GEN. IV. towns, when built upon the sound principles, and governed by the judicious regulations, and, I may add, superintended by the active humanity and established gravior. talents which are so conspicuous in the Fever Hospital of this metropolis. Putrid fever. Jail typhus, complex enlargement &c. only a of the above To describe the typhus of jails, ships, camps, and other large bodies of men, we have only to multiply the single family we have just beheld into fifties or hundreds; ever remembering, that the virulence of the febrile poison picture. increases in power, not in a numerical, but in a sort of geometrical proportion to the numbers by which it is fed. So that if five patients produce a given ratio of pestilence, ten will produce, not as much again, but nearly a hundred times as much. And hence we may readily account for the fearful and deadly ravage which this cruel scourge is well known to inflict upon a people when closely pressed together, and incapable of flying from its pestilential aura, as in crowded encampments, or a besieged and pent-up town: and especially where, as is often the case, there is considerable carnage from the casualties of war, and a deadly calm prevails for weeks together in the atmosphere. This last concomitant, indeed, gives completion to the whole; and is a heavier calamity than it is generally conceived to be; for the most fatal pestilences of which we have any account seem to have been preceded by a stagnant atmosphere. Thus Maitland, in his History of London, observes, "that for several weeks before the plague broke out in this metropolis in 1665, there was an uninterrupted calm, without sufficient motion in the air to turn a vane." The assertion is confirmed by Baynard, a contemporary physician; and a like harbinger, as is observed by Diemerbroeck, preceded the plague at Nimeguen. and means In both varieties, the prognosis must be collected from Prognosis the vehemence of the symptoms, and the character of of cure. the idiosyncrasy; and the cure must depend upon the means we may possess of supporting the vital power, and restoring its lost energy. The peculiar properties by which typhous miasm is Specifie properties of SPEC. II. GEN. IV. distinguished from miasms of every other kind, are the E.Typhus rapid and direct debility with which it affects the nervous gravior. system, and seems to prevent a due secretion of nervous Putrid fever. fluid, or its secretion in a state of healthful elaboration; the activity of its leaven, by which it assimilates all the fluids of the body to its own nature, and the urgent putrefactive tendency it gives to every part. typhous miasm. Septic power not upon its debilitating power. The last of these properties may in some degree be necessarily dependent upon the first; but it does not appear to be dependent entirely so; since we often find the sensorial power reduced to a much lower ebb, as in asphyxy from hanging or drowning, suffocating exhalations or lightning, catalepsy, and deliquium from loss of blood, while there is an almost infinitely less degree of tendency to putrefaction. And, in like manner, although the miasms of many of the exanthems, as rosalia or scarlet-fever, smallProofs that pox and plague, are also capable of tainting the secretions of the body, none of them appear to do it so completely and universally as that of typhus when in its most malignant state; in which the breath, all the egesta, and all the fluids are loaded with contagion. It has been propagated by the excrement*, by the odour of flowers employed to decorate the dead body+; by washing the bandages employed in typhous gangrene ‡, and, in innumerable instances, by the communication of a minute drop of any of the fluids of the dead body to a punctured finger during dissection. all the se cretions of the body are contaminated. These pecu liar properties should be always in the mind and guide the practice. Congestion and effusion frequent from weakness and irregular action. In forming our prognosis, and attempting a cure, these properties should always be prominent in the mind; for they will best enable us to calculate the nature and result of symptoms that are present, and will guide us to the most rational and satisfactory mode of practice. From the debility that prevails throughout the living fibre, even from the first, the pulse is feeble and tremulous, the extreme vessels torpid or nearly so, and the circulatory balance greatly disturbed. Hence, we have * Riedlin, Lin. Med. 1695. p. 402. Eph. Nat. Cur. Dec. Ann. VII. VIII. Obs. 193. GEN. IV. SPEC. II. 6E. Typhus Putrid fever. inflamma reason to expect that effusion and congestion, or an irregular determination of the blood, will in many cases be an early attendant: and, if there be energy enough re- gravior. maining in the organs thus affected to produce any degree of re-action, that local re-action will follow, and perhaps lead on to inflammation terminating in suppuration or gangrene; of which Sir John Pringle has given numerous examples. And hence there is some ground for contemplating typhus, as Dr. Armstrong has done, under the three varieties of a simple, congestive, and inflammatory affection; this last being sometimes seated Sometimes in one organ, and sometimes in another: most frequently tion. perhaps in the brain, where Marcus supposes it to exist in every case whatever; and occasionally perhaps in some of the secreting membranes, through all of which it is conceived, in every instance, to extend by Hildenbrand, the rete Malpighi, the membrane that lines the cavity of the nose, of the mouth and throat, the tunica arachnoidea, and the mucous membranes of the stomach, intestines, and organs of urine and generation. But it should never be forgotten that the disease in every stage and variety is one and the same; a disease of sensorial debility leading on to putrescency; and that our only hope of cure depends on economizing the nervous power that remains, supporting it as far as we are able without farther loss, and opposing the natural tendency of the disease by such tonics as the system will best bear. On this account whatever tends to weaken the animal frame generally, or any one of its functions particularly, must, as a common rule, be carefully abstained from: and hence severe evacuations, by bleeding or purging, are among the foremost objects of prohibition. In what best hope consists the of cure. As a comsevere mon rule The bowels, indeed, ought by all means to be moved by a gentle aperient, in order that no acrimonious material may be lodged there; but beyond this we ought bleeding and purging not to proceed, as we shall add to the debility without to be abobtaining any correspondent advantage. The grateful stained • Ueber der austechenden Typhus, &c. Wien. 1815. from. aperients; GEN. IV. acids of tamarinds, cream of tartar, or prunes, are preferable, if found sufficiently powerful; but, if not, they should be combined with rhubarb or senna. And, as Putrid fever. the stomach is less irritable than in yellow fever, an emetic may be given whenever indicated; but unless emetics, un- there be a troublesome nausea, even this had better be BE. Typhus gravior. Treatment. but not less nausea be present. Marks of congestion or oppression. Is the general rule here to be departed from? Only a choice of difficulties left: but the danger must be combated avoided. Ipecacuan will answer better than antimonial preparations, and the evacuation should be followed with a cordial draught. But congestion, as already observed, may take place, and this too in the larger and more important organs of the animal frame, as the head, the lungs, or the liver. If in the first, there will be a sense of oppression in the brain, most commonly combined with stupor, or low muttering delirium; if in the second, a laborious weight on the chest and a difficulty of respiration; if in the third, the bowels will usually be found costive, the motions pale and argillaceous, and sometimes the skin and the urine chlorotic, or of a greenish-sallow from a regurgitation of bile, morbidly secreted, into the sanguineous system. Hence the fever will be aggravated from local irritation, and the affected organ will be in danger of inflammation if not of gangrene. Is the general rule in this case to be departed from? is blood to be taken from the system? and, if so, is it to be drawn locally or generally? and to what amount? We have here only left to us a choice of difficulties. Nothing, as Dr. Fordyce has justly observed, is more dangerous in any fever than its affecting one part more than another; but in typhus the danger is extreme; and it must be combated boldly and rapidly by whatever plan has a chance of taking it off, and however hazardous in itself, provided the hazard be less than that of the disease. And hence, in this case, bleeding must be had recourse to, for there is nothing we can so well depend upon. If we have reason to believe that the overloaded organ is without inflammation, the blood should be drawn locally and till relief is afforded; if there be good ground for suspecting that inflammation SPEC. II. gravior. Putrid fever. Risk in the has commenced, and especially if the organ affected be GEN, IV. large and important, it will be better to employ the lancet; and it cannot be employed too soon, nor ought it to be relinquished till it has attained its object There is a risk in the practice, but there is death without it. Fainting may perhaps take place in the midst of the operation; but this is rather to be wished for than guarded against; for the exhaustion of sensorial power produced by deliquium bears no comparison to that produced by the influence of the typhous miasm, acting as a leaven throughout the system. death with out it. purgatives. In this state of the disease, also, instead of merely Stimulant keeping the bowels open, we should employ purgatives that may stimulate and maintain a stimulating effect upon the whole of the intestinal canal, so far as that three or even four evacuations may be obtained daily; and calomel will be commonly the best medicine for this purpose. For such an irritation will frequently prove revellent; and the drain of sensorial power hereby pro duced will be trifling in comparison to that occasioned by a continuance of the local excitement it is intended to remove. Examinapractice of venesection as a general instead of a special rule. tion of the Such are the exceptions, and the only ones, we should allow to the general rule of opposing the disease, by economizing, supporting, and restoring the depressed tone of the nervous system. But there are pathologists, and of considerable authority, who recommend bleeding, and even full bleeding, in almost every instance of the disease, as the first step to be pursued: thus inverting the mode of practice here laid down, and taking the exceptions for the rule, and the rule for the exceptions. The theory of this recommendation is but of little im- The advoportance provided it be justified by its result. At the same time I cannot avoid observing, that its chief advocates have not been able to bring themselves to any thing like a common theory, or to support their recom- principles. J. P. Frank, De Cur. Hom. Morb. Epit. Tom. 1. p. 136, 8vo. Mannh. cates for such prac tice not agreed upon common |