« ПредыдущаяПродолжить »
vered with a whitish fur; the cheeks are alternately pale and fushed throughout the day; the countenance has a heavy, wearied expression; and the eyes often feel uneasy, as if small particles of sand were in them. Besides, some of the rest of the external senses are almost always disordered, particularly the hearing, which, though occasionally more obtuse, is generally more acute than natural. The forementioned symptoms continue without material alteration for three or four days; although the patient may often be remarked to sigh, breathe quicker, and grow more irritable, as well as restless, seldom remaining long in the same place or position. At length, pain of the head, and uneasiness in the orbits of the eyes, are more severely felt; the eye-brows are sometimes suddenly knit together; the arms tossed about the bed, or one or both hands now and then pressed against the forehead. The pain of the head continues to increase; and in two or three days more there are symptoms of an indescribable uneasiness, constantly and distinctly referred to the brain. The eyes are now rather blood-shot, and intolerarit of light; the anxiety of the præcordia is much augmented; the respiration more hurried; the htat of the surface more elevated; the face permanently flushed; the tongue drier and stiffer; and the involuntary sighing more frequent. The patient now.lies at nights with his eyelids half closed, in light indistinct dozings, associated with moaning, frightful dreams and startings; or he is harassed by perpetual watchfulness, joined with frequent wanderings of the mind. As the inflammatory affection advances, day after day the sensorial functions continue to be more and more disturbed. At last, delirium becomes unceasing, when signs of an oppressed brain gradually make their appearance; under which the patient slowly sinks into dissolution, with hiccup, petechiæ, cubsultus tendinum, an apoplectic expression of the features, and a red glary-eye, floating insensibly in an envelope of mucus.” (p. 28–30.) · For a particular account of the symptoms attending typhus, when accompanied with inflammation of the other viscera,--and for some allusions to dysentery, puerperal fever, and erysipelas, -we must refer to the work itself; but we cannot quit this part of the subject, without noticing the admonition given to the speculative and the inexperienced, not rashly to conclude that inflammation exists in every instance in which the head, chest, or belly, are seemingly affected; for, by neglect and improper treatment, by confinement in a close heated chamber, under a stifling load of bed-clothes, and by indulgence in the use of stimulants, a state of high delirium is often induced, with dry burning skin, parched tongue, flushed face, and red eyes, or there are cough and oppression of the chest, or uneasiness and tension of the belly; yet all these unpleasant symptoms CRIT. Rev. VOL. IV. Dec. 1816.
will probably soon be removed by a simple change of mea. sures; it is indeed surprising - what a pleasing amendment
may be frequently produced in mismanaged typhus patients, by the abstraction of heat, noise, and diffusible stimuli; and the substitution of fresh cool air, sub-acid drinks, a spare diet, and remedies which move the bowels, and tend to take off general excitement and local determi. nations."
III. Congestive Typhus.“ The attacks of the most dangerous forms of the congestive typhus are generally sudden, and marked. by an overpowering lassitude; feebleness of the lower limbs; deep pain, giddiness, or sense of weight in the encephalon; a dingy pal lidness of the face ; anxious breathing; damp relaxed, or dry withered skin; and those peculiar conditions of the tenperature which have been noticed above, the surface in some parts preternaturally hot, in others cold). The pulse is low, struggling, and variable; the stomach irritable; frequently there is an inability from the first to hold up the head; and the mind is more often affected with dulness, apprehension, or confusion, than with delirium. The whole appearance of the sick impresses the attentive practitioner with the idea that the system in general, and the brain in particular, are oppressed by some extraordinary load. Both the manner and look of the patients undergo early and great alterations : sometimes they slowly drawl out their words, or utter them in a hasty and yet imperfect mode, like people who slightly stammer when embarrassed; they not unfrequently seem as if stunded by a blow, half drunk, or lost in a reverie ; and at times have the bewildered aspect of persons suffering under the first shock of an overwbelming misfortune. The eye is occasionally glary and vacant, without redness; but at other times it is heavy, watery, and streaked with blood, as if from in toxication, or want of sleep. At the commencement, the pulse is often less altered as to frequency than might reasonably be expected ; yet in general it becomes very rapid towards the close; the tongue is usually little altered in the first stage, but in the last it is frea quently rough, foul, and brown; the bowels are mostly very terpid in the beginning, and the stools procured dark and scanty; whereas, in the advanced stage, the bowels are generally loose, and the stools copious and involuntary. Eructations are not uncommon at all times, and the epigastric region is often much inflated. On account of the general torpor, the secretions are diminished or suppressed; and, as justly remarked by Dr. Robert Jackson, the skin is often in that peculiar state, that if blisters be applied, they either do not act at all, or so defectively, as to leave an appearance as if the part had been slightly seared by a heated iron. Petechiæ in general appears earlier in these than in any other varieties of typhus; and in the last stage there are sometimes gangrepous spots on the extremi ties, oozings of blood from the mouth and nostrils, and hemorrhage from the bowels.” (p. 68-69.)
There are other comparatively milder forms of the con• gestive typhus, which cannot here be particularly noticed; their general character, however, is marked by symptoms of a similar description with those already detailed. The most striking phenomena of this variety seem to depend upon a loss of balance between the venous and arterial systems, occasioning a morbid accumulation of blood in the veins, that oppresses every vital function. The organs most frequently and seriously affected with congestion are the brain and liver, and next to them the spleen and lungs: the fever in some instances continues purely congestive throughout, in others there are signs of partial arterial re-action: there is a singular disposition to relapse, symptoms of amendment being often suddenly succeeded by the utmost peril; and altogether the congestive typhus is far more dangerous than any other, and less susceptible of being brought to a favourable issue.
In this part of the volume a parallel is drawn between typhus and the plague, between which (so far as a person acquainted with the latter only in books can judge) the resemblance in every important particular is most exact; and it is but reasonable to think, that the same principles of treatment which have been found most salutary in typhus and in yellow fever, may be extended with equal advantage to a disease that so completely resembles them. What these principles are, as laid down by Dr. Armstrong, we shall proceed to state with as much brevity as the nature of the subject will allow.
In the simple typhus, if the physician be called in the first stage, the exhibition of an emetic, followed by a brisk purgative, is advisable; the fever will sometimes be thus cut short at once, or at least its subsequent stages will be mitigated. At this period, too, the warm bath is useful, by its effects in equalizing the circulation : the patient should be kept perfectly quiet, in a comfortable temperature; and, in general, all diffusible stimuli should be withheld. During the first three days of the stage of excitement, the affusion of cold water, repeated as often as the heat of the body arises to an excessive degree, agreeably to the rules of the late Dr. Currie, will be of eminent service; but after that period, tepid affusions or ablutions are in general better adapted to the state of the case. The bowels should continue to be freely evacuated every day, by tolerably full doses of medicine, without any fear at this time of weakening the patient by such measures. In the stage of collapse, however, it is necessary to beware of too much activity; the milder cases requiring nothing more than a proper
attention to diet, and the bad being commonly rendered worse by purgatives or evacuants of any kind. There are nevertheless some exceptions to this rule, which shall here be noticed in the words of our author.
• When the exhibition of purgative medicines has been neglected in the beginning of typhus, an extraordinary accumulation of fæces often exists in the last stage, and occasions an alarming oppression of the brain, accompanied with great prostration of the natural powers, flushed face, suffused eye, delirium, or some degree of stupor, high breathing, foul tongue, and quick uneven pulse. In such cases, the abstraction of the smallest portion of blood would be eminently hazardous; but I have frequently seen the most agreeable change induced by full doses of brisk purgatives, such as calomel with jalap, aided by stimulating enemata, the strength of the patient being supported during their operation by moderate allowances of good wine.
In the advanced stages of typhus, when cerebral oppression is thus secondary of loaded bowels, much sometimes may be effected by the combined employment of purgatives and cordials, care being taken that the former act with tolerable freedom, and that the latter only be given to obviate the debility, without too powerfully exciting the general circulation.
“ In the last stage of typhus, when the bowels have not been regularly moved in the preceding stages, it is not uncommon for patients to pass frequent, small, loose, fætid stools, which are sometimes mixed with slime and blood; yet such an occurrence does not prohibit aperients, but rather pressingly indicates the necessity of their exbibition, since the distressing looseness is the consequence of offensive sordes retained in the bowels, and ceases when they are effectually removed by active purgatives ; though it is always prudent to give a moderate opiate soon after their operation, and to support the strength with cordials, as in the instance before men. tioned.” (p. 117–119.)
It is now perhaps unnecessary to introduce any remarks upon the evil effects of that profuse and indiscriminate administration of wine, which some years ago prevailed so far, that there appeared a sort of emulation amongst physicians as to who should cause his patients to swallow the greatest number of bottles in a given time: that folly is happily past, and a more rational practice has taken its place. Wine ought almost never to be exhibited but at the latter end of these fevers, and even then it should be cautiously tried, and, according to its effects, continued or withdrawn; neither in any case ought it to be given in larger quantity than is just sufficient gently to excite and support the actions of the system.
In the inflammatory typhus, the measures above recited are not alone sufficient : in order to remove the topical inflammation, blood-letting, either general or local, or both, is indispensable; and, after proper evacuations, blisters are very useful auxiliaries. Inflammations of the acute species pass rapidly to a period when bleeding is no longer admissible; ihe practice ought, therefore, to be early and decisive; estimating its efficacy not by the quantity of blood taken, but by the effects produced. In the sub-acute species bleeding may be employed with safety and advantage at a considerably later period. It is to be observed, that the loss of blood cannot be borne to the same extent in contagious fever, as in a case of simple inflammation; and further, that the antiphlogistic power of blood - letting is never more conspicuous than when it produces syncope: our object, then, should be to bring on some degree of faintness with as little loss of blood as possible, and with this view, we
must bleed from a large orifice, whilst the patient is sup- ported in an upright position. Dr. Armstrong is no advo
cate for large repeated abstractions of blood in these cases, but after one or two well-timed and moderate attempts by the lancet, places bis chief reliance upon saturating the system with mercury. His general plan has been to admi. nister calomel, so as to ensure its purgative and specific effects at the same time; giving it in the quantity of ten, or even twenty grains in the day, followed by some other active cathartic, that plentiful evacuations might be procured before bed-time; and during the night exhibiting it in divided doses, combined with opium, by way of accelerating its more complete absorption. The practice of giving calomel and opium in inflammatory complaints was intro. duced by Dr. Hamilton, of Lynn Regis, and no medicine possesses greater power of equalizing the circulation, and thereby relieving the viscera from engorgement: but in order that this compound may produce its full effects, it must be administered in the liberal manner recommended by our author, who carries the practice much farther than Dr. Hamilton ventured to do.
In the congestive typhus little good can be done, except in the first stage. If a warm bath can be speedily prepared, the patient may be immersed in it, and bled whilst he remains in that situation, or immediately after leaving it; the quantity of blood taken away must be such as will relieve