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not being in operation, we may be generally able, even at an early period of the disorder, to diagnose typhoid fever when it is present. We would speak advisedly, however, since MM. Rilliet and Barthez express themselves not less doubtfully in reference to childhood, than do MM. Friedleben and Fleisch in respect to early infancy. After describing the morbid anatomic changes in primary follicular enteritis, MM. Rilliet and Barthez go on to say:
"It is unnecessary further to dilate upon this description, since this inflammation of the patches' is identical, with exception of intensity, with that which is seen in typhoid fever. In fact, the appearance is the same; and if there exist differences between these two diseases, it is elsewhere than in the lesion of the patches that they must be sought. . . . . Further, this development of the patches,' so common in children, is accompanied by symptoms which are analogous to those of non-follicular enteritis; whilst we shall find certain examples of the latter assume the typhoid form, from whence there further arises an approximation between typhoid fever and enteritis in the child." (Vol. i. p. 188, op. cit.)
But the difficulties of diagnosis, according to these eminent writers, become insuperable when we arrive at what they term “typhoid enteritis.” In the follicular form the morbid changes are those of the idiopathic fever; in the typhoid variety it is the symptoms which are so markedly the same.
“Does there exist an enteritis whose symptoms are typhoid ?
" We should think that the disease is of the saine nature as dothinenteritis, with a different anatomical expression. . . . . We have seen elsewhere that there exist in the child alterations of Peyer's patches which recal those of typhoid fever, though the symptoms of the disease of which they are the expression are very different from those of this pyrexia. H-re we find typhoid symptoms without follicular or mesenteric changes; farther, we shall afterwards see examples of dothinenteritis of the form of the simple affection. It appears to us natural to group together all those facts which would constitute an incomplete, bastard, simply anomalous typhoid fever-so that between typhoid fever and acute catarrhal diseases of the intestine it may be shown there exists an intermediate affection (typhoid enteritis), connected to the former by symptoins, to the latter by morbid anatomic changes, and which would establish the union between them.” (Vol. i. pp. 787 et seq., op. cit.)
Now, with all deference to the reputation of the two French pathologists, we must confess that we do not always perceive that clearness and consistency of description in their writings upon the above and correlated topics which we have a right to expect, notwithstanding the difficulties which undoubtedly exist. In the first place, we would observe, that although we are told (vol. i. p. 787,) that the symptoms accompanying follicular enteritis are very different from those of typhoid fever, we are informed (vol. ii. p. 695) that in young children the symptoms of the one may so simulate those of the other malady, that they may be confounded together; indeed, M. Rilliet has himself confessed to making the mistake. And “if the acute catarrhal affection of the bowel may in very young children be easily confounded with dothinenteritis, the mistake is still easier when the intestinal inflammation assumes the typhoid character.” (See also vol. i. p. 704.)
Secondly, at vol. i. p. 787, it is affirmed that in typhoid fever the lenticular spots manque rarement, whilst elsewhere (vol. ii. p. 684,) it is maintained que l'éruption manquait assez souvent, and also that they have the same characters as the rose spots of enteritis !
We have before seen that MM. Rilliet and Barthez maintain the "rose spots” are met with in other affections, as well as in typhoid fever-as in “slight gastritis," &c. They, however, admit that “in all these cases it is true that they have not been very abundant, and were of short duration.” (Vol. i. p. 684.)
Now, our readers will understand how difficult must be the diagnosis where fever exists with diarrhea, slight tympanitis, splenic enlargement (vol. i. p. 703), and rose spots: between these as manifestations of primary enteritis, or, on the contrary, of typhoid fever! No wonder that MM. Rilliet and Barthez have come to the conclusion, that “in certain cases it is impossible to distinguish between the two affections.” (Vol. ii. p. 698.) That this must be the case, we would be the last to deny, but we must agree with Dr. Parkes in his assertion,* that "the diagnosis of typhoid fever is absolute when, in a febrile disease attended by looseness of the bowels, unequivocal rose spots appear on the sixth or eighth day.” If they do not appear then, the diagnosis cannot be perfected until the case has been watched for several days, and the age of the patient and history of the malady been carefully studied; but the rose spots appearing in a hitherto doubtful case
cases particularly in children between one and five years of age, an absolute diagnosis is scarcely possible. The truth of this and some previous statements will be sufficiently apparent on consulting M. Hervieux's essays (referred to at the head of this article), containing the results of minute investigation into disease of the glands of Peyer during early life. In his first memoir, children up to a month old are included; in his second, those from one to twelve months old;, and in a third essay, yet to appear, children from one to five years will form the subjects. The first series of observations tend to show that it is not in very early infancy that great difficulty of diagnosis can arise, as the symptoms (speaking generally) are then more those of entero-colitis or diarrhæa and marasmus, than of typhoid fever. But as the child gets older,
"The peculiar typhous manifestations (which are entirely absent in the new-born child) begin in the second infancy-i. e., from one to twelve months of age-to make themselves evident, particularly in children approaching the end of their first year; yet more proininently shall we perceive this to be the case in patients between one and five years old.” (p. 282).
" In children of the second period, the diagnosis of the morbid changes of the Peyerian and Brunnerian glandular apparatus is capable of no greater surety than in those of the first, and we could very easily prove that none of the many manifestations we have as yet adduced belong directly to these morbid changes, and that only the totality of these manifestations determines to some extent the diagnosis.” (p. 236.)
According to M. Hervieux, the toute ensemble here referred to "produces, in a word, just such a physiologic and general expression which forcibly recals to mind the typhous condition of the adult.” (p. 243.)
Further, it is worthy of remark, that although gurgling and splenic enlargement were present in a great many cases, along with the other signs, yet we do not think M. Hervieux refers to the occurrence of the rose spots in any of his
But independently of the difficulties arising from a confusion of the symptoms of typhoid fever and its intestinal complication with those of certain forms of enteritis and their reactional typhoid pyrexia, there are several others which complicate the diagnosis here involved. Acute tuberculosis, simple and granular meningitis, bronchio-pneumonia, may all be mistaken for typhoid fever, or vice persd. We have no space, however, for discussing their differential diagnosis, but would limit ourselves to the following consideration—What, viz., is the nature of those numerous cases, of comparatively slight febrile movement, of very marked remittency, in which the bowels are generally constipated, the thirst great, and the emaciation occasionally by no means inconsiderable? What, too, is the nature of those allied cases, occurring more particularly in the summer months, in which vomiting is allied to the constipation, and intense heat of skin present with, apparently, cephalalgia? No doubt such forms of disease are also, along with others we have mentioned, frequently called "mild remittent," "gastric remit
gastric fever.” But in these, is the pyrexia a primitive one? Or is it not rather reactional upon what the French writers denominate, though perhaps a Medical Times, vol. xxi. p. 896. 1850.
The new edition of Dr. J. Hughes Bennett's Clinical Lectures may be referred to (p. 882), where the question, Remittent fever--can it be separated from acute hydrocephalus *" is discussed, and answered in the negative; p. 878 also, quoad the value of the
little vaguely, embarras gastrique ! We confess we have not yet been able to determine the matter; nor perhaps should we be surprised at this, seeing that Dr. West observes :*
" There are still many questions that might be proposed with refence to the remittent fever of children, but on which I do not enter now, because I am at present unable to give you what would be, even to my own mind, a thoroughly satisfactory solution of them.”
And that MM. Rilliet and Barthez are so puzzled to know what to make of these varieties of " mucous," “ remittent," and "gastrie" fevers, as to be obliged to invent a new theory and name for some of them-viz., " fièvre catarrhale gastrointestinale," and in which the fever is said to be "non-reactional," whilst others in which the fever is “reactional" (though they are admitted to be occasionally tainted by the taches rosées), are included under the embarras gastrique of old acquaintance. Speaking of the former class of cases, they remark:
"It is easy to understand the possibility of the existence of a catarrhal fever having a remittent, or an intermittent, or a continuous type. . . The admission of is pyrexia into the nosologic list, contradicts in nothing the opinions we have expressed upon the nature of catarrhal diseases. So far from that, if we compare with the former the analogous pyrexia of which we have spoken under the name of ficore catarrhale broncho-pulmonaire, froin such comparison a new proof will result of the identity of catarrhal maladies (wherever they be seated), as well as a confirmation of our theory." (Vol. i. p. 728.)
A careful review of much that has been written upon our present subject, together with a very fair experience derived at the bedside of the sick child, forces us to admit that although the diagnosis of typhoid fever in the mass of cases may with due attention be substantiated, yet there occur numerous instances where the diagnosis cannot be made absolute until such time as it is next to useless for purposes of treatment, and that this is more particularly the case where the differential diagnosis lies between “follicular enteritis” with reactional pyrexia of a low form, and the fever in question.
On Squinting, Paralytic Affections of the Eye, and Certain Forms of Impaired
Vision. By CARSTEN HOLTHOUSE, F.R.C.S.E., Surgeon to the Westminster Hospital, and Lecturer on Surgical Anatomy at its Medical School; Surgeon to the South-London Ophthalmic Hospital; and late Surgeon to the British Hos
pital, Smyrna.-London, 1858. pp. 210. In the preface to this work, Mr. Holthouse expresses his conviction, that common as strabismus is, there are few deformities the pathology of which is less understood; the array of conflicting opinions adduced is certainly not flattering to medical science, nor can reflecting men look back with feelings of satisfaction to the undignified competition, the literal searching of highways and byeways for cases, the puffing announcements of operations astounding in number and incredible in results, which followed the introduction of ocular myotomy into this country. A natural reaction took place, and with many surgeons the operation is now discountenanced, except in extreme cases. Nor has the warfare, which has almost, constantly raged upon this subject, elevated it in public estimation. Not long
* Lectures on the Diseases of Infancy and Childhood, p. 502, second edition. ,
since, the leading journal of the day, commenting on the speculative character of the age, stated its opinion that “paper,” in the commercial sense, was the bane of the present day. The character of many of the communications to serial journals leads us to suspect that “print” is scarcely less injurious from its profuseness in certain professions; and the subject of strabismus has proved as vexed a question, and has led to as much ink-shed as any we happen to remember. These remarks, however, do not apply to the little book before us; it is modest in its pretensions, and is evidently written by one who has observed and thought for himself.
Much pains have been bestowed by Mr. Holthouse in determining the true pathology of strabismus; and his conclusions are these :
u" 1st. The most frequent exciting cause of strabismus is some lesion of the nervous centres or nerves; and next in frequency are inflammatory affections of the eyes.
“ 2nd. The essential or immediate cause of confirmed non-paralytic strabismus is a shortening, with or without hypertrophy; or simple hypertrophy of the orbital muscle in the direction of which the eye is drawn.
"3rd. These muscular changes may be associated with thickening and contraction of the conjunctiva and sub-conjunctival tissue, and an adhesion of these to the sclerotic coat of the eye.
" 4th. The above-named changes may affect both eyes, though they are more commonly confined to one eye. In the former case it is immaterial which eye is operated upon. In the latter it is not immaterial, but on the contrary essential that the affected eye should be distinguished and selected for the operation.
"5th. The imperfect vision of the strabismic eye may either precede and be the cause of the distortion, or may follow and be the consequence of it. In the former case, the operation of dividing the affected muscle will not remove the imperfection of sight. In the latter it will.
* 6th. The morbid changes referred to in deductions 2 and 3 are competent to explain all the phenomena of strabismus.
" 7th. The phenomena of strabismus cannot be accounted for on any other bypothesis.” (p. 128.)
The effect produced on the sight by division of the muscles, was one of the facts which early attracted notice, after the introduction of ocular myotomy. So far back as 1841, Guerin recommended division of the recti muscles as á cure for myopia, and other practitioners performed it not only for the relief of that affection, but for asthenopia also. In some cases it answered, in others it signally failed, mainly from the class of cases to which it was really applicable not being fully recognised. On the whole, the treatment was too heroic to gain a firm hold on popular favour, seeing that spectacles supplied the coveted want; but there can be no doubt that where imperfect sight exists in connexion with strabismus, the division of the rectus generally improves not merely the aspect, but the sight of the patient; had John Wilkes lived in our days he would doubtlessly have been rendered pot merely a handsomer, but a more far-seeing man, by the rectifi. cation of that villanous squint of his.
The imperfect sight attending strabismus is regarded by Mr. Holthouse as a very important aid in diagnosing the squinting eye, especially in cases in which it is by no means easy to distinguish between the eye which is primarily and structurally affected, and that which is secondarily and often only functionally involved.
“Here, then,” (says he), “ some reliable means of diagnosis is required, and this is to be found in the condition of vision which is nearly always in perfect in the worse eye; if, however, no difference should be discovered in the power of either, it is immaterial which is selected for the operation. Mr. Walton, in a letter published in the · Medical Times and Gazette,' of October, 1856, has called in question the value of this test, and vaunts one which he has proposed as superior; but I have had occasion already, in several parts of this work, to point out its shortcomings, and shall therefore now merely refer my readers to Cases 11, 23, and 24, where its failure was too patent not to be noted. The objections which Mr. Walton urges to the vision test, rest on a solitary case of strabismus, in which he says he satisfied himself that the worse seeing eye was the one that did not sqnint." (p. 41.)
So much for the test, which is important," because,” says Mr. Holthouse, "on the selection of the eye to be operated on, will ofttimes depend the necessity, or otherwise, of a second operation.” (p. 143.)
Mr. Holthouse was, we believe, the first in the country to draw attention to the merits of the subconjunctival section for strabismus, and to that operation he still gives the preference. In many cases undoubtedly this operation is of great service, but no one should attempt it on the living subject until he has thoroughly familiarized himself with it on the dead. To perform it satisfactorily, and with success, requires more practice than falls to the lot of the majority of surgeons, and failure is annoying to both patient and operator. The author points out that there are cases in which the ordinary operation is to be preferred to the subconjunctival one-those in which mere division of the shortened muscle is not sufficient, but the conjunctival fascia require to be freely divided before the eye can be brought into a central position.
In addition to the subject of strabismus, Mr. Holthouse devotes a chapter to paralytic affections of the eye, and another to certain forms of impaired vision. The cases narrated possess considerable interest, and add to the value of this book, which may be consulted with advantage by the student and by the practitioner.
ART. I.- On Malformations, &c., of the Human Heart; with Original Cases. By
Thomas B. PEACOCK, M.D., Fellow of the Royal College of Physicians, Assistant Physician to St. Thomas's Hospital
, and Physician to the Hospital for Diseases of the Chest, Victoria Park.-- London, 1858. Pp. 143. The present volume is in the main a reprint of lectures and papers that have already appeared in various periodicals; important and interesting as the subjects are with which it deals
, we cannot but feel grateful to Dr. Peacock for having collected the disjecta membra, and presented them in an easily accessible form to the profession. While the author carefully investigates the history of the individual malformations, he presents us with a large number of illustrative cases which have fallen under his own observation. The value of these cases is further enhanced by numerous lithographs, which have the double merit of being perfectly intelligible, while they are well drawn.
The subject matter of the book is considered under five main heads. Under the first, Dr. Peacock discusses misplacements of the heart occurring congenitally; under the second, congenital deficiency of the pericardium. The third division is devoted to malformations of the heart, in the strict sense of the term; this includes malformations dependent on arrest of development at an early period of foetal life; malformations preventing the changes which should ensue after birth; and such as lay the foundation of disease in after life, while they do not in themselves interfere with the functions of the