159

Reviews and N otices of Books.Statistics and Treatment of Typhus and Typhoid Fever, fi’01n

twelve years’ experience gained at the Semphim, Hospital inStockholrra (1840-152.) By MAGNUS Huss, M.D., Professorin the Medical Clinic, &c. &c. Translated from the Swedishoriginal by ERNEST ABERG, M.D. pp. 200. London:Longman and Co. 1855.

Report of all the Cases of Fever which occurred in Guy’ Hos-pital during the ?/ear 1854, with Rema1’7,;.s having especialreference to the Typhus and l’yphoicl Distinctions. BySAMUEL <o </t6 M.D. "Guy’s Hospital Ileports." ThirdSAMUEL WiH:s, M.D. " Guy’s Hospital Reports." ThirdSeries. Vol. I. London: Churchill. 1855.

To our minds one of the most interesting pathologic ques-tions of the present day is that relative to the generic differencebetween typhoid and typhus fever. "Common continuedfever" was a term but lately in everybody’s mouth, when Dr.Jenner, some five or six years back, industriously set to workto find out what was really meant by it. By the result of hislabours, and from the publication of what Dr. Wilks welldenominates "a model series of cases," we have been shownthat not less than four, if not more, distinct febrile affectionshave hitherto been included under the above general appellation.These affections, many of our readers well know, are typhoid,typhus, and relapsing fevers, &agrave;&uuml;d aa yet, it must be con-

fessed, a nondescript kind of general acute malady, called"febricula." To Dr. Jenner we conceive very high praise isdue for his able investigations, and although several other patho-logists, both here and in America, have more or less successfullyworked in the same field, with the same purpose in view, to

the former we are undoubtedly indebted for the clearest andmost satisfactory exposition of the general subject. The ques-tion, however, to which at present we shall confine our atten-tion is the following :-Are there not two distinct generalspecific acute affections or fevers met with in this countryoften confounded together under the one term of typhus ortyphoid, or low or common continued fever, and which feversare as distinct from each other as are scarlattna and measles,and like them characterized by a particular exanthematiceruption ?The schools may be said to be divided in opinion, one division

(of which Dr. Jenner, amongst us, may be regarded as the ex-ponent) affirms there are two such distinct affections, one tobe called Typhoid, mainly characterized by a sparsely-evolvedrash of lenticular, rose-coloured spots, an attendant diarrh&oelig;aand disease of the glands of the ileum ; the other, to be deno-minated Typhus, marked chiefly by a more full, and mottling,and mulberry-coloured rash, attended by no true diarrhcea, norevincing lesions of the glands of the small intestine. The same

school also affirms that these two affections each arise .from adistinct specific or zymoticpoison; that typhus cannot bestow thetyphoid germ, nor typhoid the typhus poison ; that their generalinvasion, course, and complications are different, their rate ofmortality likewise, their epidemic prevalence variable, andtheir climacteric relations distinct, when France, Britain,America, &c., are considered, or even to a certain extent,when parts of Great Britain and Ireland are compared witheach other. On the other hand, it is asserted that the so-calledtyphus and typhoid fevers are only different species of thesame genus ; that they are convertible the one into the

other; and that the differential signs cannot be maintained.That a patient who has had a rose-coloured rash will not

necessarily have diarrhoea and disease of the ileum, and thatone who has a mulberry and mottled rash may evince them.That the two rashes are often not to be distinguished one fromthe other ; that it is often impossible to say whether the exan-them of a fever patient belongs to the one or the other category;and that a person who has shown a distinct rose-coloured rash

may bestow a febrile poison on another, who shall present a mnl-berry and mottled exanthem. What is remarkable is the in-

tense interest which this question presents to a wide circle ofpathologists, while to many of the profession we really believethe whole subject will, from the time they peruse this, be anentirely new one for their consideration : nay, we have amplereason for asserting that in some of the schools of this metro-polis, the question is annually passed over sub silentio. And

yet, how important-how interesting the thing To our minds,we again repeat, it is the most attractive pathologic difficulty,if we may so call it, of the day. About the whole subject ofthe fevers, there is, to borrow an artistic phrase, a " breadth"which makes our more fashionable quarrellings about nucleiand nucleoli, Malpighian corpuscles, granular and caudate cells,&c. &c., very insignificant indeed.

Dr. Huss and Dr. Wilks are respectively representatives ofthe two opposed opinions just alluded to. According to theformer, during the lapse of twelve years the whole number offever patients received at the Seraphim Hospital, under thecare of Professor Malmsten and himself, has amounted to 3186,and in the work before us Dr. Huss explains the circumstanceswhich have led him to conclude-

" That typhus and typhoid fever, (typhus petechialis ettyphus abdominalis,) such as they appear in the climate of theNorth, neither can nor ought to be considered as two distinctmaladies, but only as two varieties of the same morbid process."- p. 23.

Dr. Huss believes that he has observed one epidemic influenceevidently produce at the same time " the two manifestations of

the typhus process, the petechial and the abdominal;" thatthe two eruptions are not absolute diagnostic marks, and thatintermediate forms occur which cannot be satisfactorily allottedtogether.

" Finally it must be added that I have seen cases where,during life, petechi&aelig; alone have appeared, and where yet afterdeath all the lesions of the glands of Peyer and mesenterium,which are considered as exclusively belonging to the typhoidfever, have been found. "-p. 13.In the opinion also of the Swedish physician, " typhus con-

tagion" may be transformed into "typhoid contagion," andit is his belief that a man and his wife, "who had evidentlytaken the same infection," died of the two different forms.

Six years ago, after reading Dr. Jenner’s paper, Dr. Wilksdetermined to investigate the subject by the observation of thecases occurring in Guy’s Hospital. He reported a large num-ber ; but, from unavoidable circumstances, was obliged tdesist for a time, but commenced afresh in April, 1853. Sixty-one of the latter cases have been already published in the gene-ral series of the "Guy’s Hospital Reports," and 126 moreare now placed on record in the first volume of the new series.The author’s most able report and essay concludes with thefollowing amongst other remarks in reference to the specifieddifferences between typhoid and typhus :-"I think it will be conceded that in the majority of cases

the distinctions are well marked, both by their general historyand the particular symptoms attending them, but that occa-sionally instances do occur which it is difficult to assign to theirproper class. If it were not so the question of difference oridentity would no longer exist.......In the few cases in whichsome doubt may arise, on account of the obscurity of a rash orsome other symptom, a light will be subsequently thrown uponthem by the completion of the history, and it will then clearlybe seen to which type they belong......The greater tendency toconfound them has been owing to the want of a correct know-ledge of their history, as well as to the non-recognition of someparticular and important symptoms attending them. "&mdash;p. 359.The large number of cases which have served as the basis of

Dr. Huss’s deductions would appear to overbalance any evi-dence of a contrary nature, which might be brought againstthem, gleaned from a more limited range. We must confess,however, that the perusal of the author’s treatise has not

strongly impressed us with the opinion that the author’s con-clusions have been validly inferred. There is much useful infor-mation in the "Introduction" andin the chapter on "Statistics,"

160

the latter, however, it must be remembered, being derivedfrom the natural history and course of an assumed single maladycalled typl6us by the author, and which includes the typhusand typhoid fevers of other writers, whose history and progressfurnish data of a different value on each affection. That por-tion of Dr. Huss’s treatise relating to treatment presents a mostremarkable contrast to the expressed views of Dr. Wilks. Itis true that the former states that

" The general principle which I have tried to follow in thetreatment of the different forms of the typhus process has beento allow the vis )nedical2-ix natur&aelig; to act as freely as possible."&mdash;p.

It may be so, but we have rather felt confused amid the massof therapeutic weapons which Dr. Huss has submitted for ourconsideration, from syrupus althe&aelig; up to phosphoric acid, whichlatter is at present, we are informed, the fashionable " remedywhich the physicians most commonly employ" in Sweden.

p. 124.)Let us hear Dr. Wilks :" I know little of cutting short the disease by any powerful

remedy, but in all probability it may sometimes be accom-

plished. The opinion, however, that its course, when once com-menced, may be curtailed by ordinary judicious remedies is onewhich the above cases will entirely refute.... The plan ofcuring fever by stimulants has of late been strongly advocated,and this not only by the administration of large quantities ofwine, but by the early exhibition of brandy and other spiritsand, moreover, the method has been stated to be eminentlysuccessful. "-p. 349.

" The inference to be drawn from the above cases is clear-that fever, both typhus and typhoid, will run its course, illspite of remedies ; that patients die with stimulants and with-out them, as well as recover on both plans.... Over andover again have I been surprised at the favourable terminationof many bad cases of typhus where little or no stimulant wasmade use of. Patients to whom I should order a, large quan-tity of wine had I had the opportunity, nevertheless recoveredon the very small pittance they were able themselves to pro-cure. In concluding this subject, let me again repeat that I aman advocate of the plan of nourishing cases of fever, and, ifnecessary, of stimulating them, but am opposed to the idea, asthe reported cases negative it, that wine or spirit is antidotalto fever. "-p. 352.We close this notice of the labours of Drs. Huss and Wilks

with the regret that our limits entirely prevent us from doingmore than cursorily alluding to the very general and moreprominent points of this important question in pathology.

HINTS ON MEDICAL EDUCATION.To the Editor of THE LANCET.

SIR,&mdash;I shall feel obliged if you will find space for the fol-lowing remarks :-

In my first letter on Medical Education," I gave, in fewwords, my views on this important subject; in the present, Ipurpose stating the reasons, or grounds, on which those viewsare based.

I considered the matriculation examination of the LondonUniversity important, as a guarantee for such an amount ofclassical, mathematical, and general attainments, as everyyouth entering one of the so-called learned professions, is sup-posed to possess ; and without which, he could hardly fail,sooner or later, to bring disgrace upon himself and his profession ; but I did not attach importance to any further andhigher cultivation of either classics or mathematics. A certainamount of classical knowledge is necessary, to enable the stu-dent of medicine to comprehend, and rightly employ, in de-scription, the terminology of the natural sciences ; but, as heis to be a practical man, a quiet observer, reasoner, and doer,rather than a talker,&mdash;as his destination is the bed-side, andnot the bar or the pulpit, it is obvious that a very extensiveand critical acquaintance with the classical models of antiquitywould not aid him much in his work. And, although the stu-dent should be familiar with the exact and rigid demonstr.1-tions of mathematics, still this is not the kind of evidence orform of reasoning which he will be called upon to employ inthe study and practice of his nrofession. and should not. there-

fore, occupy too much of his time. What I especially insistedon was, the cultivation of Natural Philosophy, combined withthe study of four special books-viz., Locke’s ’’ Essay on theHuman Understanding," Mill’s "Logic," Bacon’s "NovumOrganum," and Comte’s "Philosophie Positivp." The studyof the laws of Natural Philosophy, and 4i)f the facts, experi-ments, and modes of reasoning, by which those laws wereoriginally arrived at, is of incalculable use, because a know-ledge of those laws is the key to the solution of the pheno-mena of chemistry, physiology, and disease ; and a knowledgeof the facts, experiments, and reasonings, on which those lawsare founded, furnishes the student with excellent models,&pgr;&rgr;&agr;&dgr;&isin;&tgr;&ggr;&micro;&agr;&agr; of the inductive process, on which he may framehis own reports, experiments, and conclusions; for they willteach him to observe attentively, to report faithfully and con-scientiously, and to reason fairly and thoroughly. A carefulstudy of Locke’s Essay, will give the student confidence in theevidence of his senses and reflective powers, and develope aspirit of independence and individuality. Mill’s System ofLogic will supply him with a model of clear and powerfulwriting, teach him the importance of a right use cf words andaccurate descriptions, and will familiarize him with all kindsof evidence and forms of reasoning. Bacon’s immortal workwill show him the one path, in which every humble and sin-cere enquirer after truth must walk, and convince him that" all idols must be abjured and renounced with firm and solemnresolution, and the understanding must be completely freedand cleared of them ; so that the access to the kingdom ofman, which is founded on the sciences, may resemble that tothe kingdom of heaven, where no admission is conceded exceptto children."* Comte’s work will enable the student to seizethe grand principle of the "universality of laws," and to extendthe inductive form of reasoning to sociology, politics, metaphy-sics, ethics, and other subjects.

It would be impossible, in one letter, to give the scope ofeach of these great works ; but, if I might venture to state, infew words, what I consider to be the grand lesson which theyteach, it would be as follows :-Facts must be collected beforeany general principle or law can be evolved from them ; and,during their collection, great care is required in observing anddescribing them ; observation must be free from preconceivednotions &isin;&tgr;&ohgr;&lgr;&agr;, and description must be conscientious-true to Nature&mdash;a faithful copy of what really is-a sort ofword-painting, as true to the original as are some of the worksof our English -landscape painters; lastly, the facts, so col-

lected, must be carefully classified, with a view to the evolutionof a general law.How very few of our profession are busily at work, on the

plan sketched out in this and my former letter ! but how manyof us discover, when it is too late, that it is only by workingon such a plan that great results can be achieved ! At thismoment, we must all lament that so few of us are competentfor the duties so admirably explained in the " instructions ofthe General Board of Health ;" and that simply because theself and college education of most of us has not been an edu-cation for men of science, but for routine and empirical prac-bitioners of medicine !

I am, dear Sir, yours very truly,A LONDON GRADUATE IN ARTS AND MEDICINE.

January, 1856.* Novum Organum, Book L, Aph. 68.

NATIONAL HONOURS TO MEDICAL MEN.&mdash;We do notobserve the name of any medical officer amongst the Frenchmilitary officers who have received honours from this country.It might have been supposed that even though our Govern-ment were blind to the merits of medical men of their owncountry, they would not be so to those of foreigners. Such is,however, not the case. We contrast this with the liberalityshown in the grant of the Cross of the Legion of Honour toDr. Macloughlin, years after his services had been rendered,when in our country it is probable that any national recogni-tion would have been considered quite out of date, even if anyservices were held to be otherwise worthy of distinction. Hewas accidentally recognised in Paris by one of the inmates ofthe Coimbra Hospital in Portugal, of which Dr. lVlacloughlinwas in charge, and to which a large portion of the sick andwounded of the French army was consigned after the captureof Madrid, and in consequence of this recognition was waitedupon by all those in Paris who had been in hospital under hischarge. These also made application for the grant of the Cross,and for further application to be made to our Government forleave to accept the same. The Cross was granted, and theapplication for leave to accept it successfully made.