« ΠροηγούμενηΣυνέχεια »
facts which are accumulated, and provided the principle be adhered to by the author, and comprehended by the reader, the principal object will be attained. It is of more consequence, as Dr. Grisolle remarks, to be accurate in the special details, and to these he has carefully, and we believe successfully, applied himself. As he informs us in the conclusion of his preface, he has treated of special Pathology without attempting those views which belong to general Pathology and Semeiology, for which he refers to the classical work of Professor Chomel, which he regards as unquestionably the most remarkable introduction to the study of medicine which has yet been produced.
In making a distinct class of fevers, the author necessarily rejects the views of those who have endeavoured to reduce all these diseases to the class of inflammations, and says—" I believe there is no one, in the present day, who would dare to defend such a doctrine. On the contrary, every one admits the existence of diseases of which fever forms the predominant character, and which are not connected with any local derangement; or in which, if the solids are affected, their lesion is subsequent to the fever, and incapable of explaining it, being, like the fever, the effect and consequence of a more general cause."
He proceeds to enumerate the general phenomena of fever, and speaks of it as an element to be considered in forming a diagnosis. He repeats the remark of Andral, that in fevers not attributable to any local derangement there is everywhere a tendency to inflammatory action, which, if the fever continue, will give rise to various phlegmasia according to individual predisposition, or to the varied susceptibility of particular organs. Piorry believes that, in these cases, there exists a primitive inflammation of the blood, to which he gives the name of hémite. The author divides fevers into1. Continued fever-including ephemeral, inflammatory fever-typhoid
fever, (the typhus of Europe)-typhus fever of the English-the bilious fever of warm climates--yellow fever, and the typhus of the
East. 2. Eruptive fevers, such as small-pox, chicken-pox, measles, scarlatina. 3. Intermittent, containing the mild, pernicious, and anomalous. 4. Remittent and pseudo-continued fevers, which are rather to be re
garded as a sub-genus of the intermittent, 5. Hectic, lingering, or chronic fevers.
Under the head of " typhoid fever” the author treats of that important febrile affection which constitutes the greater number of severe cases of fever which occur in our temperate zone, and which has received a variety of appellations, of which the following are enumerated at the head of the article :-Phrenitis, of the Greeks and Latins; Pestilential, Malignant, Putrid, Bilious, Mucous Fevers, of most authors; the low nervous Fever of Willis and Huxham; the adynamic and ataxic fevers of Pinel; the entro-mesenteric of Petit and Serres ; the dothin-enteritis of Brettonneau ; the Gastro-enteritis of Broussais, the Typhoid affection of Louis, Chomel,
and Andral ; Follicular Enteritis of_Cruveilhier and Forgèt; the Typhoid entro-mesenteric of Bouillaud; the Enterite septicémique of Piorry.
It would be difficult to adduce a more signal instance of the transitory character of individual popularity than that which has struck us in the perusal of this excellent article in the work before us, written and published in Paris, where the facts and views which it records have been collected. It does not contain a single mention of the name of Broussais except as having given one of the synonyms prefixed to the chapter. Broussais, who but a very few years ago was in the mouth of almost every medical man in Paris, from the professor to the student, applauded by many, and combated or condemned by a few : Broussais, who told the crowds of his admiring pupils, that they might disregard all preceding authors from the time of Hippocrates to the present day, and throw them aside as mere ontologists, whilst the only necessary key to medical theory and practice was to be found in the physiological doctrine which he propounded to them—Brous, sais is not even once quoted. We looked in vain for the name of Broussais in the bibliography of the disease, in the exposition of its symptoms, and in the general and special instructions which are given for its treatment. Not a word of his exaggerated dread of aperient medicine—of his toleration of a loaded intestinal canal, that the fæces might serve as poultices to the ulcerated mucous membrane-of the myriads of leeches which he employed, or of the strict regimen which he prescribed. His merits and his defects are passed over in silence, and we are the more forcibly reminded of him by the very fact that so great and recent an idol is so completely thrown aside.
Nature of the Malady. Typhoid Fever is anatomically characterised by lesion of an inflammatory nature situated in the follicular glands of the intestines and mesenteric ganglion. Louis regards this lesion as constant, whilst, according to Chomel, Andral, and Dalmas, it may in some cases be absent. Chomel having seen subjects sink when only one or two patches or only a part of a single patch of aggregate glands was diseased, was led to believe the possibility of the total absence of any lesion of the kind, and he was confirmed in this opinion by facts collected by Louis and Andral, in regard to individuals who had died after having presented many of the symptoms appertaining to Typhoid Fever, without any of the intestinal lesions which characterise it having been discovered on inspection.
“ I stated,” observes Dr. Grisolle, “ in the first edition of this work, that I have myself seen two similar cases, but made the objection that the phenomena noticed were not precisely those which occur in Typhoid fever, and that they ought in consequence to be regarded as belonging to another disease, to an affection pot as yet defined. I am still of the same opinion. I find amongst my notes a case, which on other grounds is important to the solution of the question before us; it is that of a man 22 years of age, who in 1835 died in the Hôtel Dieu, in the ward of M. Caillard, on the 27th day of continued fever, who bad exhibited all the symptoms of severe Typhoid Fever, viz. intense headache (unaccompanied by epistaxis), vertigo, prostration of strength, absence of sleep, rambling, deafness, delirium, dryness of tongue, sordes of the mouth, diarrhea, tympanitic distention of the abdomen, sibillant rattle, numerous sudamina (miliary eruption,) rose-coloured spots, gangrene of the sacrum, penis, and scrotum. On dissection, however, no characteristic lesion, either of the intestinal follicles or mesenteric ganglia was detected, but the spleen was enlarged and of a difluent consistence. This single fact would lead me to believe with Chomel that the intestinal affection is not an indispensable characteristic of Typhus Fever, since, in some excessively rare cases, it may be absent. Nevertheless, if the follicular affection of the intestines is not constant in the rigorous sense of the word, we repeat, again employing the expression of M. Chomel, that it is extremely rare for it to be altogether absent, and that there is not a single authentic case on record in which this lesion has existed, unattended by the symptoms of typhoid fever. One circumstance which has greatly contributed to excite doubts as to the importance of the derangement of the Peyerian glands is the assertion of medical men in London, Edinburgh, and Dublin, who aver that derangement of the intestinal glands is frequently absent amongst their patients, who, during life, had exhibited symptoms of typhoid fever. But it is now proved by the clinical cases collected in London by our friend Dr. Shattuck of Boston, and analysed by M. Valleix, as well as by the labours of Drs. Gerhard and Penwick of Philadelphia, that there exist in the United States and in England two febrile disorders, hitherto confounded together under the name of Typhus fever, but which are really distinct, and only resemble each other in their general symptoms. The one affects young subjects, and is the Typhoid fever, such as we see it here in Paris), the other common to all ages, with the exception of infancy, is Typhus fever. It is a disease distinct from typhoid fever ; it is the typhus fever which we shall describe by-and-bye.
“ It is a question whether the lesion of the intestinal follicles is a primitive affection, as in the case of most inflammations, or consecutive to a general state, like the eruption of small-pox, to which it has been compared. The first supposition has the greatest appearance of probability, when it is remembered that in most cases the abdominal symptoms, diarrhea and colic, commence with the disease, which is not generally the case in other febrile affections. We cannot, however, speak with certainty as to the point.
" Does the intestinal affection constitute the sum of the disease? This does not seem to be probable, when it is known that there is frequently no proportion between the severity of the symptoms and the extent of the intestinal lesion. We have seen with M. Chomel death occur, although there was but a single patch of glands diseased, while, on the other hand, we often see in persons who have died from accidental causes very extensive lesions, although the symptoms during life had been of moderate severity. There are moreover, in the course of the disease, a number of morbid phenomena which are only explicable on the supposition of the existence of a general cause as yet unknown as to its nature and seat, which is placed by some in the nervous system, but which is more generally supposed to consist in an alteration in the blood, which has not yet been made out. Typhoid fever has sometimes been compared to eruptive fevers, and at others to simple inflammations, but if it have some points of resemblance with these, it has also many of dissimilitude. It is therefore expedient to consider typhoid fever a special disease, separated from all other affections by several fundamental characteristics."
The author then gives both sides of the question in the words of Professor Louis, who sums up the parallel, and the contrast between the eruptive fevers and the typhoid affection, and arrives at the conclusion adopted by our author.
Dr. Grisolle is one of those who admit the contagious nature of typhoid fever, although this character is disputed by many of his countrymen : but he
agrees, with Louis and others that it may be brought into existence by other causes, independently of contagion ; and with Gendrin, that those who have been once affected acquire thereby a protection against future attacks.
1847) Typhoid fever.
27 Of the treatment he speaks under different heads. Under that of the Antiphlogistic he especially treats of the abstraction of blood. He admits its utility in certain cases, especially where there is a marked inflammatory character, but he condemns its general and copious employment, as adopted by M. Forget, and such as we remember to have been in vogue in the North of this island. He equally condemns the often reiterated bleedings of Professor Bouillaud. He gives the preference to leeches applied to the iliac region, if there be acute pain there, but he objects to their application to the anus, which he regards as not merely useless but liable to become a source of fresh irritation or even of gangrene. He likewise recommends the occasional application of leeches to the head, behind the mastoid process, but gives a salutary recommendation against allowing the bites to bleed long in children. He recommends the abundant use of drinks con. taining gum, or barley, as well as those which are flavoured with sugar and juicy fruits, some of which, we think, it would be better to omit, or give with great moderation. He enumerates emollient glysters, fomentations and cataplasms to the abdomen, and tepid baths, from which last, he ob. serves, that great benefit is derived when the fever is violent, and the skin very hot and dry. He might have insisted more strongly on the efficacy of this treatment, and pointed out the circumstances which should direct its application, had he been acquainted with the classical work of Dr. Currie of Liverpool, and with that of Dr. Jackson.
He notices the contra-stimulant treatment merely to observe that he is unable to judge of the mode of employing tartar-emetic as recommended by Rasin, and that the use of sulphate of quinine in large doses and as a contra-stimulant is of questionable utility, although quinine, he admits, is decidedly useful in those cases in which regular paroxysms are established, when much smaller doses are employed.
Under the head of antiputrid or antiseptic treatment, he notices the employment of bark, camphor, musk, aromatics, wine, alcohol, mineral acids, internally and externally. He says of this treatment, that it was generally followed in France, whilst the opinions of Pinel in the Nosographie Philosophique) were in vogue—that it has still many proselytes in England and Italy, and especially in Germany, but that it deserves no sort of confidence —that Andral has shewn that of 40 patients so treated 26 died, and that three only of the 14 who recovered appear to have been benefited by the treatment, and that the others recovered as they would have done if left to themselves. Nevertheless, he sanctions the use of wine in extreme cases, though on the more reasonable ground of combating prostration of strength rather than the tendency to putridity.
In treating of the evacuant plan the author observes, that medical men have alternately adopted and rejected the employment of evacuants in the treatment of continued fevers, according to the theory which they adopted respecting the nature of the disease. They were at one time generally abandoned, and Brettonneau and Lerminier, who were almost alone in adhering to the older doctrines, were unable to inspire their brethren with the confidence that purgatives might be brought into contact with ulcerated intestines without danger. More recently, M. Delarroque, physician to the Hospital Necker, has demonstrated how groundless were these fears, and proved, by a numerous series of well-observed facts, the advantages of evacuants in the treatment of severe fevers. This physician administers aperients in all the forms and periods of the disorder through its whole course up to complete convalescence. He generally commences by an emetico-cathartic, which Dr. Grisolle does not consider as useful, except there be symptoms of gastric oppression. The patients take every day a bottle of sedleitz water, or thirty grammes of castor oil, or two grammes of calomel, or a dose of cream of tartar. Pains in the belly, cholic, diarrhea, and materorismas are, in his opinion, far from contra-indicating the use of purgatives, but seem, on the contrary, to call for their employment. If, in extraordinary cases, they increase the pain or produce hyper-catharsis, they are to be suspended for twenty-four hours. Delarroque conjoins with these means sweetened drinks and poultices on the belly, and gives tonics as soon as the fever is turned. In adopting this treatment, Delaroque has only lost one patient in ten. This plan has been tried by Honoré, Guenneau de Mussy, Bricheteau, Beau, Piédagnel, Jadioux, Andral, Louis, and many other physicians in Paris, who have all acknowledged the good effects of the evacuant treatment. Louis, after analyzing the different methods of treatment adopted in typhoid fever, gives the first place to the evacuant plan. It not only diminishes mortality, but shortens the duration of the disease. Grisolle adds, that by employing purgatives we are not favouring the development of any complication, and that the two most dreaded accidents, hæmorrhage and intestinal perforation, are much more rare than when the other modes of treatment are employed. He states that, in France, castor oil or sedleitz water is generally prescribed. In Germany and some parts of Switzerland calomel is most in favour, and this medicine is also preferred by Lombard and Fauconnet, who declare that they have only lost nine patients in a hundred so treated. He notices the assertion of Barthez, Rilliet and others, that the purgative plan is inapplicable to infants, though useful in adults; but he regards the assumption as doubtful, and worthy of further enquiry.
It is remarkable that the author makes no allusion to the employment of purgatives in this country, where, since the publication of the important work of Dr. Hamilton, they have been so generally employed, that the prescriptions, and books, and records, of almost every medical man in the country during the last thirty years might be appealed to in proof of the general adoption of the very plan to which the author has given such decided preference. In fact, the use of purgatives has not unfrequently been a subject of reproach against us on the part of our continental brethren, and it has been one of the happy results of the eminently eclectic character of British medicine, and of our readiness to profit by the observation and experience of our contemporaries, that the immoderate employment of purgatives has been checked, without our falling into the opposite error of rejecting them.
Typhus.—It has been attempted to constitute a disease distinct from typhoid fever under the name of “ Typhus, or Plague of Europe.” The fever so designated has been seen in prisons, hospitals, and camps, and has been common in besieged cities, wherever numerous individuals are brought together in close situations or under other unfavourable circumstances. It is eminently contagious, which has been regarded as one of the grounds of