1846.]

SYNOCHUS WITH TYPHOID SYMPTOMS.

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"The continued fever, which precedes the first fever of acute cutaneous eruptions, specific and contagious, and of some other analogous affections, (the Italics are ours, Rev.,) is probably attributable also to the introduction of miasms, virus, or subtle foreign principles, into the sanguineous system. Under this aspect, the fever in question may be associated with the different species of inflammatory or angeiotenic fever. But then we must remember that these principles, of whatever kind they may be, impress a peculiar stamp and special physiognomy upon the fever, in consequence probably of some specific action upon the blood and, it may be, the nervous system also. We must wait for further researches before we know what to make of this point of etiology."

As a matter of course, the treatment of simple inflammatory or angeiotenic fever is one of the easiest things in the world. We have only to withdraw from the mass of blood a certain amount (une proportion donnée) of its plastic elements, then prevent its rapid reformation by keeping the patient upon a spare diet, and dilute the remainder by administering cooling diluents: voilà tout!

So much for Synochus, or Angeio-carditis when it is "simple, franche et legitime;" let us now hear what M. Bouillaud has to say about "angio. cardite typhoide, c'est-à-dire, avec une complication d'un état putride ou septique (anynamique)." This species of continued fever is said to be often (we had fancied that it was always; otherwise why call it angeiocarditis? Rev.) associated with a local phlegmasia; but then this phlegmasia has become the focus of a septic infection: it is from the existence of this double morbid element that the peculiarities of the disease arise. "When Synochus or inflammatory fever is idiopathic, the typhoid phenomena may be the effect of septic matters or miasms received from without or generated within the vascular system, the inflammation of which must have terminated in a genuine suppuration, and have given rise to what, of late years, has been denominated purulent infection.'

We have no intention of following M. Bouillaud through the "tableau fidèle" which he professes to have given of the symptoms of typhoid angeio-carditis, or Synochus putris; they are exactly those usually specified as attending cases of typhus gravior. His description of the blood in this disease is worthy of notice, as evidencing a desperate clinging to a favourite doctrine in spite of the most damning proofs of its utter fallacy.

"I have previously said that the presence of the typhoid element exercises a marked influence upon the accompanying inflammatory element: this influence is especially obvious in the state of the blood. In truth, we must no longer expect to meet with the characters of inflamed blood, such as we have described above. If the typhoid condition be decided, or if it has continued for some time, the coagulum is soft, dissolved, of a blackish colour, and generally adhering to the walls of the vessel in which it is contained; it exhibits either no buffy coat at all, or this is remarkable for its softness and serous infiltration." These characters, we are then gravely informed, are so very different from those of inflammatory blood, that nothing is more easy to any one who has clinical experience than to pronounce at once, after a simple inspection of the blood drawn, whether the case be one "d'une fièvre franchement inflammatoire ou d'une fièvre avec complication septique ou typhoide." We should think so, indeed. Here again, the notice of MM. Andral and Gavarret's researches upon this

66

point is most expressively (!) short. All that we learn respecting them is that in fevers or phlegmasiæ (is not the introduction of phlegmasic here a very wilful and most unwarrantable interpolation of M. Bouillaud himself?) with typhoid phenomena, the proportion of the fibrine in the blood is diminished, the very reverse of what exists in active inflammations." Why our author should so rarely and imperfectly allude to the hæmatological investigations of M. Andral, and so designedly slur over their cardinal and most essential conclusions as to the marked difference of the blood in genuine Phlegmasia and in Fevers, is very strange. Is it retaliation for neglect of the nouvelle formule?

So decided a humoralist has M. Bouillaud become of late, that he even finds fault with other writers for ultra-solidist opinions.

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"If," says he, "anything can astonish us now, it is the fact that Pinel should have considered as purely imaginary, and as utterly incompatible with life, a certain degree of putridity of the blood. Nothing is more positive or more real than this important alteration of the circulating fluid;-an alteration that results from a sort of poisoning of the living fluid by putrid principles, in the same manner as intoxication results from the introduction of alcoholic principles into the torrent of the blood. The typhoid intoxication, if we may so speak, being in truth the effect of a lesion of the blood, the term adynamic, applied to the fever in which it exists by Pinel,-because there is, as he said, une atteinte profonde portée directement aux forces musculaires-suggests no idea of the true nature of the disease. "

Lastly, it deserves to be noticed that our author now expressly cautions his readers against mistaking certain post-mortem appearances as evidences of inflammatory action :

"In consequence of the rapidity with which the corpse of a patient, who has died with typhoid symptoms, runs into decomposition, we must be on our guard, in necroscopic examinations, not to refer to any vital lesions certain alterations which may be the simple consequences of cadaveric decomposition. Such are, among others, certain ramollissemens, certain rednesses of the lining membrane of the heart and arteries, certain productions within this apparatus, as well as underneath the mucous membranes, &c.”

Such is the sum and substance of the section of the present work that is devoted to the consideration of inflammatory and of typhoid Angeio-carditis; in other words, of the Synochus and Typhus of Cullen, if we can judge from the narrative of their symptoms, apart from all speculation as to their nature or seat. But it would be giving a very imperfect notion of our author's views, if here we closed our remarks upon this subject; as much yet remains in other sections of this Nosography that unquestionably appertains to it. Passing over a great variety of phlegmasiæ, including all the contagious exanthemata as well as other cutaneous eruptions, we at length (Vol. III., p. 92) come to the well-known theme of Entero-Mesenterite, under which appellation M. Bouillaud has hitherto been in the habit of treating of the disease, which has been at different times called putrid, malignant, typhoid, ataxic, adynamic, &c. fever. After a variety of details, which it is not necessary for us to notice, the following passage arrests our attention :

"We now add," says M. Bouillaud, "the epithet typhoide to the term entero-mesenterite; as, in truth, this phlegmasia-in consequence of its seat in

1846.]

ENTERO-MESENTERITIC FEVER.

217

an organ which always contains certain fætid and fermentable matters-is more than any other apt to give birth to this class of phenomena. Nevertheless, in its early stage, this phlegmasia is exempt from all typhoid or septic elements, and indeed the supervention of the typhoid symptoms may be almost always prevented by the employment of active antiphlogistic measures at first."

Its essential and-pathognomonic character, it is to be remembered, is an inflammation of the Peyerian and Brunnerian glands of the mucous coat of the intestines.

Having given a very minute account of the anatomical lesions of the intestines and mesenteric glands, our author proceeds to describe some other morbid appearances that are often met with. "We should be much deceived if we were to believe that the alterations hitherto described are the only ones discoverable in the alimentary canal in patients who have died of the so-called essential fevers of Pinel, which by certain writers have been all classified together under the general term of typhoid fever or typhoid affection. In an immense majority of cases, the stomach and the large intestine will be found to exhibit marks of inflammation more or less severe and extensive." But then, with a most diverting inconclusiveness, he seems to imply that it is only one sort of Typhoid Fever to which the preceding remarks apply: "I have formally concluded, from my observations, that a veritable gastro-adynamic or bilioso-putrid (here the regular terms of Pinel are employed) has, for its essential and characteristic anatomical lesion, an inflammation of the mucous glands of the small intestine, and especially of those situated in the lower end of the ileum. The secondary or consecutive lesions of this entero-mesenteric fever are said to be various; we shall only notice those that appertain to the sanguineous system. They are thus enumerated-redness of the internal membrane of the large vessels, as of the aorta, pulmonary artery, &c. ; notable puffiness of the valves, and a softening of the muscular substance of the heart; a black dissolved state of the blood; softness of the fibrinous concretions sometimes met with in the cardiac cavities. In a subsequent page, we read the following description of the characters which the blood exhibits in this disease: "In the early stage, when the fever exhibits itself under an inflammatory aspect, the coagulum presents a certain degree of retraction (retraite ;) its consistence is nearly normal; its surface is sometimes covered with a general or partial buffy coat; but the blood is never, unless some complication is present, franchement inflammatoire, as in a pure simple phlegmasia. * In the second and third stages of the disease, when it assumes the typhoid or putrid (adynamic of Pinel) type, -i. e., when the septic are superadded to the inflammatory phenomenathe state of the blood is what has been already described in our first volume," under the head of typhoid Angeio-carditis. Then, M. Bouillaud had a hit at M. Pinel for his neglect of humoral pathology; now, M. Chomel comes in for a gentle rap: "For the last 13 years, I have treated more than 500 cases of typhoid fever, and the blood has uniformly exhibited the characters we have described to be present in the different stages. How then comes it to pass that a clinical professor, who has published his lectures on this disease, should assert that the blood drawn from a typhoid patient does not exhibit any appreciable alteration, except in a small number of cases?" We may fairly ask, what are the morbid changes that are specified by our author himself to be present in the first stage of

*

*

typhoid fever. From his own description, it is utterly impossible to make out; there is such a confusion and jumbling together of different things on the one hand, and such a forcible divorcement and separation of the same, or nearly the same, things on the other. M. Bouillaud here, as on the former occasion, when treating of angeio-carditis, slurs over and even mis-states some of the leading facts and conclusions connected with the recent hæmatological inquiries of M. Andral.

With respect to the general symptomatology of entero-mesenteric fever, it seems to be identically the same with what had been described in a previous volume as indicative of typhoid angeio-carditis; with the simple exception that, in the former, certain abnormal symptoms-diarrhoea, tenderness over the right iliac region, &c.,-may be (for it is acknowledged that they are not always) present. That the Diagnosis of the disease by the physicians of Paris is any thing but easy or to be depended upon, is abundantly obvious from the following account by one of themselves of the blunders often committed in that seat of learning and centre of medical knowledge: "I have seen," says M. Bouillaud, "I regret to say it, physicians of established reputation, but who have not been educated in the principles of exact medicine, mistake for a case of typhoid fever one of peritonitis and even of pneumonia. On how many other occasions, have I not witnessed a clear case of typhoid fever entirely overlooked; and, on the other hand, a case of simple gastric or intestinal derangement set down as a specimen of fever!" After this acknowledgment, who will gainsay the fairness of those strictures which, for the last ten years, we have felt it necessary to make upon the untrustworthiness of much of French medical literature upon practical subjects?

It is certainly passing strange that, when M. Bouillaud treats of the diagnosis of entero-mesenteric fever, not even a hint is made of the very disease, which of all others we should have thought would be most apt to be mistaken for it—we mean, the angeio-carditis of which we have already heard so much. Does he really suppose that his readers are so very forgetful, or that they peruse his work with so little attention, as not to be struck with this remarkable oversight (to call it nothing else) on his part? He evidently feels sore at the incredulity of many of his brethren as to the correctness of his own diagnosis in what may be called his pet diseases, in spite of his confident and ever-repeated assurances of his almost unerring certainty. Witness the following passage :—

"I know that for the purpose of explaining why, in my clinical practice, the mortality of real typhoid fever (is this entero-mesenteritis, or angeio-carditis, or either of them?-we cannot tell.-Rev.) is found reduced almost to zero when the disease is treated in time according to my method, many persons have found nothing better to say than that the cases cured were not examples of typhoid fever. Happily for me, and more especially for my patients, this assertion is a most gratuitous insinuation. I can appeal to the impartial judgment of competent men who have followed my clinical visits, and under whose eyes I have dictated the diagnosis and prognosis in each case after an examination whose precision and exactitude are well known. Is it to me, in conscience, that such a reproach, such an insult, can be addressed? What! some one will say, do you cry out so sharply against others who accuse you of errors in diagnosis, and yet make this very charge against them? It is quite true; but be it remembered that I have not done so until after I had acquired the certainty of the error, and it is not assuredly in this manner that my opponents have acted towards me."

1846.]

CAUSES AND TREATMENT OF TYPHOID FEVER.

219

How liberal! how modest ! how convincing! We have already said that the mechanism (to use our author's language) of the typhoid phenomena in entero-mesenteritis is supposed to consist in the absorption of putrid matters in the intestines by the ulcerated abraded patches on their inner surface. The supervention of the general or systemic typhoid symptoms is always coincident with that of local septic phenomena, evidenced by tympanitic distension of the abdomen, discharge of fætid stools and gas from the bowels, &c. These latter phenomena attest, in the most striking manner, the transformation of the pure inflammation into one that is putrid or even gangrenous.

"This circumstance," continues our author," superadded to the conditions of natural septicity which occur in the inflamed organ, serves to increase the activity of the focus of infection; and whoever seriously reflects upon this union of causes of putrid infection, which do not exist to the same degree in any other phlegmasia, must cease to wonder at the circumstance that of all inflammations it is that of the mucous glands of the last convolutions of the small intestines, which is peculiarly apt to give rise to septic or typhoid phenomena. It would indeed be surprising, if it were otherwise; and it is a thing truly most satisfactory, that. the researches of anatomy and physiology have led the moderns to the discovery of a phlegmasia so situated in a very great number of patients affected with putrid or adynamic continued fever, the point de depart of which had been so long unknown, and to which the term essential had been so unfortunately applied."

As to the exciting causes of true typhoid or antero-mesenteric fever, M. Bouillaud has absolutely nothing to tell us. He has rigorously examined 600 cases within the last 13 years, in the hope of arriving at some certain conclusions on this head; but hitherto without success. Vitiated air from the crowding together of masses of people may have occasionally some effect; but we must be on our guard, we are told, not to attach undue importance to this particular; for "how many are the patients that have assured us that they were well lodged and breathed a pure air!" Truly, M. Bouillaud is a most believing man, on some occasions. With respect to contagion having anything to do with the diffusion of the disease, he unhesitatingly determines the point in the negative.

After what we have said of our author's pathological views, we need scarcely dwell upon the treatment which he recommends. As a matter of course, bleeding is the sheet-anchor in the first or (alleged) inflammatory stage of the fever. In the second and third stages, the chief reliance should be placed on the use of demulcent, detergent, and anti-septic drinks and enemata, for the purpose of purifying and cleansing the abraded intestinal surface from the putrid matters adhering to it. The closing paragraph in the chapter on the treatment of the disease conveys the following most instructive advice :

"In the second and third (the putrid) stages of the disease, ought we to have recourse to the purgative method, as it has been proposed (formulée) of late years? I declare that I do not possess the necessary data for the perfect solution of this question. But I must from this moment confess that, after the results obtained from the use of this method, such as I myself know them, it seems to me preferable to keep to the use of mucilaginous diluent drinks, emollient poultices and injections, anti-septic medicines such as the chlorurets, external revulsives, and of some other means suited to the various complications of the disease.".