critical and explana- tory, by Nathaniel Potter, M.D. Professor of the Theory and Practice of Medicine in the University of Maryland, member of the Medical and Chi- rurgical Faculty of Maryland, member of the Medicai Society of Maryland, member of the Medical Society of Baltimore, honorary member of the Medical Society of Georgia, and corresponding member of the Physico- Medical Society of New-York. " Human experience, which is constantly contradicting theory, is the great test of truth." — Du. Samuel Johnson. "First American, from the Third English Edition." In conformity to an act of the Congress of the United States, 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 also to the act, entitled, " An act supple- mentary to and to amend the act entitled, ' A.n 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 tliereof to the arts of designing, engraving, and etch- ing historical and other prints." D. CALDWELL, Clerh of the Eastern District of Pennsylvania. TO , JOHN RALPH FENWICK, M.D. OF DURHAM. My dear sir, Knowing no individual who unites in his character more talent and benevolence than yourself, I inscribe this volume to you, as a token of my sincere respect and esteem. Believe me to remain, dear sir. Your much obliged and faithful friend, John Armstrong. JuhjSl,lSl6. CONTENTS. Pago Prefack, --  the vtirious Acute and Suh-acute Inflammations of the internal Organs, - - - - -.--34 The Congestive T\p!ius, _..-.. 63 History of the different Forms of the Congestive Typhus, in which it is shown, that they are intimately connected with the Conditions of the right Side of the Heart and of the ve- nous System, - - -- - - - -64 Allusions to Animal Heat, -_--.. 78 Remarks on the Doctrine of Critical Days, - - - 81 Tre;itment of tlie Simple Typhus, in which it is shown how highly important it is to attend to the different Stages of this Variety, -._.--. -84 R'lnaiks on the Modus Ofiorandi of Purgatives, - - 92 Specific Powers of certam Purgatives alluded to, - - lOQ Treatment of the Inflammatory Typhus, in which the Pro- priety of bleeding and other Evacuations are considered in reference to the Stages, 8cc. . -  Action of the Heart, the Principle upon which its Utility chiefly depends, 120 Secondary Fever of Irritation, _ . . . . 133 Allusion to Dr. Dickson's View of Typhus, ... 135 Practical Objections to the Opinion, that Fever always con- sists in Inflammation, - 136 Treatment of the Congestive Typhus, - . - . 139 Utility of attending to the Pulse in Bleeding, - - - 144 Necessity of restoring and equalizing the Animal Heat, 144 VI CONTENTS. Page Influence of Calomel, 145 Stimulants sometimes needful, - -. 149 Cautions against late Evacuations, - - -. - 15 1 Means best fitted for the milder forms, - > _. 153 Cases of Congestive Fever to vyhich the forementioned Treat- ment is not applicable, 156 Result of the Author's Observation  generally originat- ing from the Influence of the Atmosphere,. - - 203 The history of those Forms in which the Brain is chiefly im- plicated, with their Pathology and Treatment, - - 204 Various Names under which the Common Continued Fever has been designated, .-._... 222 Objections to Cullen's Definitions of Synocha and Synochus, with Remarks respecting the Origin and Nature of Con- tagion, ---- 223 What has recently been called the Epidemic not one but three Diseases — nan)ely Typhus — the Common Continued Fe- ver, and a low Fever of Irritation,. _ 226 Objections to Cullen's Definition of Typhus — that Disease contrasted with the Common Continued Fever, - - 227 Observations on the Atmosphere, 233 Observations on the peculiar Circulation of the Brain, - 235 Allusions to Hydrocephalus Internusand Dropsical Diseases, and to the Irritation of the Heart through the Nervous Sys- tem, by which  Heart, in which the Circulation of Lymph and Chyle is referred to the Dilata- tion of the right Ventricle, and to the Pressure of the At- mosphere, ..._.--. 242 Allusions to Apoplexy, ------- 244 An Endeavour to show that whenever Fever is ushered in by a cold Stage, Inflammation is a Consequence, and not a Cause of Fever, even in those affections called Pneumo- nia, Enteritis, &c. which are usually mere Modifications of the Common Continued Fever, as the Circumstance of Lo- cality in the Inflammation does not affect the Nature of the Disease, .-- 246 The Treatment of Internal and External Inflammations, - 255 Recipe of the Black Drop,  directed to the investigation of a favourite science, is unwilling to per- suade itself that its powers, however feeble, have been concentrated in vain ; since the faintest rays, when col- lected into a focus, can produce some degree of illumi- nation. It was an impression of this kind, which first led me to think of publishing the results of my expe- rience; and the present volume is a part of the series of commentaries on acute diseases, promised at the publication of some facts concerning the puerperal fever. During an extended practice of several years, my views, with respect to the treatment of fevers in general, have undergone gradual, and at length great changes ; and it is hoped that an impartial exhibition of the causes, nature, and object of those changes, may not be wholly useless. No disease is here brought forward, with the exception of the plague, but what has repeatedly fallesai X PREFACE. under my observation ; and typhus has been made the foundation for most of the principles attempted to be estabhshed. By the term typhus, many have meant that combination of malignant symptoms which may take place in the last stage of any acute disease, and hence they have said, that to deplete is death in typhus; but though it doubtless would be so under the ultimate symptoms supposed by them to constitute typhus^ yet this is an abuse of the term, which in the subsequent pages denotes a specific disease that, like the epic poem of ancient critics, has a beginning, a middle, and an end. Some of the advised methods of cure differ from those taught by certain medical professors and lectur- ers; but whatever regard I entertain towards men justly eminent for their rank and acquirements, I am morally bound to maintain what experience has shown me to be efficacious, how much soever it may oppose prevailing opinions. Now and then 1 have felt it a duty pointedly to dissent from the doctrine of noted authors, because error is always most dangerous when sanctioned by a celebrated name; yet fully sensible of their general superiority, it has been my aim to mingle respect PREFACE. XI With animadversion. So far as recollection or extracts could assist, acknowledgments have been made for the thoughts really suggested by the perusal of other works; and, therefore, if any omissions be discovered, they ought to be imputed to forgetfnlness alone. At the same time, it must be remembered, that medical in- quirers may make similar observations respecting dis- eases, without being at all indebted to each other, as distant and unacquainted astronomers may, by their telescopes, discover similar phenomena. Febrile affections have acquired an additional claim to notice, from their extensive prevalence in many dis- tricts of the United Kingdom, since the first publication of this work; and having been placed in situations fa- vourable for observation, I have endeavoured, in this revised edition, to give a much more extended view of the subject. At the suggestion of an able friend, the diflferent topics, before blended in the pathology and treatment of typhus, have been separated, and now form a series of distinct illustrations of the principles advanced. Among many others, one advantage of this new arrangement is, that it has enabled me to express my thoughts with greater precision as to those very ^11 PHEFACE. particulars upon which the chief pecuh'arities of my doctrine are founded; for in thus again soliciting the attention of professional readers, I must inform them, that the practice recommended is by no means so uni- form as some have represented, but varied by many minute circumstances, to point out which was the main reason of my attempting the illustration of acute dis- eases, Jv A. 23, Southampton-row, Russell-square, July, 181 9, ■^y :j^'' PREFiVCE FIRST AMERICAN EDITION. The delay of the American edition of Armstrong on Typhus Fever, requires an apology to the pubHc. The pledge so long given could not have been sooner redeem- ed, without an act of injustice to the excellent author. A complete suite of notes, adapted to the second edition, were prepared for the press, in August, 1819; when it was intimated that the author had published a third edition, so amplified and improved, that it would be un- becoming to present him to the faculty in his former dress. Every effort to procure a copy of the last edition proved abortive, till July, 18^0, when it was presented to us by our colleague Doctor Howard. Our engage- ments, both private and public, since that time, will account for the appearance of the work, at a period so remote from its first enunciation. Any encomium upon a work which has attained so just and great a celebrity, would be superfluous. No man, however deeply versed in theoretic refinement, or XIV PREFACE. experienced in practical observation, can read it without pleasure and instruction. It conspires, with all the most valued medical writers of ancient and modern times, to prove, that an accurate observatioa of the phenomena of fevers, and the deductions fairly deducible from them, constitute the surest and most solid foundation of prac- tical improvement. The writings of Sydenham, Cullen, Rush, and a host of others, who have pursued a similar mode of investigation, have succeeded in the exact ratio they have deviated from, or imitated Hippocrates, who applied the same mode of reasoning by deduction to medicine, which has since been so successfully applied by Lord Bacon to the other departments of science. Our partiality to the work on Typhus Fever, is to be attributed as much to an accidental coincidence of opinion upon a particular point, as to a conviction of the general excellence of the work. In December, 1809, we delivered a lecture expressly to demonstrate that the pathology of typhus did not justify the conclusion, that typhus and local inflammation were incompatible. The practice we had long and successfully pursued, was predicated upon this opinion, and the experience of al- most every year furnished new facts in corroboration of the sentiment. The application of the theory o[ venous congestion to typhus, has created a new era in the prac- tice of medicine; and although the learned and inge- nious author has acknowledged that it had been long before suggested, it can but be a source of high gratifi- cation to every liberal and ingenuous American, to learn, PREFACE. XV that the theory so happily applied to the malignant yel- low fever of 1 793, is now adopted as the basis of the greatest medical improvement that has been made in Great Britain since the days of Doctor Sydenham. From 1793 to the day of his death, our illustrious coun- tryman Doctor Rush, applied this principle to inflamma- tory diseases, in practice, and eloquently inculcated it in his public lectures. We have avoided the controverted question of conto- gion, to the affirmative of which the author is so wedded, that it is to be presumed no remonstrance from us could induce him to waver, nor any argument produce convic- tion. By dividing typhus into three varieties, he takes a distinction that will permit him to apply the epithet con- tagious only to one; and thus abandons two-thirds of the ground which has been so long and so strenuously de- fended by all his coadjutors. With this concession, we leave him to examine himself truly, availing himself of the lights of future experience to determine, whether typhus is a contagious disease, or his opinion one of the impressions of an early education, one of those habitual associations which even his great mind cannot disor- ganize.^ Perhaps it may appear to some more fastidious of lite- rary decorum, than is consistent with the true interests of science, that the notes appended, are clothed rather in the style of a solicitude to correct error, than to express the pleasure of approbation. On the few items in which we Xyj PREFACE. have had the misfortune to express an honest difiference of opinion,^ the verdict of the faculty, the sagacity of the critic, and future experience must decide. Our prin- cipal motive iu presenting so noble a monument of human genius to the American public, arises from a thorough conviction of its intrinsic excellence. We did not con- ceive ourselves obliged, by a false courtesy, to divest our- selves altogether of the right and character of a critic, however incompetent our pretensions to such an office may appear. It would have been scarcely possible, in the fallible condition of man, for two men to have viewed so great a variety of objects in the same light. Different optics must always contemplate the same objects through a different medium. That charitable indulgence the author has so liberally extended to others, we ask for ourselves " Veniam damns petimusque vicissim." NATHANIEL POTTER. Baltimore, February 28, 1821. PRACTICAL ILLUSTRATIONS OF TYPHUS FEVER, Sfc. Sfc. INTRODUCTION. Numerous theories have heen formed to explain the nature of lievers ; but the history of medicine proves, that none have been so constituted as to remain permanent. At different periods, by accident, genius, or dihgence, many dis- coveries were made, which opposed the prevailing doctrines of the day, or for which those doctrines could not satisfac- torily account. By the investigations which such occurrences naturally produced, the most elaborate theories, time after time, hg,ve been overthrown, and others, supposed to extend to a greater number of appearances- successively advanced, which in their turn have also fallen before the progressive improvements of the medical art. And as men in general are more fond of pursuing abstract inquiries than collecting and arranging matters of fact, it is likely, that some authors will continue to erect, and others to demolish systems, until the desirable period, should it ever arrive, when general prin- ciples shall be as firmly established in physic, as in the more perfect sciences. The most celebrated of modern theories, like those of preceding ages, have been drawn from partial or imperfect views, and are more or less fallacious when tried by experiment. It is, therefore, my intention in treating of fevers, to adhere, as closely as the nature of the subject will admit, to the consideration of their phenomena and effects ; and to endeavour from these, together with the known pow- ers of remedial agents, finally to deduce some special prin- ciples of treatment, capable of considerable extension. IS INTRODUCTION. The term lever has been used comprehensively to express a whole class of diseases, and limitedly to express some ofthe specific affections of that class ; and it has also been em- ployed in an abstract sense, denoting the combinations ol febrile phenomena, without signifying any particular fever. One set of authors has arranged under this term every dis- ease attended with increased action of the heart and increased heat; while another set has restricted it to those febrile dis- orders, which have been supposed to be independent of all local affections, and on this account called idiopathic. Nor is it uncommon to see it used as an abstract term in the me- dical publications of the day, as if fever were some peculiar and subtile essence, and the concourse of attendant symptoms iuere accidental appendages. But as the disorder of the con- stitution designated fever, has always appeared to me as the result or the sign of some antecedent change in the system, howsoever induced, an extended, though a definite signifi- cation of that term will be preferred in the following pages. The pyiexiae of nosologists shall, therefore, be considered as a class in which three orders are comprehended ; two orders in which the causes are specific, though at the same time es- sentially different, and one order in which the causes are not specific but com.mon. The first order comprehends fevers proceeding from contagions ; the second, fevers proceeding from n)arsh and similar miasmata ; the third, fevers proceed- ing from the vicissitudes of the weather, and other ordinary causes. It must be manifest, that the first order admits of a subordinate division, since some of its varieties only affect the same individual once, while he may be repeatedly affected by others; but still all the varieties of this order are distinguish- ed in arising from, and propagating themselves by peculiar contagions. The second order is characterized by exclu- sively deriving its origin from marsh and similar miasmata : its species certainly do not necessarily possess the power of disseminating themselves by any inherent quality ; and in this they differ from the varieties of the first class, while the nature of their origin marks them from those of the third and last. The third order embraces all those fevers which jiroceed from the general impression of heat or cold, from local irritations, or from any cause not having the special properties of contagion or of marsh effluvium ; and therefore what are called symptomatic fevers naturally fall under this order, although it shall be shown that several of its varieties arise out of an universal impression on the system, the force INTRODUCTION. 19 of which is finally spent upon those parts which had previ- ously been disposed to disease. Ic may perhaps be asked, in objection to this arraug;ement, that if we do not class diseases by a reference to the simi- larity or discrepancy of the pathoo;nomonic symptoms, shall we be safer in founding our arranjijements on their causes, some of which may rather be conjectured than positively as- certained? Certainly if theory be allowed to influence our ar- rangement, it oui^ht to be theory successfully investigated and established by observation. As it has not been proved that eveiy contagious fever is in every instance produced b}^ a specific contagion, and as considerable obscurity still hangs over the subject of marsh effluvia, it probably might have been quite as satisfactory, if the classification of fevers had been founded solely on iheir phenomena. Yet the arrange- ment here chosen, however defective it may be, presents some great pathological outlines, which I have not been able to find in any other ; though it is not my design to limit my- self to them throughout, but to abandon them whenever they may be likely to lead from any point of practical importance. Whatever may be the advantages of methodical arrangement in medical pursuits, I am chiefly anxious that my views on specific and determinate subjects should be clear and com- prehensive ; and if I can but accomplish this, shall be con- tent to leave, for the present, the general conceptions which relate to nosology as things only of secondary regard. How various soever the causes of fevers may be, their great and most important effects upon the vital organs are nearly the same. These effects shall be made conspicuous in the follow- ing pages, so that the reader may consider them among the leading objects of the work ; and in concluding the series or illustrations, an attempt will be made to reduce the pathology and treatment of all acute fevers to a few plain principles. The nature of my plan having been thus premised, several diseases, referrible to one or other of the above orders, shall be successively examined, and first of all typhus fever in par- ticular, as it is intended to be made the ground-work of the most important parts of the discussion. TYPHUS FEVER. IT is probable, that the disease now called typhus existed from a remote period, and though it is alluded to by Syden- ham, it appears not to have been distinctly characterized, as an (1) infectious complaint of its own kind, until about the beginning of the eighteenth century. Since that time, however, various works have appeared, and thrown consi- derable light upon this interesting distemper. Yet it must be confessed, that the term typhus is still used in medical writings, but more particularly in medical speech, far too in- discriminately. Instead of being solely confined to the in- dividual disease in question, it is made to include a great variety of widely different affections ; especially when in their course, the concomitant fever puts on a low or putrid type, as frequently happens in the last stages of many in- flammatory diseases of the external and internal textures. It strikes me, that to call any species of fever typhus, which has not the contagious essence capable of producing an une- ?uivocal typhus, is equally incorrect in logic as in language, n this essay, therefore, the word typhus shall be limited to the peculiar disease, which is allowed to originate from a specific contagion which, doubtless, has the power of produc- ing an affection of its own nature, in individuals exposed to its influence. The word typhus is still too generally associated with the opinion, that the fever, which it properly designates, is in all its stages a disease of real debility ; but this notion has either been taken on the word of those authorities, who for a time gave the tone to medical opinions and theories, or it has been impressed upon the minds of those who entertain it, from a contemplation of the disorder wholly limited to its advanced periods. An extensive observation, however, (1) The distinction between Infection and Contagion, suggested by the American Etiologists, has not been adopted by the learned author ; nor has it (as far as we have learned) been acknowledged by any Euro- pean writer. If there is no foundation for this discriinination, there is no difference betwixt a vitiated secretion, the result of morbid arterial action, and such causes as have their existence independent of the living body. 22 during a series of years, has convinced me, that the genuine tj'jjhu'j- s<) .ai Trnn- being of an asthenic nature, is most ''sr- tainly an affection of excitement or of congestion, in its first stages, demanding at such times the evacuant plan. Enter- taining these sentiments, the professional reader will perhaps excuse their hrief annunciation in entering on the subject ; as they may continue to warn him against the undue influence of some early associations, and thus incline him to give a fair hearing to the facts and arguments about to be adduced. Typhus is unquestionably most prevalent in cold and tem- perate climates. It would indeed appear, from an author of great research, that this disease had probably not occurred on either side of the Indian peninsula ;* though it is uni- versally known, that the warmth of tropical regions is most congenial to the generation of those effluvia, which produce the remittent yellow fever. I have known, however, prac- tical men who were confident that the contagion of typhus occasionally exists in some hot countries ; but they seemed to consider, as Sir Gilbert Blane long since asserted, that there is something in those countries unfavourable to its production and continuance. In England, typhus is evi- dently favoured by a low temperature, being most prevalent in the cold seasons of winter and spring, generally abating or disappearing, as the heat of summer advances, and often prevailing to a considerable degree in cold wet autumns ; but nevertheless it occasionally prevails at all times in the year, and is even undiminished by the hottest weather in this country, as. I once witnessed when the thermometer was unusually high during the greater part of a summer. In a number of persons exposed to the contagion of typhus, some, though rarely, are attacked as early as the first or second day, and others even after the thirtieth ; but per- haps the most common periods of sickening after exposure are, from the end of the first, to the middle of the third week. (2) It has been affirmed, that it follows at so great a * See page 510 of an Essay on the disease called Yellow Fever, wjth observations concerning Febrile Contagion, Typlius Fever, Dysentery, and the Plague. I5y Edward Nathaniel Bancroft, M.D. London. Print- ed for T. Cadell and W. Davies, Strand, 1818. (2) The difference of time between the periods of attack, (even if we admit the infection to have been received at the time supposed) would not avail the author in maintaining the doctrine of contagion. Each con- tagious fever observes nearly an uniform law, as to the interval between the first impression of the vis nocens and the incipient state of diseased, sensation. There are no causes capable of producing fevers, so certain 23 distance as the ninth or tenth week after exposure, but this seen:s very questionable. If an author is pursuaded that there must be specific contagion as the source of every fever resembling typhus, he will undoubtedly go far to seek for it. When this disease once prevails, it generally assumes dif- ferent forms, which may, however, be arranged under three varieties, namely, the simple, the inflammatory, and the con- gestive typhus. These three varieties shall first be concisely characterized, and afterwards separately examined, in order to illustrate the rules of treatment fitted for each. In strict propriety of language, typhus can only be deno- minated simple in a relative sense. It is in reality the least complicated form of the disease, in which the febrile excite- ment or hot stage, is completely developed, and in which there are no decided marks of topical inflammation. The inflammatory typhus has the same open characters of general excitement as the simple ; but with these are conjoined symptoms of some visceral inflammation. The congestive typhus is distinguished by the hot stage not being at all, or only imperfectly developed, and by simultaneous signs of ve- nous congestion in one or more of the internal organs. THE SIMPLE TYPHUS. The simple typhus has a first stage of oppression, a second of excitement, and a third of collapse. (3) These succes- sive stages, but more particularly the two last, bear a pretty exact ratio to each other, as to degree, but not as to dura- tion. The stage of oppression is usually marked by a variety of symptoms, among which the following are mostly con- spicuous. Paleness of the face ; a peculiar look of dejection and weariness ; some degree of darkness or livor in the in- in their effects as contagions. They seem to require fewer auxiliaries to give effect to their influence. They would appear to act as both a remote and proximate cause, while marsh etfluvia and all infections may act upon the living body, and in many ])ersons not occasion a fever, with- out the aid of an additional or exciting cause. (3) This state is common to this, and many other fevers, and has not attracted the attention to which it is entitled. While the cause impairs the healthy function of the nerves, and through them the muscular powers, a more energetic action of the heart succeeds. The primary action of tlie cause would seem to increase the sensibility of the nerves to impressions, and thus to establish a disproportion between the vis a tergo, and the capacity of the nerves to sustain it ; this state of collapse is only another name for indirect debiUty, but as it is the effect of febrile excitement, it should be denominated the debility of morbid action. 24 teguments surrounding the eyes ; prostration of strength ; diminution of mental energy and of sensibility ; cold creep- ing sensations on the surface, or short hot and chilly fits alternately ; loathing of food, nausea or vomiting, whitish or clammy tongue ; sense of weight or anxiety about the praecordia; occasional sighing and hurried breathing; aching, heaviness or giddiness of the head ; coldness of the back, and pain of the loins; a quick, low, struggling pulse, change- able as to frequency, and even irregular as to force. These symptoms are accompanied with feelings of general uneasi- ness, somewhat resembling those which are experienced after a long journey, or any other great fatigue. The stage above described sometimes comes on and reveals itself with rapidity; but generally it is more insidious in its approaches, and oc- cupies, from first to last, a period of two or three days ; when, after various irregular demonstrations of reaction, it is succeeded by the second stage, or that of excitement, in which there is a complete developement of the fever. In subjects who possess constitutional vigour, the tone and ve- locity of the circulation are now preternaturally increased, and the pulse accordingly becomes comparatively expansive, thrilly, and somewhat resisting; at least widely different from the variable, confined, inelastic pulse of the former stage, and from the uniform free, and smoothly flowing one of health.* The cheeks are flushed with a dusky redness ; the eyes heavy ; and the lips parched. The respiration is quick; the skin almost invariably dry; the heat universally diffused, and steadily above the common point ; the tongue foul; the thirst urgent; the uneasiness in the head increas- ed ; the sensorium in a highly susceptible state — every symptom, in fine, denoting an excess of excitement. This second stage of the simple typhus naturally holds a tolerably even tenor for some time. As it proceeds, however, the brain at intervals is usually disturbed with revery, or slight * Perhaps some may be inclined to doubt the correctness of number- ing a preternaturally increased tone of the circulation among the most frequent symptoms of typhus. My own experience, however, in the country fully authorizes me to do so in the early periods of the simple form of the disease ; and Dr. But certainly the pulse is sometimes very changeable, as will afterwards be more particularly demonstrated. 25 delirium, coming on towards evening, when there is an ex- acerbation of the fever, and receding towards morning, when there is a remission; but the prostration of strengtli, which is at all times very evident, is generally greatest in ihe pe- riods of the exacerbations, and the tongue is then drier. During the predomination of the excitement, the bowels for the most part have a tendency to constipation. The excre- tions as well as secretions also undergo gradual and material changes, which are evinceii b}' the dark and offensive na- ture of the faeces, by the peculiar odour of the breath and whole body, and by the morbid appearances exhibited on the tongue, in the fluids formed from the liver, from the kidneys, and from other organs of secretion. After six or seven days, sooner or later, according to its mildness or severity, the stage of excitement gradually gives place to that of collapse, which is first announced by signs of depression in the voluntary powers ; by a certain degree of relaxation in the skin ; by a more variable and less concen- trated state of the temperature; and by a notable diminution in the force of the circulation ; the pulse being of less volume, softer and undulating. In the mildest cases, the approach of the stage of collapse may be viewed as an indication of convalescence. For although the patient may complain of much general weakness, and sometimes of soreness in the flesh, with flying pains or cramps in the extremities, yet the tongue will be found softer and cleaner, the thirst diminish- ed, the pulse slower, the breathing deeper and less frequent, and the skin of a natural warmth as well as moisture. Be- sides, the patient will pass much better nights, the functions of the stomach will be in some degree restored, with an evident improvement in the appearance of the fasces, and in general with a lateritious sediment in the urine. Whereas, in the more marked instances of this sort of typhus, the su- pervention of the stage of collapse considerably augments the danger. The prostration of strength then becomes far greater ; the pulse is commonly quicker, and always much weaker ; the tongue fouler, darker, and drier ; the voice fainter, and the articulation less distinct; the respiration shorter, feebler, and more anxious. The sensorial functions, too, are more disordered, and the countenance is more de- jected, sunk, and inanimate. Added to these symptoms, the skin feels looser, and appears more shrivelled, vvhile the temperature is no where so intense as in the stage of excite- ment, but variable in the course of the day, even on the cen- 4 26 tral parts ; and there is an increase of general restlessness? a more perceptible and peculiar fetor about the body, and often an irritating species of cough, which comes, as it vvere^ in convulsive fits. In this state the patient is disposed to lie upon his back. The foregoing description is intended to apply to the sim- ple typhus, as it runs an unimpeded course ; but between its slightest and its most marked forms, there are intermediate ones, whenever it extensively prevails. Some of the worst cases of it which I ever saw, existed in subjects who had been kept in a warm, close atmosphere ; and some of the mildest, in those who had inhabited cool, airy apartments. When properly treated from an early period, this variety of the disease generally terminates favourably ; but when ne- glected or maltreated in the beginning, it frequently proves mortal, and then dissection commonly reveals some remains of an injected state of the capillary arteries, without any ef- fusion of coagulable lymph, adhesion of parts, gangrene, or suppuration, which are the results of genuine inflammation. Some writers have stated, that, on minute inspection of the bodies of patients who died in simple fever, no derangement whatever could be detected. Nevertheless I am inclined to think, that such occurrences are exceedingly rare, although it cannot be questioned that in some cases, as I have myself witnessed, the morbid appearances are not sufficient to ac- count for the unfavourable issue ; and we are almost com- pelled to infer, that it chiefly depended upon an actual exhaustion of the vital principle, induced by the preceding excitation. At the same time, however, I cannot help sus- pecting, that in almost every fatal instance of the simple typhus, there is really a degree of lesion in the structure of some vital organ. In the present state of our knowledge, there are perhaps many morbid changes, which elude the in- quisition of the anatomist. In fact, until we are more thoroughly acquainted with the minutiae in the natural or- ganization of some delicate and complicated parts, we cannot expect satisfactorily to detect those slender and latent lesions, upon which, in all probability, the suspension of function more frequently depends, than is usually conjectured. On more than one occasion I have seen a patient sink in typhus.. 27 with all the common indications of ah oppressed brain, and on the most careful dissection of the part, nothing decidedly morbid could be discovered : yet all the circumstances of those cases, taken in conjunction, seemed almost to preclude the possibility of doubtino; that the principal mischief had existed there. But such examinations ought to humble the pride of professional opinion, and to show us the necessity of acquiring m.ore minute information. It was once the fashion, through the influence of CuHen's genius, to illustrate the phenomena of most fevers, by what occurs in the successive stages of an attack of an intermit- tent. These stages may in some degree convey an idea of the changes observable in the duration of the simple typhus. The cold stage of the former is somewhat analogous to the stage of oppression, while the hot and sweating stages also are resemblances of those of excitement and collapse in the latter ; and the analogy, too, is the closer, when we consider that the pure intermittent is an example of simple fever, un- combined with any inflammatory affection of the viscera. In the more marked examples of the simple typhus, the circulation is evidently disordered from the beginning of the stage of qpjiression: when the reaction has once taken place, the pulse continues to rise, unless timely controlled, through nearly the whole of the second stage ; and the preternatural acceleration of the blood can only be said to subside on the approach of the last stage. It cannot but be supposed, that this long continued tide of the fever, though it may leave no visible traces behind it, must make considerable impressions on certain organs of delicate structure ; such as the brain, for example, through which currents of blood must have repeat- edly flowed with more velocity, and in greater quantities, than natural. But in the mildest instances of this variety, it must be admitted, that no kind of organic lesion is pro- duced, and they consequently end favourably ; and in this they likewise resemble the simplest intermittent, in which the morbid excitement of the circulation does not give rise to greater local irregularities or accumulations of blood, than can be finally removed by the energies of the constitution alone, or by very gentle expedients of art. Almost all the larger viscera can sustain a certain degree and duration of vascular distention, without their structure being thereby at all impaired, or even their functions very greatly disor- dered. Many of the examples which Hippocrates has so minutely related in his epidemics, were fevers of simple ex- 38 citement, so that they terminated favourably by some spon- taneous evacuation ; and when typhus prevails epidemically, many cases of the simple typhus usually occur, which do well either entirely without medicine, or by the very mildest means. The characters of the simple typhus, it will be perceived, vary according to the time of its continuance ; and, as some of those variations demand correspondent changes in the mode of treatment, it is hoped, that the attempt which has been made to point out the pathognomonic signs of each of the leading stages, will be found both correct and useful. For want of having carefully noted the different expressions, which this complaint puts on at different periods, some sys- tematic writers have almost entirely overlooked many of the most essential parts of the first and second stages ; and by having dwelt principally upon the last, contributed to sup- port the dangerous doctrine, that typhus is always a disease of real debility. There is, however, so wide a difference between apparent and real debility, that the practitioner who would successfully condi-.-'t the treatment of febrile disor- ders, must attentively distinguish the one from the other. An opinion should seldom be formed wholly from external ap clearances, as they often mask the true character of fever, which for the most part can only be perfectly ascertained by penet^'oting beyond the exterior, and by inferring the state of the internal organs themselves. In matters of morality those men are constantly deceived, who judge of others from external appearances ; and a similar conduct, in the concerns of medicine, often leads to the most serious mis- takes of opinion and practice. In the first stage of the simple typhus, the debility is merely apparent, and chiefly dependent upon the preter- natural accumulations of blood in the veins about the head, heart, liver, and other internal parts, while there is less cir- culating upon the surface of the body, than in a natural state. In the second stage, the debility is still only apparent, being then the consequence of over-excitement of the heart and arteries ; but in the third and last stage, beyond all dispute, the debility is real, as it is then connected with a general collapse, which sooner or later succeeds to a state of febrile excitement, as certainly as exhaustion follows a fit of intoxi- cation. Those who have adopted the beautiful but decep- tive doctrines of Dr. John Brown, will on no account admit, that the debility of typhus is only seeming, during the 29 greater part of its progress. In candour, the impartial ob- server must confess, that Ihis proposition is not evident at first sight ; yet it is as certainly true as any in physic, as is proved from the debility in the first and second stages being increased by wine and cordials, and lessened by a spare re- gimen and evacuations. Soon after the attack of this fever, there is a peculiar de- pression of the mental and voluntary powers, which has been justly placed, by authors, among those symptoms, that most forcibly press themselves on the attention of practi- tioners, and of which patients most frequently complain. 