Dunglison's American Medical Library. A SHORT TREATISE ON TYPHUS FEYER. BY GEORGE LEITH ROUPELL, M. D., iu 1 1 PHYSICIAN TO ST. BARTHOLOMEW’S HOSPITAL, CONSULTING PHYSICIAN TO THE SEAMAN’S HOSPITAL, LATE PHYSICIAN TO THE FOUNDLING HOSPITAL, &.C. &.C. PHILADELPHIA : PRINTED AND PUBLISHED BY A. WALDIE, 46 CARPENTER ST. 1840. PREFACE The subject briefly discussed in the following pages involves a considerable share of medical literature, and is as complicated in its nature as difficult in practice. To have approached the consideration of a most important fever without thought and reflection would have been quite unpardonable, yet the pains bestowed upon it appear as nothing when compared with the attention that it de- serves. Of the faults and incompleteness of this short treatise, no one can be more aware than its author, but only those who have studied the prevailing epidemic, traced the history of corresponding disorders, and con- sulted the numerous works which have been written upon it, can appreciate the toil which a full investigation would require. The objects which have been aimed at are the following: to assert the claim of the prevailing epidemic to be ranked among specific fevers, to separate it from some with which it has long been improperly confounded, to show at the same time its analogy with others, and to im- prove the pathology of all. The following treatise would IV PREFACE. have been more complete, and been illustrated by more cases, had not the author’s time been much occupied by various professional avocations, and his labours interrupted by severe indisposition: but he prefers that his work should at once be published, imperfect indeed, but with the chance of being useful, whilst the fever which gave rise to it is still raging, than be kept back with the possibility of improvement till the disease which it treats of has passed away. 15, Welbeck street, Cavendish Square, February 28, 1839. ON TYPHUS FEVER. It will readily be granted that we are but imperfectly acquainted with the nature and cause of many diseases. It will also be ad- mitted, that unless the seat, the character and the progress of a dis- order be ascertained and understood, treatment will be without pre- cision, and practice must be unsatisfactory and often unsuccessful. Typhus fever will exemplify these remarks. True it is that we have very many writers on the subject, but their descriptions are so indefinite, and their nomenclature so varied, as to leave it doubtful whether their several statements allude to the same affection under different appellations, or to numerous ailments allied in character and only to be distinguished by nice discrimination. Febrile diseases of various kinds are always present to a great extent amongst the humbler classes of the community ; they often prevail epidemically, unknown to or unnoticed by society at large, and provided they be mild in degree and confined to a circumscrib- ed district, little general attention will be paid to them. When, however, the occurrence of any such disorder is frequent, and its attacks severe, alarm is excited, calculated on this as on other occa- sions to distort facts and to favour erroneous impressions. The ag- gravation or more full developement of any ordinary malady may thus be mistaken for a fresh commencement, and an unusual form or a heightened feature in a known complaint may be thought to constitute a new disease. In every city the great hospitals will always indicate the general state of health, and in proportion as they afford facility of admission will be a true criterion of the rise, extent and decline of any serious ailment. The regulations of our public institutions for the reception of the sick, throw the door widely open to those labouring under fever, and by this wise as well as humane arrangement, the spread of many infections maladies is arrested and the best means are 6 ROUPELL ON TYPHUS FEVER. afforded of relieving the severest afflictions of the poor. To the records kept at such establishments and to the cases therein ad- mitted, must we turn for instruction, and to those entrusted with their charge will the public naturally look for information. When therefore, as during the present year, apprehension has been created by the unusual prevalence of an infectious disorder, some account of it from one attached to such an institution may rather be expect- ed as a duty than need an apology for presumption. A malignant disease has been, and it may be said is at this moment, rife amongst us. This is a fever which, from its fre- quency as well as from its nature, well merits the especial notice of the profession. It has in truth been more or less prevalent for several years past, and my attention has been particularly directed to it from the fact that a disorder precisely analogous appeared as an epidemic in the outskirts of London in 1831, when many cases were sent from the river side to the floating hospital for merchant seamen at Deptford, where they were under my charge as physi- cian. Both before and since that time similar cases have frequently been met with, especially during the spring of the two last years. Numerous instances have occurred in the crowded and ill-venti- lated districts in the neighbourhood of St. Bartholomew’s Hospital: and the admission of many patients under my care in that establish- ment, has enabled me to watch the course of this complaint, and from experience to learn much in its treatment. To this disease it is proposed to apply and confine the name Ty- phus. As this term has been used by authors to designate diseases entirely different in their type and origin, much ambiguity exists, and many contrary opinions are entertained upon the subject. It becomes then an important matter to define accurately the malady to which the term should be restricted, and at the same time to as- sign to it a proper nosological position. This has not been accom- plished, either by Sauvages, or Cullen; nor, it is submitted, has its real character been elucidated by more recent authors in our own country, though a point of the highest possible interest, and essen- tial to the proper treatment of the disease. Before my views on this subject are stated and the reasons speci- fied which induce me to differ from the authority of others, it is imperative to give the definitions of the best and most modern writ- ers. Typhus is ranked by Sauvages in his Nosologia Methodica, pub- lished in 1768, amongst the continued fevers, and he thus describes it “Genus est febris contitiuse quae ultra duas septimanas ssepius tres extendi consuevit, cum calore et urina sanorum similibus, pul- suque quoad frequentiam, sano fere simili, quoad robur, non majori: artubus interea maxime prostratis.”1 Cullen also places typhus in the list of continued fevers, and gives us the followingdescription of it: “ mobrus contagiosus, calor 1 Sauvages Nosol. method. 4to. Amst. 1768. vol. i. p. 30S. -INTRODUCTION. 7 parum auctus, pulsus parvus, debilis, plerumque frequens,” “ urina parum mutata; sensorii functiones plurimum turbatse, vires raul- tum imminutae.”1 In the Cyclopaedia of Practical Medicine, published in 1833, we find typhus constituting a division of continued fever; and it is there described as “ a peculiar form or type of fever, characterised by the more early and severe affection of the brain and nervous system—by the more constant changes which the mucous mem- branes undergo—by the affection of the cutaneous and glandular tissues—and in the advanced stage by great prostration and symp- toms denoting putrescence.” And it is further added, “ That it is not uncommon to find fever, which at first is very mild, assume by degrees the typhoid cha- racter,” And again, “ There can be no doubt of the existence of every intermediate gradation between the common forms of fever (synochus) and typhus, so that it becomes a matter of nicety to dis- criminate to which class a particular case or number of cases pro- perly belongs. Sometimes we find, indeed, the one form passing into the other, more frequently mild fever lapsing into typhus.”3 In the elaborate work of Dr. Copland,3 typhus is described to be “ a disease which after lassitude and general mal-aise, imperfect or suppressed vascular reaction, depressed vital power manifested espe- cially in the nervous, vascular, and muscular system, gives rise to changes more or less evident in the circulating fluids and soft solids.” Dr. Copland goes on to observe “that this fever cannot be said to differ specifically from synochoid fever, although certain varieties of it present, very marked distinctions, indeed the severer forms of synochoid fever very closely approach or run into certain states of typhoid fever, the chief difference consisting in the sthenic vascular reaction in the early part of the period of excitement in the former. Even the milder cases of simple continued fever may gradually as- sume a typhoid state.” In the above descriptions, typhus is considered to belong to the continued fevers. It is looked upon by the more recent authors in this and other countries, not as an individual disorder, but as one into which others may readily be and frequently are converted. Now the result of observation has been forcibly to impress upon me the conviction that the prevailing fever is owing to a certain specific cause. For when closely observed, it has been found to pursue a definite course, passing through its stages with regularity, spreading by infection, and being marked in its progress by a dis- tinctive rash. Here then we have all the characteristics of the genuine exanthemata of authors, to. which class it seems correctly and exclusively to belong. It has indeed for many years been so considered by me, and this view was submitted to the public in a 1 Culleni Synop. Nosol. method. 8vo. 1780., vol. i. p. 82. 2 Cycloped. Pracl. Med. vol. i. p. 175. * Dictionary of Pract. Med. still in progress, by James Copland, M. D. 8 ROUPELL ON TYPHUS I EVER. paper read before the College of Physicians in 1831, and has been daily impressed upon my pupils on all occasions of clinical instruc- tion. The idea I thought original, and, feeling that if established it would be important, my time has been much occupied in its inves- tigation. On referring to authorities, in order to trace this epidemic in different countries and at various periods, I lately met with quo- tations on the subject, from a treatise by Professor Hildenbrand of Vienna.1 In the account of this distinguished author the ideas just expressed are most explicitly stated. It becomes then necessary to give up all claim to originality, and as the disorder is fully detailed by this eminent physician, it is but just to adopt his account as a standard with which others may be compared. An abstract of his description will then be given in the first place, the analogy of other epidemics to this will be shown, afterwards some remarks will be made upon the succession of the symptoms and the nature of the phenomena observed in this fever. Although Professor Hildenbrand especially alludes to the epi- demic typhus of 1806, yet he observes that for twenty years and upwards he had studied the disease and had been placed in circum- stances singularly favourable for such an enquiry, having had the charge of many prisoners as well as other persons infected with it. After explaining the meaning of the term typhus, and after giving a short history of the disorder, and other preliminaries, he proceeds to state that simple contagious typhus has eight stages or periods. 1. The first stage is that of contagion; this period he considers to be probably instantaneous, and is not indicated by any marked impression of which the infected person is conscious. On this point he speaks from his own personal experience as well as from that of others. 2. The second stage is that of incubation. In this there will be some slight alteration in the character or temper of the individual, there will often be vertigo, lassitude, weakness after exercise, unre- freshing sleep, tremor of the hands, pain in the loins, uneasiness at the praecordia, and foul breath. Yet the persons infected are able to pursue their usual occupations and do not consider them- selves ill. This period may vary in duration, it is not usually shorter than three days nor longer than one week. 3. The third stage is that of the invasion or commencement of the fever. Typhus begins like other fevers by pain in the head, creeping sensations in the back, shiverings, alternating with flushes of heat, paleness of the skin, horripilation, and with feelings of des- pondency and great general depression. The effect on the system is a powerful one, as is the case in all serious and important maladies. Its actual commencement lasts six hours at least, and never exceeds twelve. 1 This work is apparently but little known in our country, as not a single copy of the original could be met with iu any of our libraries. I have there- fore been obliged to content myself with a French translation by Mons. Gasc. INTRODUCTION. 9 4. The fourth period is the inflammatory stage. This stage lasts a week, and the condition of the patient on the first day is as fol- lows :—To the shivering which marked the commencement, febrile heat succeeds, irregular however in its distribution; the limbs if covered are hot, if exposed are liable to be chilled, moisture is often found on the skin. There is weight on the head, with a feeling like intoxication and vertigo, which is one of the most constant of all the symptoms. Nausea and vomiting are often present, which are rather to be referred to the state of the brain than to any mor- bid condition of the stomach, as the tongue is clean. The face is flushed, the urine scanty and high coloured, the pulse is full or de- pressed. On the second day, after a sleepless night, the patients are rest- less and agitated. The nausea and vomiting have abated, traces of delirium begin to show themselves, a roaring in the ears takes place, with impairment of the sense of hearing. The vertigo greatly increases, the patients stagger if they attempt to walk, sometimes they appear to sleep, but are in a state of great internal agitation and excitement. The mucous membranes of the throat are gorged and the chest is oppressed, but pains in the back, loins, and calves of the legs are sources of the greatest distress. These symptoms continue to increase during the third day. There is disinclination to the least exertion, and even to speak is an effort. On the fourth day extraordinary redness appears on the surface of the body, which is the exanthema. Hildenbrand considers that a condition similar to that of the skin may exist in the membrane of the lungs and in the inner lining of the intestinal canal. The rash to which he applies the epithet “purpurous” is especially seen in those parts of the body which are kept warmest, as the back, the chest, and a portion of the limbs nearest the trunk. After the eruption of the rash, the disease continues without any particular change for the remaining three days of the first week. In this, the inflammatory period, there is no real debility; the pulse is frequent, strong, more or less sharp, but never really weak: there is a diminution of muscular power, there is general turges- cence with redness of the skin, with a disposition to epistaxis; the tongue is white and moist, the skin damp, the bowels sluggish. The fever has no apparent remission; and on the authority of Lind and Milman, as well as on his own, Hildenbrand asserts that blood now drawn exhibits a buffy coat. This inflammatory period typhus shares with all infectious diseases. It is connected as in other ex- anthemata with a rash ; the appearance of which is always pre- ceded by the febrile disturbance. In this as in others disorders of the same class, the excitement of the system has not the stamp of simple inflammatory fever, and it is often associated with symptoms referable to the chest and abdomen which in many cases render the diagnosis extremely difficult. This complication shows itself by an inflammatory state of the throat or of the trachea, with oppression 10 ROUPELL ON TYPHUS FEVER. of the chest and consequently by pneumonia. The eye is often con- gested in this period. According to our distinguished author the gastric symptoms are consecutive upon the catarrhal. In this stage there are none of those signs of weakness which so essentially characterise this disease in the advanced periods. Exa- cerbations take place on the third and on the seventh day. 5. The next period of the disease is the nervous. Towards the end of the seventh day an extremely remarkable aggravation of symptoms takes place, additional features present themselves, there is an accession of febrile heat, the proper exanthematous and in- flammatory symptoms disappear and other phenomena succeed, and occupy in their course the second week. The nervous system is now principally affected, and the weak- ness becomes real which before was only deceitful and false. The fever itself continues, accompanied however by a new train of symptoms precisely opposed to the former ones; the pulse becomes more feeble and in general slower, the tongue dry, the skin dry and burning, the urine pale and clear, the evacuations by stool more frequent and liquid. There is dulness of hearing with delirium, loss of sensibility, muscular irritation, tremblings, subsultus, and convulsions. These symptoms, says M. de Hildenbrand, are proofs of an affection of the nervous system, but they must not always be referred solely to debility; and he states among other reasons for coming to this conclusion, the fact that the disease is comparatively little under the influence of medicine, that a slightly depleting plan is not unsuccessful, and that the pulse in this state is not without power. It is now that the disease is most infectious. In this stage he observes that although the exanthema disappears yet the petechiae remain : they indeed increase, and if they have not previously appeared they now show themselves, though less numerous than in the earlier stage. The intellectual faculties are greatly deranged, the patient is perfectly indifferent to all impres- sions and ceases to call for drink although the tongue is dry, the throat parched, and the cavities of the mouth and nose are black. The oppression of the chest is relieved although the breathing con- tinues hurried ; the cough ceases but hiccup comes on ; the stools are fetid; and pains in the bowels from inflammation of the intes- tines are invariably present at this period of typhus. The urine is more abundant than is common in acute fever, it is clear and rarely deposits a sediment, and is retained in the bladder by spasm of the sphincter. The pulse varies much in number, force, and fulness, it is frequentlyslow and has a peculiarity difficult to describe, which Hildenbrand says is rather a constant dilatation than a beat: and there is a sort of irregular agitation of the blood in the artery which he compares to the movement of boiling water, or to the impulse of certain aneurisms. In this period, the second week of the disease, the affection of the INTRODUCTION. 11 brain and the nervous system furnish the prominent symptoms. The hearing and all the other external senses are blunted. The charac- ter of the delirium is peculiar, being singularly incoherent, ideas are furnished by the brain with wonderful rapidity, but there is always some one prevailing notion. It is a dream without sleep, and the mind seems entirely occupied with its own creation, and totally in- sensible to all external objects. Stupor reigns throughout; hence the propriety of the term typhus. 6. The next period he calls that of the crisis. The disorder which has now continued a fortnight is found to diminish without the intervention of art or the employment of any special remedy. A change in the state of the patient takes place, which in the regular and moderate cases of typhus brings with it the cure, provided no obstacles arise. According to Hildenbrand, at the close of the thirteenth day the heat of the skin increases, and a peculiar coma- tose state comes on ; nevertheless, he adds, towards the middle of this day or on the fourteenth, the skin evinces a disposition to be- come moist, the exhalants begin to act. This is the crisis. Some patients are a second time subject to hemorrhage affording relief to the head, the nostrils discharge and the tongue becomes moist, cleaner, and red at the tip. A salutary perspiration breaks out, which has a peculiar odour; the urine passes freely, and there is a disposition to diarrhoea, which in this case is beneficial to the pa- tient. 7. The next period is that of remission. The time of the crisis, like that of the invasion, only lasts for a few hours. When the crisis is favourable, the remission of the disease is obvious in twelve hours; but the transition to health is not immediate, a series of pro- cesses are to be undergone which dissipate the remains of the dis- order and thus by degrees bring about the cure. The first active symptom which abates is the delirium. The patients awake as it were from a dream or from a fit of intoxication; some instantane- ously recover their consciousness and are astonished at their situa- tion ; the memory however will be found to have suffered much, and passed events are completely forgotten or only recalled with great effort. The indifference testified in the earlier periods sub- sides, the eye and look become more lively and free, notice is now taken of passing events. All the natural feelings are restored, but the hearing remains dull and noise in the head continues. The muscular system gains power and the pulse becomes calm, and even, and free, but its feebleness continues: the heat of skin is moderate and uniform, the thirst abates, appetite and sleep are re- stored, though the functions are not performed as in health, and the patients complain much of their weakness. Any exertion produces fatigue; the mind is weak; there is great irritability, and a dispo- sition to perspiration and costiveness. The head still feels heavy, but every day removes some of these ailments, the last of which is the dullness of hearing. A period of seven days is thus occupied. 12 ROUPELL ON TYPHUS FEVER. 8. The eighth period is that of convalescence. All the pheno- mena of the disease are dissipated during the period of remission ; still the strength is not firmly re-established, the patient is emaci- ated, the skin loose, the flesh soft and flabby, desquamation of the cuticle takes place, the hair falls ofF, and the nails are renewed. The appetite returns, nay is craving. There is usually constipa- tion, and in women menstruation is suppressed; this secretion how- ever is restored when the strength is regained. The period of con- valescence in many cases lasts some weeks ; recovery varies, being slower after this than after any other fever. Complete restoration, with exemption in some degree from the recurrence of the disease, at length takes place, and other ailments previously existing some- times depart with it. Such is the outline which professor Hilbenbrand has given of the disease to which he proposes to apply the term typhus. In this sketch he considers the disease as occurring in a marked but regu- lar manner. There are many circumstances which complicate the disorder; many irregularities in its course, which render it difficult in some cases even to identify it. Irregularities however which typhus shares with other exanthemata. The disease offers many variations in its course, and its order is not unfrequently disturbed. The same cause may produce differ- ent phenomena in different individuals according to their age, tem- perament, habits, present or previous state of health, or season of the year. Anomalies may thus arise in the different periods: the irregularities however of the first or second period, according to M. de Hildenbrand, are but little perceptible; there may be some differ- ence in the intensity of the shivering fit, it may be very severe, last an unusual time, or there may be none at all. The most remarkable modifications take place in the inflamma- tory period—and are such as quite to change the aspect of the fever; the anomalies which it presents are innumerable. The inflamma- tory character is sometimes unusually intense : the fever at this time will put on the form of severe feverish cold without in some cases any marked local affection. Sometimes the symptoms of vio- lent local inflammation mingle with the signs of typhus. Should the determination to the head be intense, the delirium becomes frenzy, and stupor becomes true apoplexy. The throat and the parotid glands, the lungs, the bowels, the liver, the intestines, the peritoneum, the bladder, all become the seat of acute inflammatory action. The tendency to inflammation is indeed the great cause of the anomaly in the progress of this disorder. The symptoms referable to the bowels are often so prominent as to deceive even the most observant. The rash varies, sometimes it does not appear at all, or is so little developed as to escape notice; it occasionally presents itself under INTRODUCTION. 13 the form of miliary petechiae, and disappears in a few hours, or hav- ing been out its usual time departs without affording corresponding relief. Instead of the inflammatory symptoms, nervous ones present themselves, as tremors, subsultus, convulsions, a dry and parched tongue; or the local inflammation changes its nature, and real weak- ness declares itself The disease highly malignant may prove fatal at once, or putrid symptoms show themselves and under the influ- ence of the general weakness the blood and circulating fluids may become extravasated both internally and externally, in the form of black petechias, or hemorrhage. A disposition to gangrene appears, a putrid smell is exhaled—signs which portend speedy dissolution. In this form carbuncle is sometimes seen. The duration of the inflammatory stage has been found to vary; it is very short in some cases, in others it is prolonged beyond the ordinary period of a week and extends to the ninth or eleventh day. Irregularities during the nervous period in some measure depend upon the preceding stage. Should inflammation, for example, have been set up in the first period it may extend into the second, in which case there will be an especial tendency to gangrene. Nervous inflammation, as Hildenbrand terms it, will be produced ; this most commonly is met with in the lung, the brain, or the in- testines, when it assumes the character of putrid dysentery. The rash which usually diminishes may continue, the petechias put on a new aspect, or swelling of the parotids take place. Amongst the signs of nervous debility, the most remarkable, Hildenbrand adds, are the dry, hard tongue, extreme thirst, dry- ness and heat of skin, a disposition to dysentery with distention of the abdomen by flatus, urgent pains in the belly, universal tremors, convulsions, delirium with the picking of the bedclothes, muttering, hiccup, cramps, paralysis, black sordes on the tongue and teeth, fetid breath, passive hemorrhage, coldness of the limbs, and clammy sweats. When these symptoms occur the fever instead of termi- nating on the 14th is prolonged to the 17th, 21st, or 28th day, or even longer. Amongst the anomalies during the critical period, he notices, that the natural termination may be retarded by many circum- stances, such as local inflammations, especially those of the lungs and abdomen, by debilitating causes, or by large evacuations, and that sometimes the amendment at the critical periods takes place without any obvious evacuation, either by the skin or from the bowels. During the period of remission unusual occurrences are met with, such as stupor, delirium, unrefreshing sleep, deafness, much loss of appetite, derangement of the intestines, weakness and slow- ness of the pulse; or the fever, though slight, may continue. A sort of metastasis may come on and prove fatal, though not imme- diately. Sometimes at this period an inflammation of the throat will take place, or a fresh infection occasion relapses. 14 ROUPELL ON TYPHUS FEVER. Sometimes, when the earlier periods of the disease have been re- gularly passed, anomalies arise during convalescence. The state like intoxication, vigilance, great weakness, exhausting perspira- tions, constipated bowels or irritability of temper may long remain. Such is the description given by Professor Hildenbrand of the fever, which he clearly defines and vividly portrays. A disorder peculiar in its character, obeying the laws which regulate other contagions, and presenting phenomena which are common to other exanthemata, such as measles and scarlet fever. The next point to be considered is whether or not the epidemics which have appeared from time to time, and have recently pre- vailed, ought to be classed with the disorder thus described. Those who have had an opportunity of watching the symptoms and pro- gress of the now prevailing fever, and have had many cases under their care, will agree with me that it is impossible to deny its iden- tity with the one described by the German professor; no leading symptom of the one is indeed wanting in the other, all the essen- tial characteristics, all the irregularity and appalling complications, are met with. We daily recognise the suffused dusky countenance, the injected eye, the great prostration of strength, deafness, confu- sion of the head, rash upon the skin, tremors of the muscles, ten- dency to hemorrhage, disturbance of the mental faculties, and in- flammation of various parts. The disorder has conformed to its prescribed course ; and too many proofs amongst members of our own profession have attested its infectious nature. Some additional circumstances will be pointed out at a future time, which took place this year, and either did not occur in the epidemic of 1806, or then escaped the attention of Hildenbrand. During the spring of last year the same fever prevailed exten- sively, and the cases which were then under my care accurately corresponded in all important particulars with our standard of re- ference. The epidemic in 1831, of which an account has already been published by the author,1 presented all the striking features of this formidable malady. If Dr. Armstrong’s description of the typhus fever of 1817 be referred to, the symptoms of this same disease may be collected from amongst his different varieties. He notices the congested eye, the confusion of mind, the delirium, the black parched tongue, the low mutterings, the tremor of the hands, the subsultus tend ilium, the watchfulness or stupor, the relaxation of the sphincter muscles, signs which enable us to recognise this disease. He takes but slight notice indeed of one important characteristic, when speaking of the symptoms, viz. the rash. He says, however, that “peculiar petechias show themselves upon the extremities, which are at first only few in number, and appear as if a drop of very black ink had been allowed to dry here and there upon the skin—they soon be- come numerous and spread over different parts of the body, and at 1 Some Account of a Fever prevalent in 1831. 15 INTRODUCTION. last are generally accompanied by discharges of blood from the nos- trils, mouth, bladder, or bowels.”1 And later in his account he adds, “ most recent writers on fever seem disposed to attribute the appearance of petechias to the hot regimen, and thus account for their frequency in the typhus of former times when that practice was prevalent; but though they may have been often thus pro- duced formerly, yet this was not the case in a great many of the epidemic cases which have occurred in the metropolis, for the pe- techiae in some instances appeared on the first day of the attack, and frequently on the second and the third ; and it is therefore highly probable that petechias sometimes occur as epidemical pecu- liarities wholly unconnected with the mode of treatment which may be pursued ; nay, this is certain in the instances above adduced. The petechias were sometimes so peculiarly small as to have the character of an almost anomalous rash, and sometimes so large and thick set as to make the skin almost as red as in the measles or scarlet fever, for the eruptions of which, indeed, l have known them occasionally mistaken.”3 Real petechias could never be mistaken for measles or scarlet fever, the eruption therefore here described could not have had re- ference to them, but such a mistake would be very pardonable, with regard to the rash in typhus, for in some cases it is extremely difficult to distinguish it simply by the aspect of the patient. Many of the other symptoms too are analogous; there are, however, abundant means of distinction which will be hereafter pointed out. The description by Huxham of the epidemic of 1734-5, which he calls slow or nervous, bears great analogy to that under con- sideration. Of this he gives us the following description in his work De Aere et Morbis Epidemicis. “ Lenta adeo,” he says, “ et nervosa febris lento quodam invadit gressu at firmo nimis ; hac quippe correpti de levi vagoque horrore ; incerto quodam et errante calore intercurrente subinde ; de lassitudine porro membrisque quasi fatigatis queruntur quidem, dum obambulant interim osci- tantes tamen et torpidi. Accedunt mox prsecordiorum oppressio, nausea, gravedo capitis, astricta tempora aut vertigo qusedam. Pulsus frequens est semper, at debilis plerumque, ac inordinatus. Calor autem hand insignis excitatur unquam ; at saepe dum volae manuum uruntur extrema frigescunt, dum caput ardetalgent pedes. Obrepit indies malum, jamque loqui aut moveri piget. Ac vel inopinantes lecto affixi vix quo se habent modo exponere vellenf, aut sopore nimio detenti aut vigiliis mire anxiis et fere perpetuis. Nihil poscunt interea prorsus ne vel potiim. Jam tendinum sub- sultus adest, tremunt manus, tremit lingua quse muco subalbido obducta, haud multum fere inarescit, nisi media solum in parte ubi fusca est. Tandem et aliena murmurant subinde et desipientia, furens tamen abest insania. Tenuem plerumque reddunt urinam, 1 Armstrong on Tvphus Fever. 3d edit. Lond. 1819, p. 117 1 Ibid. p. 223. 16 ROUPELL ON TYPHUS FEVER. vapidi instar vini, aut cerevisiae luridam, aliquando limpidam hand raro etiam subnigram, subinde paulo crassiorem inspersa quasi farina. Breves, insequales et parum constantes habent sudores sEepe frigidulos et glutinosos saepe profusos maxime, et paulo ante mortem non raro gelidos cum pulsu exili et formicante. Stragula contrectant interim, et inanes quasdam imagines prehendere ten- tant, jamque vox faucibus haerens, ungues digitique lividi, facies cadaverosa perpetue fere et frigide suspiria certissimam instare mortem denunciant. “En hujus febris dira facies quam nervosam ideo nominarnnt quod nervos potissimum afficere videatur lentam vero quod ad diem vicesimum primum et ultra saepe perduret.” The leading features of the fevers which have recently prevailed are surely portrayed in this description; we perceive the great loss of strength, the confusion of the head, the stupor or vigilance, and the tremors of the hands and tongue. But he goes on still further to prove the identity, “ pestifera semper est,”he adds, “ubi aphthae nigrae, petechiae fuscae, Iiviclae, atrae, aut vibices quasi, apparent. Praesertim si accedit alvus cita, plumbea, nigra, colliquans aut su- dores oleosi—ubi pustulis, papulis, aut maculis cutim deturban- tibus febris lenta stipata, contagiosa est ut plurimum; cum vero exanthemata mali sunt moris vulgo (audit) maligna. Papulae, rubrae, floridae copiosae aut plurimae pustulae miliares turgidae, statu morbi erumpentes bona praesagiunt—salutaris nonnunquam erum- pit parotis,—convalescentes frequentissime surdiscunt et saepe ha- bent apostemata in meatu aurium salutifera.” It is unnecessary to insist upon the identity of this disorder with that described by Hildenbrand. On very many occasions, judges, jurymen, and others in attend- ance at courts of law have fallen victims to a similar pestilence; so frequently indeed have examples of this occurred that the epithet black has been applied to assizes, thus rendered unfortunately no- torious. One black assize took place at Oxford in 1577. Another at Exeter in the year 1586. One at Dublin in 1776. Twice it has occurred in London, first in 1536, and again in 1750. We have but little record of these occurrences, other than as historical facts, excepting of the last. Of the black assize of London in 1750 Sir John Pringle1 observes. “ This unhappy instance is so fresh in our memories that I need not have mentioned it here, had it not been to inform such as live at a distance, or those that are to come after us. The fever3 in the beginning had an inflammatory ap- pearance, but that after large evacuations the pulse sank, and was not to be raised by blisters or cordials. I have more than once known a large bleeding sink the pulse and bring on a delirium: except by this last mark and the tremor of the hands, the disease is not easily to be distinguished in the beginning from any common 1 Diseases of the Army, 2d edit. Svo. Lond. 1753, p. 246. * Ibid. p. 292. INTRODUCTION. 17 fever. When the fever advances fast, to the ordinary symptoms are added great lassitude, nausea, pains in the back, a more con- stant pain and confusion in the head, and an uncommon tremor of the hands ; the pulse often varies in the same day as to strength and fulness, and sooner or later sinks, and gives then certain indi- cation of the malignity of the disease. If the sick lie warm and have had no preceding flux, the body is generally costive, but when they lie cold a diarrhoea is a common symptom. In the most cases a flux appears in the last state, when the stools are involuntary, colliquative, ichorous, or bloody, and of a cadaverous smell. The tongue is mostly dry, and without the constant care of the nurse becomes hard and black, with deep chaps. What may be particu- lar to this,” he adds, “ is that sometimes the tongue will be soft and moist to the last. The drought is sometimes great, oftener moder- ate ; in the advanced state, the breath is always offensive. Some are never delirious, but all are under a great stupor or confusion. Few retain their senses to the last, many lose them early. They rarely sleep, and unless delirious, have more of a dejected than a feverish look. The white of the eye is generally of a reddish cast, as if inflamed. All along as the pulse sinks, the delirium and tre- mors increase, and in proportion to its rising, the head and spirits are relieved : frequently from the very beginning he patient grows dull of hearing.” He still further confirms the similarity of this fever with the one first described, by observing, “ that there are certain spots which are the frequent but not inseparable attendants of this fever. These are,”he says, “the true petechiae,” a statement however, which we may fairly doubt from his further description of the eruption; for he says that they are “sometimes of a paler red, at other times of a livid colour, and that they are small and commonly distinct, but are sometimes so confluent that at a little distance the skin looks only somewhat redder than ordinary, as if the colour was uniform ; but upon a nearer inspection the inter- stices are seen. For the most part these spots are so little conspi- cuous that unless looked for attentively they may escape notice. They come thickest out on the breast and back, less on the legs and arms, and I do not remember to have seen any on the face. They sometimes appear as early as the fourth or fifth day, and at other times as late as the fourteenth. They are never critical, but only concur with other circumstances to ascertain the malignity. The nearer they approach to a purple the more ominous they are. “ The length of the fever is uncertain, the time depending upon the malignity. In the hospitals we had it running from fourteen to twenty days, but some have died or recovered after four weeks’ illness. “ From the time of the sinking of the pulse till death, or a favour- able crisis, there is perhaps less change from day to day than in any other fever not of the malignant kind. When the course is long, it often terminates in suppurations of the parotid or axillary glands. Many upon coming out of this fever complain of a pain in their 18 ROUPELL ON TYPHUS FEVER. limbs and want of rest; and almost all of great weakness, confu- sion of the head, and noise in the ears.” In Sir John Pringle’s account we thus find all the leading cha- racteristics of the fever in question, and what he terms petechise may probably have been the rash usually seen in these cases, or perhaps a mixture of both.1 The description given by Dr. Rasori, of a disease prevalent in Genoa in 1799 and 1800, and which he calls “petechial fever,” accurately resembles the typhus of Hildenbrand. Dr. Rasori had ample opportunities of seeing the disease, as he was, at the period alluded to, Professor of Clinical Medicine at the Civil and Military Hospital at Milan. The disorder, he observes, was indicated by pain in the head, by great weakness and pain in the limbs, by early and considerable wandering of mind, by vigilance, and by deafness. He remarks also, that the heat of the body was sometimes but little increased, that the pulse was somewhat accelerated, but did not usually exceed 100. That it singularly varied in the same indi- vidual even during the same day, that sometimes it could be felt in one hand, while it was not to be detected in the other. In some cases, he says, the pulse was imperceptible in both wrists. He no- tices the hemorrhagic tendency, and crowns the whole by allusion to the eruption which appeared on the skin. In the account, how- ever, of the eruption he is obviously confused. He notices that petechise were present, and so commonly that he entitles the fever, petechial, but in describing the cutaneous affection he states that there were petechiae, or an eruption little differing from petechice, or a miliary eruption, or both.2 Here then we have an eruptive disease, with all the genuine features of the exanthemata, not however, as we may fairly con- clude belonging to any known variety, or it could not have es- caped the observation of this bold and learned practitioner. M. Louis published in 1829 his researches upon the disorder termed “ gastro-enteritis, putrid, adynamic, ataxic, typhoid fever.” In this account we find the description of a disease so closely re- sembling the fever noticed in the preceding pages, that we cannot I conceive refuse our assent to place it in the same class. M. Louis paid great attention to a number of cases which were admitted into the Hopital de la Charite in Paris, between the years 1822 and 1827, and were under the care of M. Chornel. He gives an account of 123 cases of this disorder. Few works on any subject show more devotion to science, more care and pains in tracing symptoms and recording post mortem appearances. M. Louis, in his general description of the symptoms, says that the disorder began with shivering, accompanied by trembling, headache, lassitude, loss of appetite, thirst, pain in the abdomen, and 1 Gentleman’s Magazine, May, 1750. * Storia della Febbre petecchiale di Genova negli anni 1799 ed. 1800, terza editione, 1813. INTRODUCTION. 19 in the larger number of the cases with liquid evacuation within the first twenty-four hours. These symptoms, he observes, indi- cated that the disorder had its seat in the abdomen alone. They gradually increased, others were added to them, and gave the dis- ease its proper physiognomy. He then goes on to describe a train of symptoms which satisfy me of the identity of this disease with the one selected for reference. We find in the recital, the excessive prostration of strength, the disturbance of the brain, the ringing of the ears, the injected eye, bleeding at the nose, the eruption of a rash, rosy, lenticular mixed with sudamina, the tympanitic disten- tion of the abdomen, the involuntary stools, the hemorrhage from the bowels, the tongue unchanged in some cases, clammy and dry, coated, cleft, red, black, or enlarged in others, put out with diffi- culty, and trembling when protruded. The debility, M. Louis adds, increased every day, the skin over the sacrum readily became inflamed, excoriated and gangrenous; shivering rarely took place after the commencement, except to indicate some new accession of disorder, such for instance as erysipelas. The pulse was mostly about 100, large at first, small, weak, and irregular in the course of the disease ; cough when it occurred would be accompanied by ronchus and crepitation ; the countenance, tumid and loaded in the beginning, lost by degrees all expression and exhibited no trace of intelligence or consciousness, or it became the fierce index of fury or wandering, according to the character of the delirium. The muscles of the lips, cheeks, and lower jaw, were observed to twitch, and similar contractions were observed in the limbs ; in some cases however there would be permanent rigidity of these parts or of the neck. Death at length would arrive, sometimes unexpectedly, sometimes due to secondary lesions, or accelerated by the perfora- tion of the intestines. He notices several varieties in the severity of the symptoms, and observes that sometimes one train, sometimes another, appeared to take the lead, and as one or another might prevail, so would the fever put on the putrid form, ataxic character, or sometimes even that of inflammatory fever. In spite, however, he adds, of the difference of aspect the affection was one and the same, indicated by one anatomical sign, a peculiar change of the glands of the mucous membrane of the elliptical patches of the small intestine. In this account, we find all the leading indications of the epidemic described by Professor Hildenbrand, and that va- riety appears to be described in which the gastric symptoms pre- vailed ; this will appear more marked still, when the duration of the disease, its contagious nature, and the organic lesions in typhus come under consideration. It would profit as little to trace the disease much further as to question the propriety of the term typhus, which has at any rate antiquity for its sanction. It was originally employed by Hippo- crates not to indicate a specific disease but as including a great variety of fevers. In his chapter concerning internal diseases, he gives us five varieties of typhu The first variety, he says, appears 20 ROUPELL ON TYPHUS FEVER. in summer time, during the period when Sirius presides, and arises from excess of bile in the system. He speaks of pain in the bowels as a leading symptom and asserts that this fever is completed in a period from seven to fourteen days. Another typhus occurs at all seasons, from too great fluidity, as he thinks, of the body, which is prone to swell; the disorder, he says, intermits and the patients live twenty-four days. Another typhus originates from putrefied bile mixing with the blood. Another typhus takes place in the apple season, when people have eaten too much fruit with a thin rind; it is marked by profluvium of the belly; patients suffering under it are troubled with diarrhoea, which continues for several days, and then they are well. Another typhus of Hippocrates is certainly marked by symptoms more decidedly referable to the head, by de- lirium and picking of the bed clothes ; but his account by no means corresponds accurately with the disorder under consideration, and it is obvious that under the term typhus very dissimilar maladies are arranged. The actual meaning of the word is stupor.1 It will not be necessary to dwell longer upon the proof of iden- tity between all the diseases above enumerated. Many of the symp- toms are found in all fevers, others again are common to what are called putrid or pestilential fevers, and a third class are peculiar to the disease in question. Each of these orders of symptoms will claim some notice at my hands, with the hope of being able to ar- rive at a general conclusion from particular propositions. Typhus fever, in common with all others, exhibits in the first place all the phenomena incident to symptomatic or secondary fevers. The constitutional febrile symptoms which arise in conse- quence of local inflammation so closely resemble those of idiopathic fever that they cannot often be distinguished, except by the history of the case or by the local affection.2 It occasionally puts on those signs which are supposed to denote putrescence; such for instance as extreme prostration, great ten- dency to gangrene, fetor of the evacuations, cadaverous smell of the whole body, copious discharges of blood, and a rapid tendency to decomposition after death. Scarlet fever as is well known not unfrequently puts on this appalling character. Putrid symptoms may also come on during the progress of the measles or small-pox. These signs therefore may be called accidental, and are common to a variety of specific diseases. It has in the third place some other symptoms essentially its own ; these are rash upon the skin, the power of spreading by in- fection, and the certain period of duration. The Rash.—To entitle typhus to rank amongst the exanthemata and to distinguish it from the other varieties of that class we must look to the character of the eruption and to the time of its appearance. Rayer defines the exanthemata to be inflammatory diseases of the 1 Hippocratis opera, vol. ii. p. 246. 5 Thomson on Inflammation, 8vo. Edinb. ed. 1813, p. 103. INTRODUCTION. 21 skin, characterised externally at their acme or highest degree of de- velopement by the morbid accumulation of blood in a point, a dis- trict, or the entire surface of the integuments.1 In general, how- ever, exanthemata are considered to be cutaneous eruptions, ac- companied by fever, arising from contagion, and liable to occur but once during life. All the authors who have written expressly on typhus, or who have described those diseases which appear allied to it, mention the circumstance of a rash; sometimes vaguely, some- times erroneously. Huxham it will be recollected says “ Papulae rubrae floridae copiosse aut plurimae pustulae miliares turgidae statu morbi erumpentes bona praesagiunt.” Sir John Pringle observes that “there are certain spots which are the frequent attendants of this fever of a paler red and so confluent that at a little distance the skin only looks some- what redder than ordinary.1’ Rasori states “ there is eruption of petechias, or an eruption little differing from petechias.” Armstrong says that “ the petechiae were sometimes so peculiarly small as to have the character of an almost anomalous rash, and sometimes so large and thick set as to make the skin almost as red as in measles or scarlet fever; for the eruptions of which indeed” he adds “ I have known them occasionally mistaken.”3 According to M. Chomel3 there is an eruption in the majority of cases. Mons. Louis takes notice of the “ taches roses lenticulaires” as a frequent occurrence in the disorder described by him. Bate- man remarks that in a few cases an efflorescence made its appear- ance resembling measles, and this is considered by Rayer to be a variety of roseola.4 Sauvages describes the rash in typhus, but objects for the following reasons to place that fever amongst the exanthemata. He says “ differt a morbis exanthematicis ex eo quod exanthemata in typho, vel a regimine calidiori inducantur, vel non nisi in morbi statu superveniant, eaque ut plurimum sint maculae, non vero tumores, etiamsi parotides quandoque subnascantur : in exanthematicis vero eruptiones miliares, variolosae, robeolosae, bubo- naceae, &c. ante morbi statum etiam prorumpunt.”5 There are many circumstances which throw obstacles in the way of obtaining accurate information respecting the rash in typhus. Patients frequently delay their application to hospitals for several weeks, so that in one class of cases it will have disappeared before the disorder came under notice. In another class it will probably be overlooked, for it is often so slight as to escape any but an expe- rienced eye. Then again it will not be perceptible on the chest or arms, where it is usually expected to be found. On one occasion where it had been sought for in vain on the front part of the body, it was perceived abundantly on the back, which was accidentally 1 Rayer, Treatise on Diseases of the Skin, p. 57. 1 Armstrong on Typhus, p. 223. sLe