Chapter XIII: Puerperal Fevers (3)

Where the powers of the system are not annihilated from the commencement of the attack by the depressing effects of the poison with which the circulation is impregnated, an effort at reaction is frequently made, and for some hours afterwards the surface of the body is hot and dry; but sooner or later, as the stage of collapse comes on, it then assumes the same cold death-like feel, as in the worst cases of malignant cholera. The character of the attack will be in great measure modified by the intensity of the poison, and the extent with which the circulation has been infected by it. The same effort to produce such a state of reaction as will raise the temperature of the skin, will probably assist nature in throwing it off under the form of peritonitic or gastro-enteric species of puerperal fever already described; whereas, where the circulation has been thoroughly impregnated with it in its concentrated form, the vital powers succomb at once, and a state of collapse exists from the very commencement of the disease. The course which the symptoms follow and the duration of the disease, will, therefore, depend not only on the severity of the attack, but also on the power of the particular constitution to resist the deadly effects of the morbid principle upon which the disease depends. When broken down by previous disease, intemperance, poverty, and depressing passions of the mind, the vital powers can make no stand against the powerful enemy by which they are attacked; "the blood is so much vitiated, even early in the disease, that it loses the power of stimulating the heart so as to keep up its healthy action; and, perhaps, also the vascular organs are early affected by the action of the poison, and lose the power of either feeling the stimulus, or reacting with force on the impression, which is communicated to their internal surface by the vitiated blood. In such cases, in place of increased excitement, there is frequently a want of action in the whole system." (Stevens, _op. cit._ p. 188.) The patient sinks without pain or complaint, beyond that of debility, but in such cases with a rapidity which would almost claim for the disease the name of "plague." The tongue becomes dry, red, and brown at the back part, the pulse weaker and more rapid, the debility and exhaustion more overpowering; still, even in this state, her mind usually remains clear, unconscious of the fate which awaits her, and occasionally even cheerful: a peculiar sickly odour exhales from the skin, and in many cases so distinctly, as to warn us the moment we enter the room of the patient's condition. The dusky ashen hue of the skin becomes darker, the fingers are shrivelled, and the nails dark, or of a livid black as in cholera; diarrhoea frequently attends, the fæces are unhealthy, and of the same peculiar odour just noticed; during the first stage the lochia are generally present, although of an unhealthy character; the milk also continues in the milder cases, but as the stage of collapse approaches they both disappear, and the breasts become quite flaccid. In some cases there is vomiting from an early period, with more or less tympanitic distention; but these symptoms rather depend upon the disease being complicated with one of the other modifications. Livid purpurous blotches sometimes appear upon the legs, &c. and in some epidemics it is accompanied with dark or livid eruptions. The surface has now the cold wet feel in its greatest degree, and in some cases even the tongue feels cold to the finger; a drowsy state of insensibility generally follows and continues until death.

The symptoms here enumerated present the characteristics of fever under its different degrees of intensity. The peritonitic and gastro-enteric forms may be compared with the ordinary fevers of temperate climates, and which are attended with more or less inflammation of some organ. The malignant adynamic form corresponds closely with the malignant typhus of this, and the pestilential fevers of warm countries, more especially the plague and the African typhus or yellow fever. In all of these diseases, the vitiated state of the blood appears to be the essential condition of their existence, quite independent of any inflammatory action; in fact, in this form, so rapid and overpowering are the effects of the poison which pervades the circulation, and so completely does it paralyze the whole system, that there is neither time nor sufficient vis vitæ to make any effort at reaction. Hence, as Mr. Moore has correctly observed, "when the patient is rapidly destroyed by the violence of the disease, the morbid changes bear no proportion to the severity of the previous symptoms; a dubious trace of inflammation, a little serum, or a few feeble adhesions, are all that dissection under such circumstances displays." (_Inquiry into the Pathology, Causes, and Treatment, of Puerperal Fever_, p. 63.) In many of the most rapidly fatal cases which we have witnessed, there have not been even these questionable evidences of inflammation. The tissues have been pale and bloodless, the uterus softened, its internal surface ragged, and with a dark gangrenous appearance, extending to the os uteri, and dark thin claret-like blood in all the larger vessels. The heart is flabby, soft, and filled with dark blood; the lungs, liver, spleen, and kidneys much softened; the spleen dark, sometimes enlarged and almost pulpy. If we compare these appearances with those observed by M. Bulard in cases of plague, we shall find a striking coincidence between the two diseases. This intrepid pathologist remarks, that "the state of general turgescence and dilatation of the venous system; the presence of inflammable gas in eight cases in the cellular tissue, in the veins of the head, feet, and abdomen; the presence of petechiæ, both internally and externally; the general softening of the tissues; the enlargement, softening, and breaking down of the spleen; the petechial state of the mucous membrane of the stomach; the effusions of blood on the inner surface of that organ; the passive hæmorrhages and boils, are symptoms which result from a change in the condition of the blood. The symptoms connected with the state of the nervous system, viz. the rigours, headach, and confusion of mind, the quick and small pulse, the hurried respiration and vomiting, and also the petechiæ, carbuncles, and buboes, are neither those of vascular nor nervous inflammation. The blood has never shown the buffy coat; it was found just as black in the arteries as in the veins, but in the former, in much smaller quantity; it always had the appearance of being dissolved." M. Bulard observes, that the decomposition of the blood is quite independent of putrefaction being present before death takes place; and he feels convinced that it is not only the sole cause of death, but must also be looked upon as the origin of the various morbid phenomena during the course of the disease. He considers "these phenomena to result from an actual poisoning of the blood, similar appearances being observed in all cases where putrid matter and morbid secretions have been introduced into the system." With regard to the supposed inflammatory nature of the plague, M. Bulard states, that in many cases not the slightest trace of inflammation could be found. The changes in the spleen are of by far the most invariable occurrence. In one hundred autopsies, this organ was found only five times in a healthy state.

Where, on the other hand, the powers of the constitution, or the diminished virulence of the disease, have enabled the system to withstand the depressing action of its immediate effects, we find it considerably modified, both in the symptoms which it presents during life, and the appearances after death. Instead of being little else than a state of collapse from the very outset of the disease, under which, not a single attempt is made by the powers of the system to set up even the most feeble effort of reaction, a variety of symptoms attend its commencement and progress, indicating that the vis vitæ has not altogether succumbed beneath the deadly effects of the malady. The very rigour itself, when violent, the headach and flushing of the face, if severe, are rather favourable than otherwise, and show that the system still possesses some power of reaction. It is usually observed, that where the attack commences with these precursory symptoms well marked, it is generally accompanied with peritoneal pain, tympanitis, and other symptoms of inflammatory action; whereas, in the worst cases, we have already stated, that from the very commencement of the disease there is neither a symptom of inflammation during life, nor a trace of it to be found afterwards. Dr. Armstrong rightly observed, that inflammation is not an essential constituent of typhus; and the same holds good in the strictest sense of the word, with the typhoid or adynamic puerperal fever.

"Whatever the remote cause of fever may be, it is very evident that this cause must invariably exist, not only at the moment of attack, but even previous to that period. Now in the fevers from poison, the blood is invariably diseased previous to the commencement of the cold stage. During this period there are premonitory symptoms; but these are evidently the effect of the diseased state of the vital fluid: and that these precursors of fever are not the effect of any local inflammatory disease, is evident from the fact, that frequently during this period there is no pain in any of the organs, but a want of action, particularly in the extreme vessels, and consequently a decrease of heat in the whole system.

"If inflammation in any of the organs were, in reality, the cause of fever, then the disease ought to be fatal, exactly in proportion to the violence of the local affection; but the very reverse of this is the truth. Mere excitement can easily be reduced, and the inflammatory form of fever is decidedly the most easily cured, though in it the excitement is often so great that the organs are very liable to be injured; while the malignant form of fever is by far the most fatal, though in this the excitement is less, and the organs are seldom affected. This is particularly the case in the worst form of the African typhus, and probably other varieties of malignant fever, where the blood is under the influence of an active poison, and where its vitality is diminished, and its structure is injured even before the attack.

"Those who have seen most of the malignant diseases know well that excitement in fever is invariably a good symptom; for this is a sure sign that the blood has not yet undergone any fatal change, and independent of this, mere increase of action is always at the mercy of the lancet. But neither the lancet nor leeches, gum water, vitriolic emetics, calomel, antimony, brandy, opium, or acids, can redden the colour of the black blood, which we invariably meet with in pestilential diseases, or remedy the diseased state of the vital current, so as to cure that fatal form of fever where the malignant symptoms are produced, not by excitement, but by the vitiated state of that mysterious fluid, which in health gives life and nourishment to every solid of the system, and which, when diseased to a certain extent, is by far the most frequent cause of death in all those fevers that are produced by some deleterious poison acting, in the first place, on the vital current, and then on the brain and the whole system through the medium of the blood." (Stevens, _on the Blood_, p. 186.)

We have quoted thus largely from the observations of Dr. Stevens and M. Bulard, to whose admirable researches we are so greatly indebted for our present knowledge, respecting the nature of pestilential diseases both of the East and West, for they tend not only to show the true pathology of malignant puerperal fever, but also the class of diseases to which it belongs.

_Appearances after death._ Where more or less inflammatory action has accompanied the first part of the disease, the lesions observed after death differ considerably from those of acute peritonitis: the effusions of cogulable lymph, of serum, and sero-purulent fluid, are seldom met with to such an extent where the case has been one of inflammation uncomplicated with the adynamic form of puerperal fever, even although it may have been exceedingly violent; whereas, in the present case, although there has been scarcely sufficient power in the system to set up even a moderate degree of inflammatory action, the intestines and uterine appendages are found glued together, and thickly imbedded in immense effusions of lymph. The ovaries, Fallopian tubes, and broad ligaments are engorged with purple vascularity, softened, and, especially the ovaries, quite disorganized, with numerous effusions of sero-purulent matter beneath their peritoneal coverings, or into their parenchymatous tissue. In others, their whole substance has been softened and pulpy, with little cyst-like cavities filled with blood or pus, the remains of the Graafian capsules. During the fatal epidemic which prevailed at the General Lying-in Hospital, in the early part of 1838, we met with several cases where the ovaries had entirely disappeared, their site being only discoverable by an oval thickening of the broad ligament, something like an empty cyst of peritoneum; this contained a small quantity of livid pulpy débris of the ovary, and (on that side where conception had taken place) a remarkably well marked or rather exaggerated corpus luteum. The uterus is larger and its tissue much softer than under ordinary peritonitis, so that, in many instances, the finger can be easily pushed through its whole substance.

Where the constitution has borne the brunt of the attack without immediate collapse, and the local mischief been controlled by appropriate means, we find that fresh efforts are made to rid the circulation of the morbid matter with which it is infected. The patient is suddenly seized with severe pain, with heat, redness, and swelling of one of the large joints, presenting all the appearances of arthritic or rheumatic inflammation, and also of certain muscles, especially the supinators of the arm, the glutæi, and gastrocnemii. The painful spot soon becomes hard, it is intensely tender, and in two or three days the feeling of fluctuation indicates the formation of an abscess, from which a large quantity of greenish coloured pus mixed with blood and serum is discharged. The cellular tissue beneath the skin and between the muscles is equally affected, and if examined when the abscess is just beginning to form, will be found of a dirty brown colour, softened, infiltrated, and here and there condensed with lymph or pus, precisely as in cases of gangrenous erysipelas: the muscular tissue has entirely lost its red colour, and closely resembles the appearance of boiled meat, its structure so softened as to tear easily under the fingers, and interspersed with deposites of immature lymph and purulent fluid, the commencement of what would have been an abscess. Like gangrenous erysipelas the extent of the abscess does not seem to be limited by a surrounding wall of healthy lymph, as seen in a common phlegmon, but if deep beneath the surface it continues to spread in all directions until nearly the whole limb appears to be implicated in one immense abscess: hence, in those patients who have recovered under these attacks, the limb has frequently been rendered useless, the muscles being atrophied and coherent.

Inflammation of a similarly arthritic or rheumatic nature occasionally also attacks the eye, and presents all the usual characters of arthritic iritis under ordinary circumstances: there is the same intolerance of light, pain of the eye, dimness of vision, contracted pupil, and peculiar white ring round the edge of the cornea, which distinguishes this affection; but in the present case, the disease runs a far more rapid course, and defies the remedies which in common cases would be sufficient to check it; the inflammation soon extends to the deeper seated structures of the eye, the pain is excrutiating, and, in two or three days, disorganization takes place, followed by suppuration, staphyloma, and bursting of the cornea. So rapid and destructive is its course, that, although five or six cases have come under our notice, in only one instance, with the greatest difficulty, was the eye saved, and, even then, not before it had been considerably injured.

These attacks are attended by severe pains of a similar nature in different parts of the body, more especially the joints and limbs; and, from the arthritic character which they assume, tend, in our opinion, still farther to elucidate the real condition of the system. The analogy between gout or rheumatism, and those diseases which arise from a vitiated state of the blood, is exceedingly close, nay, even identical, for in both, a principal pervades the circulating fluids which requires to be removed; and if this be not effected by any of the excretory organs, nature endeavours to throw it off by some process of local inflammation. The connexion between puerperal fever and typhus is very close, for it not only assumes the characters of the typhus epidemics which may chance to be prevailing at the time, but we have distinct evidence that the contagion of typhus will, in a puerperal woman, manifest itself under the form of puerperal fever. Dr. Collins has recorded a very interesting case of this sort:--"A patient was admitted at a late hour at night into one of the wards, labouring under a bad form of typhus fever, with petechial spots over her body; when observed next morning, she was removed into a separate apartment, where she died shortly after. The two females who occupied the beds adjoining hers, while she remained in the large ward, were attacked with puerperal fever, and died." (Collins, _op. cit._ p. 381.) During a typhus epidemic which prevailed a few years ago in the poor districts of the metropolis, a prominent feature of which were petechiæ and a livid rubeoloid eruption, precisely the same appearances were observed among the cases of adynamic puerperal fever at the General Lying-in Hospital.

The same has been observed with erysipelas; and, in one short but severe epidemic, the child of every woman who had died of the disease perished also from erysipelas, so severe that it ran its course in a few hours. Dr. Gordon, of Aberdeen, remarks, that "with it and, at the same time, epidemic erysipelas began, progressed with equal pace, arrived at its acmé, and terminated together." He also says, that a very frequent crisis of the disease was an external erysipelas. Mr. Hey remarks, that infectious fevers were common at the time; and he does not recollect ever having seen such malignant cases of erysipelas as then. Dr. Clark also observes, that those inflammatory diseases which occurred were principally erysipelatous. Dr. Armstrong states, "that in 1813 (the year of its greatest prevalence throughout England) low fever, typhus, and acute rheumatism also prevailed to an uncommon degree." (Moore, _on Puerp. Fever_, p. 164.)

During the same epidemic, to which we just now alluded, the housemaid of the hospital, a healthy young woman, was suddenly seized with sore-throat and violent erysipelas of the head and face, from which she was saved with great difficulty; her sister came and attended her, as the nurses were too much occupied by the number of patients who were ill; just at the time that she was pronounced out of danger, her sister, not feeling well, went home, sickened, and died, in less than three days, of typhus fever.

The contagious nature of puerperal fever has long since ceased to be a matter of doubt, and instances have repeatedly occurred of practitioners and nurses communicating the disease to several patients in succession. Dr. Gooch has recorded some striking instances of the kind, and we could enumerate many others if necessary. Where a practitioner has been engaged in the post mortem examination of a case of puerperal fever, we do not hesitate to declare it highly unsafe for him to attend a case of labour for some days afterwards. The peculiar smelling effluvia which arises from the body of a patient during life is quite, in our opinion, sufficient to infect the clothes; and every one who has made a minute dissection of the abdominal viscera, especially in fatal cases of puerperal fever, knows full well that it is almost impossible to remove the smell from the hands for many hours, even with the aid of repeated washing; it must be, therefore, self-evident, that, under such circumstances, it would be almost criminal to expose a lying-in patient to such a risk.

That the discharges from a patient under puerperal fever are in the highest degree contagious, we have abundant evidence in the history of lying-in hospitals. The puerperal abscesses are also contagious, and may be communicated to healthy lying-in women by washing with the same sponge: this fact has been repeatedly proved at the Vienna hospital; but they are equally communicable to women not pregnant; on more than one occasion the women engaged in washing the soiled bed linen of the General Lying-in Hospital have been attacked with abscesses in the fingers or hands, attended with rapidly spreading inflammation of the cellular tissue.

We have stated that puerperal fever may arise from the effluvia which exhales from the body of the patient, and from the various discharges; it may also be produced by noxious exhalation from sewers, ditches, and other sources of miasmata, the effects of which in producing typhus have been long ascertained. "With regard to the General Lying-in Hospital, its locality rather below the level of the river, and surrounded by a mesh-work of open sewers fifteen hundred feet in extent, receiving the filth of Lambeth, and some not thirty feet from the wards of the institution, may account for its unhealthiness. It is only after repeated remonstrances, that these sources of pollution have in part now begun to be obliterated." (Dr. Ferguson, _op. cit._ p. 104.) The commissioners of sewers refused the application of the hospital, to have the nearest of these nuisances properly bricked over, and assigned this remarkable reason for so doing, viz. that the hospital had come to them, not they to the hospital. Consent was ultimately only obtained by the agreement, that a large portion of the expense should be borne by the institution. On completing the work they afforded us a striking instance of the effects of effluvia on lying-in women; a large quantity of black pestilential mud had been thrown out in making the necessary excavations, this they refused to remove, and actually spread it upon the ground to a considerable extent; the consequence was, that the first two cases of puerperal fever after the re-opening of the hospital occurred within twenty-four hours of this unjustifiable act.

_Treatment._ The fatal character of this disease and the varied form of its epidemics will in part explain why so much discrepancy of opinion should have existed among authors and practitioners respecting its treatment. Where its remote cause has been but imperfectly known, it is not to be wondered that practitioners, finding their efforts unsuccessful, should lose their confidence in any one set of remedies or mode of treatment, and try a variety, in the vain hope of hitting upon the right one. But in a great measure this is to be attributed to the difference of the affections which have been described by various authors under the same head; each has described it as it occurred to himself; and in many instances it has been only the description of a single epidemic, and, therefore, has given to the world the treatment which his experience in that particular form has proved successful. Thus, the lancet has been looked upon as the only means of saving the patient by those who have witnessed the inflammatory modification of the disease; whereas, in the hands of those who had to treat it in its adynamic malignant form, bleeding (as but too frequently every thing else) proved utterly inefficacious.

A variety of plans have been tried in this last species, and their success described by Dr. W. Hunter in his lectures, gives a fearful view of the nature of the disease we have now to deal with. We continue the quotation which we have already made from him. "In two months thirty-two patients had the fever, and only one of them recovered. We tried various methods. One woman we took from the beginning and bled her, and she died; to another we gave cooling medicines, and she died: to a third we gave warm medicines, such as Confect. Cardiac., cordial julep, Mithridate, &c., and she died. In private practice it was the same, and at least three out of four would die." (_MS. Lectures._)

There is no doubt that, wherever the state of the patient will permit it, the lancet should be tried. Where the pulse is quick and small, with little power, it is scarcely more than an experiment to ascertain how the system will bear the bleeding: in the worst cases of the adynamic form, uncomplicated by the slightest effort at reaction, the state of collapse at once forbids such an attempt: but in many instances the circulation is merely oppressed, the pulse rises in volume as the depletion proceeds; and where from its feel before the operation we had little hopes of taking away more than five or six ounces, we are often enabled to continue it until a considerable quantity is lost. In other cases frightful exhaustion is the immediate effect, and warn us instantly to discontinue it. The capability of bearing bleeding may be always looked upon as a favourable prognostic, not only because the patient's strength is better than we had perhaps expected, and also because these are precisely the cases where mercury can be used with decided benefit. Whether it be the bleeding, which, in all probability, renders the system more easily brought under the influence of this medicine, we will not stop to consider; at any rate, its effects are not only more easily obtained, but they exert a more decided control over the progress of the disease, the pain abates, the tympanitic abdomen becomes less tense, the pulse slower, fuller, and softer, the tongue moister, and there is a sense of general improvement in the patient's feelings. But in the adynamic form, when present in its greatest intensity, either there is not sufficient time to impregnate the system, or it is less sensible to its effects; at any rate, even if we succeed in producing salivation, little or no improvement follows.

In those cases where the inflammatory symptoms assume a metastatic character, we must act according to the organ implicated. The attacks are frequently of a very sudden nature, the patient being seized, without the slightest warning, with severe pain and heat of head, throbbing of the temples, intolerance of light and sound, and occasionally violent delirium; the face is flushed, the carotids are seen strongly pulsating. These signs denote a dangerous attack of cerebral congestion, which requires the most prompt and active measures for its suppression. In these cases the aberration of mind frequently continues for some time, even after the symptoms of active inflammation have subsided, and form a species of puerperal mania of a very dangerous character, which we shall describe under its proper head. In other cases, effusion rapidly comes on, followed by fatal coma or convulsions.

In some instances, the inflammatory action seems to fix itself upon the chest: the patient is suddenly seized with great dyspnoea, oppression, and pain, which latter is much increased by every effort at respiration, and sometimes is so violent as to threaten suffocation, unless promptly relieved by the lancet. These attacks sometimes return two or three times, with the same degree of sudden violence, or change with equal rapidity from one part to another.

So long as there are symptoms of local inflammation present, leeches and hot poultices, &c., must be applied, as already mentioned; but it must ever be borne in mind, that the local affection is _not_ the disease, but one of its effects. We must, therefore, direct our energies to ridding the system of the cause upon which it depends. In all cases we think it desirable to begin the calomel in doses of five grains, at intervals of two hours; and if properly guarded with Dover's powder, no disposition to purging will be produced: by this means we not only gain time, but, which is also of great importance, we premise a general increase of the excretions, which tends not a little to relieve the system. After two such doses, the calomel may be given at the ordinary rate of two grains every two hours, with half a grain of opium, or, what is still better, a little Dover's powder, until slight marks of salivation begin to appear. The action should now be kept up by an occasional dose, but never allowed to become at all severe, as considerable exhaustion may be the result. The dark and offensive lochia should be constantly removed by the most scrupulous attention to cleanliness, and by frequently washing out the vagina and uterus with warm water.

If diarrhoea has set in to an exhausting degree, the opiates must be increased, and the Hydrarg. cum Cretâ substituted for the calomel. Saline draughts of citrate or acetate of ammonia, rendered alkaline in excess by Sp. Ammon. Arom. may be given from time to time; they appear not only to refresh the patient, but also to allay flatulence and vomiting, if present. For her common drink we recommend a solution of carbonate of soda in water, in the proportion of two drachms to a pint, slightly flavoured with orange peel; and whenever she has taken this freely, we have observed a considerable amelioration in her symptoms.

Although strongly inclined to advocate Dr. Stevens's views respecting the action of salines in diseases of this character, we must confess that we have been in great measure deterred from carrying them out to the full extent that we could have wished, by the repugnance of the patient to taking a draught so intensely salt as his celebrated mixture. On several occasions we have seen the most beneficial effects from the use of salines; and in two cases, during one of the most malignant epidemics, where every thing seemed to be equally fruitless in arresting the progress of the disease, the exhibition of repeated doses of soda, and encouraging the patient to drink largely of the above-mentioned solution, was followed by the happiest effects. We have again recently tried the common salt, disguised as far as possible in the form of an effervescing draught, and in two cases with very decided results.

The acid state of the mouth is a very constant symptom in this disease, and the contents of the stomach after vomiting are frequently intensely sour, so that in most instances the soda drink has been greedily longed for, and by some patients even called lemonade. We have also tried still more recently warm injections into the vagina, of a weak solution of salt and water, but at present, can give no opinion from merely a case or two.

Ice has been lately recommended by Professor Michaelis, of Kiel, not only internally but externally, by means of a large bladder. According to his observations it diminished the pain and tympanitis, reduced the quickness of the pulse, and relieved the patient considerably; this was followed by a profuse diarrhoea of light coloured and offensive evacuations, under which the pulse rose in power, followed by general improvement. We tried it on one occasion; it was swallowed with avidity like barley-sugar; it relieved the sense of inward heat and thirst, stopped the hiccough and vomiting which had become very troublesome, and seemed to diminish the tympanitis, but collapse followed as rapidly as in other cases; nor have our subsequent observations been more favourable. It may be given with advantage with other medicines to relieve several distressing symptoms, but does not appear to us to exert any power in arresting the progress of the disease.

The patient's diet should be mild but nutritious, much more so than in the other forms of puerperal fever; and if there be symptoms of sinking, wine and ammonia, &c., must be given with a liberal hand.

In reviewing what we have said upon the treatment of adynamic puerperal fever, we repeat our conviction, that where the state of collapse has precluded all antiphlogistic measures, and given us but little cause to expect much relief from mercury, we know of no treatment which holds out such rational hopes of success as the saline, based as it is upon the same principles on which it has been employed by Dr. Stevens, in the malignant fevers of warm climates, and by British physicians in the epidemic typhus of this country.