ART. V.-Practical Illustratious of Typhus and other Fe - brile Diseases. By JOHN ARMSTRONG, M. D. Longman and Co. London; and Constable and Co. Edinburg, 1816. 8vo. pp. 305.

NOTHING has contributed so much to the improvement of medicine in modern times, as the extended cultivation of pathological anatomy, aided by a more perfect system of physiology. Before the accumulating light which continues to spring from this source, the fanciful and erroneous spe culations of some ingenious men, whose influence too long ren dered medical inquirers blind to the legitimate objects of in vestigation, have for some time been gradually disappearing; and it is probable, will soon be recognized only in the ob solete writings of their authors, and in those of their immediate followers. Within these few years a new class of medical writers has arisen, uniting to great accuracy of observation a spirit of rational inquiry; little disposed to yield implicit deference to the unsupported dogmas of any authority, however high; rejecting, in general, the aid of hypothesis in the explanation of morbid phenomena; and relying on the direct testimony of their senses, instead of delusive fantasies of the imagination, for guidance in discovering the true nature and most suitable treatment of diseases. In this honourable class we have no hesitation in placing the author of the volume now under review, which (and higher praise can hardly be given) is worthy of standing beside the admirable work of Dr. Blackhall: what that writer has accomplished with regard to dropsies, Dr. Armstrong has successfully attempted in the case of fever,-a careful discrimination between the several stages, degrees, and varieties of the disease; and a judicious adaptation of remedies to each: this is the only sure method of enlarging the boundaries of medical science, and not to be effected without an unusual share of intelligence and zeal. Some idea of this writer's excellence we shall, without further preface, endeavour to communicate; but it is not possible that any analysis should be capable of doing justice to a work where every page is important.

Our author distributes the class of febrile diseases into three orders: namely, such as are excited and propagated by specific contagions, those which arise from marsh and similar miasmata, and those which depend upon topical affections. With respect to the latter, it is said, they differ from the others chiefly in this, that "the fever can be

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traced as the mere effect of the local disturbance:" we entertain some doubt of the accuracy of this distinction, being of opinion, with Dr. Watt of Glasgow, that in the early stage of these complaints no symptoms appear to denote what character the subsequent stages will exhibit; for, according to his observations," prior to the paroxysm, a case of pneumonia was not more distinguishable from a case of rheumatism, diarrhæa, or asthma, than one case of pneu monia was distinguishable from another." The above division is nevertheless sufficiently convenient for every useful purpose. The principal subject of the present volume is the contagious fever denominated typhus, of which three varieties are described, under the titles of the simple, the inflammatory, and the congestive typhus. The simple form is that" in which the febrile excitement, or hot stage, is completely developed, and in which there are no decided marks of topical inflammation. The inflammatory typhus has the same open characters of general excitement as the simple; but with these are conjoined symptoms of some visceral inflammation. The congestive typhus is distinguished by the hot stage being not at all, or only imperfectly developed, and by simultaneous signs of congestion in one or more of the internal organs. But we must take the liberty of extracting a more particular description of each yariety, satisfied that it could not be so clearly given any but our author's own words.

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1. Simple Typhus. "The simple typhus has a first stage of oppression, a second of excitement, and a third of collapse. These successive stages, but more particularly the two last, bear a pretty exact ratio to each other as to degree, but not as to duration. The stage of oppression is usually marked by paleness of the face; a peculiar look of dejection and weariness; some degree of darkness or livor in the integuments surrounding the eyes; prostration of strength; diminution of mental energy, and of sensibility; cold creeping sensations on the surface, or short hot and chilly fits alternately; loathing of food, nausea, or vomiting; whitish or clammy tongue; sense of weight or anxiety about the præcordia; occasional sighing and hurried breathing; aching, heaviness, or giddiness of the head; coldness of the back and pain of the loins; a quick, low, struggling pulse, changeable as to frequency, and even irregular as to force. These symptoms are accompanied with feelings of general uneasiness, somewhat resembling those which are experienced after a long journey, or any other great fatigue. The stage above described sometimes comes on and reveals itself with rapidity; but generally it is more insidious in its approaches, and occupies, from first to last, a period of two or three days; when, after various irre

gular demonstrations of re-action, it is succeeded by the second stage, or that of excitement, in which there is a complete developement of the fever. The tone and velocity of the circulation is now preternaturally increased; and the pulse accordingly becomes comparatively expansive, thrilly, and resisting; at least, it is widely different from the variable, confined, inelastic pulse of the former stage, and from the uniform, free, and smoothly-flowing one of health. The cheeks are flushed, the eyes heavy, and the lips parched; the respiration is quick, the skin almost invariably dry, the heat universally diffused, and steadily above the common point; the tongue foul, the thirst urgent, the uneasiness in the head increased, the sensorium in a highly susceptible state; every symptom, in fine, denoting an excess of excitement. This second stage of the simple typhus naturally holds a tolerably even tenour for some time. it proceeds, however, the brain at intervals is usually disturbed with reverie, or slight delirium, coming on towards evening, when there is an exacerbation of the fever, and receding towards morning, when there is a remission; but the prostration of strength, which is at all times very evident, is generally greatest in the periods of the exacerbations. During the predominance of the excitement, the bowels for the most part have a tendency to constipation; the excretions, as well as secretions, also undergo gradual and material changes, which are evinced by the dark and offensive nature of the fæces, the peculiar odour of the breath and whole body, and by the morbid appearances exhibited on the tongue, in the fluids formed from the liver, kidneys, and other organs of secretion.

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1. "After six or seven days, sooner or later, according to its mildness or severity, the stage of excitement gradually gives place to that of collapse, which is first announced by signs of depression in the voluntary powers; by a certain degree of relaxation in the skin; by a more variable and less concentrated state of the temperature; and by a notable diminution in the force of the circulation, the pulse being of less volume, softer, and more undulating. In the mildest cases, the approach of the stage of collapse may be viewed as an indication of convalescence: whereas, in the more marked instances of this sort of typhus, the supervention of the stage of collapse considerably augments the danger: for the prostration of strength then becomes far greater; the pulse commonly quicker, and always much weaker; the tongue fouler, darker, and drier; the voice fainter, and the articulation less distinet; the respiration shorter, feebler, and more anxious; the sensorial functions more disordered; and the countenance more dejected, sunk, and inanimate. Added to these symptoms, the skin feels looser, and appears more shrivelled; while the temperature is nowhere so intense as in the stage of excitement, but variable in the course of the day, even on the central parts; and there is an increase of general restlessness, a more perceptible and peculiar foetor about the body, and often an irritating species of cough, which comes, as it were, in convulsive

fits. In this state, the patient is disposed to lie upon his back, and as the peril increases, not only labours under subsultus tendinum, visual deceptions, low muttering delirium, and difficulty of deglutition, but has also a tendency to slide downwards in the bed, and to draw up the feet frequently towards the body." (p.9—13.)

Some writers, attending too exclusively to these latter symptoms, and almost overlooking those which preceded them, have disseminated the pernicious doctrine, that typhus is in every instance a disease of debility; but, in fact, real debility exists only in the stage of collapse, and that which occurs in the previous stages is merely apparent,—depending, in the first, on oppression of the vital organs by preternatural accumulations of blood; and in the second, on over-excitement of the heart and arteries. That this is the true state of the case is evident, from the debility in the first and second stages being increased by wine and cordials, and lessened by evacuations. The doctrine of debility was still more dangerous in the inflammatory typhus, in consequence of the improper treatment to which it led; its falTacy, however, begins now to be universally perceived, and a more successful practice is the result of this change in opinion. Let us proceed to a description of some of the forms under which this variety makes its appearance.

II. Inflammatory Typhus. Our author does not agree with Dr. Clutterbuck and some others, in thinking topical inflammation to be an inseparable and essential constituent of typhus; but his experience has been amply sufficient to convince him that it is a very frequent occurrence, and requires much vigilance and activity on the part of the practitioner. The parts most apt to be inflamed are the brain and its membranes, the lungs, pleura, mucous membrane of the trachea, stomach, liver, peritoneum, with the small, and large intestines. The distinction of inflammation, proposed by Corvisart, into acute, sub-acute, and chronic, is adopted by Dr. Armstrong, who very justly contends that the difference between these several states deserves more consideration than has usually been given to it by systematic writers: the two former only are concerned in fever, but the latter is suspected to be the foundation of many nervous affections, which have been most commonly treated on a very different supposition; of this doctrine we are given to expect some practical illustrations from the same pen, to which we owe the present essay; we are quite satisfied that the treatment, founded on such a pathology, of nervous disorders, will be more successful than any other.

The acute form of inflammation generally commences on the first, second, or third day of the second stage of typhus, and the symptoms are unambiguous; the sub-acute form seldom arises till after the third day of this stage, and the symptoms are at first obscure.

"So far as my remarks have extended (Dr. A. says) the brain and its investing membranes are more subject to inflammation in typhus, than any other parts of the system. When the acute form of inflammation exists within the head, it is generally marked by great mental and corporeal irritability; an anxious, oppressed, or intoxicated cast of the countenance; dry, foul tongue; quick, vibratory pulse; flushed, turgid face; deep pulsating pain in the head; increased heat of the temples, forehead, and hairy scalp; throbbing of the carotid arteries; tinnitus aurium; redness, rolling, and morbid sensibility of the eyes; and more or less disorder in some other of the external senses. There are generally transient pains in the limbs; oppression of the præcordia; torpidity of the intestines; uneasy respiration, attended with heavy sighs; nausea, retching, or vomiting, augmented on motion; fretfulness and jactitation. Watchfulness, confusion of mind, visual illusions, and high delirium, follow each other in quick succession. If the inflammation should uninterruptedly advance, to these symptoms succeed indifference to surrounding objects; faultering or imperfection of the speech; gradually increasing stupor; bloatedness of the face; brown or black parched tongue; low mutterings; tremors of the hands; stupid, suffused, watery eye; squinting, or dilatation of the pupil; paralysis of one of the palpebræ; vibices or petechiæ; oozings of dark blood from the mouth and nostrils; stertorous breathing; general convulsions; relaxation of the sphincter muscles; and other mortal signs.”

This form sometimes proceeds with great celerity to a fatal termination, but is more commonly protracted a little beyond the first week; the sub-acute form occurs more frequently than the preceding, and occupies a considerably longer period.

"For some days, the sub-acute inflammation of the brain most frequently steals on in typhus by almost imperceptible approaches. At first, there are little more than the usual degrees of head-ach and of vertigo, with general lassitude; fugitive pains in the muscles or joints; torpid bowels, and uneasy feeling at the pit of the stomach, commonly accompanied with loathing of food, and a disposition to vomiting, especially on any sudden change of posture. The pulse is small and quick; but the carotid, and even the temporal arteries, beat with rather more than ordinary force. The tongue at first is co

* "In a few instances of this nature, I have known the face even paler than natural; the contrary, however, as stated above, is generally the case."