The class of neuroses comprises the numerous and varied forms of neuralgia, hysteria, and spasmodic and convulsive diseases. Venereal affections are comprised in one family, forming also a distinct class, and with these the volume closes.

On looking over this nosological arrangement, we find as many anomalies as in any other. As propounding a natural system, it seems to us altogether artificial. The leading characters of the hæmatoses, namely, a morbid condition of the vascular system and of the blood, with increase or diminution of temperature, are by no means exclusively characteristic of the diseases grouped together under that designation. In numerous forms of neuralgia, in hysteria, in various forms of asthma, as, for example, the asthma urinosum, these characters are most prominent.

The family of the phlogoses alone are a natural group. But what pathological relation is there between insolation and delirium tremens, in group 2 of the phlogoses, that there is not between insolation and puerperal convulsions in group 2 of the neuroses? or between ischias postica (sciatica) and meningitis in group 2 of the phlogoses, that there is not between sciatica and the neuralgia properly so called, placed in the somatic neuroses?

In our opinion, the exanthematic typhus placed among the typhoid fevers, is, in all its pathological characters, one of the exanthematous fevers, and much more nearly allied to scarlatina, variola, or morbilli, than to typhus cerebralis. While measles are placed amongst the catarrhal affections, with influenza, catarrhus senilis, blennorrhea, &c., scarlatina and variola are grouped amongst the erysipelatous, with erysipelatous angina, and rose of the intestinal mucous membrane, in the same genus as urticaria! This breaking up of the class of epidemic exanthemata, so well defined, and so closely allied to each other, is alone a fatal objection to the adoption of Schönlein's nosology in Britain. This is one of the many anomalies we might notice, but these we leave to be detected by our readers, having already provided them the means of forming a judgment.

Special Pathology of Schönlein. Such being the nosology, what is the pathology of Professor Schönlein? We had marked several passages for criticism and animadversion, in which our author states not only erroneous views, but erroneous facts. Take, for example, the following description of cryptorchidismus, or non-descent of the testicle:

"The patient, although at the age of puberty, is imperfectly developed. The body is elongated, the patient being tall, but he is weak, and in appearance childish. The muscles are weak, and not consolidated: the external genital organs diminutive; the penis does not enlarge, the scrotum is contracted, and contains often one testicle only. There is no beard; the voice is unchanged at puberty, is unmanly, or the 'break' is peculiar, mixed up with bass tones. The patient cannot learn to pronounce certain letters, as particularly the letter R. The mind is also affected; it is childish. The testicles remain altogether in the abdomen, or in the inguinal canal, where they form a perceptible tumour, which may be mistaken for hernia. The absence of the testes from the scrotum, the want of manly development, and the absence of all symptoms indicating incarceration of a portion of intestine, are sufficient for distinguishing the two." (Part I, p. 61.)

The symptoms of atrophy, or non-development of the testicles, are here detailed. The pathology of cryptorchidismus has been recently discussed

in this Review, (vol. XIV, p. 61,) and all that need be repeated here is, that in the above description, Schönlein betrays not only a want of practical or clinical skill, but also of literary and physiological knowledge. A testicle, if fully developed, is just as efficient within as without the abdomen, and the patient will have a bass voice, a developed penis, and other marks of virility, and be quite able to pronounce the letter R, although they both be stuck fast in the groins, if so be that they are so large as to simulate a hernial tumour.

Again In describing phlebitis, no mention is made whatever of a symptom which, in Great Britain, is considered almost pathognomonic; namely, the formation of abcesses in different parts of the body. Schönlein states that coagulated fibrin is often found in the inflamed vein, and beneath this a pus-like fluid; and this is all. We observe that the causos of Aretæus, or febris ardens, is described amongst the venous inflammations, as inflammation of the ascending vena cava. We might note other views entertained by Schönlein, as, for example, that scrofulous and tubercular disease are not identical; that tubercles are the result of suppressed secretions or excretions. Thus, he describes menstrual tubercles from suppressed menses, puerperal tubercles from suppressed lochiæ, tubercles from drinking cold water, from repulsion of exanthemata and impetiginous diseases, and from suppressed gout, -the lungs being affected in all cases. Schönlein also objects to the modern doctrine that phthisis is but the continuation and higher development of tubercular disease. It often is so, he argues, when the lungs are the seat of the disease, but hepatic, or gastric, or muscular phthisis, occurs without tubercles having preceded it. In phthisis, according to Schönlein, a morbidly-secreting surface is formed within the organ affected, which secretes a peculiar fluid, commonly termed pus, but which is by no means identical with that fluid. This morbid surface has a great resemblance to mucous membrane. Yet enterophthisis is described as dependent on ulcers of the intestines, which not unfrequently perforate the intestines. Further, phthisis meseraica is simply the mesenteric disease of infants, and phthisis hepatica is neither more nor less than abscess of the liver. Then we have phthisis of the brain, of the ovaries, of the bladder, &c. Here is another instance in which Schönlein sets aside not only the nomenclature generally received by medical writers, but the first principles of taxonomy. Phthisis, as the term is now used, is applied to a disease of the lungs only, accompanied with hectic fever and atrophy. No systematic writer has applied the term to tabes generally, to hectic fever, to hepatic abscess, or to mesenteric disease. Schönlein makes phthisis synonymous with hectic fever and marasmus, and then contradicts, as if he had made a great discovery, the general opinion, that phthisis, in its ordinary form, is a higher development of tubercular disease. We certainly have read the arbitrary definitions and reckless contradictions displayed by Schönlein, with very great astonishment.

The Clinical Medicine of Schönlein. Dr. Güterbock having been a clinical student with Schönlein, and so having had an opportunity of hearing and appreciating his clinical discourses, felt certain that good service would be done to the medical commonwealth by the publication of them. That the reader of these clinical discourses may not mistake their

XLII.-XXI.

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object and spirit, Dr. Güterbock premises a few observations. He remarks, in the first place, that they are not intended for beginners; that they do not profess to afford detailed descriptions of disease, or medicinal formulæ, or rules for prescribing. Schönlein takes it for granted that his hearers are already acquainted with the theory of medicine. He wishes rather to form the ripe student into the scientific practical physician; to teach him how to observe; how to apply his five senses to the detection and comprehension of the phenomena of disease, and his understanding to the elaboration of a true pathology. Schönlein therefore rather sketches the outlines for his hearer to fill up, than draws a finished picture.

Having said so much by way of preface, and as an explanation due to Schönlein, we take for our criticism the first case in the volume, which is one marked as Typhus abdominalis.

"2d Nov. 1840. Christian Kämpfer, aged 19, a weaver's apprentice. He states that he has felt poorly and languid for the last four weeks, his feet being too weak to carry his body. He has often experienced vertigo. His sleep was light, and often broken by dreams, and he had an oppressive pain in the forehead. Eight or nine days ago, as nearly as he can remember, he experienced frequent rigors, followed by a continued heat. These data are important, as, previous to this period, was the stage of opportunity, and with it commenced the second seven-day period. We now observe three series of symptoms in the case: "I Nervous symptoms, as weariness, dulness of the head, dizziness, tottering gait, sleeplessness.

"2. Symptoms limited to the intestinal mucous membrane. The abdomen is soft, not painful on pressure, even if the cæcal region be strongly pressed. Three more watery stools have been passed during the last 24 hours. The tongue with a white fur was dry at its point yesterday evening.

"3. Symptoms of reaction. The fever is distinctly remittent, the remission occurring in the morning, the exacerbation in the evening. The pulse was 104 yesterday evening, to-day it is 84. The skin is harsh, dry, and in the evening hot. The urine is turbid, and deposits a slimy sediment, not pathognomonic. "After a comparison of these three series of phenomena, there can be no doubt that the case is one of abdominal typhus in the second seven-day period. "In modern times, we have heard of attempts to cut short this disease, to render it abortive from the first, or at least to alleviate the symptoms. This method is directly opposed to that which is founded on the principle that, after rigors have once set in, and all the symptoms of the disease are manifested, it must be allowed to run its course, through all its stages. The elder physicians (as Hildebrandt, Stoll, Richter,) have attempted to cut short the disease by emetics, and maintain that these have been the most effectual when gastric symptoms are manifest. I must distinctly express my disapproval of this means, which I have never found beneficial, even when ipecacuan only has been given. So far from cutting short or ameliorating the disease, I believe emetics have had an injurious effect, especially when tartar emetic has been combined with ipecacuan. At least, I found it so, in the case of some strong healthy nurses in the Julius hospital at Wurzburg, who were attacked with typhus fever after nausea, taking cold, &c. An emetic was administered to them, and the tongue became still more coated. The stools were rendered also more frequent, and death in some instances took place on the fourth day. The similarity between this disease and the acute exanthemata ought not to be overlooked. As in the latter the eruptions are the most marked where the skin is irritated, (as, for example, after bleeding in smallpox, the pocks are most numerous around the wound in the vein,) so after the irritation of an emetic on the intestinal mucous membrane, in the former, the eruption is likely to be more vivid. It is for similar reasons that simple saline aperients are so hurtful in this disease. Partly for these theoretical reasons, and partly

from experience, I have come to the conclusion, that the use of emetics for cutting short the affection ought to be abandoned. A more valuable remedy for this purpose is that recently adopted, namely, calomel. To Autenrieth is due the merit of having first used it for this purpose; he administered it so early as 1806 and 1807, continuing its use until the peculiar green evacuations were induced. An objection may be thus raised at once to its use: How, after warning us against the administration of the innoxious neutral salts, can you recommend calomel?' It is true that calomel excites alvine evacuations, but they are not such as follow on stimulation of the intestinal mucous membrane. Further it is allowed that calomel is useful when it excites its peculiar evacuations, which were formerly thought to contain the constituents of the bile, but, according to more modern researches, is altered colouring matter of the blood. The difference between the operation of calomel and of the neutral salts, is further shown by this, that, while the diarrhea increases with the latter, and the stools become more watery, they are more and more consistent with the continued use of calomel; so that at last, aperients (clysters) must be had recourse to. In what stage of the disease ought calomel to be administered? All observations agree that its administration must be limited to the first seven-day period, and the beginning of the second, and that the earlier it is administered, the more notable are its good effects. Its use is contra-indicated when phenomena referrible to the intestinal mucous membrane, and nervous system, as tenderness of the abdomen, dry tongue, and frequent pulse intervene. Given at a late period, it is injurious; it is most useful on or before the fourth day.

"The mildness of the symptoms in the present case leads to the conclusion, that this method of cutting short the disease should be adopted. Opinions vary as to the proper dose of calomel. Some recommend from three to four grains every two or three hours, until the characteristic evacuations are produced: another method (originating with the Tubingen school,) is to give the full dose of a scruple; then to omit it the next day, then on the third day repeat the dose, until the evacuations are less frequent. We have on former occasions followed the former method, let us now adopt the latter; and since calomel is apt to excite acidity in the stomach, we will combine it with eight grains of carbonate of magnesia.

3d Nov. The patient took a scruple of calomel yesterday at two o'clock, and up to the present time only three characteristic motions have resulted, nevertheless watery motions continue. At first there was vomiting; no tormina. The exacerbation was very slight; the pulse was 96 per minute, and the patient slept for some hours during the night.

"This morning the pulse is only 80: the skin is still tense and drier. The urine deposits a slimy precipitate. Since the kidneys appear inclined to act, while the skin remains inert, to excite the latter, we will give the acetate of ammonia, and early to morrow the scruple dose of calomel shall be repeated.

"4th Nov. Yesterday there was no stool; the exacerbation was still more slight than on the day before (pulse 84,) and this slighter exacerbation was followed by a quieter sleep. To-day the patient feels much stronger, and his head is better, although there is still some intolerance of light.

At half-past five this morning, he took another dose of calomel; but up to this moment (and six hours later,) there have been neither evacuations nor molimina. ..... The abdomen is soft and without pain, the tongue moist, and its yellow coat coming off, the fever moderate as yesterday, the pulse yet strong. (p. 6.)

On the 5th Nov. it is reported that an alvine evacuation took place 14. hours after the calomel was taken, and shortly afterwards three more. The stools were of a brownish or green colour. The pulse was 75, as on the previous evening. Schönlein conceiving the critical day to be near, and the crisis in this disease occurring through the skin, warm bathing and diaphoretic drinks were ordered. On the 6th of Nov. the patient complained of weakness and sleepiness, and seemed more soporose. The

warm bath was followed by a copious sweat, the skin becoming softer. The patient was quiet during the night, but it was rather a state of stupor than regular sleep. The head not better than usual. On the 6th Nov. the same soporose state continued; the tongue coated, but moist; little or no thirst; the abdomen soft, and "the characteristic noise in the cæcal region." The fever and pulse as before. To encourage diaphoresis the dose of liquor of acetate of ammonia was increased from 3vj to 3j, with 3j of the tincture of valerian. In the evening the warm bath, and if the sopor continued, sinapisms to the calves of the legs. From the 9th to the 14th, all the cephalic symptoms were aggravated. On the 9th the patient lay on his back in a state of stupor, from which he could be readily roused, to relapse again immediately. Urine passed involuntarily; head hot; pulse accelerated; abdomen tender on pressure; hemorrhage from the nose and delirium during the night. Leeches and lotions to the head, and a clyster of liquor of acetate of lead and starch. The acetate of ammonia and valerian continued. On the 10th the patient was in the same condition, the pulse small, the speech stammering, the abdomen tender on pressure. Schönlein inquires, "is the congestion of the head consensual, proceeding from the ulceration of the intestinal mucous membrane? or is it the consequence of the fever? or is it idiopathic? The questions are not easily answered.” Blisters to the legs were ordered; the saturnine clyster repeated, and infusion of cinchona with gum and oil. On the 11th, paralysis, dilated pupil, and profound apoplexy are reported, and death on the same day.

"Post-mortem examination. On the muscular and peritoneal covering of the small intestines there were found small bodies, varying in size from a millet to a pea, and filled with a cheesy substance. In the lower portion of the small intestine, not far from the cæcum, were a few small ulcers, the largest no bigger than a lentil; these were in the act of healing. In the large intestine, about four or five inches from ilio-cæcal valve there were a few similar ulcerations, but a little larger. The affection of the intestinal mucous membrane was much less than is usually noticed in this disease. There were a few miliary tubercles on the pleura pulmonalis. On removing the skull, the convolutions of the brain were found flattened, and the sulci of the pia mater contained a yellowish gelatinous lymph. This was in greatest quantity at the base of the skull, around the chiasma and infundibulum. The vessels were congested; the lateral ventricles, and particularly the left, filled and dilated with fluid, so that the fornix was stretched and appeared softened. Tubercles, the size of beans, were found in both hemispheres of the cerebellum.”

Schönlein remarks on the the paucity of ulcers in the intestines. He thinks that no one could justly attribute the cerebral changes to the large doses of calomel, but on the contrary, the post-mortem appearances corroborate the views as to the utility of that remedy in abdominal typhus!

We have given this case at some length, that our readers may have a clear idea of Schönlein's clinical practice and instructions, and that we need not multiply quotations. For ourselves, we can aver that we have written it with surprise and astonishment. The elaborate "Pathology and Therapeutics" of the author had prepared us for a logical, rapid, yet ef fective examination of the patient; a clear and discriminating view of the symptoms; a separation of what was essential from what was accidental; an exposition of the causal relations of the symptoms: a well-reasoned and decided plan of treatment. Nothing, we need scarcely say, of this kind is in the case before us. The information as to the early history of the patient, his temperament, constitution, expression of countenance,