unfavourable symptoms increased, the patient became more and more comatose, and died on the 17th or 18th day of the disease.

Dissection.-A number of small scrofulous glands or tubercles were found in the omentum, and peritoneal covering of the small intestines. On the mucous surface of the lower end of the ileum, and of the commencement of the colon, there were several small ulcerated points, which seemed to have been in the act of healing at the period of death. The Peyerian glands were but little affected. The intestinal lesions in this case were therefore much less decided than is usual in Typhus fever. The lateral ventricles of the brain were distended with serosity; and there was also a yellow-coloured gelatinous deposit under the pia mater at the base of the brain.

Dr. Schoenlein attributes the death in this instance to the cerebral changes. He considers that the appearances found in the bowels-viz. the traces of healing in the ulcerated points on the mucous surface-may fairly be considered as evidences in favour of the use of Calomel: although it does not prevent, it seems to moderate, the severity of the intestinal eruption.

(Remarks.-There are several points in this case that deserve notice. Schoenlein's condemnation of emetics in the early stage of Typhus, and his reasons for so doing, are not at all satisfactory. In our opinion, they are quite fallacious, and appear to be founded much more on his theoretical views of the disease, than upon the results of actual observation. Nature herself often points out the practice that should be followed; and how decided is the relief that is generally obtained by free and copious vomiting! For our own parts, we cannot too strongly recommend the administration of an emetic at the commencement of almost all fevers. The practice of giving scruple-doses of calomel in mild cases of Typhus is not likely to find favour with the British physician: moderate and repeated doses of the hydrarg. c. creta, to which a few grains of carbonate of soda may be added, with grateful effervescing draughts in the intervals, will be generally preferred.-Schoenlein seems to be haunted every moment with the danger of dothinenterite; and yet his patient died, he admits, of cerebral effusion, and not of any intestinal lesion.-Query. Ought the case therefore to be called one of typhus abdominalis ?-Bloodletting, in any form, is seldom or ever admissible for the relief of the comatose affection in the advanced stage of Typhus.-The doctrine of "critical days," is, it will be observed, much insisted upon.)

SECOND CASE.--Typhus Abdominalis-Thoracic Affection - EpistaxisEmaciation of Typhus Patients—the Blood in Typhus and in Chlorosis

-recovery.

A young man, when admitted, exhibited the usual symptoms of mild Typhus. The cerebral disturbance having been at the first more severe than the abdominal, he had been bled from the arm in consequence. There was little or no pain, but only a rumbling, in the cœcal region. A slight pneumonic affection existed on the left side: it was indicated by a somewhat increased dulness upon percussion, by the presence of a moist rhonchus, and by the sputa being a little tinged with blood. As the fever had

already existed nearly 14 days, the treatment was directed chiefly with the view of promoting a critical eczumation from the Skin by the use of mild diaphoretics; and, for the purpose of relieving the pulmonic disorder, 2 grains of Muriate of Ammonia, with of a grain of Camphor, were given every two hours. Two days subsequently, an Epistaxis supervened: Schoenlein regarded it as of a "critical" nature. When this hæmorrhage is excessive, he advises that the nostrils should be plugged with lint dipped in Aqua Thedeni, that Alum be administered internally, and that sinapisms be applied to the surface to produce irritation of the peripheral nervous system. In the present case, these remedies were not called for. For the purpose of acting upon the skin and lungs, the mur. ammon. with sulphur. aurat. was given; and some mercurial ointment was rubbed in over the lower lobe of the left lung. But, as next day the chest symptoms were rather increased than diminished, a few ounces of blood were then drawn from the affected side by cupping: the blood thus obtained was very thin and watery: when examined with the microscope, it was found to contain a much smaller proportion of red globules than exists in healthy blood. The objective (auscultatory) as well as the subjective (rational) symptoms were decidedly relieved by this practice. In reference to the very mild character of the abdominal symptoms in the present case, Schoenlein remarks:

*

"The alvine evacuations are in no way pathognomonic in this disease, as some writers have maintained; and it requires that we should be well acquainted with the anomalies that are apt to occur, in order that we may not, by their mere absence, be led into error. Notwithstanding the long (for three days) constipation, and the absence of pain or any rumbling noise in the region of the cæcum, there are doubtless (in the present case) certain lesions of the intestinal mucous surface present."

* Schoenlein on this occasion remarks that the result of this examination was quite in accordance with his opinion as to the nature of Typhus fever, which he regards as " a blood-disease or a hæmatosis, essentially distinct from inflammation." Besides a deficiency of Fibrine and Albumen, the proportion of the red globules is often very sensibly diminished in Typhus. The blood in the present case was examined by Dr. Simon, and the following are the results of his analysis.

There are several reasons that make us believe that there is a decided change in the colouring matter of the blood in Typhus-viz: the formation of the dark pigment on the teeth, lips and tongue, the stained appearance of the inner surface of the blood-vessels and of the intestines, and especially the state of the urine. Dr. Simon has found, in the deep-coloured urine of a Typhus patient, the colouring matter of the blood and uric acid in combination with a basis.-Dr. Schoenlein accounts for the greater emaciation and the much slower recovery of the strength after an attack of Fever than of Inflammation, in which a large quantity of blood may have been lost, by the circumstance of the greater deterioration of the blood in the former instance.

It here deserves to be remarked that the physician should never trust to the mere feelings of a patient, or to the answers which he gives to questions, touching the existence and severity of his abdominal and thoracic symptoms; for these are often, as it were, disguised, and thus are apt to be sometimes entirely overlooked. Nothing, therefore, but an "objective examination," every day, should satisfy the judicious practitioner. This is more especially necessary, as the visceral affection is often observed to oscillate, or alternately to subside and to be excited, several times in the course of an attack of Typhus fever. In the present case, after a lull of five days, the thoracic affection was again aggravated, the rhonchus sibilans being again heard on the left side, and being now accompanied with a slight crepitating noise. As it would seem from this that the Bronchitis was in some degree complicated with Pneumonia, 8 ozs. of blood were drawn from the arm, the cupping-glasses applied to the chest, and frequent doses of Nitre and Sal Ammoniac administered. Under such circumstances, we must be on our guard lest the pneumonic inflammation pass into the suppurative process; for this is an accident that is occasionally observed to occur in protracted typhoid affections. The symptoms were considerably relieved by the use of the remedies employed; the sibilant had changed more into the mucous rale, &c. But, as the cough was still dry, harsh and ringing, and as no decided critical evacuation, nor any local crisis had taken place, it was deemed advisable to have the mercurial ointment rubbed in upon the chest, especially between the shoulders. What we desire to find is, that the moist rhonchus may be heard over a wider extent of the chest, also that the cough may become looser, and that the sputa assume a more globular and distinct character. The febrifuge expectorant mixture-half-a-drachm of nitre and the same quantity of Sal ammoniac in six ounces of emulsion-was ordered to be continued. The symptoms gradually gave way, and the patient eventually was restored to health.

Schoenlein remarks that it has been only of late years, that the attention of the physician has been specially directed to the not unfrequent existence of a latent pulmonic affection in cases of Typhus fever. The subjective symptoms of this complication are usually not very prominent or striking; and it is therefore only by the aid of the objective phenomena, as disclosed by Auscultation, that our diagnosis can be accurately formed. It is to M. Louis, more than to any other pathologist, that we are indebted for our more exact information upon this subject. He has most convincingly shewn how apt Pneumonia is to supervene, when we little suspect it. Too often it passes on into phthisical disease, especially in those persons in whom there exists any constitutional tendency to this malady. The frequency of chest complications in Typhus varies much in different seasons. Hence the importance of studying the epidemic and endemic constitution of each fever, with which we have to do.

(Remarks. In spite of his bias to the abdominal pathology of Typhus fever, Schoenlein expressly recognises the importance of studying the changes and abnormnal condition of the fluids.-The occasional complication of pulmonic inflammation, it is of the highest importance to be

aware of. In the treatment of the present case, we miss the use of two very important remedies—the tartrate of Antimony, and Blisters).

In the third case of (what is still called) abdominal typhus," the points most worthy of notice are these. An emetic had been given to the patient before his admission into the hospital; and, as after its administration a loose state of the bowels supervened, Dr. Schoenlein inferred that it had accelerated the eruption upon the intestinal mucous surface. Had this not been the case, he remarks, we might have hoped to have prevented its development by the use of Calomel: the disease having reached that point when its resolution by some critical evacuation is still possible, but cannot be, as it were, compelled. Aqua oxymuriatica, in a demulcent beverage, was ordered to be taken frequently.

There was an unusual tendency to exhaustion and syncope in this patient whenever he sat up. This peculiarity Schoenlein regarded “as a pathological equivalent of the intermittent fevers, which are strikingly rare this Spring." I have," he continues, “at the present moment under my care a patient, in whom his usual Spring attack of Ague is replaced by a regular and periodic return of faintishness."*

""

Relation between Typhus and Intermittent Fevers.

That Typhus Fever and Ague are often very closely associated, more especially as respects their genetic cause the former so frequently springing from the latter is well known to those who have practised in marshy districts. The truth of this remark was abundantly witnessed in the great epidemics, which prevailed in the North of Europe during the years 1827 and 1828. One example will suffice. Where the Rhine opens into the Bodensee, the stream of the river becomes as a matter of course nearly still, and there Malaria is generated and Agues abound; but in Appenzel, where the land becomes more elevated, there are no Agues, but often a most destructive form of Typhus fever prevails.

This subject of pathological relationship is one of such high practical importance, and withal so little attended to, that we shall make no apology for introducing the following remarks by our enlightened author.

"These equivalents of intermittent fevers, as we may call them, generally shew themselves in this manner. The affection appears at first only as an inconsiderable irritation of the gastric or bronchial mucous membrane, perhaps as a trifling catarrh; but there is always-and this symptom may have existed for some days previously-an unusual degree of powerlessness and general oppres sion. In young plethoric subjects, there is not unfrequently at the same time a discharge of blood from some part, to a greater or less extent in women, it is often an excessive flow of the menses-all indicative of a vitiated state of the fluids. In such circumstances, let the physician be on his guard: for it is not with a simple catarrh that he has to do. If, having regard only to the loaded tongue, nausea, and headache, he administers an emetic or saline purgative, the

* This truly Sydenhamian remark well deserves attention; and we are the more anxious that our readers should notice it, from its being so completely in accordance with those highly instructive observations of Dr. Harden, on what he has called the "Isopathia or Parallelism of Diseases :" vide our last No. p. 277. The very expressions used by the two writers are equivalent.

chances are that he inevitably hastens on and aggravates the development of the disease. During various epidemics, many cases have been observed by me where the patients have complained of little save weakness and tendency to fainting, without perhaps any symptoms of intestinal disturbance or any febrile excitement. Such cases were well known to the old physicians, who have described them under the appellation of febres epidemicæ maligne sine febre. Not unfrequently about one of the critical periods, usually the end of the third week, a violent vascular tumult (gefass-sturm) is excited; and then either quickly subsides by some critical evacuation from the skin, kidneys, or bowels; or a rapid and perhaps fatal collapse ensues."

(The modifying influence of an agueish character or constitution upon the progress of continued Fevers is, as might be expected, most conspicuous in hot climates. As the modern French school of medicine is that which has most grievously erred in overlooking this important point of practice, we are always pleased to meet with evidences of sounder therapeutic views in the writings of our neighbours. The following passage, from a recent work on the Diseases of Brazil, may be not inaptly introduced as a specimen of the wholesome change that is beginning to take place in their pathology.†

Experience has taught me, as well as others, to modify my opinions, and change my therapeutics, in the presence of a host of grave fevers, which I used to regard as symptomatic of inflammatory lesions of the liver, brain, or intestines. It has convinced me that, in those countries, where the agueish principle predominates, every thing is subjected to its action; and therefore that to persist in the employment of antiphlogistic remedies in those countries, especially when an epidemic of grave intermittent fever exists, is to cause almost inevitably the death of our patients. For the last twelve years, I have been satisfied of the truth of this: before that time, I held the exclusive doctrines of Broussais, who used to quote me as a zealous follower of his doctrines in South America. It has cost me much regret to separate myself from the school of this puissant genius, but facts speak louder than any doctrine can do; and I am bound to proclaim the infallible efficacy of the sulphate of Quinine in the treatment of intermittent fevers, even in their acute stage.")

CASE 4.-Typhus Abdominalis, nervosa, stupida-Pneumonia-Epistaxis -Threatening of Edema Glottidis-Ammoniacal Urine-ParotitisRecovery.

A man, 23 years of age, was admitted into the hospital, with the ordinary symptoms of Typhus: according to his report, he was in the beginning of the second week of the fever. The headache had been so severe as to require the application of leeches. Although the patient made no complaint of any thoracic ailment, Percussion and Auscultation shewed that there was incipient inflammation of the posterior part of the right lung; the sound that was elicited over it being duller than usual, and a

It is in such cases, where the symptoms are so obscure and ill-marked during life, that inflammationes occulte in the viscera are so often met with upon dissection.

+ Du Climat et des Maladies de Bresil, ou Statistique Medicale de cet Empire, par J. F. Sigaud, Medecin de S. M. l'Empereur dom Pedro II. Paris, 1844. NEW SERIES, NO. III.-II.

FF