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Typhoid and Typhus Fevers.

29 distinction by those who doubt the contagiousness of the typhoid affection. Many of the symptoms are admitted to resemble those of the typhoid affection. It has been attempted to shew that the derangement of the alimentary canal is slight or altogether absent in many cases of typhus. That petechiæ are much more common in typhus and miliary eruption than in typhoid fever—that the red lenticular spots appear some days earlier in the former-that hæmorrhage and intestinal perforation are also more uncommon, and that the spleen is not essentially in a morbid condition. Notwithstanding these attempts at distinction, the author regards it as proved by the pathological researches of Chomel, of M. Gaultier de Claubry, and by the narratives furnished by M. Landouzy himself (who adopts the opinion that they are different), that these two affections are essentially the same, and that the supposed differences merely belong to the accidental varieties of different epidemics.

The case is different with the typhus or continued fever in England and Ireland. The medical men of Great Britain, and even French physicians who have had the opportunity of visiting British hospitals, have noticed cases of fever in which the lesion of the Peyerian gland was absent. At first the French physicians of the school of Louis were disposed to doubt the accuracy of such narratives, and to presume that the inspections had not been made with sufficient care. But the concurrent testimony of seve. ral able and experienced observers, and more especially of Drs. Gerhard and Shattock, American physicians, who had studied in Paris, removed all doubt on the point, and have led to the conclusion adopted by Professor Louis, as well as by the present author and many others, that there is a really distinct malady not uncommon in Britain, and occasionally occurring as an epidemic in the United States, which, notwithstanding many symptoms common to it and the typhoid, it is essential to distinguish from that form of fever. Whilst the most important anatomical difference is observed in the absence of lesion of the aggregate glands, a difference is also to be noticed in the cutaneous eruption occurring in the two diseases. In typhus fever the eruption consists in numerous, irregularly grouped spots, varying in size from that of the head of a pin to that of a pea, of a violet or deep red colour, and not disappearing under pressure. It appears on the sixth or the eighth day, and rarely disappears before the twentieth, but sometimes persisting to the twenty-eighth, or even thirty-first day. Miliary eruption is said to be uncommon in the English typhus fever. Blood drawn from the veins has no buff, and the clot is soft and again becomes fluid. Epistaxis is much less common than in typhoid affection.

If, with Dr. Grisolle, we have made the distinction between the typhoid affection as characterized by the specific derangement of the aggregate glands and the cases of fever noticed in England and America, which we think must be conceded, various considerations not altogether unimportant necessarily suggest themselves. If, in these days of careful anatomical research, the distinction has been with difficulty established, how are we to receive the narratives of the best older authors who have written on fevers, and who, with the same varieties of disease under observation and treatment, were incompetent to draw the distinction ? If the derangement of the aggregate glands characterizes a disease as distinct and specific as scarlet fever or measles, and which is wont in its progress to be accompanied with many symptoms in common with typhus fever, are we prepared to admit that the cases in which the derangement of these glands has been absent, as in the fevers noticed in Britain and the United States, as really constituting a second specific form of fever, and are there not, rather, sufficient reasons for concluding that the conditions and symptoms, regarded as common to typhus and typhoid fever, may present themselves in several febrile diseases in common, constituting, as the older authors led us to believe, the tokens of a particular stage in the morbid process ? Such is the idea which we are disposed to adopt, and if it will not remove the whole difficulty, it will at least prepare us to appreciate the importance of those accurate pathological researches which alone can enable us to distinguish different forms of fever tending to some common results.

The other forms of continued fever which are noticed are the bilious fevers of warm climates--yellow fever and plague, which we pass over. The eruptive fevers constitute the next group. In speaking of variola, he notices Piorry's plan of softening the skin by baths and moist compresses, and then breaking the pustules to prevent the formation of scars ; and also the plan of cauterization advocated by Brettonneau, Seres and Velpeau ; but these plans are not commended by the author. He has a better opinion of the application of mercurial ointment.

In speaking of Vaccinia, he admits the deterioration of the vaccine virus since its introduction by Jenner, and recommends frequent recurrence to the original matter from the cow, which produces a much finer pustule, attended with more constitutional affection than is the case with the older virus. He says that, by inoculating the cow with old virus from the human subject, we do not obtain any advantage; but he says nothing of the means of re-producing efficient vaccine virus, as taught by the remarkable researches of our countryman Mr. Ceely, or rather he merely alludes to them to express a doubt of their accuracy.

In treating of modified Small-pox and Chicken-pox, he alludes to the opinion held by the late Dr. Thomson and Mons. Rayer, that modified small-pox and chicken-pox are only varieties of the same affection, being both produced by the contagion of small-pox. He does not consider the question as fully decided, though he inclines to the opinion of their being distinct affections. The fact of chicken-pox being seen in those who have had neither small-pox nor cow-pox concurs with the characteristic appearance of the eruption to place chicken-pox as a disease wholly distinct from small-pox. In his article on Measles he does not agree with Willan, that this disease was known to the Greeks and Romans, but thinks that it was probably derived from Asia, the apparent source of so many of our diseases, at a period not known, since Rhazes, the first author who has given an exact description of it, does not describe it as a new disease. He notes as varieties-measles without catarrh—and measles without eruption, and the black measles of our countryman Dr. Willan, to whom he frequently refers in the course of his work. He mentions the formidable complications of measles ; namely, Pneumonia, which in infants is almost always of the lobular form-Entero



Intermittent Fevers. colitis-Gangrene of the lips and lungs-Inflammation of the membranes of the brain, with Delirium, Coma and Convulsions, and Hooping Cough and Croup, which often succeed to it. He does not omit to mention the curious fact pointed out by Hunter, that the contagion of small-pox and measles may simultaneously exist in the patient at the same time, and produce their characteristic eruptions, but that measles is suspended whilst small-pox proceeds with its development, and then resumes its ordinary course. The measles greatly favour the production of consecutive tubercles. And, measles attacking those already affected with phthisis, the progress of this disease is accelerated. Cold, he thinks, produces in those who are convalescent from measles, anasarca much more frequently than after scarlatina.

Measles, on the other hand, have sometimes been seen to produce a favourable effect on pre-existing maladies. Thus Rayer gives an example of chronic Exema of the face, and Alibert one of Empetiginous exema of the scalp, which were quickly cured after the recurrence of measles. He notices the inoculation for the disease by means of blood taken from the spots, as practised by Home in Edinburgh, and Speranza at Milan, which caused the appearance of the disease after six days of inoculation, and also inoculation with tears or saliva, which does not appear to be quite so effectual.

We pass over the other eruptive fevers, to notice the important division of INTERMITTENT Fevers, which he distinguishes as simple, mild, or pernicious, manifest or masked, essential or symptomatic, regular or irreglar.

SIMPLE INTERMITTENT FEVER, Having no local seat, furnishes no pathological appearance after death which can be regarded as the starting-point for the phenomena noticed during life. The enlargement of the spleen, which is almost never absent, being rather to be regarded as a concomitant affection. The softening of this organ is only to be met with in those intermittents which are pernicious.

The types of intermittent fever, distinguished by the returns of the paroxysms, are the quotidian, tertian and quartan, with their varieties, double quotidian, double tertian, and double quartan, but these last, with the exception of the double tertian, may be regarded as either exceptional or altogether doubtful; and the same may be said of triple tertian, triple quartan, and also of the quintan, septan, octan, monthly and annual, which have been admitted by some nosologists.

It is needless to quote descriptions of the different stages, which, though good and concise, offer nothing remarkable in relation to facts which are sufficiently known. A comparison of the frequency of different types is interesting. From a comparison of more than 160,000 cases observed in different countries, it appears that quotidians are more common than tertians, in the proportion of 9 to 1, and that quartans are so rare that there are scarcely two or three in a thousand. The author does not agree with Boudon that there is any connection between the type of the fever and the intensity with which the malaria is disengaged.

The preparations of bark hold, of course, the first place among the curative means, and the sulphate of quinine is preferred to all the others. Besides the ordinary mode of giving it by the mouth, Dr. Grisolle notices

its administration as an enema, which is less certain than the endermic employment, as tried by Chomel. The sulphate of quinine applied to the skin only two hours before an expected paroxysm, succeeded in setting it aside, but a much longer time was required when the remedy was given by mouth. The application to the skin had the serious inconvenience of producing sloughs and ulcers, both painful and slow of cure. He notices, besides quinine, a list of other articles, such as salicine, chesnut bark, opium, tonquin bean, orange-peel, digitalis, armica, iron, mercury, alum, salt, phosphorus, all of which he rejects as entitled to no confidence. He has some reliance on arsenic, but he appears to regard it as so dangerous as to be only admissible in the smallest doses in those cases which resist the influence of quinine.

Our cautious author rejects the attempts to localise the affection by placing it either in the intestinal canal where cadaveric changes have been mistaken, or in the spleen, where Piorry and Audouard would fix its seat.

“ It would be idle,” he says, " to enter into a discussion to prove that intermittent fever is not an inflammation. Shall we, with Giannini, call it a nevrod. sthenie, or, with Brachet and Rayer, à neurosis, a cerebro-spinal irritation, with 'Maillot, or with Worms, an affection of the ganglionic system? It seems reasonable to connect the principal symptoms of the disorder with nervous derangement. We are not, however, in possession of any positive knowledge on this subject, and it is much better to confess our ignorance than to attempt to conceal it under ill-defined pretensions. It has not merely been attempted to localise the derangement in intermittent fever, but also give an explanation of its periodicity. The opinions which have been advanced in relation to this question are so extravagant that we think it best wholly to pass them by.

“ In fine, we must admit that we know nothing of the composition of miasmata, of the organ upon which they act, or of the manner in which quinine operates to neutralize their influence.”

PernicioUS INTERMITTENT Fevers. The term pernicious is applied to those intermittent fevers which, on account of their great severity, and rapid progress, may terminate. fatally in a few paroxysms. There are several varieties of pernicious fevers. In some there are many severe symptoms without the predominance of any one. The countenance is remarkably changed-the strength is prostrated -the pulse is small and irregular—the tongue dry, and the intellectual faculties blunted. More often, there is some symptom which arrests particular attention. Sometimes the cold stage is so intense that the countenance appears cadaverous ;-the shivering is extreme, the breast cold, the voice gone, the thirst great, the pulse small and irregular. Death may take place in the first paroxysm, but if this be survived the warmth is slowly and imperfectly restored, and without prompt assistance the second attack is generally fatal. In the next variety death occurs in the sweating stage. This is a more insidious form, the case at first appearing mild, but in successive paroxysms the sweating becomes increasingly profuse, and soaks every part of the bed; the patients become cold, their strength is exhausted, their pulse extremely small, but the intellect is not affected.

Class 2. In the second class, or that which comprises those diseases which con


33 sist in a disturbance of the due proportion of blood, we have first the cases of excess of blood constituting plethora and local congestions, which are either active or passive. He properly distinguishes this state from that of inflammation, though he regards it as one of the modes in which inflammation may be set up.

The opposite state furnishes the character of the second division of this class, in which are placed Anæmia, Chlorosis, and the Anæmia of particular organs. With respect to general Anæmia, he refers to the researches of Andral and Gavarret, Bouillaud, Marshall Hall, and Piorry. He mentions the views of Drs. Hope and Ward, respecting the peculiar sound termed bruit de diable, which is heard in patients labouring under anæmia, but he does not agree with them in the opinion that it is produced in the larger veins, having been shaken from this opinion, which he had once adopted, by the observations of Mons. Beau, who maintains the old opinion that the sound is arterial.

Anæmia not being solely the consequence of loss of blood, but originating in many instances in serious visceral disease, the treatment must of course be various, as well as the probability of success. He gives the first place to ferruginous preparations, as not only contributing to improve the blood, but also as the most effectual remedy to the neuralgic pains which are apt to occur in the course of the disease.

Chlorosis is regarded as essentially a state of anæmia, and not necessarily distinguished as a special affection, yet the class of subjects to whom the affection is peculiar seems to render the division not altogether unsuitable.

The cases of partial anæmia are merely alluded to, the author observing " that, in the present state of our science, we know absolutely nothing about them.”

Class 3. The third class, or that of Inflammations, in which are included not only inflammations of the viscera, but also various forms of skin-disease, occupies a considerable part of the first volume. The several speciai affections are arranged in the following groups :

1. Inflammations of the digestive organs.
2. Inflammations of organs accessory to digestion.
3. Inflammations of the organs of respiration.
4. Inflammations of the organs of circulation, including angioleucitis,

or inflammation of the lymphatic vessels.
5. Inflammations of the nervous system.
6. Inflammations of the organs of the senses.
7. Inflammations of the urinary organs.
8. Inflammations of the genital organs.
9. Inflammations of the cellular membrane.
10. Inflammations of the skin.

Class 4. In speaking of Hæmorrhages he distinguishes the spontaneous from the tromatic, which fall to the care of the surgeon. The spontaneous are either symptomatic or essential; the former being referrible to some anterior affection, of which it may be considered as forming a part, but, in the latter, the hæmorrhage itself constitutes the disease. These hæmor



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