1847.] Classification of Diseases. 23 amongst French physicians, it is evident that even he is imperfectly informed regarding the state of medicine in England. In a systematic work like that of Dr. Grisolle the arrangement of the subject is a matter of no small importance. The author has adopted that which he calls a philosophical or nosological system, by which it is to be understood that his object is to bring together those diseases which are allied by the character and nature of the symptoms which they present, and which may therefore be supposed to require a parity of reasoning for their explanation, and analogous treatment for their cure. He prefers this to a pathological system, which might be founded either upon the classification of tissues, in which the particular derangements characteristic of different diseases occur, or upon the systems of organs subservient to the different functions of the body. There are advantages presented by each of these methods, but in the opinion of the author they are not equal to those of a nosological arrangement. The alphabetical order he rejects at once, condemning it as the worst that could be selected. In this opinion, if it is to be restricted to a comprehensive work for the use of the medical student, there is no one acquainted with the subject who will not readily concur. But in the application of the alphabetical method, as practically employed, it must be remembered that it is almost entirely restricted to large works of reference, such as the various Encyclopædias of medicine and surgery which are adapted to the use of those who are engaged in practice, or who may be already far advanced in the study of their profession. Each article in such works constitutes a monograph, in which the attention of the writer, as well as that of the reader, is concentrated upon the particular subject without his being necessarily obliged to consider what may be advanced in other parts of the extended work. In such a publication, the superiority of an alphabetical arrangement cannot be disputed. The author observes with Requin, that Nosography must, in the present day at least, be neither exclusively organic, ætiological, nor symptomatic, but must assume a triple character. A mixed system must therefore be adopted to avoid mutilating the science, or leading it astray into hazardous hypotheses. On this principle the following division into ten classes is employed :- II. Diseases consisting in a fault in the proportion of blood. III. Inflammations. IV. Hæmorrhages. V. Morbid secretions. VI. The results of poisons. VII. Diseases of nutrition. VIII. Structural changes and accidental productions. IX. Nervous diseases. X. Diseases peculiar to certain organs or tissues. We shall not attempt to criticise this classification, which the author does not pretend to be perfect. The number of authors who have already tried their hands on the construction of nosological systems sufficiently attest the difficulty of the task. These systems, which are necessarily more or less artificial, serve as the frame-work or skeleton to the body of کر 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. FEVERS. 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 effected, 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 hemite. The author divides fevers into 1. Continued fever-including ephemeral, inflammatory fever-typhoid fever, (the typhus of Europe)-typhus fever of the English-the bilious fevers 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 regarded 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, 1847.] Fevers. 25 and Andral; Follicular Enteritis of Cruveilhier and Forget; 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-Brouissais 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 characterized 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 Typoid Fever, without any of the intestinal lesions which characterize 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 not 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 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 had 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, diarrhoea, tympanitic distension of the abdomen, sibillant rattle, numerous sudamina (miliary eruption), rose-coloured spots, gangrene of the sacrum, penis, and scroOn dissection, however, no characteristic lesion, either of the intestinal tum. 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, Edingburgh, 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 analyzed 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, diarrhoea and cholic, 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 not 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 Bouillard. 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 containing 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 observes, 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 shown 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 |