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REVIEWS AND BIBLIOGRAPHICAL NOTICES.

Lectures on the Study of Fever. By ALFRED HUDSON, M.D., M.R.I.A.; Physician to the Meath Hospital.

A WORK on any practical subject recording the experience of Dr. Hudson must be a valuable boon to the profession. With peculiar pleasure, then, we hail a volume on the subject of "fever, the disease which," in the author's words, "beyond all others, presents the strongest claims to our careful investigation, whether regarded as an object of scientific interest or of social importance; whether on account of the varied and complex phenomena it offers for our investigation, or the immense influence which it exercises upon the welfare of individuals and of the community."

The lectures are dedicated to the author's colleague, Dr. Stokes, and were delivered to the students of the Meath Hospital to guide them in the bedside analyses of cases of fever; a subject which, in the author's opinion, has as yet been but imperfectly cultivated, but to the pursuit of which he ardently encourages the student by telling him that "it more than any other disease will call into requisition his knowledge of healthy and perverted function; educate his faculty of observation, cultivate his talent for judging the value of existing signs and symptoms," adding that while "no single disease will teach the student so much that is of value, or so train him for the future practice of his profession as fever, yet it must be admitted that the difficulty of the study is in proportion to its interest." To solve these difficulties or to aid in their solution is the aim of the author, and we will now endeavour briefly to analyse how far he has effected his object.

The first lecture is devoted to the "theory of fever," and it is classed with all other morbid poisons as producing its effects on the human system by means of catalysis, which the author explains to mean that the "poison has a force or power by which a compound body like the blood is decomposed by mere contact with it." We would rather incline to the belief that in the majority of cases the fever poison is introduced directly through the nervous system; in no other possible way can be accounted for, the instantaneous communication of the disease which the recipient himself is often distinctly conscious of. Of course the blood becomes vitiated at a

more or less early period; but, even then, we doubt that it is strictly in the manner of catalysis, but rather by cell growth, which will more satisfactorily account for what Dr. Hudson himself so much insists upon, the susceptibility to the disease being exhausted, and the various atttempts at crisis at various periods.

Lecture IV. is devoted to pathology and symptomatology. The different modes of invasion of the various forms of fever is, of course, first considered. The author holds that if the fever be traceable to communication with a typhus patient it will prove typhus; but if the cause be civic miasm, enteric fever will follow. The classification of the pathological phenomena is the usnal one of primary and secondary, but it is very intelligibly put:

66 Primary or essential arising out of the action of the poison on the blood and nervous system and its affinity for certain tissues or organs, as well as out of the special predisposition of the organ which in certain states may be said to attack the fever poison.

"Secondary or accidental arising (a) from some peculiar exciting cause; (b) from some secondary blood contamination; (c) from reactive irritation. The secondary phenomena alone can be termed complications; those of the first class are either purely tonic or arise from the tendency of the poison to be eliminated by certain surfaces or excreting organs. To the tonic action of the poison we refer the majority of the nervous symptoms of typhus. To the elimination effort of the system we ascribe the infiltration into Peyer's follicles and the mesenteric glands in typhoid."

The symptoms of the various forms of fever are considered seriatim and completely. We cannot follow them throughout, but we may refer to the value set upon at least two:-1st. Temperature, in which the conclusions of Dr. Aitken are strictly adopted; and the author's faith in their value is well shown by his prescience (some would term it rashness) in cupping a patient advanced in typhus, because his temperature rising four degrees, with increased rapidity of breathing, indicated the approach of a pneumonia of the sthenic form with rusty expectoration.

In the remarks upon the characteristic eruptions we find the following:

"You will occasionally find it by no means easy to distinguish the one form of eruption from the other. An imperfectly developed or discrete typhus eruption in its earlier stages may be readily mistaken for a typhoid, if this is more than usually abundant; the frequent uncertainty of the date of access of typhoid favouring this error. Such cases require the

exercise of caution and further investigation, and you will best arrive at an accurate diagnosis by a careful inquiry into the origin and previous history as well as the accompanying symptoms of each case. Not unfrequently we will have reason to believe that the two poisons co-exist in the case, the conditions being commingled or the one succeeding the other."

We consider this statement to be one of great importance. There can be no question as to these facts; but, on the other hand, they are no evidence of the identity of the two diseases which they are daily quoted to prove. There is too much stress laid upon the one symptom of the eruption in the matter of diagnosis, and if any physician could be found so imprudent as to rely upon that or any one other symptom he would frequently be mistaken. The complete distinction between typhus and enteric fever is now so universally recognised that it seems to many strange that they should ever have been connected. Yet there are some who still assert the unity of the two diseases, because in individual cases some particular symptom will frequently arise, which, according to their rule, belongs more properly to the other disease; thus, for instance, if diarrhea occur in an otherwise well marked case of typhus, or if, in what would otherwise be termed enteric fever, the temperature rise very high very early in the disease, such cases would be termed mixed cases. The distinctive marks between typhus and enteric fever are, by almost all authors, now clearly laid down, and Dr. Hudson also holds their complete and perfect distinctness; and we may here anticipate his remarks upon diagnosis, and enumerate the following as the broad grounds upon which he bases the distinction. The two diseases differ. 1. In their invasion and early history.

2. In their conformity to the laws of periodicity.

3. In their duration and mode of termination.

4. In their external phenomena, more especially their eruptions. 5. In the special affinities of the poisons, the order of symptoms, and their internal pathology.

6. In the mode of fatal termination.

7. In the anatomical appearances.

8. In the law regulating the mortality with regard to age.

9. In the comparative rapidity and security of the convalescence in typhus, and its complete exemption from relapse as contrasted with the comparative certainty of relapse in epidemic synocha; its frequent occurrence in typhoid; and the other risks and uncertainties of the convalescence in this disease.

Instead of describing the different forms of fever as they are met with, Dr. Hudson, we think wisely, goes through the different lesions as they are found to occur in the various organs. Lectures V. and VI. are devoted to the cardiac and pulmonary lesions.

Dr. Stokes' remarks upon the softened condition of the heart in typhus are quoted at full length, and that condition of lung which he has termed aborted or arrested typhus, an explanation which we can by no means accept.

There are other ways for explaining the phenomena connected with this disease: why should not the fever, although of a very low type, be symptomatic of the local lesion which we know to be most varied in point of time as to its development, or at least in the proof of its existence by physical signs; and we confess it is contrary to all our experience of typhus fever to suppose that once established in the system it will abort. The analogy adduced that in certain cases of simple variola we see the fever to subside on the appearance of the pustule is really no analogy at all, nor need we delay to explain how it is not so.

Dr. Hudson alludes to another form of pulmonary affection which he says is unnoticed by any other reader:-" In several instances in which fever was attended with cerebral symptoms, particularly with great emotional excitement, and with marked cerebral breathing. These symptoms have been succeeded, after some days, by inflammatory congestion of the upper lobe of one or other lung. This complication differs from the affection described by Dr. Stokes: first, in the period in which it has occurred; secondly, in not being attended with resolution of the fever; and lastly, in having been always preceded by highly marked excitement of the emotional nervous centres, as if originating in the nerves of the respiratory organs."

There is no doubt but that irritation of the gangliform plexus of the vagus will cause general and intense pneumonia; and we can therefore imagine that, as Jones very well puts it, "certain nerves, when stimulated, exert a very considerable influence in the districts to which they are distributed, in the way of increasing the amount of blood circulating through the tissues, and herein exactly antagonise the ordinary vaso-mortor nerves accompanying the arteries whose activity induces the opposite condition."

Lecture VII. comprises the abdominal lesions or rather the derangements of the digestive organs. The absence of thirst is judiciously considered as one of the most serious symptoms, more especially when conjoined with other forms of an obsthesia, to which, VOL. XLIII., NO. 86, N. s.

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and not to an arrest of the function of nutrition, as stated by Corrigan, it is referred. The different forms of vomiting are very well described, and the different forms of diarrhea; and the student is warned that even in far advanced enteric fever there may be no diarrhea.

Lecture VIII. is on the derangements of the urinary organs, and is occupied with many practical remarks upon their nature and mode of occurrence. The two last subjects under this heading are particularly worthy of being remembered-1st. Tthat what may appear at first view to be simply the adynamia of fever is often, in a great measure, due to secondary blood contamination-in fact, to uremia; and 2ndly, The occurrence of bullæ during the course of fever should lead us to pay more than ordinary attention to the state of the urinary secretion. The existence of these bullæ being ascribed by Henderson and others to the conversion of the retained urea into carbonate of ammonia, which has the power of dissolving the fibrin of the blood.

Lectures IX., X., and XI. comprise the cerebro-spinal lesions, the importance of which is not over-estimated in the assertion, that while they are not seldom obscure, latent, and difficult of diagnosis, the safety of the patient will often depend upon the sagacity with which they may be recognised or even anticipated, and the promptitude with which they may be met by suitable and energetic treatment. The various causes of these lesions are gone over seriatim and fully. The difference of the symptoms, according to the different parts of the cerebro-spinal system affected the principal object is, of course, to show how the symptoms arising from reflex irritation-from the toxic action of the fever poison-from the effects of secondary blood poisoning in its various forms-are all to be distinguished from each other, and from those cases in which there is more or less of organic lesion, which the author, in our opinion, most erroneously considers the effect of inflammation. The cases which he adduces in support are most unfortunate for his purpose and inapplicable.

Lecture XII. enters fully into the subject of diagnosis; and Lecture XIII. exhausts the subject of prognosis. It is very comprehensive, and very accurate, and will repay a careful perusal. Lastly, Lectures XIV. and XV. are devoted to treatment. In these important chapters the first subject considered is, "are there any means by which the operations of the poison once set up may be arrested, shortened, or modified, if these measures are employed at an early period"-in other words can fever be arrested? Dr. Hudson

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