THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA PRESENTED BY PROF. CHARLES A. KOFOID AND MRS. PRUDENCE W. KOFOID SKETCHES OF BRAZIL; INCLUDING NEAV VIEWS ON TROPICAL AND EUROPEAN FEVER, WITH REMARKS ON A PREMATURE DECAY OF THE SYSTEM INCIDENT TO EUROPEANS ON THEIR RETURN PROM HOT CLIMATES. BY ROBERT DUNDAS, M.D., PHYSICIAN* TO TUK NOKTIIKRX HOSPITAL, LIVERPOOL J FORMERLY ACTING S TO H. M.60TH RKG1MKNT ; AND FOE TWENTY-THREE TEAKS MEUKJAI SUPERINTKNUENT OF THE BRITISH HOSPITAL, JBAHIA. LONDON : JOHN CHURCHILL, PRINCES STREET, SOHO. MDCCCLTI. b 1 u PEEFACE. THE principles laid down in the following pages have occupied the writer's thoughts for many years, and in many lands; and a profound conviction of their truth, and of their importance to the preservation of health, and in the treatment of disease, has imposed on him the duty of publishing them. The Author is well aware that these opinions are in direct opposition to those held by the profession ; and he has, there- fore, clearly and briefly, submitted the chief evidence on which, against his own early VI PREFACE. convictions, he was led first to doubt, and finally to reject doctrines, sanctified, as it were, by the greatest names in ancient and modern medicine. As to the rest, the Author cares only for truth. He has performed what he deems a duty to his profession, and waits its final judgment. "Opinionumcommentadelet dies; nature judicia confirmat." CONTENTS. INTRODUCTORY REMARKS Modern Authorities on Fever : Cormack, Jenner, . Liquoris Taraxaci, %viii. Liquoris Potassse, 5 SS -M"- Half an ounce to be taken twice a-day, in a glass of the real or artificial Vichy water. ALTERATIVES. Should the bowels prove torpid, and the excretions depraved, a com- bination of aloes and extract of guaiacum, with two grains of capsicum, and one of acetous extract of colchicum, will prove useful in improving the character of the 92 LECTURE II. secretions, and restoring the action of the bowels. Or the following draught may be substituted : $>. Tincturse Guaiaci Ammon. n\xxx Liquoris Taraxaci, 5i Vini Colchici, HI x Decocti Aloes Compos. 3 ii. M. Fiat haustus bis in die sumendus. When the skin is dry and harsh, the pulse slow, the extremities cold, the lips clammy, the urine turbid, the sleep unrefreshing, arid the spirits oppressed, advantage will be derived from the administration of mistura guaiaci with liquor potassas, and a few drops of vinum colchici, with five or six minims of liquor opii, followed by some bland mucilaginous drink. Enemata of cold water will afford much relief in moving the lower bowel, and giving tone to the intestinal canal. DIURETICS. As a diuretic, and certainly not an inefficient assistant to the assirnila- TONICS. 93 live process, the liquor potassse, taken about an hour after dinner, in pure water, will be found of considerable service. Minute doses of the tincture of sesquichloride of iron, in cold water, will also be found use- ful where we wish not only to excite the kidneys, but to invigorate the system. TONICS. In cases where a tonic is re- quired, the nitro-muriaticacid, or some slight- ly aromatic bitter, as the infusum aurantii compositum, may be taken with advantage, being changed according to circumstances. Small doses of the different preparations of iron, either alone or combined with quinine, will often be found highly useful. I am satisfied, Gentlemen, from pretty extensive experience, that the above mea- sures, singly or in combination, or slightly modified according to circumstances, will fulfil all the indications, as far as they can be fulfilled by medicines. I need scarcely point out to you, that the complexity of our 94 LECTURE II. prescriptions offers but a sorry apology for our limited knowledge of the essential pathology of the disease. In these, as in all other maladies, the vast practical impor- tance of the doctrine laid down by that dis- tinguished physician, Dr. Latham, should never be lost sight of that where great things are to be performed by medicine, they are to be effected by the right under- standing of single indications, and by the right use of single remedies which have power to fulfil these indications. With reference to mercury, so generally regarded almost in the light of a specific in all diseases arising from residence in tropi- cal climates, I am decidedly of opinion that, although a dose of it may, occasionally, be given with much advantage, and may even sometimes be imperatively called for in such maladies, there is yet no class of cases in which its administration is worse borne, and attended by more pernicious conse- BATHS. 95 quences, than in those persons who have returned to Europe after lengthened resi- dence in warm climates. Rare are the exceptions to this rule; and I cannot too earnestly impress its great practical value on your minds. The indications commonly supposed to demand the administration of mercury will be found more advantageously and permanently fulfilled by a combination of aloes, soap, and taraxacum, with an occa- sional emetic, than by the use of any other drugs. The notion of aloes causing ha3moi< rhoids is altogether a popular fallacy, and cannot too soon be exploded. BATHS. In persons affected with the deranged state of the system under consi- deration, we shall frequently find a want of sufficient vigour to support the powerful shock of the cold shower-bath ; and yet it is of great importance that they should be subjected to its action. This will be accom- plished by immersing them in the hot bath 96 LECTURE II. at 98, in which they should remain for five minutes; and while the patient is standing in the bath, let the cold shower-bath be at once administered. After this, they are to be vigorously rubbed for some time with coarse towels, or a flesh-brush; then being warmly clad, they should immediately proceed to take active exercise in the open air. In all cases, the bath-room should be properly heated an important item in the administration of baths, too often, I fear, neglected. In many instances an occasional use of the hot air or vapour bath, immediately followed by a shower-bath cold or tepid, according to circumstances will prove a valuable element in restoring a healthy tone to the cutaneous circulation. CHANGE OF SCENE AND CLIMATE. Another important element in the treatment of all chronic diseases, and more especially of those now under consideration, is change of scene and climate. HYGIENE V. PHYSIC. The stimulus of new impressions on the nervous system, and consequently on all the organic functions, cannot be too highly estimated. Often, indeed, when the effects of the most appropriate medicines seem unavailing, a temporary change of scene and air will render the system more amenable to your prescriptions. I would finally observe, that you will find a modification of the foregoing treatment, in various anomalous and painful diseases of a dyspeptic character in this country, to be attended with decided advantage after the ordinary routine of treatment has totally failed. I am firmly convinced that, in their general principles, the causes of these mala- dies share much in common with the affec- tions now under consideration. Instead of the daily tonic, the dinner pill, the nightly purge, and the ever-ready mutton-chop, with its modicum of sherry, I have seen that careful attention to the skin and kid- F 98 LECTURE II. neys, rational habits, rational diet, and rational exercise, will play a far more im- portant part in the restoration of tone to the stomach, and strength to the system, than the whole host of stomachics, altera- tives, purgatives, et id genus omne. In some forms of anomalous gout and rheumatism, occurring in individuals who have returned from tropical climates, when the vital powers are not especially depressed, and the constitution is free from serious organic change, you will obtain important advantages from the modern system of hydropathy, judiciously modified. It exerts a beneficial action on the renal and cutane- ous secretions; and I am satisfied, that some form of the hydropathic treatment will maintain a permanent place in scien- tific medicine, after the mass of obscurity in which it is overwhelmed, through the ignorance and quackery of its present apos- tles, has been forgotten. In the wards of EARLY DECAY OF EUROPEAN FEMALES. 99 our own Hospital, Gentlemen, I have fully tested, under your own eyes, its great value in certain forms of chronic rheumatism. EUROPEAN FEMALES ix TROPICAL CLIMATES. In connection with this important sub- ject of the decay of the system, my experi- ence in Brazil has established a proposition which might not have been a priori expect- ed; viz., that the European female, espe- cially of the upper classes, feels the injurious influence of climate more sensibly, and at an earlier period, than the male. This unexpected result must, I apprehend, be accounted for by the more indolent habits and mode of life of the former, favoured, if not altogether induced, by the languor in- separable from high temperature, and sanc- tioned by the prevailing customs in most tropical climates, where household occupa- tions are not attended to as in Europe, where fashion or custom precludes the 100 LECTURE II. enjoyment of active exercise abroad, and where even mental exertion is to some extent laborious, and, consequently, the muscular, nervous, and vascular systems are deprived of their due and healthy stimuli. Notwithstanding, therefore, the more regular and temperate habits of the female, and her exemption from many of the ordinary sources of tropical disease, as exposure to the sun, atmospheric vicissi- tudes, over-fatigue, &c., yet are these advan- tages more than counterbalanced by the inactivity and indolence almost necessarily connected with her position. This mode of life, by interfering with the efficient exercise of those depuratory functions which are so essential to health in all warm and humid latitudes, leads directly, and often quickly, to the development of nume- rous and grave derangements, in which the uterine system is frequently involved. This question deserves the most serious DURATION OF RESIDENCE. 101 attention of the professional advisers of those European ladies who are doomed to a lengthened residence within the tropics; for many of the inconveniences, and some of the dangers, to which they are especially obnoxious, may be prevented or removed by careful attention to the considerations to which I have just alluded. On their return to this country, these cases will necessarily demand the same careful investigation, and will be benefited by the same principles of treatment as have already been laid down, modified, of course, by the sex of the individual. TIME DURING WHICH EUROPEANS CAN SUSTAIN A TROPICAL RESIDENCE WITHOUT INJURY. In immediate relation to the questions which have hitherto engaged our attention, though but indirectly bearing on the sub- ject of the origin and treatment of these 102 LECTURE II. affections, are the inquiry how long an European can sustain a tropical climate without injury, and also the examination into the indications in the animal and organic functions, which determine the necessity for the removal of the invalid to his native land. These considerations are so intimately connected with our subject, that I should deem my observations alto- gether imperfect, if I did not offer some principles to assist and guide you in deter- mining points of such practical importance. I shall, therefore, devote a few moments to the examination of these highly interesting matters, premising a few remarks on the agency of tropical heat and light, which exert such powerful effects on the animal frame, but have not hitherto been suffi- ciently considered. The examination of the latter subject, we shall perceive, is not altogether without reference to the im- mediate subject of my lecture. TROPICAL LIGHT AND HEAT. 103 INFLUENCE or SOLAR HEAT AND LIGHT IN TROPICAL CLIMATES. The power of the direct rays of the sun is little less influen- tial on animal than on vegetable life, as is evidenced by the salutary influence which they exert over all the organic and mental manifestations, and by the ill effects which follow their exclusion. Independently of direct physiological proof, this proposition will be fully admitted by every tropical sojourn er, in whom years of subsequent exhaustion can never entirely efface the recollection of the buoyancy of spirits, un- clouded mind, and exquisite appreciation of mere animal existence, which, unless coun- teracted by some special influence, charac- terise the first years of a tropical life. Authors have, indeed, attributed these vivid sensations to the novelty and splendour of a new world; to the brilliancy of its skies; to its perpetual verdure; to the richness, variety, and luxuriance of vegetable life, 104 LECTURE II. &c. : agencies, I admit, of importance, but utterly trifling, as compared with the direct influence of the heat and light of a tropical sun, in supplying a great and novel stimu- lus to the energetic performance of all the functions, not only of organic, but also, for a time, of animal life. This favourable condition of the economy, however, as in vegetable life under similar circumstances, proves but of limited duration, the precise epoch being determined by numerous con- current circumstances, as the constitution, occupation, predisposition, and habits of life of the individual. Hence arises the serious and important question : At what period does a tropical residence begin to affect the European constitution to such an extent as to influence longevity, or per- manently to injure health? The fallacious doctrine of acclimatisation by lengthened residence in high and un- healthy latitudes, so long an established LIMITATION OF RESIDENCE. 105 axiom with the British Government, is now happily exploded. This fatal and heartless system, long sustained under false and ill un- derstood motives of economy, has at length slowly yielded to the light of experience, and to the prevalence of sounder and more humane principles ; five years being the limit beyond which, I believe, our troops are not now suffered to remain in the West Indian and other unhealthy possessions. This limitation is certainly judicious, and entirely in accordance with the results of my own experience, which fully warrant the conclusion, that a European in the prime of life, and free from any especial tendency to disease, will resist the deleteri- ous influence of the tropics for a period varying from five to seven years, according to circumstances. After this time, first the animal, and then the organic powers, will commonly give evidence of decline; and although the necessity which even then 106 LECTUKE II, exists for immediate change of climate may not seem urgent, yet its eventual importance, in enabling the constitution to resist or throw off the ailments incident to all hot climates, cannot possibly be over- rated. Nor should it be forgotten, that the ill effects of a tropical residence are often not displayed immediately, but in after life, and subsequently to the return of the individual to Europe an important consideration, which should not be lost sight of by the judicious practitioner. In my endeavours to solve the difficult problem of the period at which a tropical residence can no longer be borne with im- punity, I have been much aided by the observation of a fact verified by experience and repeated experiment. For the first seven or eight years during which an European resides in hot climates, the urine is characterised by a marked excess of its acid constituents; this state, under the in- IMPORTANCE OF THE QUESTION. 107 fluence of climate, gradually changes; and finally, as health deteriorates, a neutral or even alkalescent condition of that fluid super- venes. This change, however, is subject to considerable variation, and is largely in- fluenced by the habits of life and the con- stitution of the individual. Still, the rule will prove sufficiently general to assist the practitioner in arriving, under circum- stances of doubt, at a sound opinion on one of the most serious and embarrassing, as well as one of the most frequent questions submitted to his judgment in all tropical countries; viz., the period beyond which a longer residence cannot safely be permitted to the European. As this decision will frequently involve not only the health, but the future career and fortunes of the in- dividual, the bearing and importance of this question will at once be comprehended by all tropical residents, professional and non- professional. I therefore feel anxious that 108 LECTURE II. the above-mentioned test should be sub- mitted to further examination by my pro- fessional brethren in other hot countries than Brazil, so that its value and frequency may be satisfactorily defined. In tropical climates, under favourable circumstances, as where the mind is tran- quil and buoyed up by hope, where fatigue, exposure, and the distressing emotions are avoided, where the body and mind are judiciously exercised, where the diet and regimen are attended to. and where to O ' these are superadded an equable atmosphere, never stagnant, nor exposed to great or sudden change, though otherwise loaded with moisture and animal effluvia, it is surprising to observe the length of time during which an individual will pursue his ordinary avocations without the develop- ment of any specific malady; although the obvious and unquestionable evidences afforded, by the nervous and vital manifes- FIRST SYMPTOMS OF BREAK-UP. 109 tations, clearly show how profoundly the economy is charged with the elements of disease, awaiting but the slightest touch from any disturbing moral or physical agency to determine an explosion. In Brazil, for example, how frequently have I observed individuals go on for months aye, and for years complaining of mental and bodily fatigue on slight exertion their air languid, the feelings below par, the coun- tenance sallow, the eye dull and with a slight tinge of yellow, the pulse weak and easily accelerated, the appetite modified, the lips slightly clammy, the bowels irregu- lar, the urine commonly scanty arid turbid, the testes pendulous, with a peculiar sense of uneasiness, irregular distribution of animal heat, profuse perspiration from trifling causes, moral or physical, and a morbid sensibility to the slightest atmos- pheric vicissitudes. The foregoing condition of the economy 110 LECTURE II. will display numerous shades, some slighter, some more intense, but all requiring the careful consideration of the physician. In all, the diet and regimen will demand strict attention; the moral and physical powers must be alike carefully examined and regulated; the secretory and excretory functions must be modified, and, if pos- sible, restored to their healthy condition. I need not particularise the most efficient means for the attainment of these essential objects; first, because they must be familiar to every well-informed practitioner; and secondly, because the successful result must mainly depend on a judicious selection and application of the resources, suited to the ever-varying circumstances of each indivi- dual case. Should, however, (notwithstanding the due administration of remedies), the above- described state of the economy persist, I would strongly impress on the minds of TREATMENT OF BREAK-UP. Ill those among you who are destined to a tropical career, the paramount importance of change of climate, if possible, to Europe ; at all events, to some other locality, or even for a few days to sea. Debarred from this, the most valuable of all remedies, the tro- pical invalid will too commonly find the most skilful treatment unavailing ; for the epoch has at length arrived as arrive it will sooner or later to every European resi- dent when the administration of medicinal agents proves either useless or hurtful. On your correct appreciation of this critical era will depend, probably the life, cer- tainly the health, and in numerous in- stances, the prospects and happiness of your patients. LECTUKE III. OBJECTOFPBESENT SECTION OFLECTURES UNCERTAINTY OF THEORIES AS TO NATURE AND CAUSE OF FEVER - EXAMINATION OF DOCTRINE OF LANCISI, SHOWING HIM NOT TO BE THE AUTHOR OF THE MODERN EXCLUSIVE THEORY OF MARSH MlASM HlS ORIGINAL WORK SCARCELY READ HlS VIEWS ON THE UNITY OF THE MARSH POISON ITS ACTION ON THE NERVOUS OR SANGUIFEROUS SYSTEM Two KINDS OF MARSH POISON DESCRIBED BY HIM ON THE SUPPOSED PRODUCTION OF ITS EFFECTS IN ONLY ONE MODE THREE MODES DESCRIBED BY LANCISI MARSH POISON NOT THE CAUSE OF INTERMITTENT FEVER ALONE ANIMALCULAR THEORIES OF V~ARRO, COLUMELLA, AND VlTRUVIUS LANCISl's STATEMENT, THAT A WIND MAY PRODUCE AGUE SUMMARY OF HIS VIEWS ON MARSH POISON AND ITS EFFECTS. GENTLEMEN, The chief object contem- plated in the present section of our lectures is to lay before you certain facts which have come under my own especial notice, during OBJECT OF PRESENT SECTION. 113 a period of upwards of twenty -eight years, spent in extensive and active practice in Brazil, and in the public service in different regions of the globe. These facts are com- pletely at variance with the received doctrine that marsh poison is the immediate cause of intermittent fever or ague. I must at the same time plead for some indulgence in entering on the discussion of a subject so extensive, and which has engaged the attention of our medical brethren in almost every quarter of the world. The facts which I have to lay before you are plain, simple, unvarnished; as such, I submit them to your attention, with this special remark, that, as the whole phenomena of nature cannot be conceived to have been as yet completely explored by man, so the statements which I have to offer must be considered as truthful exponents only of the actual experience which I have enjoyed. I may, in all truth and confidence, declare 1 14 LECTURE III. that I am the partizan of no theory ; that, like the practical men of old, I saw first, and formed my conclusions afterwards. To this, indeed, I was ultimately driven, in spite of preconceived notions formed in the schools, and sanctioned by the most cele- brated authorities in the profession, and fur- ther strengthened by the additional guaran- tee that upwards of a century could add to the imposing array of great names, connected during that period with our medical schools, both at home and on the continent. PRELIMINARY REMARKS UNCERTAINTY OF THEORIES OF FEVER. Fever has, at all periods, been a sub- ject of engrossing interest to the medi- cal practitioner. Sydenham was wont to say, that nine-tenths of the human species were sent to their graves by dis- orders in which fever was the most promi- RANGE OF FEBRILE DISORDERS. 115 nent agent. Nor was the observation of a late celebrated professor less pertinent, that a thorough knowledge of the treatment of febrile disorders in all their varying forms, types, and anomalies, embraces the great bulk of that range of human suffering, which can be relieved by the skill, science, and assiduity of the medical practitioner. There are probably few hardy enough to contravene these propositions; and those who, in the heyday of self-sufficiency, boast of possessing a remedy for every ailment that flesh is heir to, a few short years will undeceive, and will prove to them the woful inefficiency of physic, as well as the uncertainty of even their firmest convictions. Few subjects, therefore, relating to theo- retical medicine, have excited a more lively interest in the minds of the members of the profession, than the inquiry into the nature of fever ; whether with regard to its proxi- 116 LECTURE III. mate cause, or to the nature of those various remote causes, which exert so powerful an influence in predisposing the animal body to the accession, or which, under certain specified conditions, become the excitants of the febrile disorder. The theories on the question present the formid- able appearance of " legion;" and the dense phalanx of their array is still daily augmented by the speculative fancies of ardent minds, and by the positive facts of more mature judgments. The rationalist on the one hand, and the empiric on the other, claim the divided empire of the realm of medicine. It cannot certainly be affirmed in strict language, that any of the theories of the immediate exciting cause of disease rests on a basis 'so secure, as to be impregnable to the assaults of new theoretical writers, or to the still more convincing refutations of broadly established facts. The converse, MEDICINE IMPERFECT. 117 indeed, can only be conceived to be com- patible with a perfect state of science ; and the department of medicine is more remote from the prospects of such a happy consum- mation, than any other branch of human knowledge; although we have theorists, as well as practical men, who are convinced of the perfection of their science, even in its present imperfect condition. Nor must we be surprised that such ideas should obtain among certain members of the profession, when we revert to the fact that, but a cen- tury ago, when the mathematical pathology reigned predominant, propositions like the following were announced for discussion : "Proposito morbo, invenire remedium" If there are phases in the cycle of opinions and doctrines, these are not the phases of a recurrent series, but of an expanding and advancing intelligence. And if, from the circumscription of our facts, we are almost localised, as it might seem, 118 LECTURE III. in our philosophy of causes, the extension of our facts must consequently enlarge the sphere of the basis of our principles, and dissolve the errors arising from the almost provincial mode of our philosophical pro- positions, by the broad and unerring light of universal truth. Propositions, delivered as true and infallible, may be so, if applied to the partial conditions under which they are developed; but they will become abso- lutely false when transferred to another locality, or merged in more general and comprehensive problems. I am, therefore, Gentlemen, strongly con- vinced that much of the obscurity and uncertainty, and many of the contradictory doctrines espoused by different parties, are more to be ascribed to the imperfect views taken by the respective authors, than to wilful perversion of facts, or positive ignor- ance of the relations of various morbid actions with the series of changed functions HOMOGENEITY IN DISEASE. 119 which they involve, and of their direct or indirect connexion with each other. There is a homogeneity (if the expression be per- mitted) in the laws of disease, of which we are just now beginning to enjoy the first glimpses; and although it would be too much to allege that fever and inflammation are but one and the same morbid action, greatly diversified, no doubt, through the influence of numerous concurrent circum- stances, we nevertheless know that the theory of the day which rendered a special reason of the proximate cause of the one, was deemed to be equally illustrative and explanatory of the other. The phenomena of fever, nevertheless, as specially distin- guished from inflammation, are, I am dis- posed to believe, essentially one and the same ; the simplest expression of that mor- bid action being delineated in the paroxysm of an ague in the succession of its three stages, hot, cold, and sweating; and assum- 120 LECTURE III. ing, under certain circumstances of climate, constitution, modes of living, &c. &c., the various forms of typhus fever, plague, remittent fever, yellow fever, and all the subordinate varieties of fever denominated essential by the French school. An unfortunate prejudice attaches to almost every subject that comes within the range of the speculations of the medical philosopher, arising from the necessary un- certainty of our imperfect science; so that no proposition is mooted which does not imme- diately become a subject of controversy; and almost every assertion is met by a plausible counter-assertion. Such, indeed, is the unhappy state of theoretical medi- cine, that it may too often be said of the disputants on either side, " Each claiming Truth, " And Truth disclaiming both ; " so delicately poised is the balance of evidence offered by the litigants. Not- DOCTRINES OF LANCISI. 121 withstanding this doubt, however, and "end- less errors," in which the sons of Esculapius are apparently lost, I am emboldened to lay before you various facts and circumstances connected with the origin of intermittent fever, which are totally irreconcileable with the commonly received theory of the or- dinary exciting causes of that disease, and which would seem to connect the sources of the different forms of febrile action with a more broad and more comprehensive prin- ciple than the sectional causes which are expounded in our schools, and taught in our accredited works on the practice of physic. EXAMINATION OF THE DOCTKINES OF LANCISI. In examining the question, whether Marsh Poison or malaria is the sole generative cause of certain forms of fever, you will recollect that this doctrine is alleged to have been first propounded to the world in the 122 LECTURE III. year 16 95, by the celebrated Italian physician Lancisi ; and that, from its first promulga- tion, till within the last thirty years, it was adopted by the almost universal consent of the whole medical world, flourishing in the schools as the theoretical dogma of the professors, and with practical men as the sole and only cause of intermittent fever. Prevalent, however, as the doctrine has been incorporated with all the theories on the phenomena of essential fever and embrac- ing the fundamental pathology of one of the most numerous and most common class of diseases in tropical as well as in other regions it is surprising to find how few men of our profession are conversant with the works of this original writer. In truth, among a wide circle of the medical pro- fession in various quarters of the globe, including some of the most distinguished and learned physicians in London, I have never met with a single individual who HIS WORKS LITTLE KNOWN. 123 has perused the original works of Lancisi ; and lately, being desirous to consult his works I must confess, for the first time no copy could be found either in our great national library, or in the library of the College of Physicians ; and I finally obtained a perusal of his works in the library of the Royal College of Surgeons of England. * This, you will admit, is passing strange, when we consider that the theory of marsh poison or malaria has influenced all our reasoning on the subject of fever, and has exercised an absolute sway over the medical world for the last 150 years. All, indeed, seem to have formed their ideas of Lancisi's doctrines on report and hearsay; for I feel satisfied that, had his works been read instead of quoted, we would have heard less of his doctrines, or, at least, we would have been less tutored * LANCISI, J. M., Opera Omnia, Geneva, 1718. The pages refer to his Essay "De Noxiis Paludum Effluviis." 124 LECTURE III. into the abstract idea of marsh poison being one and indivisible of its being the ex- citing cause of intermittent fever by its poisonous action on the nervous or the sanguiferous system of its producing these effects in only one mode and of its being limited to the sole generation of intermit- tent fever, specially and individually, as distinguished from continued fever. On each of these points I shall now offer a few observations. I fear, Gentlemen, that some of my auditors may find the matter of our present lecture dry, though its importance will be readily admitted by all; and I can only say that, however tedious the critique, the wading through the somewhat barbarous Latin of the original author was no amusing task. 1. Is THE MARSH POISON ONE AND INDIVISIBLE ? Lancisi observes of the effluvia : " Non VARIETY OF POISONS. 125 ubique et semper eadem sunt, ejusdemque materice ;" " They are not everywhere and constantly the same, nor is their con- stitution always identical." And again : " Yaria quoque in aerem ferri corpus- cula, seu particulas solutas, et casu potiiis quam certa lege societas, qua?, in nostrum corpus ingests, minorem vel majorem nox- am inferunt, prout minus vel minime inter se temperatse, aut etiam ad veneni prope naturam evectse sunti (p. 37) ;" "There are also carried into the air various kinds of cor- puscles, or particles held in solution, and connected rather by accident than by definite laws, which, on being received into our body, produce greater or less distur- bance in it, according as they have been variously tempered together, or as they may even approach the nature of a poison." s^ Thus he admits, virtually and positively, variations in the nature and character of the reputed poison (but he says riot a 126 LECTUEE III. word about unity all throughout), as in the case of other specific poisons, such as the animal poison of small-pox, or the inorganic poison of prussic acid, or that matter which is believed to be the common poison of continued fever conta- gion. He further remarks in this matter : " Idcirco apud scriptores legimus, hujus- modi epidemias raro inter se omnino similes fuisse, turn qualitate et gravitate symptomatum, turn malorum exitu ad salutem, aut ad mortem. Quamobrem fateri necesse est, vapores a fracescentibus lymphis assurgentes noxios utique et plerumque malignos esse, sed singulos sub und eddem- que specie comprehendi non posse; ac propterea medicos illos a vero quam longis- sime abire, qui unam semper certamque in omnibus ejusmodi effluviis particularum naturam aut quserunt cum spe inveniendi, aut se jam invenisse existimant" (p. 35). " We accordingly read, that epidemics of VARIETY OF POISONS. 127 this description have very rarely resembled each other, either in the nature and severity of their symptoms, or in their mode of ter- mination in recovery or in death. While, therefore, we confess that the vapours aris- ing from the fermenting waters are indeed hurtful, and generally malignant, we are bound to allow that they cannot all be indi- vidually comprehended in one and the same species; and consequently that those physi- cians have wandered very far from the truth, who inquire with the hope of discovering, or think that they have already found out, that the nature of the particles in all these effluvia is always one and invariable." If there be, according to Lancisi, effluvia of a poisonous character, he surely, Gentle- men, cannot be deemed the author of the theory of a special poison. This must rather be considered as the doctrine of his commentators, as delivered in the following graphic definition by the most recent writer 128 LECTURE III. on this subject Dr. Watson; who, in his admirable Lectures on the Practice of Medi- cine, says: "The exciting cause of inter- mittent and remittent fevers the primary caused mean, that without which ague would not occur at all deserves a somewhat par- ticular attention. I need scarcely say, that it consists in certain invisible effluvia or emanations from the surface of the earth, which were formerly called marsh mias- mata, but to which it has, of late years, become fashionable to apply the foreign term malaria The malaria is a specific poison, producing specific effects upon the human body .... In its medical sense, it is not simply bad air, or impure air . . . The impure air incident to large and populous cities is prejudicial enough to health, as I formerly took occasion to show you ; but it does riot generate fever ; nei- ther continued fever, nor intermittent . . . The effluvia, which thus form the sole ex- LANCISI AND MALARIA. citing cause of intermittent and remittent fevers, proceed from the surface of the earth .... The inference that they exist was not made till within the last century and a half . . . Lancisi was the first, so far as I know, to put forth distinct ideas con- cerning malaria in his work, De noxiis paludum efflumis. This is the great ori- ginal work on the subject." But, as already stated, Lancisi certainly cannot be consi- dered a special pleader for the doctrine of marsh miasm, in the sense so clearly de- fined by Dr. Watson. This we shall see more fully immediately. By breaking down the unity of the cause, and therefore admitting the agency of other forms of the same cause, he tacitly confesses the probability of other causes than the miasm of marsh effluvia; and thus the whole fabric of the hypothesis of a specific poison falls necessarily at once to the ground; for the malaria, as such, can only be con- 130 LECTURE III. sidered a specific agent so long as its indi- viduality and indivisibility remain unques- tioned. Moreover, his words just quoted, " aut etiam ad veneni prope naturam evectce sunt" distinctly imply a doubt as to the existence of any poison at all. 2. ARE WE TO SUPPOSE THAT MARSH MIASM ACTS AS THE ESSENTIAL CAUSE OF INTER- MITTENT FEVER, BY ITS POISONOUS ACTION ON THE NERVOUS OR ON THE SANGUIFEROUS SYSTEM ? That there might be a poison existing in the atmosphere of marshy districts, we possess no grounds, a priori, for denying ; but the onus probandi assuredly rests with those who maintain the existence of such poison, more especially as they assert that its presence is not the subject of direct de- monstration, but rather inferential. ORGANIC AND INORGANIC EMANATIONS. 131 But Lancisi propounds, as part of his doctrine, that there are two kinds of poi- sonous emanations disengaged from, waters in a state of corruption (putrefaction) ; one altogether inorganic in nature; the other distinctly organic in character. The for- mer he conceives to be " an accumulation of dead and inorganic particles, with im- pure sulphur, and acrid and volatile salts, with other extraneous matters, which being densely evolved in the exhalations from the waters, affect, in a very unpleasant manner, the sense of smell. The other genus of effluvia is composed of a multitude of worms and ova, which float about in the atmos- phere a distinct host of aerial animalcula." " Alterum quidem est congeries inorganic- arum atque inanimarum particularum, im- puri sulphuris, saliumque lixivio acrium ac volatilium, aliorumque exoticorum, quse, aqueis halitibus crasse obvoluta?, ingratum etiam naribus ernpyreuma propinant. Al- 132 LECTURE III. terum vero effluviorum genus constat mul- titudine vermiculorum atque ovulorum, quse animalium quasi agmen instruuntur in aere." Hence it is obvious, that the constitution of the vegetable or marsh miasm is alto- gether of a heterogeneous and contradic- tory nature ; for the first, or inorganic con- stituent, can scarcely be conceived to belong to the vegetable world at all, as the sulphur and saline elements sufficiently testify; nor is the character of the second less emphati- cally marked, as it has no claim whatever to the title of an effluvium or poison, being positively an atmospheric congeries or aggregation of animalcules. The application of these, therefore, to the body, must neces- sarily produce, if any, very diverse effects. Confining my observations to the effects of the organic or vitalised effluvia, let me again quote the words of Lancisi. He observes : " Exploratum quidem nobis videtur, or- MODES OF ACTION. 133 ganica atque animata effluvia a paludibus prodeuntia triplici potissimiim modo nos- trum corpus vitiare ; Primo, 1. Per se ipsa irritando, vulne- randoque. Secundo, 2. Quod forte deterius est, pravos suos succos cum nostris liquidis permiscendo. Tertio, 3. Denique indigenas lumbricos nutriendo, saginendoque" (pp. 53). " It seems to be ascertained, that the organic and animal effluvia, proceeding from marshes, affect our body chiefly in a threefold manner : 1. By mere irritation, and by the wounds they inflict. 2. What is more serious, by mingling their corrupt juices with the fluids of our bodies. 3. Lastly, by affording nourishment to the parasitic intestinal worms." Thus, in accordance with the views of 134 LECTURE III. Lancisi, it is less by a direct action on the nervous system, than by a positive agency on the fluids of the body, that the delete- rious effects of marsh effluvia arise. The third mode that of affording a supply of nourishment to the worms within, after which, he believes, the economy of the body is disturbed by these animalcules, is not a little remarkable, and does not in any way countenance the idea of a specific poi- son acting as a cause of ague, whatever other influence they may be supposed to exercise. It is, moreover, Gentlemen, an incontestable proof of the very crude and unsatisfactory nature of the ideas attached by Lancisi to the assumption of an efflu- vium, from marshes; for, under his plastic hands, while in one instance it is purely and distinctly of an inorganic constitution, in another form it assumes not the character of a specific poison, but of a hybrid medley of organic mixture, represented by worms. WANT OF EVIDENCE. 135 ovula, et id genus omne, in the action of which he perceives a source of irritation applied to the organic tissues, and a pabu- lum of nutrition to the worms and ova indigenous to the intestines of the human body. In vain do we search here for the dis- tinctive proofs of a purely vegetable poison, arising during the putrefactive process of vegetable life ; in vain do we endeavour to discover those more simple forms into which the decomposing process resolves all that has lived, be it animal or vegetable; in vain do we recognise in these representations of the simple forms of animalcular life, aerial essences, whose constitution is so happily adjusted, that they rise, by the expansive influence of the solar heat, to be condensed and precipitated earthwards, on the approach of the shades of night, like any inorganic gasiform body. For it is paramount, in our consideration of the ori- 136 LECTURE III. ginal marsh miasm theory, that we always have before our eyes a distinct perception of the physical properties of the supposed poison, as well as a notion of those matters which enter into its constitution. 3. ARE THE EFFECTS OF MARSH MlASM PRODUCED ONLY IN ONE MODE NAMELY, BY ITS ACTION AS A SPECIFIC POISON? We shall presently see, that the influence of marsh miasm is not solely limited to the production (according to many of the mo- derns) of ague alone, but that it is further effective in exciting other forms of diseased action, such as diarrhoea, dysentery, cholera, neuralgia, rheumatism, &c. The observa- tions of Lancisi, however, do not refer to the different kinds of diseases induced by the marsh effluvia, but to the different modes in which these effluvia act as an ALLEGED MODES OF ACTION. 137 exciting cause of intermittent fever. His words are too remarkable to be omitted here : " Corporibus nostris magnam affe- runt labem, quia scilicet partim recremento- rum perspirationem prsepediunt ; partim de- trahunt quse incolumitati suffragantur ; par- tim (quod maxime advertendum) multa inge- runt, quse sanguini spiritibusque nostris, immo etiam solidis partibus, peculiaria inferunt detrimenta;" " They are highly injurious to our bodies, partly because they prevent the perspiration of certain excre- tions, partly because they withdraw those elements which contribute to safety, and partly (and this is particularly deserving of notice) because they introduce many prin- ciples of highly pernicious character into our blood and vital fluids nay, even into our solid tissues." Now Gentlemen, we are here obviously presented with some of the leading doctrines of the pathology of intermittent fever, as 138 LECTURE III. entertained by Lancisi. It is scarcely neces- sary to remark, that only in the third of these propositions is there any countenance given to the idea of a poison. Nor is the description which he offers such as would lead to the doctrine of the special oper- ation of one element as the efficient agent in exciting ague; for he employs the word multa, as expressive of the general character of the matters which contaminate the blood a term altogether abhorrent to the idea of one agent affecting the animal economy. It would, indeed, appear, that Lancisi had not any very definite idea as to the individuality of the poison, and the individuality of its effects; for, while he assumes a contamination of the fluids and solids as one of its effects, he unhesitatingly admits the positive influence of suppression of the excretions as another result of the application of the effluvia ; and furthermore attributes a negative action to their effect, ACTION OF THE ATMOSPHERE. 139 that of removing, impairing, and weaken- ing certain states or conditions especially requisite to the perfect health of the body. Whatever, then, modern authorities may please to assert of Lancisi, it is apparent that he was not so wedded to the idea of marsh poisons as not to appreciate, clearly and distinctly, that the existing condition of the atmosphere in malarious localities had a decided action in effecting most im- portant changes, positive as well as nega- tive, on the functions of the animal body. Was Lancisi acquainted with the fact of the great amount of the cuticular perspiration, and the influence of moisture in diminishing all the secretions? Into this question it is immaterial to enquire, as he sufficiently evinces the weight he attaches to the fact, mentioning suppressed perspiration as one of the leading heads (three in all) of the effects of marsh effluvia on the human body. 140 LECTURE III. In proceeding farther with his observa- tions, and in adverting to the reasons which may be given explanatory of the injurious agency of a marsh atmosphere, he writes as follows: U E contrario palustris aer, cum crassus, minus mobilis, minusque elasticus, immo, quod pejus est, impuro sulphure acri- busque salibus sit inquinatus, naturales certe functiones alterabit, liquidisque nostris ad- mixtus eorundem crasim motusque vitiabit, fibrarum quoque inducta laxitate" (p. 45 ;) " On the other hand, a marsh atmosphere, as it is dense, less mobile, and less elastic, nay more, what is worse, as it is rendered corrupt by impure sulphur and acrid salts, will cer- tainly affect the natural functions, and, com- mingling with the fluids, will vitiate their cohesion and movements, inducing also a relaxation of the animal fibres/' And again, at p. 45, he says : " Unde fit, ut qua? nostris a corporibus perspirari deberent vel noxia, vel saltern inutilia ACTION OF ATMOSPHERIC POISON. 141 corpuscula, inagnarn partem prohibeantur effluere (cujus efFectus signum e vestigio est vitiatus in advenis color, inductaque corporis lassitudo) ; rursumque deteriora propter extraneorum admixtionem effecta, in sanguinem, in praecordia, atque in csetera viscera refundantur; quibus locis eo usque accrescunt, et cumulantur, donee, naturalibus solidorum et liquidorum viribus superatis, febrem accendant, reliquis comi- tatam symptomatis, quibus castrenses et pestiferae stipari solent;" "Hence it is, that those corpuscles, which ought to be thrown off from our bodies as detrimental, or at least as useless, are in a great measure prevented from being removed (an almost immediate indication of which is the change in the complexion of strangers, and the readiness with which they become fatigued) ; and, rendered still more noxious by the admixture of foreign matters, they are again thrown back upon the blood, the praacordia, 142 LECTURE III. and the other viscera ; in which parts they increase and accumulate to such an ex- tent, that, overcoming the natural powers of the solids and the fluids, they induce a fever, accompanied with all those symptoms which usually attend on camp and malig- nant fevers." In this paragraph we have the chief action of the effluvia developed in two dis- tinct and different circumstances first, the checked and impeded state of the perspira- tion ; and, secondly, the admixture or in- troduction of foreign matters into the course of the circulation. That our author should attribute the greater influence to the latter, was natural enough; but, in attaching no small importance to the former, he evidently proves that he was not so completely ab- sorbed in his theories as to resist the clear evidence of his senses. Facts, or rather statements, like the above, speak strongly in favour of the candour of Lancisi; for we DELETERIOUS EFFECTS OF BKEEZES. 143 have no right to lay to his special charge the notion of the impure sulphur, and the acrid salts mixed with the atmosphere; these were portions of the theory of his era, and would, therefore, naturally tinge the current of his reasonings. But, whatever faith Lancisi may have been disposed to give to his own doctrine of the marsh miasm, as the essential cause of ague, he certainly did not believe that ague could not arise from other causes than this contamination. He distinctly states that breezes, from whatever quarter they blow, although most completely pure, ( " tametsi saluberrimus") are adequate to induce dis- ease, solely by the force of their current a proposition completely heterodox to the general tenor and drift of his observations, but altogether consonant with my own experience. 144 LECTURE III. 4. Is THE EFFECT OF MARSH Ml ASM LIMITED TO THE SOLE GENERATION OF INTERMITTENT FEVER, AS SPECIALLY AND DISTINCTLY SEPARATED FROM CONTINUED FEVER ? Singular as it may appear, Lancisi does not make that decided difference between intermittent and continued fever which obtains so generally in all our modern works, and which has received the sanction of the schools. On this topic he uses the following explicit arid emphatic terms : " Cognitum itaque perspectumque medicis erit, ideo primum sub sestatis initium, ter- tianas paludum habitatores adoriri ; postea continuas ac nialignas febres, deinde etiani pestilentes; tandemque eosdem longissimis morbis implicari;" "It is, accordingly, an established and well-known fact to physicians, that, at the very opening of the summer, the inhabitants of marshy districts are attacked MODE OF INVESTIGATION. 145 by tertian ague; continued and malignant fevers then succeed, and also pestilential; and at length they are subject to tedious chronic diseases." His testimony here is the more valuable, as his bias must have naturally been to restrict the effects of marsh miasm to inter- mittent fever, as its sole product. But it is apparent that Lancisi read the Book of Nature, as she unrolled her pages, not as he might have viewed her through the spec- tacles of the theoretical nosologist, leaving to a more complete and more perfect state of the science the task of apportioning each disease to its special rank and position in the nosological chart. In his further observations on the effluvia of marshes, reference is made by Lancisi to the remarks of Varro on the same subject, who describes a host of animalcules not patent to the eye " qua? non possurit oculi consequi," which, nevertheless, are suffi- H 146 LECTURE III. ciently adroit to insinuate themselves into the body by the mouth and nostrils, occa- sioning very serious diseases " difficiles morbos." Colurnella he also quotes, as testifying to the same fact. Nor were the philosophers in those days inadept practitioners in the art of splitting hairs, " 'twixt north and north-west side ;" for, while Yarro and Columella ascribe the fevers to the introduction of these animals into the system, Vitruvius, adopting a some- what more rechercM pathology, ascribes all the disorder to the effects of the hysteric winds and secretions of the aforesaid animal- cules. The words are : " Sed in flatibus collocat, exhalationibus et spiritibus ab iisdem insectis potissirnum emissis.'' Re- ferring the ague " to the winds and flatulent discharges and exhalations thrown off by the insects " ! ! ! So much for theory ! Thus Gentlemen, you will perceive that, whatever opinions the moderns may have HE HAD NO PET THEORY. 147 ascribed to Lancisi, the perusal of his works will sufficiently prove that he had no special pet theory to advocate and support ; as his remarks, to which I have just adverted, in describing the different characters of the effluvia evolved in marsh districts, abun- dantly testify. Nevertheless, the following passage is too striking to be passed over in silence, especially as it exactly corresponds with my own experience, to be subsequently noticed, of the influence of the sea-breezes, under certain conditions of the animal eco- nomy, in exciting a paroxysm of intermittent fever. The words are : " Quamobrem quilibet ventus, tametsisaluberrimus, malum istud sola impulsionis vi prod u cere valet, et contra ipsemet auster interdum tueri et conservare ambientem aerem alicubi potest, quoties alio ac potissimum in contrariam plagam malignos habitus validissime trans- fert;" (p. 40). "Wherefore, a wind from any quarter, however salubrious it may be, is 148 LECTURE III. adequate to produce this malady by the force of its current alone ; and, on the other hand, the very same wind may sometimes preserve the atmosphere of any place, by the force with which it repels malignant vapours in another direction, and especially if towards an opposite region.' 7 Words cannot more definitely describe the generation of inter- mittent fever, independently of all vegetable or marsh effluvia. I have thought it proper to put this testi- mony on record, as it must be admitted to be free from all bias, and therefore more invaluable as an adjunct in support of the doctrine which I have myself embraced. I am perfectly sensible that it might be con- ceived by some to prove too much; this, however, I imagine, it must be allowed to demonstrate, most clearly and explicitly, that Lancisi never entertained or promul- gated the idea of a poison being the inva- riable exciting cause of intermittent fever. LANCISl'S REAL NOTIONS. 149 Upwards of a century, then, has this reputed doctrine of Lancisi ruled in the medical world, receiving implicit credence on every hand, while all the methods of treatment, preventive as well as curative, have been fashioned to the mould of the hypothesis, and have been lauded or con- demned in proportion as they corresponded with it, rather than in proportion to the success with which they were attended. In framing his doctrine, Lancisi obviously was influenced by the then prevailing notions of the animalcular origin of dis- eases; and whatever opinions the moderns, from tradition and mere hearsay, have adopted regarding it, the extracts which I have submitted to you will clearly demon- strate that, in his eyes, the cause of marsh fever was neither simple nor uniform, and in no mode whatever entitled to the name of a specific poison. It distinctly em- braced two kinds of emanations organic 150 LECTUEE III. and inorganic the former of which was not to be distinguished as a special poison, but was a heterogeneous mixture of organic compounds, combined with the ova of ver- micular animalcules. So far, then, the authority of Lancisi cannot be adduced in favour of the doctrine of a special poison; but his authority is invaluable as proving the distinct origin of every variety of fever from the agency of moisture, cold and heat, and other atmos- pheric vicissitudes. In this respect, his observations become of the highest interest, and in a great measure corroborate the views which I have myself been led to adopt ; first, as to the cause of these fevers, and second, as to the means of prevention and cure. His words on the effects pro- duced by the effluvia are distinct and em- phatic : " Checking the perspiration by which the noxious and useless matters, which otherwise accumulate in the system, HIS VIEWS OF MAESH POISON. 151 ought to be carried off from the body." " Unde fit, ut quae nostris e corporibus per- spirari deberent vel noxia, vel saltern inu- tilia corpuscula, magnam partem prohi- bentur effluere." I shall conclude, Gentlemen, with a brief and condensed statement of the chief views entertained by Lancisi on the subject of marsh poison and its effects. You will at once perceive, how widely his recorded doctrines are at variance with those so universally and erroneously imputed to him, more especially by the moderns. He observes : 1. That the poisonous emanations of marshes are not of a simple nature. 2. That they are always compound. 3. That they are composed of inorganic and organic effluvia. 4. That the inorganic portion can scarcely be held of itself to be a cause of disease. 152 LECTURE III. 5. That the organic constituent (which, by the way, is almost wholly of an animal composition), conjointly with the preceding, occasions the fevers, &c. 6. That these emanations are conse- quently of a very compound character. 7. That these emanations or effluvia vary very much in their physical and chemical constitution. 8. That they are more especially in- fluenced by the season of the year. 9. That they produce a diversity of diseases. 10. That they excite continued and re- mittent fevers, as well as the intermittent. 11. That they give rise to other maladies, such as diarrhoea, &c. 12. That the fevers are not always caused by marsh airs or miasma. 13. That they occasionally arise from a disturbed state of the elasticity of the atmosphere. LANCISI QUOTED, NOT READ. 153 14. That they are materially influenced by worms taken up by the animal body. 15. That they occasionally originate where the atmosphere is in the state of highest purity; and finally, 16. Lancisi never employs, throughout his work, the word " venenum " or poison ; and, consequently, he cannot be charged with the theory of marsh rniasm being a specific poison. The diversity of effects, indeed, which he ascribes to its agency, fully negative any such proposition. In fact, as 1 have already stated, Lancisi has been quoted, not read. I hold in my hand, Gentlemen, numerous other extracts from the works of Lancisi, bearing out the views I have just submitted to you, and no less striking than those which I have already quoted. Our time, however, will not admit of my reading them, nor is it necessary. H2 LECTURE IV. PKE VAILING DOCTRINES ON MALAKIOUS FEVERS PE- RIODICITY NOT CONFINED TO INTERMITTENT FEVER PARALLEL BETWEEN GOUT AND AGUE KEVIEW OF THE CONFLICTING OPINIONS AS TO THE SOURCE, NATURE, AND PROGRESS OF THE ALLEGED MARSH PoiSON SUMMARY OF THE VIEWS OF STANDARD AUTHORS. GENTLEMEN, I have now to direct your attention to a brief consideration of the prevailing doctrines or opinions on those forms of fever of which marsh poison is the (supposed) special cause. For the term marsh poison, the more general, though not less equivocal term, malaria, has been re- cently substituted. Nor has this change in the term been altogether fortuitous, or pro- duced by mere fashionable caprice, as sug- PREVAILING DOCTRINES. 155 gested by Dr. Watson, but rather the result of an extension of our knowledge of the conditions under which the fever originates ; for, in the term malaria, we have eventually expressed a doubt as to the invariable ori- gin of the fever from emanations arising through the decomposition of vegetable matters in marshy districts. I have already noticed the clear and concise definition of Dr. Watson, and shall now present you with the general foundation of the doctrine that marsh miasm and ague stand to each other in the relation of cause and effect, as laid down in a modern work of standard character the Cyclopcedia of Practical Medicine. " We infer the existence of the matter designated by one or other of these terms (malaria or marsh poison), as we do that of contagion in cases of disease which do not furnish a material transferable by inocula- tion, from certain effects on the animal 156 LECTUKE IV. economy; and we trace its origin to marshes, from its having been observed, for a series of ages, that such effects are pro- duced only in the vicinity of marshes, or at least are more abundant when vegeta- ble matter and water are so situated with respect to each other, that chemical reac- tion between them is possible; and when we perceive the more familiar of them, parti- cularly intermittent and remittent fevers, we infer its existence, and endeavour to dis- cover its sources, which may not be very manifest." Medical observation, Gentlemen, is in truth a most fallacious and error-leading subject; nor does this charge apply to the discussion of medical questions alone, for error, fallacy, and doubt, beset every sub- ject which the mind of man compasses. Moreover, when we consider how much the condition of the sciences pertaining to the philosophy of nature has been altered and MEDICAL OBSERVATION FALLACIOUS. 157 changed within the last arid since the opening of the present century, we would not feel much inclined to repose unlimited confidence in this evidence " of ages ;" espe- cially when it is stated of a fundamental element in the theory, that it "is possible.'' In contemplating such questions, we should remember that the old doctrine of phlogis- ton has not long disappeared before the searching inquiries of modern chemistry; and that scarcely more than seventy years have elapsed since the compound constitu- tion of the atmosphere was demonstrated. When, therefore, we consider the brilliant discoveries which have since illumined the walks of the chemist and the histologist, it is not unreasonable to suppose that the more complex nature of animal organisa- tion, and the various agents by which it is affected for good or for evil, must have been reciprocally illustrated, and rendered more definite in their characters, and pre- 158 LECTUKE IV. else in their relations, in so far as the pre- sent age is supplied with new elements and new methods of investigation for the elimi- nation of truth, which were altogether beyond the reach of our predecessors. Is PERIODICITY A DISTINCTIVE FEATURE IN CERTAIN DISEASES ? Much importance has been attached by modern authorities to periodicity, as serving to distinguish the various diseases originat- ing in marsh poison. Now, with reference to this law, I cannot help observing, that the explanations offered by different authors afford an admirable illustration of that con- venient and laudable art by which we are enabled to conceal our ignorance under a cloud of scientific and well-sounding phrases, which, at first sight, would appear to convey something very like sense : but whose intrin- sic value, when they are analysed, is found PERIODICITY NOT DISTINCTIVE. 159 to amount to " Vox et praeterea nihil." I apprehend, indeed, that the law of period- icity, or the disposition to remission and exacerbations, at certain intervals, will be found to apply more or less distinctly to all human diseases to those arising in the most opposite conditions of the animal economy, and determined by morbific agents apparently the most dissimilar and opposite in their nature as well as in their results. For example, what conditions, within the whole range of human nosology, can be seemingly more dissimilar arid opposed than the high animal development, full plethoric constitution, and robust manifestations of vital power, evinced in the indolent, over- fed, and gouty denizen of British corporate life, as compared with the pale, sickly, aguish, and care-worn countenance, the ill- nourished and emaciated frame, of the peasant of the Roman Campagna? PARALLEL BETWEEN GOUT AND AGUE. In 160 LECTURE IV. our great cities, the wealthy citizen ordi- narily indulges in the most substantial food, the richest cookery, and the most stimulat- ing wines. His habits, pampered, indolent, and luxurious, react with certainty on the mind, which soon loses tone, and becomes unfit for healthy action. The higher attri- butes become gradually blunted ; the animal propensities are exalted ; and the expression of the countenance is unfavourably modified. Concomitant with these, and at an earlier or later date, according to the constitution and predisposition of the individual, other changes are developed. The gastro-intesti- nal mucous membrane suffers ; the digestive functions fail; the animal and mental ener- gies give way; the secretions and excretions, which have long ceased to be efficiently eliminated, are changed in quantity and altered in quality; and their accumulation in the system is revealed by derangement of the circulation, and by their deleterious PARALLEL BETWEEN GOUT AND AGUE. 161 impression on the vital powers, and on the various organs of animal and organic life. At length, oppressed nature makes an effort to remove the evil, and a paroxysm of gout, more or less regular, is the immediate conse- quence. Let us now observe the results on the animal economy, and the depressed state of the constitutional powers, incident to the individual exposed to labour disproportioned to his strength, scanty or unwholesome diet, and insufficient clothing, and residing in low and humid localities. Sooner or later, according to constitution and predisposition, the influence of these conditions will be manifest, as in gout, first, in impaired organic nervous power, producing inade- quate performance of the respiratory actions, derangement of the heart and blood-vessels, and direct or indirect affections of the secreting, excreting, and assimilative func- tions, as well as of the mental manifestations. 162 LECTURE IV. Hence arise congestion of the large vessels, and of the internal viscera, and contamina- tion of the circulating fluids, from diseased or deficient secretion and elimination of their various constituents; followed, when the accumulation of morbid principles has reached a certain height, by reaction, or an effort of nature to efface the morbid impres- sion on the different organs, to restore the blood to its normal condition, and to re-establish the energetic and healthy action of the different secreting and excreting organs. This effort will be revealed in the peasant by a paroxysm of ague, as in the alderman by a paroxysm of gout ; and here commences the law of periodicity in both. Behold, then, the citizen, flushed and rubicund, groaning under a regular parox- ysm of inflammatory gout ; the peasant, with his sallow Hippocratic face and attenuated frame, shivering in the horrors of a paroxysm of ague. Observe them again in a few REMISSION V. INTERMISSION. 163 hours. Both are restored apparently and but apparently to their ordinary health, to undergo, after a brief space, a repetition of their previous sufferings, followed by ano- ther remission. Here, clearly, is periodicity, as distinct and well marked in the gorged and gouty alderman as in the half-starved aguish peasant. But it may be urged that the analogy is incomplete that gout exhibits only a remission, the ague an intermission. I deny the truth of both propositions, at least in so far as relates to the distinction attempted to be established between remission in the one case, and intermission in the other. The term inter- mission (cessation or suspension of disease), in fact, applies correctly to neither. The animal economy does not return to its healthy condition during the interval be- tween the paroxysms of an intermittent fever, as must be admitted by every observer who has watched its progress attentively, 164- LECTURE IV. or who, like myself, has been the subject of an attack. The same holds good in gout. In both diseases, the interval between the paroxysms is marked by certain feelings of malaise, irritability, depression of vital power, and derangement of the secretions, as truly indicative of morbid disturbance as the throbbing toe, the icy chill, or burning temples. Thus, then, we perceive that in regular gout a disease to which few will be disposed to assign a malarious origin the law of periodicity applies no less closely than it does to ague. The analogy between masked or simulating intermittent, and atonic or anomalous gout, is too obvious to require comment. On reflection, however, we need not feel much surprise that an analogy so striking should obtain in the phenomena of diseases which, on cursory observation, appear so dissimilar. In truth, the general features NATURE OF AGUE. 165 of the internal conditions in both maladies are identical, in so far as, in both, the circu- lating and secreted fluids are poisoned, not by morbific matters carried into the circula- tion from without, but by deleterious or effete elements generated within the system, and which ought to have been eliminated. In considering ague, as, indeed, in almost all other diseases, there are other morbid conditions to be attended to besides those which are essentially expressed in the noso- logical character of the malady, and which not unfrequently assume the appearance of the major element. Thus ague, in its simplest form or type, may be held as a succession of three stages the cold, hot, and sweating. But to these may be added visceral, especially splenic and hepatic con- gestions ; and, in more aggravated cases, various modifications of mucous irritation arise; so that we may have three distinct forms of morbid action connected with, and 166 LECTURE IV. primarily dependent on, the same exciting cause. CAN THE SUPPOSED POISON or AGUE REMAIN DORMANT? It has been urged, in proof that a special poison acts on the system in ague, that individuals, exposed only for a brief period to the influence of marsh miasmata have been seized with intermittent fever. Now, I have myself been repeatedly exposed, and have witnessed the temporary exposure of others, in robust health, and with unim- paired nervous energy, to the most concen- trated emanations of marsh effluvia in various quarters of the globe ; and in no single instance have I ever observed such temporary exposure followed by ague. It is true that, had such persons been previ- ously subjected to the influence of long- continued heat, cold, fatigue, intemperance, DOES THE POISON LIE DORMANT? 167 the depressing passions, &c., then, indeed, intermittent or remittent fever, rheumatism or dysentery, or some other disease, might, and probably would, ensue, according to the constitution and predisposition of the individual. Such sudden attacks I have repeatedly witnessed to supervene on such temporary exposure in marshy localities; but I have invariably found, in these instances, that the constitutional powers of the individual had previously suffered from one or other of the depressing moral or physical agencies just alluded to. Nor, in this inquiry, must we lose sight of the fact, that a long interval may elapse between the application of the supposed malaria and the appearance of the intermittent, as I myself frequently witnessed in 1812, while serving as resident medical officer in the general hospital at Cadiz, the garrison of that fortress being then chiefly composed of British troops, who had been engaged in 168 LECTURE IV. the memorable and disastrous expedition to Walcheren. Even in this country, I met with a distinguished member of the English bar, who had just recovered from a severe attack of ague, supposed to have had its origin in a night journey across the Pontine marshes, under circumstances almost identical with my own. Now, this gentle- man had, in the interim that is, between autumn and spring enjoyed his usual health ; yet did his physician, one of the most eminent in England, consider that the marsh poison had lain dormant in the system during this long interval, until called into activity by a prolonged exposure, in an open carriage, to a keen easterly wind, exactly seven months after the supposed infection ! The case of a lawyer, also, under precisely similar circumstances, was reported to me while in Edinburgh; with this difference only, that the period of incubation, as the phrase goes, was con- DOES THE POISON LIE DORMANT? 169 siderably less about one-half between the supposed introduction of the poison and the development of the disease. Recently, also, Mrs. C., wife to one of the British merchants at Bahia, where she had resided for some years, and whence she had just returned, after a long sea voyage, was seized with a severe attack of ague, on the evening of her arrival in Cheltenham, months after she could by any possibility have been exposed to the influence of marsh miasm. Are we then, in these and similar cases, really to believe that a poison has entered the system, and remained dormant and unchanged for months, nay, for years? There is something so painfully unsatis- factory in our endless succession of medical theories, that the mind, in this as in other questions, longs for a resting-place it feels the want of a point (Tappui, and often, I am persuaded, actuated by that feeling, I 170 LECTURE IV. " sees a little, and jumps to a conclusion;" less from the force of the facts and cogency of the reasoning, than through the desire of enjoying some fruits for its labour, even if it be but the mere empty satisfaction of an hypothesis. EEPUTED ORIGIN OF POISON FROM MARSH MIASM. You will recollect, Gentlemen, that the proposition of the origin of intermittent fever first opened with the statement, that a rniasm from marshes was essentially requi- site to its generation ; and this' idea was, in the main, apparently substantiated by the abettors of the theory, from the extreme prevalence of that class of diseases in the immediate vicinity of those regions. It has since, however, been discovered that the narrow theory of limitation to marshes was not so universally tenable as had been com- ORIGIN OF MAESH POISON. 171 morily credited; for the poison, or rather the supposed poison, (as its existence had yet to be demonstrated), betrayed its effects under conditions of the ground and the sur- face, to which the term marsh, in any sense of the word whatever, was totally inappli- cable. Accordingly, then, as the range of observation and inquiry extended, the in- termittent and remittent forms of fever were discovered to prevail frequently in the midst of low and dense brushwood amidst reeds and grasses ; and in certain instances, its source had been traced to large and open woods. The jungle fever, which is so pro- verbially known in our Eastern possessions, originates in districts of the character now described; and, in the tropical regions of Africa and America, a similar fever is pre- valent under identically similar circum- stances, far distant and remote from every thing in the form of a morass. The wet meadow-lands, the grounds 172 LECTUEE IV. alternately flooded and dried for the culti- vation of rice, and the half-wet ditches of fortifications, were subsequently recognised as common sources of intermittent fever. Ponds and marshes dried up by summer heats, the dry mud exposed by the flow and ebb of tidal rivers in hot climates, the expo- sure of land by felling the timber have all, at different periods, and in different histo- rical records, been noted as the cause of ague. We are further particularly inform- ed, on the authority of Macculloch, that the effect of turning up land which had long lain as pasture, has been productive of fever equalling in malignity the plague; the labourers actually dying on the spot in the course of twenty-four hours, if they re- mained there all night. The above-mentioned have been common- ly reputed the natural sources of the fever. The artificial decomposition of vegetable matter, as in the process of steeping flax and VEGETABLE DECOMPOSITION. 173 hemp, is affirmed to be not an unusual source of the same malady; and Eush mentions the decomposition of coffee, potatoes, pepper, &c., as being attended with a similar effect. The leakage of sugar, the contaminat- ing reaction of bilge-water on chips and shavings, as well as neglected sewers, have all successively been condemned as productive of intermittent and remittent fevers. From the collective grouping of all these facts, the general inference was drawn, that the concurrence of the action of decompos- ing vegetable matter, along with moisture, was indispensably requisite in all cases to the generation of intermittent fever. The medical world generally was disposed to acquiesce in this idea, and, taking the hypothesis for granted, felt satisfied in tracing out the laws of the poison, in ascer- taining its actual effects on the animal eco- nomy, and in determining the modifications 174 LECTURE IV. under which its agency comes into play, &c. &c. On these topics they have dwelt with no small degree of curious precision; and, if they have not substantially proved the entity of their poison, the element, source, and origin of all their deductions, they have certainly raised a superstructure, no doubt attractive and ingenious, but as illusive, I believe, as the basis on which it rests. Nor have their researches been less curious than hypothetical; for, a pure as- sumption being the basis of their theory, a numerous progeny of fancies and hypothe- ses have issued therefrom, all bearing the common family likeness of misapplied obser- vation and incomplete evidence. That the foregoing is no exaggerated statement of the data which are current at this very hour on the etiology and semeio- logy of intermittent fever, I conceive that the following statements on different points connected with the origin, progress, dif- MARSHES DO NOT GIVE RISE TO FEVER. 175 fusion, and arrestment of marsh fever, as it is commonly named, will satisfactorily attest. The usual source has been supposed to be a marsh; but the observations of the great mass of practical men who have actu- ally witnessed these fevers, all agree in showing, that it is not when the marsh is properly entitled to that appellation that fever is most rife. On the contrary, when the rains set in, the fever usually disappears, and endemic disease subsides; and, in Africa, the natives then freely visit each other in their canoes, the danger existing when the water is dried up, the vegetation all burnt, and nothing but an arid desert remaining. In 1799, the plains of Holland did not produce any fever among our troops there, the season being wet; and it was left for the dry weather, during the fated Wal- cheren expedition, to testify to the malig- nant fevers which can arise in a situation 176 LECTURE IV. devoid alike of vegetation and of moisture. Spain and Portugal afford similar evidence. Again, Trichori, in the Gulf of Volo, in Greece, a dry limestone rock, is notorious for its malaria; in testimony of which we have the high authority of Dr. Macmichael : and there are many Trichories. Dr. Watson, in his work already quoted, observes, that " malaria, the primary excit- ing cause of intermittent and remittent fever, without which ague would never occur, is a specific poison, producing speci- fic effects on the human body." This definition, like all emanating from Dr. Watson, is clear and concise; but, unfor- tunately, the disease does not obey one single law of those attached to the histories of the so-named specific poisons. Contrast it, for example, with small-pox, or with scarlet fever, or with measles, &c. I would not, however, have this definition of a poison forced down on our opponents; but we FANCIED PAEALLELISM. 177 are justified in assuming that such is the general expression of the fact, as they are all unanimous in adopting the notion of a poison. This notion, perhaps on the theo- retical ideas of Cullen, they conceive to be in a great measure substantiated by a fancied parallelism, running through the great organic kingdoms of the animal and vegetable world. Thus, as we have animal (supposed) poisons, to produce continued fever, so we have a vegetable poison which generates the intermittent fever. I would here, however, observe, that there is a very wide difference between the two conditions ; for the contagion of typhus is deemed the result of a living action throughout the diseased animal tissues ; whereas the poison of the malaria, if any such exist of purejy vegetable character, is the unquestionable product of their decomposition the result of a dead action, if that term be not inad- missible. i2 178 LECTURE IV. I take it, then, as an admitted fact, that the established doctrine of the cause of intermittent fever the doctrine which has ruled the schools for the last century and a-half is that of a specific poison, either applied to the animal body, or received into its interior through the medium of the first passages. This poison, then, whatever be its ultimate nature, ought to have an unity of character, so that it might produce always the same effect ; arid ought, it is reasonably inferred, to be as uniform and consistent in its effects as the poison of small-pox, or the inorganic poisons, as arsenic, oxalic acid, or even prussic acid ; for, according to the doctrine of Lancisi, it claims the common character of an organic and inorganic poison. Moreover, when we examine the supposed causes or conditions which affect this supposed poison, we shall find an equal discrepancy of opinion on that subject. DISCORDANT OPINIONS. 179 Sir Gilbert Blane, for example, states that the people of Boston, and of the neighbour- ing villages in the midst of the fens, were in general healthy, at a time when the fever was endemic in the more elevated situations of Lincolnshire. To a similar purport is the observation of Montfalcon, that as it (the poison) was carried upwards, it became more energetic. On the other hand, a more recent authority, Dr. Ferguson, alleges that it has a peculiar attraction to the soil, and consequently has no disposition to rise into the higher regions. Not less discordant are the opinions promulgated as to the agency of water on this subtle Protean poison. A small quan- tity of water, it is asserted by high authority, absorbs and renders it altogether innocuous. In opposition to this, Lancisi states, that thirty people being out boating on the Tiber, the wind suddenly veered round to the south; the consequence of which was, 180 LECTURE IV. that twenty -nine out of the thirty were seized with fever. Equally opposed are the authorities of Sir John Lind and Sir Gilbert Blane. On the coast of Batavia, the malaria, according to Sir John Lind, was wafted out to vessels riding at anchor, some five or six miles from the shore ; while, in the narrow straits of Holland, Sir Gilbert Blane tells us that none of the seamen were attacked with the fever, which was so fatal to the land forces but a few yards distant. At Malta, it is affirmed that the effect of the poison on the spot is absolutely m7; but its ravages are exerted on the cliffs at a distance, so as to lead to the total abandonment of the village. Again, if we listen to Sir John Pringle and others, just to prove the happy uncertainty of every fact connected with the mazy wanderings of the pathological ghost of malaria, we find him affirming that the ground-floor of DISCORDANT OPINIONS. 181 houses where the malaria is disengaged is most deadly, while the floor above is com- paratively healthy ; a statement which appears to receive support from the medical history of Up-Hill Park Camp, in the West Indies, and the stations immediately below. Moreover, one authority asserts that a blank wall is sufficient to arrest the progress of the poison. Another, more aerial in his conceptions, says that it will mount upwards of a thousand feet above the water level, straying for miles away from its original source. A third writer, seemingly more familiar with the habitats of the marsh poison, informs us that the aqueous vapours, in which it is dissolved, are raised during the day by the heat and consequent expan- sion of the air, and are condensed and precipitated on the adjacent hills during the evening, there to display their pestilen- tial action, leaving the source of their origin perfectly salubrious ! 182 LECTURE IV. In further illustration of these opposite and irreconcileable doctrines, I shall now submit to you the opinion of two distin- guished French physicians, Parent-Ducha- telet, and Brachet, physician to the Hotel- Dieu at Lyons. The former, in his able work on Hygiene, amongst other subjects, acquaints us with the results of his inves- tigations on the effects of water in which hemp has been steeped. The fountains of the town of Mans are supplied by water in which this process had been carried on, and a commission was appointed by the Minister of the Interior to examine into certain alleged inconveniences resulting therefrom ; which inconveniences were pronounced to be imaginary. A similar opinion had been pronounced by M. Marc, regarding the flax-ponds at Gatteville. To inquire into this subject, on which much difference of opinion was entertained, Parent-Duchatelet zealously devoted himself for about two DISCORDANT OPINIONS. 183 years ; and he came to the conclusion, that water in which hemp has been steeped is not injurious to the health of those who drink it; that it is not narcotic; and that air charged with emanations from hemp is not improper for respiration. His experi- ments in confirmation of these opinions were performed on himself, his wife, and family, who, as well as others, drank flax- water, and slept in rooms with damp flax, &c., with perfect impunity. Let us now hear Brachet on the very same question. He states that the most efficient plan to convert a healthy village into a hot-bed of intermittent fever, is to furnish it with ponds, and steep hemp in them ! And such is the expression of the whole line of evidence connected with the marsh miasm question. Yet, Gentlemen, it is on evidence such as I have just laid before you, that we are called upon to admit the existence of the 184 LECTURE IV. malaria the entity of an agent which affects for its localities every possible diver- sity of physical condition, showing the most discordant disparity in its eifects and in its course ; and whose laws those assigned by its abettors set alike at defiance the estab- lished principles of medical reasoning, and the plainest dictates of common sense. We deceive ourselves, then, wittingly with the mere figments of a word ; for, however visionary not a few of the theoretical views presented to the profession have proved, there never was one which teemed with such an endless series of opposing statements and conflicting observations as that which has so long obtained in the medical world regarding the production of intermittent fever from marsh poison or malaria. T shall not attempt to reconcile such jarring elements ; and I conceive that, did any person make the effort, he would at once recognise that the assumption of any one DEFECTIVE OBSERVATION. 185 hypothesis was utterly inadequate to explain the phenomena as resulting from one primary cause. He would, therefore, be compelled to abandon the " baseless fabric," till more certain facts could be advanced, and a more positive assurance be offered of, at least, some disposition to consistency and rationality in the explanation of the differ- ent phenomena. After a careful perusal of the histories, and of the circumstances attendant on the general phenomena of the disease, I would observe that, while the main burden of the facts may be admitted, and that fever has manifestly shown itself under the various circumstances referred to, the state of the animal system, as affected by the varying conditions of the external elements to which it was exposed, had been scarcely at all taken into consideration. We should like to have been supplied with full information on the following and similar topics: the 186 LECTURE IV. habitual employment of the individual his exposure to fatigue the depressing pas- sions intemperance sensual excesses insufficient or unwholesome food insuffi- cient or inappropriate clothing heat and moisture variations of temperature during the day difference of thermometrical range between the day and the night deposition of dew exposure, after fatigue and excesses, to the cold night air, and the chill fogs of the morning, in gullies and valleys, in warm climates elevation and exposure, within the tropics, to strong, cool, and humid, though otherwise healthy, breezes. Still, the progress of inquiry has not remained stationary; and it is now pretty generally admitted, that woods, grasses, and trees, are sufficient to generate the poison, independently of marshes. The hypothesis of vegetable decomposing matter has, indeed, been generally aban- doned, in consequence of the observations PAUCITY OF WATER. 187 of Ferguson in the Peninsula. He states that fever always appeared similar to the worst form of fever in the West Indies, " whenever, during the hot season, any por- tion of the army was obliged to occupy the arid encampments of the level country, which at all other times were healthy, or at least unproductive of endemic fever." His inferences from these observations were, that the only condition indispensable for the production of the marsh poison, on all surfaces capable of absorption, was the paucity of water, where it had previously and recently abounded : a condition tanta- mount to a rapid state of percolation, suc- ceeded by a rapid evaporation ; or, in other words, that fevers arise where drought had succeeded to moisture. Now I have already observed, that no sufficient attention seerns to have been hitherto paid to the ever- varying conditions of the mere physical frame, independent of 188 LECTURE IV. other important considerations, under the very different and opposite conditions where, at times, it has been exposed to the sup- posed sources of intermittent fever. For instance, when Ferguson speaks of the rapid evaporation of water in places where it had previously abounded, as the efficient cause of ague, he places this isolated fact before the mind, without any sufficient notice of the highly excited state of the capillary and nervous systems during expo- sure to the intense heat of an almost tropi- cal climate, and the widely changed condi- tion of the same systems during night, when the solar heat is withdrawn, and the body is subjected, unprotected, to the action of the heavy night dews. He has equally failed to distinguish the extent to which the troops had been previ- ously exhausted by long or forced mar- ches, unwholesome or deficient diet, insuf- ficient clothing, inadequate camp-equipage, PUTRESCENT MATTER NOT POISONOUS. 189 the influence of depressing passions, and numerous other influences, all fertile sources of disease amongst armies in the field. Propositions of a doubtful character, I am little disposed to moot; but, as the investigations of Bancroft show that dead putrescent animal matters will not generate the continued forms of fever; so I believe the same proposition may be reasonably urged against the hypothesis of a poison emanating from the decomposition of dead vegetable matter. The analogy, indeed, is almost perfect; and it would surely be passing strange, considering the beautiful harmony that pervades the universal econo- my of nature, if the decomposition of the matters which constitute the grand divisions of the organic kingdom, affected laws dia- metrically opposed to each other. As regards the poisonous emanations from decomposing vegetable matters, I am not, 190 LECTURE IV. indeed, aware that the question has ever been raised and examined with that scru- tinizing and philosophic spirit which the late Dr. Bancroft displayed in his researches into the sources of animal poisons. One hundred and fifty years ago, Lancisi certainly did write on the noxious effluvia of marshes ; but his doctrine, though it has governed the tenets of the schools, and influenced the universal body of practi- tioners, appears to have been adopted, and based on evidence equally problematical with that which supported the other cur- rent medical theories of his day. Of his doctrines, I have already submitted to you a brief analysis, less with the view of sub- stantiating my own peculiar theories on the nature of the exciting cause of ague, than with the object of showing that Lancisi's notions, divested of the technicalities and jargon of the era, were vague and complex, (for he seems to have admitted a plurality MIASM V. PUTREFACTION. 191 of poisons), and decidedly at variance with the supposition of a poison purely of a vegetable character; and equally remote from the idea of a constant and unvarying agent doctrines which the moderns, on his authority, have so generally adopted and taught. I have, perhaps, dwelt too long on these discordant opinions; and shall, therefore, but briefly allude to one or two other topics connected with ague and its supposed pri- mary cause. First, I would remark that the putrefactive process is undoubtedly connected with the production of odours; and as a malaria has been found, by the advocates of the doctrine of its existence, in situations so dry that vegetable putrefac- tion, in the ordinary sense of the term, seemed impossible, they have alleged that it is thereby proved " that the decomposi- tion is, either in degree or in kind, different from putrefaction, though the two may 192 LECTURE IV. coexist." On this I would beg to observe, that the admission of a distinctive differ- ence, in the nature of the supposed poison, from the ordinary putrefactive process, advanced by the most zealous supporters of the malaria hypothesis, is in itself another most unequivocal substantiation of the very loose and desultory evidence on which that hypothesis is based. For, even in assuming this difference, essential to their hypothesis, but insusceptible of proof, either directly or indirectly, they testify at once to the weak- ness of their cause, professing themselves actually ignorant of the very elements of their proposition. Nor is the subject of the origin of ague from malaria rendered less obscure by the oft-repeated statement, that whenever a wet spring is followed by a summer of unusual warmth, the inter- mittent and remittent fevers are observed to reappear in districts from which they had long been banished by the improve- SUMMARY OF OPINIONS. 193 merits of agriculture. Surely, if the origi- nal fevers arose from an actual miasm, (the supposed genuine source of ague), no diffe- rence in atmospheric vicissitudes should have occasioned the renewal of the fever, when, as stated, the generating sources of the poison had been already removed by agricultural improvements. Before I proceed, Gentlemen, to lay before you my own views, it may prove interesting, as well as instructive, to sub- mit to your notice a summary of the opinions which have at different epochs prevailed among the highest authorities, as to the nature and characteristics of a poi- son, which has been so generally admitted as the special cause of intermittent and remittent fevers. The ideas successively prevalent thereon, it will be seen, are alike heterogeneous and contradictory, and we might well be permitted to reject some of them as altogether abhorrent to common K 194 LECTURE IV. sense, and the first principles of sound logic. Still, however wide they may range from the real nature of things, they must all be considered as part of that progress and career, which great truths undergo, in order to the eventual elimination of what may be deemed the constants of medical science. SUPPOSED ORIGIN OF THE POISON. Varro, Columella, and Vitruvius, sixteen or eighteen hundred years ago, seem to have entertained the idea that these forms of fever could legitimately be referred to an animalcular source. Lancisi, in 1695, passing over the long arid unsatisfactory interregnum of the dark ages, ascribed the origin of these maladies to a marsh miasm, including therein effluvia both of inorganic and of animal constitution. This doctrine, first propounded 150 years ago, has prevailed SUMMAEY OF OPINIONS. 195 almost unquestioned in the medical world up to the present hour. Elliotsori attributes the origin of the mala- rious poison invariably to the agency of decomposing vegetable matter. Ferguson denies the necessity for vegetable decomposition, but ascribes the disease to rapid evaporation of water in an arid soil. Annesley conceives that the poison is the product of elements which exist in a rich soil, subjected to the conjoint agency of the sun, air, and moisture. Watson maintains the cause to be a specific poison, and concurs generally with Fer- guson. Armstrong rejects altogether the hypothesis of a specific poison. Tulloch delivers it as his opinion, that marsh miasma and ague do not stand in the relation of cause and effect to each ^. other. 196 LECTURE IV. Murray (Inspector-General of Hospitals), to obscure further the cloud of state- ments, avers that fevers, analogous to those arising in marshy lands, frequently result from the application of intense solar or atmospheric heat. The British and Foreign Medico-Chirurgical Review finally sums up the evidence on the debated question in the following emphatic and not very flattering lan- guage : " We believe that we are as yet in utter ignorance of the nature of the agent or agencies represented by the conventional term, malaria, or marsh poison. CHARACTERISTICS OF THE POISON. Rises to the summits Does not rise into the of mountains. (MoNT- atmosphere, hut has a FALCON.) peculiar attraction for the earth's surface. (FERGUSON.) DISCREPANCIES. 197 Is stopped by the in- tervention of a wall. (Various Authors.) Attacks persons on the water ; e. g. y Rome and Batavia. (LANCISI and SIR JOHN LIND.) Has its site on dry limestone rocks ; e. g. TrichorL (MACMICHAEL.) Is connected with a dreadful smell. (SiR JOHN PRINGLE.) Distinct case of ague from repeated immer- sion in the waters of a running stream. (Ex- ample, the River Loire.) Is distinctly com- municated by conta- gion. (Parisian Case. DR. FORDYCE.) Has a great attraction for trees, and is arrested by them. (Various Authors.) Is prevented or check- ed in its progress by water ; e. g,, the dykes of Holland. (SiR G. BLANE.) Is prevalent only where marshes are to be found. (Common Doctrine.) A most rank and noisome odour arises from decomposing vege- table matter, but no ague. (At New Amster- dam.) Is produced only by the poison from marsh- es. (General Doctrine.) Is not infectious. (Common doctrine.) 198 LECTURE IV. Ague is convertible into common continued fever, and vice versa. (DR. FORDYCE, SIR JOHN LIND.) The poison is more intense in proportion to the proximity of its sources ; the elevation even of & few feet afford- ing some security from its effects. (JOSEPH BROWN and others.) Ague and continued fever are not mutually convertible. (Abstract Theorists.) The poison produces no effect on the spot where it is generated ! but desolates distant and elevated localities, as at Malta. (MACCUL- LOCH and others.) Such are the opinions, Gentlemen, enun- ciated by the highest authorities, on the origin and laws of the marsh miasm, and on which they claim our assent to the doctrine of a specific poison, as the efficient cause of intermittent and remittent fevers. LECTURE V. EVIDENCE TO BE DERIVED FROM THE AUTHOR'S PERSONAL EXPERIENCE DESCRIPTION OF CITY OF BAHIA ITS SALUBRITY EQUABILITY OF TEMPERATURE PHYSI- CAL AND MORAL CONDITION OF THE BRAZILIANS THE AUTHOR'S APPOINTMENT TO THE BRITISH HOSPITAL IN BAHIA FREQUENCY OF AGUE AMONG CONVALESCENT PATIENTS CASES IN THE HOSPITAL CASES IN PRIVATE PRACTICE-^ VILLAGE OF SAN LAZARO AGUE, INFLAM- MATORY FEVER, AND TYPHUS, OCCURRING TOGETHER IN THE SAME FAMILY THE AUTHOR HIMSELF ATTACKED WITH AGUE INTERMITTENT FEVER PROBABLY REFER- ABLE TO EXPOSURE TO MOIST SEA BREEZES CONSE- QUENT PROPHYLACTIC MEASURES ADOPTED IN HOSPITAL AND IN PRIVATE PRACTICE FAVOURABLE RESULTS. GENTLEMEN, The observations which I am now about to submit to you, and the comments which they suggest, rest partly on my experience as an army medical officer in different quarters of the globe, and partly on the evidence afforded by the 200 LECTURE V. superintendence of the British Hospital at Bahia for twenty-three years, joined to an extensive private practice there, during the same period. A brief description of the city and the adjoining districts is therefore essential, as introductory to the new views which I have been led to adopt. The facts on which these views are based I shall distinctly narrate as they were presented to me. The inferences drawn may, like every subject not determined by the rules of mathematical evidence, be the occasion of a difference of opinion ; to myself, however, they seemed to be the only rational conclu- sion that could be adopted; namely, that marsh miasmata and malaria are not the efficient cause of intermittent and remittent fever. DESCRIPTION OF BAHIA; ITS SALUBRITY; CAUSES OF ITS BEING HEALTHY. The city of Bahia, the former capital of BAHIA. 201 Brazil, is situated in latitude 12 59' S., and longitude 38 33' W., at the entrance to one of the most beautiful and extensive bays in the world, extending thirty-three miles in length, from north to south, and thirty miles in width from east to west, and containing upwards of a hundred islands, several of which are inhabited. The city contains about 150,000 inhabitants; the population in 1803 being estimated at 103,000. It may be said to form two divisions, the one constituting the upper, and the other the lower city. The former division is built on a ledge of rock (chiefly gneiss, passing often into grey primitive greenstone and syenitic granite), about six hundred feet in height, and overhanging, as it were, the lower division. The latter, built on an alluvial soil, with a rocky substratum, stretches along the base of the hill, on ground gained, in part, from the bay. 202 LECTURE V. The streets are irregular, ill-paved, gene- rally narrow, arid having a gutter in the middle, into which is commonly cast the filth and offal of the adjacent dwellings. The houses are unprovided with water- closets, and are otherwise ill-arranged for the purposes of ventilation and comfort. The slave population is numerous and crowded, the police inefficient, and a scaven- ger department unknown. The public sewers are few, the becos (alleys) leading from the principal streets serving as temples of Cloacina, and as receptacles for every kind of filth. In addition to this, the dead are interred within the churches and pre- cincts of the city. I am, however, informed, that since my return from Brazil, in 1842, the state of affairs here alluded to has under- gone considerable amelioration, through the advancing enlightenment of the age, and the more energetic efforts of the public authorities. ITS FILTHINESS. 203 Partial, though heavy rains, occur at all seasons of the year, by which the lower city is inundated, and contaminated by the filth and offal of the upper city. In some of the most public thoroughfares, as the " Con- cei9ao," for example, there are heaps, or rather mounds, of decaying animal and vegetable matters, fermenting under the powerful rays of a tropical sun, disengaging every kind of noisome effluvia, and often of such an offensive character as to impress the sense of taste scarcely less powerfully than that of smell. The soil, too, in the immediate neighbourhood of the city, is absorbent, deep, and rich, with a substratum of clay. Here, then, we have, accumulated, in almost unexampled abundance, all those physical conditions which are deemed, by the unanimous consent of physicians, to constitute the elements essential for the generation of the most deadly scourges of 204 LECTURE V. humanity epidemic and endemic diseases. I may further add, that I have myself, within the last twenty years, witnessed the city exposed, on three several occasions, to the combined horrors of .siege and famine, with all their revolting contingencies. Yet, O O 7 notwithstanding this appalling combination of physical, moral, and social evils, univer- sally admitted as the chief agents in pro- ducing the most extensive and fatal diseases, Bahia continued healthy ; and can, moreover, up to the present hour, boast the happy privilege of having escaped, since the period of its foundation, from every species of endemic or epidemic malady yellow fever, cholera, influenza, typhus, and dysentery.* * Since these pages were written, a desolating epi- demic, said to be the yellow fever, has swept over the chief cities of Brazil. It is, I believe, generally con- sidered by the profession to have been imported from abroad ; but I trust that, ere long, we shall be supplied \vith full and accurate information as to its origin, progress, symptoms, and treatment. It would appear, HEALTH OF THE INHABITANTS. 205 It is, moreover, deserving of notice, as regards the general health of the inhabitants of the upper and lower divisions of the city, that the Brazilian and Portuguese merchants and shopkeepers, who inhabit the lower di- vision, and who rarely quit their dwellings, enjoy comparative immunity from inter- mittent fever; while those whose duties frequently lead them from the lower to the upper city, often suffer from this disease, as well as from continued fever (constipacon), without other apparent cause than the sudden transition from the warm, but equal temperature of the lower city, to a strong, cool, and humid sea-breeze, which they encounter while bathed in perspiration and exhausted by the labour of ascending a considerable eminence. from the writings of an old Brazilian historian, Sebastiano da Rocha Pitta, that, in the year 1686, a somewhat similar epidemic committed great ravages in the cities of Bahia and Pernambuco, and persisted for five or six years. The fact is also mentioned by Humboldt. 206 LECTURE V. How, then, are we to explain this most singular salubrity of the city of Bahia? For while most of the ordinary endemic and epidemic diseases are found to occur sporadically, and sometimes in their most intense and deadly form, yet it is matter of history that they have never spread ende- mically. EQUABILITY OF TEMPERATURE. I am in- clined to believe that the true solution of this remarkable phenomenon is to be found in the extraordinary equability, and limited range of the temperature, the prevalence of a gentle but never-failing breeze, and the freedom from atmospheric vicissitudes en- joyed by Bahia beyond any other city with which I am acquainted. The highest range of the thermometer in the upper city (with the exception of an occasional day,} never exceeds 82^ of Fahrenheit in the summer, and the lowest in winter is 72; there is a further difference of two degrees CLIMATE. 207 between the upper and the lower city; and the extreme daily range is about six de- grees. This unexampled uniformity of temperature is chiefly to be ascribed to the absence of any high or mountainous ranges, and of all arid and sandy deserts, aided by the genial influence of refreshing showers at all seasons of the year. It is further promoted by the perpetual verdure of the country, and by a cool and powerful monsoon, laden with moisture, and sweeping along the coast direct from the southern Atlantic. This monsoon prevails from the north-east for eight months of the year, name- ly, from September to April, constituting the dry or summer monsoon; and during the winter or rainy season, from May to August, it blows from the south-east. These periods are, however, liable to some irregularity. The nights in Bahia are also usually serene and beautiful, and unattended with much deposition of dew. Unlike what 208 LECTURE V. occurs in other hot regions, the delightful serenity and coolness of tropical moonlight may be enjoyed with perfect impunity, the mind being undisturbed by those visions of fever and malaria which float before the imagination in less favoured climates. Of this we have the best practical illustration in the number of foreigners, as well as natives, at Bahia, who pass a large portion of the summer nights in the open air. Another subject of vast importance to the European in tropical climates must not be forgotten ; namely, the sound and refresh- ing sleep which may always be enjoyed at Bahia ; the nights being invariably cool, even in the midst of summer. If proper precau- tions be observed to avoid exposure to direct currents of air, the windows of the sleeping chamber may be left open with impunity at all seasons of the year ; the terrors of malaria, and the hot, suffocating winds of other tropical climates, being CONDITION OF THE PEOPLE. 209 altogether unknown. I am not, indeed, aware of any circumstance which exerts a more important influence in enabling the European constitution to resist the dele- terious effects of tropical climates, than the enjoyment of sound and refreshing sleep. CONDITION or THE PEOPLE. Among other causes which must be held as important in modifying the general character of diseases in Bahia, and probably everywhere else, the physical, social, and moral condition of the people deserves special consideration. The native Brazilian is in general compact and well-formed, and of healthy organization, but not of an athletic frame. His intel- lectual faculties are acute, though little developed by cultivation. Descended from European ancestors, he has still a consider- able admixture of African arid native American blood. He is indolent by nature, and indisposed for active exertion or indus- try; but he is protected against the evil 210 LECTURE V. influence of the former on his health, by a simple and abstemious diet ; and the injurious consequences of the latter to his social position are obviated by the circumstance, that the four great wants of the humbler classes in Europe press but lightly on the Brazilian. Fuel he scarcely requires; of clothing, but little; his primitive habitation is simply constructed ; and one day's labour will amply provide for the moderate demands of the whole week. With passions naturally quick, he is nevertheless placable; his dis- position is kindly ; the future never disturbs him with its doubts, nor the past with its regrets ; the struggles and vicissitudes of European life are unknown. The conten- tions of party, the yearnings of ambition, the bitterness of fanaticism, never disturb his repose; and after gliding down the stream of time, unscathed by those tumul- tuous passions and harassing cares which so frequently embitter the existence and EFFECT OF POLITICAL CHANGES. 211 undermine the constitution of man in other countries ; he meets at length the inevitable doom, if not with philosophy, at least with resignation ; satisfied of his claims to eternal felicity, in the confident assurance of an infallible Church. Such is, or rather was, the Brazilian. I speak of the masses, for the higher classes in all countries pretty closely approximate. But the premature, though well-intentioned, introduction of political institutions, unsuited to the material interests or intellectual advancement of a mixed population like that of Brazil, has already operated, and will probably continue to effect still more important changes on the habits and social condition of the people. These questions, however, important as they are, I must leave to the political economist and the historian. We have only to do with the past and the present, in our attempts to elucidate the causes to which Bahia has 212 LECTURE V. hitherto owed her singular and happy immunity from those endemic and epidemic scourges which too frequently desolate some of the fairest regions of the earth; and where, from similarity in geographical posi- tion, the inference of similarity in disease would appear to be almost legitimate. From the preceding account of the climate and inhabitants of Bahia, we should natu- rally be led, a priori, to conclude that disease would there present a mild and tractable character; and it is highly interesting to find that in such conclusion we are borne out by the concurring evidence of experience. STATEMENT OF FACTS WHICH FIRST LED THE AUTHOR TO DOUBT THE CAUSAL RELATION OF MARSH MIASM TO INTERMITTENT FEVER. In the year 1819, I was appointed to the British Hospital at Bahia. When I com- menced the duties of this establishment, it POSITION OF THE HOSPITAL. 213 was reported to me that the locality was considered unhealthy, as patients received into the Hospital were afterwards subject to be attacked, during convalescence, with intermittent fever. Keports of this nature necessarily caused me uneasiness; and I accordingly investigated, with much atten- tion, all the internal arrangements of the Hospital, as well as the immediate neigh- bourhood. Nowhere could I discover any obvious causes of intermittent fever. There were no marshes ; and the Hospital, built on an eminence, had well-arranged and spacious rooms, and was fully exposed to the current of a strong and regular monsoon or sea- breeze. Such being the case, and my mind being fully imbued with the universally- received notions regarding the origin of intermittent fever from marsh poison, I discredited the information as totally un- worthy of notice. In a few weeks, however, after I had entered on the duties of the 214 LECTURE V. Hospital, my attention was unpleasantly arrested by the occurrence of a well-marked case of ague, the history of which may be here briefly related. CASE. A seaman, in the prime of life, and in robust health, was admitted into the Hospital, labouring under virulent gonor- rhoea, which demanded the employment of very active antiphlogistic measures, includ- ing general and local blood-letting, very low diet, &c. In the course of three weeks, and when the acute symptoms had entirely subsided, the patient was suddenly seized with a violent shivering fit, which lasted some hours, and was followed by strong reaction ; the paroxysm being carried off by profuse perspiration. This incident struck me forcibly at the moment. I attributed it, however, notwithstanding the protestations of the patient, to some imprudence in diet or otherwise ; and, perceiving that the fever gradually subsided, I felt satisfied of the CASE OF AGUE. 215 justice of my suspicions. On the third day, however, and precisely at the same hour, the patient was seized with a paroxysm exactly similar to the former, only much more violent. In short, intermittent fever was established ; and it continued, notwithstand- ing the administration of ordinary remedies, until the period of the patient's embarkation in his vessel, for England, about five weeks after his admission into Hospital, and twelve days after the commencement of the ague. This case caused me much embarrassment at the moment, as inexplicable by the received doctrines the more so, as the patient had not only never suffered from ague, on any previous occasion, but had never, according to his declaration, been confined for a single day by illness during the whole course of his life. Another case, occurring shortly after the above, afforded further grounds for reflec- tion. 216 LECTURE V. CASE. A seaman, likewise in the prime of life, was admitted into Hospital with severe rheumatic inflammation of the shoul- der-joint, brought on by exposure to wet and cold during the voyage from England. This man was of a full plethoric habit ; the shoulder was red, inflamed, and considerably swollen; and there was strong constitutional disturbance. Under these circumstances, a rigorous antiphlogistic regimen, including general and local blood-letting, &c. 3 was adopted. By these means, the local and constitutional symptoms were rapidly sub- dued, and the patient was pronounced convalescent on the seventh day. On the morning of the tenth day, while examining another patient in the ward, I was called to this man, and found him trembling violently, and exhibiting all the ordinary appearances of the cold stage of intermittent fever. The disease was arrested after the third parox- ysm, by the exhibition of cinchona bark. PREVALENCE OF FEVER. 217 It is unnecessary to multiply cases ; they were unfortunately but too numerous; and I quickly learned, by the painful tuition of experience, that, in the British Hospital, patients convalescent from any disease more especially from rheumatism whose strength had been much and suddenly lowered, became exceedingly obnoxious to attacks of intermittent fever, which proved almost invariably of the tertian type. There was not a deficiency of cases of the same character in my private practice. The following may be offered as an illustra- tion : CASE. Mrs D., wife of a British mer- chant, lately arrived from Europe, in the prime of life, and married but a few months, had been out at afdte champtitre on the sea coast. She danced, and perspired, freely; and after the excitement of the day, was exposed to the cool Seabreeze of the country, while returning home in her cadeira a 218 LECTURE V. sort of palanquin peculiar to Bahia. The result was a sharp attack of inflammatory fever, apparently gastro-enterite, which re- quired a strict antiphlogistic regimen, but no blood-letting. On the seventh day, Mrs. D. was deemed convalescent; she was so perfectly free from all ailment, that I informed her husband that every source of uneasiness had now been removed. Scarcely six hours, however, had elapsed, after this declaration, when I was hastily summoned, and found Mrs. D. in a state of high febrile excitement, having had previous rigors of nearly two hours' duration. I, perhaps naturally enough, notwithstanding the strenuous denial of the patient, ascribed her relapse to some irregularity of diet or other imprudence. My friend arid colleague, Dr. Silveira, physician to the Mizericordia Hospital, arid subsequently physician in ordinary to the Emperor, was called in consultation, and was as much embarrassed CASE. 219 as myself satisfactorily to account for the sudden accession of fever. We prescribed some saline medicine ; and on the following morning were gratified to find our patient, after copious perspiration, free from fever, and complaining of nothing beyond debility. We accordingly again pronounced her convalescent. On the afternoon of the following day, however, at the same hour, and almost at the same minute, an attack, almost similar to the preceding on'e, came on; in short, intermittent fever was duly established, and the patient was restored to health, in the course of two or three weeks, by the ordinary tonic treatment. VILLAGE. OF SAN LAZAKO. I shall now, Gentlemen, direct your attention to the history of the Povoaqao, or small village, of San Lazaro. This place is situated about two miles southward of Bahia, on the verge of the peninsula, close to the sea 220 LECTURE V. shore, on a bold headland, and fully exposed to a strong and regular monsoon. The country around is very beautiful; the sea view magnificent. It is therefore chosen as the favourite evening ride of the British and other foreign residents. It is also frequently resorted to, for the day, by parties of pleasure, who return to the city in the evening. In this village there was only one good house, which belonged to a Portuguese merchant, and which, being unoccupied by the owner, was always at the disposal of such foreign visitors as might require it. The house was large, situated on the brow of a hill, and facing the sea. A spacious open verandah ex- tended along the entire front of the building, through which the cool sea-breeze rushed with great force. Nevertheless, the house was by universal consent deemed very aguish, as was also that of Colonel Cid, which stood on a neighbouring eminence; SEA-BREEZES U. HEALTH. 221 while some small cottages, at the base of the hill, and sheltered in a great mea- sure from the sea-breeze, were considered healthy. Mr. R., one of the resident British mer- chants, requested my opinion regarding the character of the house in question, as he was desirous of removing his family there for the purpose of sea-bathing. Guided by the same principle as had influenced my decision regarding the healthy character of the British Hospital, I stated that there appeared no rational grounds for giving the house so bad a name ; and acting on this opinion, Mr. R. and his family removed there on the following day. This gentle- man's household consisted of himself, Mrs. R. his wife, Mr. M. his brother-in-law, a youth of 17 years of age, recently arrived from England, an English housekeeper, and five black servants. On the fourteenth day after their re- 222 LECTURE V. moval to San Lazaro, the state of the house- hold was as follows : Mr. and Mrs. R. and one of the black servants were laid up with ague ; another servant with dysentery ; Mr. M. a severe attack of inflammatory fever, with great determination of blood to the lungs; and Mrs. C. the housekeeper, a woman of melancholic disposition, and weak leuco-phlegmatic habit, was attacked with genuine typhus. The whole establishment was consequent- ly removed back to Mr. R.'s house in the city, where Mr. M. advanced quickly to convalescence under active antiphlogistic treatment, as did also the two black ser- vants under the ordinary measures. Mr. and Mrs. R. recovered more slowly, but without any serious inconvenience; while the condition of Mrs. C. the housekeeper, became perilous in the extreme. She had a weak and rapid pulse, intense heat of skin, oppression at the chest, dry tongue DR. SILVEIRA. 223 with dark fur, and sordes about the teeth and lips, tenderness of the abdomen, offen- sive and depraved secretions and excretions, low muttering delirium, and petechise on the surface of the body. This patient finally recovered, but with great difficulty, having been confined to bed during thirty - three days. My friend, Dr. Silveira, saw this case repeatedly in consultation, and admitted that he had never witnessed a more exquisitely marked case of typhus. Of this he was certainly a most competent judge, having graduated at Edinburgh, where he resided several years, and per- formed the duties of clinical clerk at the Royal Infirmary. He is, moreover, a gen- tleman of great professional talent and scientific acquirements, and well merits the high office to which he has since been ap- pointed by the imperial government. The case just described sufficiently proves a fact which has often been questioned, par- 224 LECTURE V. ticularly by Bancroft the possibility of the occurrence of typhus, genuine typhus, in tropical climates.* And the different diseases from the same exposure, with which the several members of the above * In some seasons, sporadic cases of typhus genu- ine typhus are by no means rare in Brazil, and are popularly termed " febres malignas." They com- mence either as ague, or as remittent fever, or as a " constipacao," (in Portuguese), which resembles the synocha of Cullen. These cases are often fatal, and commonly run a more rapid course than the typhus of Europe. The *' constipacao" or continued fever, is a frequent, perhaps the most frequent, form of fever in Bahia, and usually runs its course in from five to seven days, terminating in free perspiration. The " consti- pacao" is rarely or ever fatal, unless, as before stated, it should run into " maligna ;" but it not unfrequently lapses into ague, which commonly assumes the tertian type, and yields readily to treatment. The so-called typhoid fever is also not unfrequent, especially at Rio de Janeiro, and has been well described by Mello Franco, (Ensaio sobre as febres do Rio de Janeiro, Lisboa 1822,) and subsequently with its abdominal lesions, by Sigaud, physician to the Emperor, and by Drs. Valadao and da Costa, as it appeared in their hospitals of the Mizericordia, and the Marine. CONSEQUENCES. 225 family were assailed, afford a striking illus- tration of the influence of secondary causes in determining the character of the subse- quent disease. Mr. M., young, robust, and just arrived from Europe, had an inflamma- tory attack with determination of blood to the lungs; Mr. and Mrs. R., who had resided for some years in the country, and had suf- fered somewhat from climate, were affected with ague; Mrs. C., the housekeeper, who had also been some time in the country, and who was weak and of a melancholic and leuco-phlegmatic temperament, was attacked with typhus ; and of the black ser- vants, one suffered from ague, and another from dysentery. On a previous occasion, while serving on the medical staff in the unfortunate expedi- tion against New Orleans in 1814 15, I also witnessed a broad illustration of the above principle. Returning from the army, with some officers of H.M. 14th Light Dra- 226 LECTURE V. goons, we were exposed for three or four days, in a frigate's launch, to cold and wet, and other privations. On reaching the fleet at Cat Island roads, all, except one, were suffering, and each from a different malady. The midshipman who commanded the boat was attacked with otitis, and became perfectly deaf; one of the officers was attacked with dysentery ; another with ophthalmia ; a third with fever ; and myself with rheumatism, to which I have since up to the present hour been occasionally liable. And all these diseases originated in one and the same cause. In fact, you will often find that the diseased action, apt to follow on the application of any of the ordinary causes of disease, often depends less on the special nature of such cause, than on the internal condition of the animal and organic functions, both at the time of application of the cause, and for some time previously. There are few diseases, perhaps none, which CAUSES AND EFFECTS. 227 can be said to arise instantaneously; and it is more than probable that the preceding condition of the individual, and the state of more or less marked malaise, which is to be detected on close investigation, must essen- tially contribute to guide and direct (if I may use the expression) the exciting cause to the development of one form of diseased action in preference to another. Thus the type and symptoms of fever will assume different forms at different seasons and under different circumstances. At one time they will be displayed through the air-passages ; at others through the nervous system, the alimentary canal, &c. ; yet, strange to say, a difference in the febrile poison has even been assumed to account for these several varieties. Names and theorems, Gentlemen, have too often usurp- ed the field of observation, setting aside the wide and unbounded expanse of nature as daily presented to our notice, ungarnished 228 LECTURE V. by the sophistry of the schools, or by the dialectic craftsmen, who labour to bend, twist, and torture natural phenomena to the pet theory of the closet, and, like Pro- crustes, endeavour to reduce each and every form of diseased action to their own stan- dard. DR. DUNDAS'S CASE. In the year 1822, I became myself the subject of intermit- tent fever. The ague arose as follows. Our envoy to the court of Brazil having stopped for a few days at Bahia, I had occa- sion to accompany him on some excursions around the city ; during which, in addition to rny professional duties, I was much exposed to the sun. On one day in particular, after lengthened exertion and exposure, I felt exhausted, and went into a tepid bath pre- viously to dressing for dinner. Finding the bath more than usually grateful, I con- tinued in longer than was my custom, and DR. DUNDAS'S CASE. 229 until warned by a slight sensation of cold. I then quickly dressed, and went out to dinner in my ordinary health. During the night, however, I was seized with a violent shivering, which terminated in tertian ague of the most obstinate character, resisting every mode of treatment for a period of fifteen months. My health finally became so seriously deteriorated, as to make it im- perative that I should have leave of absence in order to proceed to the Organ Mountains, in the province of Rio de Janeiro, for change of climate. This I was enabled more readily to accomplish through the kindness of the commaiider-in-chief on the station, the late gallant Sir Thomas Hardy, who not only afforded me a passage in H.M.S. "Fly," but permitted his flag-sur- geon, Mr. Neill, and subsequently Dr. Birnie, of H.M.S. " Tartar," to take charge of the British Hospital during my absence ; 230 LECTURE V. and, though late, I am happy in being afforded the opportunity of acknowledging my deep obligations to these gentlemen. PROBABLE CAUSE OF AGUE. Though, up to this period (1822), I was in possession of facts sufficiently strong to raise serious doubts in my mind as to the source of inter- mittent fever, I nevertheless adhered to the orthodox doctrine, that ague originated only from the agency of marsh miasmata. My faith had, however, become wavering, and whilst in this state of suspense, I was called to attend the family of an intelligent Brazi- lian merchant, residing in the Saude, whose wife and two children, the latter aged respectively seven and ten years, were affected with intermittent fever. Their house was spacious, in one of the highest quarters of the city, and fully exposed to a strong sea breeze, a locality which would a priori be pronounced unexceptionable, AN " AGUISH " HOUSE. 231 and especially exempt from all chance of malarious agency. The occurrence of three cases of ague under such circumstances (the more remarkable, as the female members of Brazilian families but rarely quit their habitations), afforded additional and very strong reasons for further questioning the received theory of the origin of ague from malaria. In conversation, I stated my doubts to the head of the family, who immediately replied that the house was muito sezonatico, (very aguish), and that he would in consequence be obliged to remove. On my demanding his reasons for considering the house " aguish," " Oh," said he, " every house in Brazil like this muito banhado do vento" (literally, much bathed in wind), " is unhealthy, and espe- cially subject to sezoes" (ague) an opinion which I found fully supported by the popu- lar voice, and which occurred to me as affording the only satisfactory explanation 232 LECTURE V. of the cases of ague in my own hospital, as well as of numerous others of a similar nature. On taking, then, a general view of the circumstances connected with the numerous cases of intermittent fever which had so unaccountably occurred to convalescents in my hospital, and in private practice, the conviction was forced upon me, in a manner altogether irresistible, that these cases did not arise from marsh poison, but sprang directly from imprudent or too early expo- sure to a strong current of cool sea-air, loaded with moisture, while the system was under the debilitating influence of previous exhaustion or disease. The capillary cir- culation is thus deranged, through the impaired energy of the nervous system, and the molecular and vital changes between the blood and tissues are impeded ; cir- cumstances of paramount weight in inducing diseased action, and which the more readily PROPHYLACTIC MEASURES. 233 arise, from the high degree of morbid sensibility acquired by the cutaneous sys- tem in tropical climates. I may here state, that I had already observed several most obstinate cases of ague apparently originate in the sudden influence of the depressing passions, at a time when the system had been weakened by profuse and incessant perspiration, and consequently rendered susceptible of the slightest atmospheric or moral vicissitude. Having adopted the above view of the subject, I proceeded at once to act upon it, and to test its truth by the unerring criterion of experience. PROPHYLACTIC MEASURES. In the first place, I made several alterations in the wards of the hospital, and had those win- dows nailed up which admitted directly the strong current of the sea-breeze. At the same time, effectual measures were taken to prevent convalescents from being exposed 234 LECTUKE V. without sufficient warm clothing, or until they had regained a certain degree of strength. The result of these measures was immediate, and the evidence they offered was complete, and apparently free from all fallacy. From that time, inter- mittent fever almost completely disappeared from among the convalescents in the British Hospital. The adoption of similar precautionary measures in my private practice was fol- lowed by equally striking and conclusive results. The sudden attacks of ague, which had formerly been so frequent among my convalescent patients, and which had caused me so much perplexity and embarrassment, ceased altogether, or rather became of rare occurrence. In my own case, too, the result was no less conclusive. After having had my health broken up by an ague of fifteen months' duration, and having had the dis- CAUTION REWARDED. 235 ease arrested by my journey to the Organ Mountains ; and although I have subse- quently been long and often exposed to the ordinary exciting causes; yet, by carefully guarding against exhaustion of the general system, and derangement of the cutaneous circulation, I remained free from a recur- rence of this disease, so liable to return, throughout my subsequent residence of twenty years in Bahia. In my next lecture, Gentlemen, I shall offer strong additional testimony, based on the evidence afforded by certain districts in the immediate vicinity of Bahia, to show not only that marsh effluvia and intermit- tent fever do not stand in the relation of cause and effect, but that, in reality, the latter has no necessary relation to the former. LECTURE VI. DESCRIPTION OF THE SUBURB OF BOMFIM EXPLANA- TION OF ITS FREEDOM FROM AGUE THE VICTORIA EFFECTS OF REMOVAL OF A WOOD EFFECTS OF COOL AND HUMID WIND ON AN EXHAUSTED CUTANEOUS SYSTEM DR. DUNDAS'S PERSONAL EXPERIENCE IN ITALY RELAPSES IN AGUE AFTER LONG INTERVALS ALLEGED CAUSES EXAMINED PROBABLE CAUSE, AN IMPERFECT RESTORATION TO HEALTH AFTER FIRST ATTACK DR. W. F. DANIELL ON WATER TREATMENT IN FEVER TYPES OF FEBRILE DISEASE THEIR ESSENTIAL IDENTITY, AND MODIFICATION UNDER CER- TAIN CIRCUMSTANCES OF CLIMATE, &C. YELLOW FEVER IN BRAZIL TRANSITION FROM BILIOUS REMITTENT INTO IT DR. CROKER PENNELL BELIEVES THE RE- MITTENT AND YELLOW FEVER IDENTICAL DR. R. PATERSON THINKS THEM DIFFERENT. AT our last meeting, Gentlemen, I laid before you the evidence by which, in oppo- BOMFIM. 237 sition to my previous views, I was led, step by step, first to doubt, and finally to reject, the received doctrines of the schools, in regard to the origin of intermittent and remittent fever from marsh poison or malaria. In my present lecture, I purpose to submit to you the additional evidence afforded by other districts in the immediate neighbourhood of Bahia, in proof of the fact that, in certain localities, you may have the most intense and concentrated effluvia of marshes, without ague; while, on the other hand, you will often find ague exceed- ingly prevalent under circumstances where marsh miasrn is altogether out of the ques- tion. In confirmation of these propositions, I now proceed to the evidence afforded by the suburb of Bomfim. DESCRIPTION OF BOMFIM. Bomfim adjoins the city of Bahia to the northward. It may be described as extending about a mile and a-half from the Agua de Meninas, 238 LECTUKE VI. along a broad and well-paved causeway, passing through the centre of an extensive morass, and terminated by a gentle emi- nence, on which stands the beautiful and, in Brazil, celebrated chapel of " Nossa Senhora do Bomfim.'' Along this cause- way is interspersed an almost uninterrupted succession of houses and gardens, with patches of cultivated ground, gained from the wide-spreading morass which surrounds them. The morass, in the midst of which stands the populous suburb of Bomfim, is bounded to the west by the Bay of Bahia, and to the northward and eastward, or windward, by a high ridge of hills, which form an imperfect semicircle, separating the rnorass from the South Atlantic Ocean. It is partially subject to the influence of the tide, and consequently exposed to those dele- terious effects which are believed to result from the intermixture of salt and fresh MARSHES. 239 water, together with immense quantities of vegetable and animal matter, exuviae, &c., constantly acted on by the powerful influ- ence of a tropical sun. Now, Gentlemen, in the course of my somewhat eventful professional career, I have visited the malarious localities of the Peninsula, and the more deadly shores of Africa and the West Indies; I have bivou- acked with the British army amidst the dreary swamps of Louisiana, and have traversed the more classic Pontine marshes near Kome; and I can safely assure you, that in none of these do the elements com- monly deemed necessary for affording to marsh effluvia their most concentrated and deadly degree of intensity, so plentifully abound as in the district of JNossa Senhora do Bomfim. Yet what is the character of this pestiferous-looking swamp in regard to public health ? That it is uninhabitable ? Just the reverse. The suburb of Bomfim 240 LECTURE VI. enjoys the reputation of being, and is in reality, at certain seasons, one of the most healthy districts in Brazil. The higher classes of the inhabitants of Bahia resort to it for the purpose of sea-bathing, during the four hottest months of the year December, January, February, and March. These are the months when the sun, nearly vertical, exerts its greatest power when the swamp is partially dried up but still a swamp ; exposed to the ebb and flow of the tide, and superabounding, as already stated, in all the elements necessary to the generation of the most abundant arid dele- terious miasmata. Such is the season at which Bomfim is thronged with visitors ; and these, moreover, in accordance with the custom of the country, pass a large portion of the night in the open air, exposed to the influence of the poisonous miasms if such there be. Yet, during these four months, a case of intermittent fever is MARSHES V. SEA-BREEZES. 241 almost unknown ; while the towns, Taboao, Eio Vermelho, &c., situated on the sea- coast, at some miles to the northward and eastward that is, to windward of the hills bounding the Bomfim marsh, and consequently excluded from its influence, but exposed to the full sweep of the humid sea-breeze from the Southern Atlantic, are notoriously subject to ague at all seasons of the year. How, then, are we to explain the pre- valence of ague in towns lying on the sea- beach, and constantly bathed by a powerful sea-breeze ; while Bomfim, situated a few miles to leeward, is, though placed in the midst of an extensive marsh, wholly exempt from intermittent fever, except at certain seasons? The solution, I conceive, will be found in the ridge of hills before alluded to, which breaks the force of the strong humid sea-breeze tempering, but not excluding it ; and thus secures, during the summer M 242 LECTUEE VI. season, an equality of temperature rarely met with in other regions of the globe. Again, the history of Bomfim, during the rainy or winter season, affords the strongest additional evidence in proof of the correct- ness of the explanation here offered. The wet season commonly sets in about the beginning of April, with a sudden change in the monsoon, when atmospheric vicissi- tudes considerable for Bahia often ensue ; the rain descends in torrents, and converts the Bomfim marsh into one entire sheet of water; and, above all, the change of wind from about north-north-east to south-south- east at once deprives Bomfim of the pro- tection of that range of hills already so often alluded to, and exposes it to the full force of a powerful monsoon, direct from the Southern Ocean. Under such circum- stances, agreeably with the received doc- trines, all noxious exhalations must be effectually arrested ; yet what, in reality, do AN ANOMALY. 243 we now find to occur? We find that Born- fim, having been almost perfectly free from intermittent fever during the summer months, when it ought to have been abso- lutely uninhabitable, now becomes subject to that disease. How, then, are we to explain an anomaly so striking, and so inconsistent with the ordinary doctrine regarding the origin or production of ague? The follow- ing, I apprehend, will afford the correct solution. In addition to the large amount of eva- poration from such an extensive expanse of water, the powerful south-east monsoon, loaded with moisture, but necessarily free from any miasmatous contamination, now sweeps in, without the slightest impediment, direct from the Atlantic; and Bomfim is thus placed under precisely similar circum- stances to those of Taboao and Rio Yer- melho, the towns on the sea-coast above alluded to; and the results, as regards the 244 LECTURE VI. health of the inhabitants, are precisely similar, and continue until the change of the monsoon to the north-east, in October, again restores to Bomfim its former hilly screen, and, at the same time, its wonted salu- brity. The few permanent residents, chiefly of the lower classes, who continue to inhabit this district throughout the year, present the ordinary characteristics though not strongly developed of the dwellers in low arid humid .localities. It is especially worthy of remark, that, along the summit of the semicircle of hills, already described as bounding the marsh to windward, there are numerous habita- tions, entirely unsheltered, and constantly swept by a powerful sea-breeze, direct from the ocean. All these, without exception, are greatly subject to ague at all seasons of the year; while, as already stated, the houses placed below, in the centre of the swamp, are only affected at certain seasons, MODERATE BREEZES. 245 these seasons being precisely those during which the production of marsh exhalations must be deemed entirely suspended. In addition to an equable temperature, I deem the uninterrupted prevalence of moderate breezes, by which a stagnant or even calm state of the atmosphere is pre- vented, to be of the very highest impor- tance in obviating disease in all warm, low, and humid localities. I am, indeed, satis- fied that, were the district of Bomfim subject to the calms and vicissitudes which I have witnessed on the coast of Africa, in the south of Europe, and in America, it would prove not less destructive to human life than the charnel-houses of the Coast, and the West Indies. What impression the proofs adduced in reference to Bomfim may produce on the minds of others, I cannot tell. In the statements submitted, from which all exag- geration is carefully excluded, I can detect 246 LECTUKE VI. none of those fallacies by which medical evidence is too often vitiated; nor can I resist the conviction that these statements, even alone, and unsupported by. any other testimony, afford irresistible proof that the ordinary doctrines relating to the produc- tion and influence of marsh poison are founded in error. Numerous striking and analogous instances are, indeed, admitted by all. America the West Indies Italy Sicily are pregnant with unquestionable examples of the security afforded against intermittent fever by woods, hills, walls, &c., to windward. The explanation offered is, that they intercept or attract the poison. But how are we to reconcile this with another statement which the supporters of the doctrine of mi asm advance with equal confidence that, while a wood, a wall, or a tree, will at times effectually arrest the progress of marsh poison, yet the same identical poison will, on other MALARIOUS LOCALITIES. 247 occasions, and under precisely similar cir- cumstances, ascend vertically for hundreds of feet to the summit of the highest hills, and there display its deadly properties un- changed ! Again, we are told that, in some cities, malaria exists only in the low, damp, and crowded quarters of the poor; in others as, for example, in modern Eome the close, filthy, and crowded habitations of the Jews, adjoining the banks of the Tiber, are comparatively healthy ; whilst the wide, open streets and squares, swept by the chilling tramontane winds, are notoriously subject to disease. To any one, however, who has experienced, as I have at Eome, the difference in temperature between one street and another, and even between dif- ferent sides of the same street, this seeming paradox will admit of rational explanation, without any necessity for the assumption of a special poison. But I have already, 248 LECTURE VI. in a former lecture, entered fully into the consideration of these subjects. In reference to that vexata qucestio the comparative healthiness of ancient and of modern Rome I am convinced, from per- sonal feeling and observation, that, among other considerations, in a climate subject to such extreme and sudden vicissitudes, due weight has never yet been accorded to the powerful influence of his woollen clothing, in protecting the ancient Roman from those diseases so generally attributed by the moderns to malaria. THE VICTORIA SUBURB. Let us now direct our attention to some interesting and re- markable facts arising out of the political convulsions of the times in Brazil, which afford strong evidence in confirmation of the opinion that intermittent fever does not owe its origin to marsh miasmata. In the immediate neighbourhood of Bahia, THE VICTORIA SUBURB. 249 to the southward, within about a mile of the city, stands the suburb of the Victoria^ where most of the British and foreign mer- chants reside. Nothing more beautiful than this suburb can well be imagined. It extends about a mile, from the Campo da Victoria to the Graca, along an elevated ridge of about six hundred feet in height, and overhanging the magnificent bay. The houses are well built, spacious and elegant, placed on the brow and summit of the ridge, and surrounded by gardens, abounding in all the luxuriance of tropical vegetation. Parallel to this ridge, and at the distance of eight or nine hundred yards to windward, stood a thick and lofty woody belt, the " Graca Wood," extending in the direct course of the trade wind, and breaking its force before it reached the Victoria. Dur- ing the war of independence in 182223, when the city of Bahia was besieged, or rather blockaded, by the Brazilians, the M2 250 LECTURE VI. suburb of the Victoria was taken possession of by the Portuguese troops, and occupied as an outpost ; and, in order to prevent the advance of the Brazilian forces under cover of the wood, it was entirely cut down by order of the Portuguese general, Madeira. Since that period, the strong sea-breeze being no longer broken by the woody screen, intermittent fevers have been of much more frequent occurrence in the Victoria. Furthermore, in numerous in- stances, particular houses have suffered from similar causes: namely, the cutting down, by order of the Portuguese general, of a tree, or the destruction of some wall or building, which had previously afforded shelter from the strong humid sea-breezes. From a like cause, houses in elevated and exposed situations are subject to ague in Brazil, though less so when built of one story, and surrounded by a deep verandah, which breaks the force of the breeze, than BENEFITS OF SHELTER. 251 when the ordinary height and construction are adopted. Instances of this nature are numerous and well marked. So well un- derstood and universally established ar$ the above facts in Brazil, that no native Brazil- ian will build his house on an eminence, exposed, without protection, to the full in- fluence of a strong sea-breeze. Conversely, it is matter of common obser- vation, that many houses in exposed and elevated situations, or built on the gorge of hills, and thus subject to a strong cur- rent of cool, damp sea-air, have, though formerly almost uninhabitable from ague, become healthy since the growth of forest timber, in the immediate neighbourhood, to windward, which had evidently no other effect than that of interrupting the force of the strong, cool, and damp, though other- wise healthy wind. In estimating the influence of a powerful cool and hurnid wind on the animal eco- 252 LECTURE VI. nomy under the foregoing circumstances, we must always bear in mind, that the cutaneous system is continually relaxed, and the nervous power depressed, in tropi- cal regions ; that the difference in tempera- ture between the sun and the shade is very great; that the slightest bodily exertion is attended by strong vascular excitement and profuse perspiration; and though, during the continuance of such exertion, little or no danger may be apprehended, that its discontinuance is usually followed by great exhaustion, and, to a certain extent, by collapse. Hence arises the paramount importance of well-sheltered situations, and the danger, in such climates, of exposure to strong damp currents of air in certain states of the system. On these principles, too, I apprehend, we can satisfactorily explain the peculiar and unlooked-for urihealthiness of certain bar- racks and stations, placed in elevated and MODE OF PRESERVING HEALTH. 253 exposed situations in the West Indies, rather than by imagining the ascent of a special morbid poison from the lower and surround- ing district, whose inhabitants it leaves com- paratively unscathed, to display its deadly influence, notwithstanding an extreme dilu- tion, on the residents of the distant ridge or mountain. The particular state of the animal eco- nomy just alluded to, is well understood by the native Brazilians, and guarded against most carefully as a chief source of sezoens (intermittent fever) as well as of constipacoens (continued fever). After exercise, or long-continued exposure to the sun, they invariably shut themselves up for a time in a close room ; and though of tem- perate habits as regards spirituous liquors, they take some stimulant in order to guard against the dangerous effects of the sudden collapse which so frequently ensues. The influence of sudden change from ex- 254 LECTURE VI. treme heat to comparative cold, under cer- tain conditions of the system, in exciting an attack of a febrile type, was well exem- plified in my own person, while travelling in Italy during 1839, for the benefit of my health. On the first of July, I quitted Kome for Naples, in company with my friend Mr Edwards, like myself an old resident in Brazil. At two o'clock, P.M., the thermo- meter stood at 87.5 in the shade, in the Piazza de Spagna, and the heat was much more oppressive than I had ever experi- enced in the tropics. We set off in the afternoon, preferring the danger of a night journey over the Pontine Marshes to the suffocating heat of a mid-day sun. Some time after leaving Albano, a spring of our carriage gave way, which compelled us to walk nearly a league to Gensano, where we arrived shortly after midnight. Here we found the inhabitants in such alarm, from a recent appearance of brigands in the ATTACK OF AGUE. 255 neighbourhood, that they refused to open their doors, and we were compelled to re- main in the open street, whilst our atten- dant patched up the damaged carriage, which occupied upwards of an hour. Never shall I forget the intense chilliness which I experienced in the streets of Gen- sano, in my summer clothing, fatigued by the excessive heat of the previous day, and bodily and mentally exhausted in taking a last look at the " lone mother of dead empires." My teeth almost chattered with cold; and on reaching Velletro, at three o'clock in the morning, I had fairly entered on the first stage of an ague fit, with visions of malaria floating in my imagination. Here, however, I managed to obtain some hot coffee, together with a supply of bad brandy, which had the effect of restoring the nervous power, and setting my blood once more in circulation; and thus I was enabled to pass the dreaded Pontine Marshes 256 LECTURE VI. without further inconvenience. On reach- ing Terracina, at nine o'clock in the morn- ing, the bright shores of the Mediterranean, aided by the less imaginative, though pro- bably not less important influence of a good breakfast, quickly dissipated all recol- lection of marshes and malaria. Now I am perfectly convinced that, had I not obtained the hot coffee and brandy at Velletro, I must marsh poison apart- have suffered an attack of fever ; the type, severity, and duration of which would have been determined rather by constitution or predisposition, than by anything specific in the original exciting cause. This exciting cause I take to have been exposure to- the cold damp night air, at a time when mind and body were alike suffering from previous exhaustion. What the actual therrnome- trical difference might have been between Rome at three P.M. and Gensano after mid- night, I cannot possibly determine; but SUDDEN CHANGE OF TEMPERATURE. 257 were I to measure it by my own feelings, I should certainly state the difference to be not less than 40 degrees; and if we take into consideration an atmosphere loaded with moisture from the adjoining marshes, a clear and cloudless sky, and the high radiating power of the rank luxuriant grasses, I am satisfied that the estimate of 40 degrees would not be far from the truth. A change so great and so sudden, when applied to an over-excited and exhausted system, will satisfactorily account for the invasion of fever, without calling in the aid of an especial poison. There is certainly nothing intrinsic in the essential nature of intermittent fever, which absolutely precludes the idea of its arising from other causes than the reputed one of a special poison. The question of periodicity, considered by the mass of medical authorities as almost distinctive of diseases originating in marsh 258 LECTURE VI. poison, I have already disposed of. I have moreover shown you, that the disease in question has been brought on simply by periodical immersion in cold water; and a singular case has been recently reported of one of those unfortunate outcasts of human- ity, who prey on the feelings of the public, through the habit of feigning shivering, and who is now stated to be unable to bring his body into proper warmth he always shivers. Let us examine the common history of a man who has suffered from an attack of ague. He is often liable, after the lapse of weeks, or months, or even of years, to a repetition of his attack on exposure to cold, or wet, or an east wind, &c. Now, what are the explanations of this remarkable phenomenon ordinarily offered by authors? One deems the law of habit to afford a satisfactory solution ; another believes that the malarious poison is still lurking in the system; whilst a third, as Dr. Elliotson CAN POISON LIE DORMANT? 259 high authority supposes that the unhappy wight, in passing through a market-place, may have come in contact with some erratic and malarious vegetable; and thus he satisfac- torily accounts for the renewal of the disease. With regard to the law of habit, I appre- hend that, whatever may have been its original force, an interval of months, or years, must in all cases be deemed sufficient to annihilate its power, to say nothing of its first establishment. I also hold, as utterly untenable on chemical evidence, the doctrine of a poison remaining unal- tered for years in the system, though ex- posed to the incessant series of organic changes and decompositions to which the human frame is subject, as well as liable to the universal law, inherent in all organised matter, 'of perishing, or dissolving into other forms. And the question of the ma- larious influence of decaying vegetable mat- ter in the common highways and byeways, 260 LECTURE IV. will be, I conceive, sufficiently set at rest by the well-known fact, that Covent Gar- den is neither a pest-house nor a desert. It would be important to know whether the authorities, to whose opinions I have just alluded, have ever carefully investigated the actual condition of health in these indi- viduals who are subject to occasional attacks of ague. My own peculiar position has ena- bled me to make such examinations on an extensive scale; and the following are the results to which I have been led. In every case of relapse which admitted of satisfac- tory investigation, I found, universally, that though the first attack of ague had been subdued, and the patient restored, in com- mon phrase, to his ordinary health and his ordinary occupations, yet his health had not in reality been perfectly re-established. If questioned under such circumstances, the re- ply would be, that he felt perfectly well ; but on a more close examination, it would be IMPEEFECT EESTOKATION. 261 found that lie had become more sensitive to slight atmospheric changes ; that his tongue was rather white and flabby, his appetite ca- pricious, his feelingsoften causelessly depress- ed ; that he was less capable of supporting continued mental or bodily exertion; and that his urine especially had become subject to much variation, being occasionally pale and rather abundant, and at other times scanty, and depositing sediments. Still he would be considered in good health. This condi- tion of system may, under favourable cir- cumstances, continue for a considerable pe- riod with little change, and finally pass away altogether; or the individual being accidentally exposed, in the above state of the economy, to one or other of the usual causes of fever, as cold, wet, an east wind, &c., a fresh paroxysm of ague may be the immediate consequence. In this mode, Gentlemen, according to my experience, is to be explained that 262 LECTURE VI. peculiar susceptibility to relapse in ague, which has so long and so seriously taxed the ingenuity of authors to account for satisfactorily. The influence of change of scene and climate in these cases is well known, and, in the higher latitudes espe- cially, often affords our only resource. The mode in which this change operates so beneficially in ague, has also given rise to various conjectures and opinions. When we reflect, however, on the remarkable power exercised by change of climate over the nervous system, and on most chronic maladies unattended by organic change, we need surely resort to no very recondite hypothesis, but may at once admit the obvious fact, that the general condition of the economy had been so far modified and improved by change of scene and climate, as to be enabled to resist those ordinary exciting causes of disease to which it had previously succumbed. CORRECT VIEWS. 263 I quote the following extract from one of the most recent works on the subject, as it suggests more correct views of the elements of febrile diseases in tropical regions ; and the principles of treatment glanced at are unquestionably superior to the fatal routine system of venesection, calomel, and salines, so commonly pursued in these maladies. The author, however, seems unacquainted with the almost mira- culous effects of quinine in large doses, in controlling every stage and form of the inter- mittent and remittent fevers of hot climates. " European practitioners, in any degree conversant with the medical customs of the negroes of intertropical Africa, cannot fail to be deeply impressed with the marked attention paid by the native doctors to the due action of the cutaneous tissues, and their encouragement of this as a means for relieving disease. The Mahomedan code of laws, whose sanitary regulations are so 264 LECTURE VI. well adapted for the advancement of the moral and physical condition of the barbar- ous pagan tribes in Central Africa, strictly enjoins not only abluent, but other hygienic measures, for the promotion of cleanliness, and the proper discharge of the cutaneous functions. The inhabitants of most of the maritime localities in the Bights are fully acquainted with the importance of these views, and treat the remittent, and other fevers to which they are subject, by endea- vouring to excite a long-continued and copious exudation of sweat from the cuticu- lar pores, by the aid of heated sand-baths, ablutions of hot water, and rude attempts to imitate vapour baths. In some countries, the patient is placed to a large fire for such purposes; while, in others, he is held t over it, water being slowly dropped thereon, so that the steam, as it ascends, may act on the affected portion of the body. After a careful observation of the good effects of MALARIA A NONENTITY. 265 this remedial system, I was led to pay more particular study to the utility of its appli- cation, and, at length, to try a modified adaptation of it for the cure of those ady- namic remittent fevers so destructive to Europeans. I have no hesitation in saying, that not only myself, but many others, who have experienced its efficacy by the speedy restoration to health, can vouch for its superiority over the ordinary practice of venesection, saline purgatives, and large doses of calomel," &c. (Pp. 119-20.) * It is scarcely necessary to repeat that, notwithstanding the almost universal as- sumption of the hypothesis of malaria, no sufficient evidence has yet been adduced to prove its entity. Indeed, so far as all chemical investigations go, the most refined analysis has been altogether unable to dis- * DANIELL, W. F., M.D. Sketches of the Medical Topography and Native Diseases of the Gulf of Guinea, Western Africa, London : 1849. N 266 LECTURE VI. cover the slightest difference between the air of the most swampy fen, and air pro- cured from the most pure and open sources. The actual presence of malaria is inferred from the succession of certain effects; but the question has never yet been fairly raised, whether certain known conditions, and states of the atmosphere, and of the indi- vidual, might not be deemed capable of explaining the phenomena more satisfac- torily than the agency of a cause which is purely hypothetical, and which has never yet been brought to the test of experience. I humbly submit that this question may be satisfactorily answered in the affirmative, on the evidence which I have adduced, and which at least demonstrates that intermit- tent fever does originate in numerous instances and probably universally from certain atmospheric conditions, in certain states of the constitution, altogether inde- pendent of organic or marsh poison. CLASSIFICATION OF FEVERS. 267 UNITY OF FEVEK The whole group of febrile diseases the essential meaning of this term being a disturbance in the sangui- ferous system may be comprised in three distinct classes : fever without local action ; fever with local action ; and fever with a speci- fic action, and arising from a specific cause. The connection of the second class or group with atmospheric vicissitudes is too palpable to demand illustration. The de- pendence of the last on a special cause, altogether apart from the physical influ- ence of the elements, separates it distinctly from the others, so far as regards the cause. But the origin of the first class is undoubt- edly, in numerous instances, as frequently the result of atmospheric vicissitudes as of any of the other commonly accredited causes contagion or malaria. In all the three classes, the common feature of family resemblance is pourtrayed in the initial symptoms the nervous depression, of 268 LECTURE VI. longer or shorter duration, the cold shiver- ing and anserine skin, followed by the glowing heat and general perspiration. It is, indeed, more than probable, that fever is the expression of a type of disease essentially one and uniform, but admitting of an almost endless variety of forms ; the simplest being displayed in the single par- oxysm of an ague. It is furthermore obvious, on the most cursory observation, that the description of fever as a disease has, in the generality of instances, been drawn for certain localities, and not from the whole group of febrile diseases, as wit- nessed in different parts of the world. The typhus fever of this country is superseded by the bilious remittent and intermittent in southern climates by the plague in the Levant and by the yellow fever within the tropics. Each of these maladies, under the special influence of climate, tem- perament, different modes of living, and INFLUENCE OF CLIMATE. 269 numerous other agencies, affects certain peculiarities in its progress; but they are all distinctly impressed by the phenomena universally characteristic of fever as a genus of disease in every clime. Climate, indeed, and its varieties, whether permanent or temporary, always modify the animal economy, and induce, if I may be allowed the expression, an epidemic or endemic state of the human constitution exposed to its influence. This state will vary, as the atmosphere may be cold or hot, dry or humid, pure or impure, variable or equable, stagnant or the reverse: the geo- logical character of the country or district, also, and the numerous moral and physical conditions already alluded to, powerfully contribute towards the formation of this endemic constitution in man. Moreover, the history of epidemic and endemic dis- eases almost universally proves that, prior to their invasion, the country or district 270 LECTURE VI. has been subjected, for a period more or less prolonged, to some well-marked devia- tion from the ordinary constitution of the climate, sufficient to modify the constitution of the inhabitants generally; so that the slightest disturbing cause, moral or physical, is followed by disease, the characteristics of which are determined as much by the constitution of the individual, as by the constitution of the atmosphere. An extensive acquaintance with the fevers of different regions of the globe has gradually established in my mind a convic- tion of their essential identity. And this has been confirmed since my return to Europe in 1842, by my observation of the typhus fever of this country and of France, which, in its more intense form, differs rather in degree than in essence, from the remittent of hot climates, or the yellow fever, as I observed it during the epidemic of 1812-13 at Cadiz, while serving as Kesi- IDENTITY OF FEVERS. 271 dent Medical Officer at the General Hospital for the reception of the sick of the army of Andalusia. In each, you have commonly the same tendency to remission ; and there is no one symptom, even to the yellow skin and black vomit, which you will not find occasionally present in each of the three diseases; neither is there any one organ or system so constantly affected, nor any lesion so constantly detected on post-mortem ex- amination, as to characterise the several maladies. There is no one morbid result, in fact, in any of these forms, that you will not occasionally find in all. The commonly rapid course of the tro- pical fevers might, perhaps, be urged as sufficient to distinguish them, and to estab- lish their claim to be placed in a distinct category : but do not other tropical diseases often run an equally rapid course, as com- pared with those of Europe, and yet who ever dreams of their being essentially dif- 272 LECTUEE VI. ferent from similar maladies in colder lati- tudes? The remittent, or bilious remittent, of southern climates, I need scarcely observe, is simply a more intense form of intermit- tent, and differs only in the severity of the symptoms, the less perfect remissions (in- termission really applies to neither), and the greater disturbance of the organic func- tions. They are to be treated on the same principles, and are controlled, fortunately, by the same remedies. In reference to that vexata qucestio the essential identity of the bilious remittent with the yellow fever of hot climates I may observe that the latter disease has lately ravaged the coast of Brazil, it is said, for the first time, and has therefore given rise to much difference of opinion among the profession. Some maintain its foreign, others, as my friend Dr. Croker Pen- nell, of Rio de Janeiro, its indigenous DR. PENNELL'S VIEWS. 273 origin. In proof of the latter opinion, Dr. Pennell states (p. 19), that " It is a curious circumstance, and may perhaps tend to elucidate the origin of yellow fever in Brazil, without having recourse to a specific source of infection, that, for the last few years, the fevers of the country, evidently not infection s, but of high temperature or marsh origin, have clearly been changing their characters. The genuine remittent has been but little seen for the last three years. In 1847-48, and 49, it was replaced by a fever of its own class, popularly known by the name of * Polka/ but in reality a remittent; arid, during the present year, U (the Polka) has been replaced by the yellow fever, a disease also with similar features. "Coincident with these and other changes in the diseases of Brazil, the climate, in its broad features, has altered strangely. Thunder storms, formerly of daily occur- rence at a certain hour, during the summer, N2 274 LECTURE VI. are now but seldom heard," &c., &c. Dr. Pennell finally arrives at the following conclusions : " That bilious remittent and yellow fever exist only under similar conditions of local- ity and climate; " That they are essentially the same dis- ease; " That yellow fever is the most intense form of bilious remittent:" Propositions entirely in accordance with my own expe- rience in Brazil and other countries. On the other hand, my friend and suc- cessor at the British Hospital in Bahia, Dr. Alexander Paterson (whom I am happy to recognise now present) considers the yellow fever, which prevailed at Bahia at the same epoch as in Rio de Janeiro, to be a disease sui generis, and imported ; and he has published some valuable and interesting evidence in support of this opinion. * * Medical Gazette, 28th March, 1851. DR. PATERSON'S OPINION. 275 Along with other reasons, he infers its essential difference from the ordinary re- mittent fever of the country from the fact, that quinine, which almost invariably con- trols the latter disease, proved powerless in the former. This evidence, however, I hold to be inconclusive. In the worst form of yellow fever, no remedy, Gentlemen, as I know by experience, will modify the disease a fact, unfortunately, applicable alike to the worst form of remittent and of intermittent fever. All three may, indeed, be characterised in the terse words of a dis- tinguished French physician, as applied to cholera " They commence with death." And, I may add, it is impossible to distin- guish, in anything essential, the more intense form of these tropical fevers from the more intense form of cholera all com- mence with death; the patient never for an instant rallies; the rational and physi- cal signs are, in all, perfectly identical; 276 LECTUKE VI. and equally so are the post-mortem appear- ances. While this sheet was passing through the press, my attention was directed to an interesting article in the last number of the Dublin Quarterly Journal of Me- dical Science, by Mr. Barton, on Hong Kong fever. Mr. B. is a believer in the theory that marsh miasm or malaria is the general exciting cause of intermittent and remittent fevers; but, as a candid and accurate observer, he does not resist the clear evidence of facts, and he therefore admits that these diseases may arise from other causes than marsh poison. In proof of this he gives his own case. He had resided at Hong Kong for four years in perfect health, until placed in atten- dance on the troops, and exposed to " unusual mental and bodily fatigue," when, after one month, he was seized with remittent fever. He however believes, (p. 347), " that a poison is imbibed into the system, re- maining latent for an uncertain period, or until some exciting cause developes a febrile paroxysm ;" though he admits that a combination of depressing moral and physical influences might account for the disease. He considers " that the organic nervous system is prima- rily affected;" in which opinion I fully concur. He notices the *' cholera form as simulating Asiatic cho- lera;" there is, in fact, no distinction. In proof of malaria being the source of fever, he notices that "the civil population at one time suffered MORTALITY AT HONG KONG. 2?7 equally with the troops, but subsequently, on pro- per sanitary steps being adopted, remained compara- tively healthy and the mild character of the disease in the Royal Navy, and persons living afloat. " (p. 348.) To this I reply, that were the Royal Navy deprived of their accustomed accommodation and advantages, or the civil population subjected to the same exposure and privations as the military, we should find that fever respected the one class as little as the other. He remarks (p. 363) on the fearful amount of mortality amongst the troops as contrasted with the healthiness of the naval forces, and of the civilians; and he very ration- ally suggests the amelioration of the condition of the sol- dier as the remedy; adding, " the reputed pestilential na- ture of the climate is now only supported by the military inhabitants, as other individuals, untrammelled by their rules and regulations, enjoy an equal if not greater amount of health . . . than most other tropical resi- dents ;" and as a proof that the disease is not attribu- table to locality alone, we have the further fact, that " the officers of the 59th Regiment, quartered in the same locality as the men, but better provided, having more space allotted to their use, and not being exposed at night, escaped fever." (p. 334.) Still Mr. Barton believes " that a poison is imbibed into the system ;" and that " the system is impregnated with this subtle essence, is shown by the constant liabi- lity to relapse." He admits, however, that " suppres- 278 LECTURE VI. sion of perspiration is a frequent exciting cause, as instanced in the number attacked on or after night guards, from exposure to draughts of air at an open window, and the frequent relapses of the patients unavoidably placed near the doors in the hospital wards." (p. 344.) He attributes to the concentration of malaria, or marsh exhalations in certain localities, the rapid putre- faction of dead animal matter, the rapid decay of silk, woollen, and other fabrics, and. the ground floors in buildings becoming quickly rotten, &c. &c., and believes these to confirm " the theory of a noxious emanation from the soil." (p. 345). These results I have elsewhere shown to be invariably contingent on the combination of high temperature and moisture, and altogether unconnected with marsh or any other noxious exhala- tions. But the evidence adduced by Mr. B. himself against the malaria hypothesis I hold as irresistible ; especially when conjoined with that afforded by Brazil. Mr. B. refers to Dr. Graves of Dublin, on the question of the origin of fever in Ireland ; and I am well satisfied that, had the penetrating and philosophic mind of this physi- cian been afforded the opportunity of observing tropical fevers, the marsh poison theory would have long since disappeared. Mr. B. tells us that " at Stanley or Chuckchoo, a military station at the south side of the island, the bar- racks are close to the water, and open to the sea-breeze." SHELTER V. EXPOSURE. 279 A detachment of troops arrived from England in Octo- ber, and were quartered here, and " all were attacked with fever within a fortnight after their arrival, and at a time when malaria could not be considered as exerting much influence." (p. 346.) Again, " the south-west monsoon blowing during the summer months, and the town of Victoria being situat- ed on the north side of the island, and under the lee of the highest range of mountains, it was conceived that the exclusion of the refreshing sea-breezes was one cause of sickness. A military station was accordingly formed on the south side, and barracks erected on a peninsula open to both monsoons, and enjoying the advantage of having no swamp or marsh in its neigh- bourhood. The mortality here exceeded the worst periods experienced at Victoria, on the north shore, and the place has been virtually abandoned. . . Six assistant surgeons ordered there during the past season to re- place each other in succession, were all attacked with fever and removed to Victoria." (p. 346.) " The same cause, whatever it may be, evidently gives rise, indifferently, to remittent fever, acute dysentery, or intermittent fever." (p. 346.) Mr. B. also suspects (there is no doubt of the fact) that "causes which in a temperate climate give rise to continued fever, or inflammations of the thoracic viscera, in a tropical climate cause periodic fever, or determination to the abdominal viscera." (p. 347.) Though holding to the marsh miasm theory, he still thinks " that it is 280 LECTURE VI. not altogether improbable that periodic fever may arise independently of malaria, and be owing to heat or pecu- liarity of climate remotely, and, immediately, to sudden chills or any depressing agency." (p. 336.) "The city of Victoria is situated on the northern shore, and stands close to the base of the highest ridge, the buildings extending up the face of the hill The town enjoys the advantage of being built upon a dry soil," &c. " The Regimental Hospital and military barracks are built at the foot of ravines or mountain gorges. . . . The winds during the hot season blowing through these ravines towards the military buildings." " Whatever the cause or causes of the fever may be, one fact is incontestibly established, that the vicinity of ra- vines and gorges in the mountains is unhealthy. . . . Both the Murray barracks and hospital are built at the foot of ravines, and the inmates will, in my opinion, always be obnoxious to attacks of fever .... Men admitted for other diseases were attacked with fever .... Observa- tion proved that relapses were most frequent in the eastern wards of the hospital, which was opposite a cutting in the hill leading from the ravine behind." (p. 338.) Dr. Wilson's " Medical Notes on China" are quoted with reference to one locality which proved singularly fatal. "It is a low narrow gorge, where a line of six cottages were lately built, with high land on either side ; and close to one extremity of the range there is cultivated rice ground, while there are deserted spaces DANGEROUS RAVINES. 281 at the other. From the height of the land forming the gorge, the wind is diverted from its natural course, fol- lows the hollow, and thus blows over the rice land, cul- tivated or waste, to the cottages. Five English gentle- men went to reside there ; in a short time four died from fever, the fifth scarcely escaped with life, and the lodging has been abandoned Three large and commodious houses were erected, of which two have been razed to the ground by their proprietors as unin- habitable, owing to their insalubrity, .... While the city of Victoria (sheltered, recollect, by the highest ridge in the island] enjoys almost entire immunity from fever, and the few cases that do occur are of a mild and tractable nature." (p. 341.) " The bad cases of fever always found in exposed positions, or in the vicinity of ravines or gorges." (p. 338.) " High temperature night and day for four or five months .... and atmosphere very humid." (p. 343.) But every page affords an illustration, which I would willingly quote did my space permit ; and I am compelled to refer the reader as I do most ear- nestly to the paper itself, which will amply repay perusal. The explanation, indeed, offered for the unhealthi- ness of the several buildings erected close to the ravines or mountain gorges, or in the valleys, is the old story of rice lands, decomposing brushwood, rank vegetation, or decayed vegetable matter carried down by the torrent, &c. But what shall we say of the 282 LECTURE VI. barracks at Stanley "close to the water, and open to the sea-breeze;" or to the still more deadly, and now abandoned station-" erected upon a peninsula open to both monsoons, and enjoying the advantage of having no swamp or marsh in its neighbourhood ;" whilst Victoria, built close to the base (to leeward ) of the highest ridge on the island, is free from fever ! Let the reader compare with the above statements the evidence afforded by the city of Bahia, the Bahia Hospital, St. Lazaro, Bomfim, &c., and he will at once perceive the solution to all Mr. B.'s doubts and difficulties at Hong Kong. Mr. B. adopts the univer- sal theory of malaria or marsh poison, and therefore considers that the vegetable products of the adjoining ravine afford a satisfactory explanation of the deadly insalubrity of his hospital and barracks ; whilst Fergu- son, in another hemisphere, found the Rocky Mountain gorge, devoid alike of vegetation and moisture, equally fatal, and from precisely similar diseases ; and he, too, invoked a malaria ! How, then, are we to reconcile such seeming anomalies ? Thus : in all hot climates (from causes stated elsewhere), if your hospital, or bar- rack, or habitation, be placed on an unsheltered emi- nence, or in the current of a gorge or ravine, though such ravine, instead of decaying vegetation, shall be lined with Parian marble, and swept by the purest ocean winds pure, but always loaded with moisture yet will such hospital, barrack, or habitation, prove invariably unhealthy ; and ague, remittent, and con- CHINESE PRECAUTIONS. 283 tinued fever, dysentery, and rheumatism, the prevailing diseases. From the height and pride of our theories, might we not cast a glance at ' ces bons ChinoisJ who ought surely to know something of their native country, and who are, besides, " subject to periodic fevers." They select invariably sheltered situations for their detached houses and villages, both being surrounded by umbrageous trees and shrubs" (p. 344), precisely as the Brazilians do under similar circumstances, in another quarter of the globe, and doubtless for the same sub stantial reasons. Let us then be guided by rational principles; let us place our habitation or our hospital in some dry and well-sheltered locality, and avoid alike the exposed sum- mit of the hill, or the cool and grateful, but deadly blast from the gorge or the ravine. At Hong Kong, as everywhere else, let the comfort of the soldier be equally cared for as the comfort of the civilian ; let him be supplied with proper food, appropriate clothing, and commodious barracks ; let over-fatigue, exposure to the mid-day sun, and night duties, be, as far as practicable, lessened or avoided ; let temperance, rational amuse- ment, and healthy exercise be encouraged ; as well as all other means calculated to maintain the moral and physical energies ; then drain, plant, and cultivate, by all means by which we shall not only increase shade and shelter, and lessen moisture, but add otherwise to our personal enjoyments. 284 LECTURE VI. I need not here repeat, what will be fully explained elsewhere, that to the observance or neglect of the above measures, and not to visionary and occult influ- ences, we must look for the maintenance of the health of our troops and stations in all intertropical coun- tries. We must, in short, cease to be terrified by shadows, and attend to realities. J greatly regret that space will not permit me to enlarge on the important questions of symptoms and treatment. I would, however, observe, that the greater gravity of the fevers, generally, at Hong Kong, as compared with those of Bahia, is explained chiefly by one single fact, viz., at Hong Kong, the thermometer ranges from 45 to 91 ; at Bahia, from 72 to 86. One or two more observations, and I conclude. Quinine was found the remedy at Hong Kong ; yet, prior to Dr. Ferguson's arrival, " His predecessors reported quinine to have signally failed" (p. 356). " Bleeding and calomel was tried with almost uniform ill success ; depletion and antimonials were equally unsuc- cessful" (p. 357). " One day's observation of the disease in the Military Hospital was sufficient to demonstrate that quinine in small doses was inadequate," &c. " The freedom from visceral disease of those cases treated with quinine at an early stage was marked," (p. 357). " Thirty to thirty-six grains commonly induced the specific action of quinine on the nervous system ;" and, " in but one case, out of nearly 900 subjected to its USE OF QUININE. 285 influence, were any bad consequences experienced :" there were " sudden sinking or collapse" (p. 355), which speedily passed off on using stimulants. My experience, in some points of treatment, does not coincide with that of Mr. Barton ; but into this subject I am unable to LECTURE VII. TREATMENT OF FEVEE, INTERMITTENT, REMITTENT, AND TYPHUS, BY LARGE AND FREQUENTLY REPEATED DOSES OF QUININE CASES OF TYPHUS FEVER TREAT- ED IN THE LIVERPOOL NORTHERN HOSPITAL MODE OF ACTION OF QUININE EXCITING CAUSES OF FEVER DOCTRINE OF MARSH POISON CRITICISED REAL CAUSE TO BE SOUGHT IN NERVOUS AND VASCULAR EXHAUSTION REMOVAL OF BLOOD OR OF ITS SALINE CONSTITUENTS EXCITES DISEASE INJURIES MORAL DEPRESSION SIR JAMES CLARK'S STATEMENT THAT AGUE IS PREVENTED BY FlRE IN ROOM EXPLANATION EXEMPTION OF NEGROES FROM FEVER MARSH MIASM DOCTRINE SHAKEN BY FERGUSON REASON FOR CONTRAST IN HEALTHINESS BETWEEN DRY AND SWAMPY DISTRICTS CAUSE OF GRAVITY OF DISEASE IN HOT CLIMATES PERMANENT RESIDENTS TEMPO- RARY RESIDENTS INFLUENCE OF ELECTRICITY OB- JECT OF PUBLISHING THESE LECTURES, TO SHOW THE IMPORTANCE OF DISREGARDING THE IMAGINARY AND FIXING THE ATTENTION ON THE PiEAL CAUSES OF TREATMENT. 287 DISEASE PROPHYLACTIC MEASURES TO BE ADOPTED IN HOT CLIMATES CONCLUSION. GENTLEMEN, I have reserved for the pre- sent lecture the few observations which I intend to offer on the treatment of the inter- mittent, the remittent, and the continued forms of fever ; and I shall not embarrass this important question by any allusions to theo- retical opinions, or to the multitudinous remedies and forms of treatment recom- mended by authors, but proceed at once to lay before you, in a few words, the results of my own personal experience in a field of observation of no common magnitude, and which eventually led me to the adoption of a plan of treatment at once simple, intelligi- ble, and generally efficacious. Neither shall I occupy your time by a recapitulation of the symptoms presented by remittent and intermittent fevers; they are given with sufficient accuracy and detail in every stan- dard work on practical medicine ; and with 288 LECTURE VII. the latter disease you have abundant oppor- tunities of making yourselves familiar in the wards of this hospital. I would here premise that, in the whole history of medicine, few more pernicious or ill-founded doctrines have been inculcated in so few words, than the following maxim, laid down in a modern standard work of deservedly high authority (the Cyclopaedia of Practical Medicine), against the admi- nistration of quinine, under certain circum- stances, in intermittent fever : viz. "the inter- missions being imperfect, and a recent local inflammation." Now, Gentlemen, the most ample and undoubted evidence has proved to me, that the judicious administration of quinine, under these very identical cir- cumstances, will not only render the imper- fect intermissions perfect, and cure the disease, but will also at the same time arrest the local malady. Active inflammation in ague is, indeed, of rare occurrence; though TREATMENT OF INTERMITTENT. 289 when it does arise it will undoubtedly dis- turb the curative influence of quinine : but this should not prohibit the use of the remedy, while the local affection should be met by cupping, with, or without, the sca- rificator, and counter-stimulation. TREATMENT OF INTERMITTENT FEVER. In all cases of intermittent fever, no matter of what type, you should invariably strip your patient, and examine carefully the condition of the thoracic and abdominal organs ; and if the tongue be loaded, and the secretions depraved, prescribe at once an emetic of tartarised antimony. Having ascertained the usual hour for the accession of the paroxysm, you should administer ' ten or twelve grains of the sulphate of quinine about two hours before the expect- ed attack, and repeat the dose after an interval of an hour. This will generally prove sufficient to modify, if not to arrest, o 290 LECTURE VII. the disease. Should, however, the cold stage arrive, apply external warmth, and the succeeding hot stage will be quickly terminated by the exhibition of two table- spoonfuls of the following mixture every five minutes, until perspiration is induced. I&. Tincturae Opii, 5!!. Acidi Nitrici, $i. Syrupi Simplicis ^i. Aquas Purae, Ib.i. M. During the period of apyrexia, give small doses (three grains) of the sulphate of qui- nine every three hours, until within two hours of the next expected paroxysm, when the larger doses are to be repeated as before. The smaller doses of quinine should be con- tinued for some time after the fever has entirely disappeared. Give your patient moderate support throughout, and avoid slops and purgatives. If a purgative be required, aloes is the best. You will, Gentlemen, find few cases of TREATMENT OF BILIOUS REMITTENT. 291 ague, in hot or any other climates, curable by medicine, which will prove rebellious to this treatment. If it fail as fail it some- times will try no other physic, but re- move your patient, with all practicable dis- patch, to a different locality. I have already expressed my opinion on the question of complication by local inflammations. De- pletion will not cure these inflammations, but cupping with or without the scarifi- cator and counter-irritation, will often prove serviceable. TREATMENT OF BILIOUS REMITTENT FE- VER. With regard to the treatment of bilious remittent fever, the sole fact which I am especially anxious to impress upon you is this : pay no attention to the violent headache, the lumbar pains, the strong and rapid pulse, the yellow burning skin, and the intense thirst, but commence at once the administration of large doses of quinine 292 LECTURE VII. ten or twelve grains every two hours. With the first dose give ten or fifteen grains of calomel, and, after the third dose of quinine, you will commonly find the severity of the symptoms abate. When you have succeeded in establishing an inter- mission, you must treat the case exactly as you would an ague, into some form or other of which it often lapses. Four or five large doses of quinine will ordinarily modify the disease; but if giddi- ness of the head and tinnitus aurium super- vene, the remedy must be suspended, or continued in smaller doses. Its curative effects are displayed in the rapid subsidence of all the more intense symptoms. Should the first four or five doses fail in checking the disease, administer tartarised antimony to the extent of causing slight vomiting; and after an interval of twelve hours recom- mence the quinine as before. Should this treatment fail which it sel- TREATMENT OF BILIOUS REMITTENT. 293 doin does, when early resorted to in rapidly checking the disease, I believe that no other will prove successful. You may, indeed, resort to other means, and patients may get well under or in spite of them. But with this question we have at present nothing to do. I place before you, Gentle- men, the cardinal points ; they will admit of some modification; and the minor adjuvants in the treatment of febrile disease will of course be attended to by every well-in- formed practitioner, and no other should undertake the treatment of bilious remit- tent fever. I may add, that the treatment here in- dicated applies more especially to those who have resided for some time in hot cli- mates. In the robust European, lately arrived, and attacked for the first time with bilious remittent, should the febrile symptoms run high, or threaten a vital organ, one bleeding from the arm, to the 294 LECTURE VII. extent of sixteen or twenty ounces, may be resorted to at the very commencement of the attack; then the treatment already laid down should be followed up. On the sequels of remittent and inter- mittent fever it is not my intention to enter further than to observe, that they are best met by change of scene and climate, by the various preparations of iron, in small doses, either alone or in combination with quinine, by a free administration of taraxacum, and the occasional use of extract of aloes, toge- ther with careful attention to clothing, diet, and exercise, such as I have pointed out in a former lecture. TREATMENT OF TYPHUS FEVER. Acting on my conviction of the essential identity of the remittent and intermittent fever of the tropics with the typhus fever of Europe, and aware of the specific action of quinine in every stage of the former dis- TREATMENT OF TYPHUS. 295 eases, I have resorted to its administration in the ordinary typhus of this country, in all its stages; and commonly with the hap- piest results. In these researches I have been greatly aided by my relative, Dr. Leslie, now of Rio, and formerly my house- surgeon at the Bahia Hospital, and who has himself extensively employed the treatment here laid down. In typhus, as in the remittent of hot climates, the treatment by quinine will be successful in proportion to its early administration. The doses also, as in the tropical fevers, should be large, ten or twelve grains, and repeated at intervals not exceeding two hours. Three or four doses will, in most cases, be sufficient to produce its specific influence on the nervous system, which is commonly displayed by dizziness of the head, tinnitus aurium, or deafness, or in the rapid subsidence of all the urgent symptoms. In the latter event, three or four grains of the quinine should 296 LECTURE VII. be administered three times a-day, and the patient supported with good beef-tea, or other light nutriment, and wine if neces- sary. Should the urgent symptoms return, the large and repeated doses of quinine must again be resorted to. Slops should be avoided, and purgatives also, unless obviously indicated; but an emetic of tar- tarised antimony will often prove useful at the commencement, and apparently renders the system more obedient to the specific influence of the remedy. Should the urgent symptoms persist, not- withstanding the administration of five or six doses of quinine, or should dizziness and tinnitus aurium supervene, the medi- cine must be discontinued ; and, after an interval of six or seven hours, small and repeated doses of tartar emetic should be resorted to, until full vomiting is induced. Then allow your patient to rest for twenty- four hours, and recommence the quinine as TREATMENT OF TYPHUS. 297 before. When there is much restlessness and want of sleep, a full dose of liquor opii sedativus, with some drops of nitric acid, will often prove highly advantageous, and enable you to resume your treatment with more prospect of success. Should the symptoms still resist, you may repeat the remedies successively, as above, for four or five days ; and unless the beneficial effects are broadly marked within that period, we can no longer reasonably hope for success from this treatment ; and it may be abandoned, or the quinine con- tinued in smaller doses. Still, in the vast majority of cases of uncomplicated typhus, taken at the com- mencement, you may calculate on complete and rapid success ; and, in all, you will almost invariably succeed in breaking, for a time, the diseased chain of actions no un- important advantage in any malady. In the advanced periods of the disease, the 298 LECTURE VII. result will be much less certain ; but, in all stages, the large doses of quinine may be safely resorted to, and will commonly calm your patient, cool the skin, allay the head- ache, and reduce the frequency and improve the character of the pulse. You must, however, bear in mind, as already pointed out, that any vital or important organ being seriously involved, will prove a dis- turbing cause to the curative powers of the remedy, which are clearly exerted on the nervous system, through which the blood and secretions are favourably modified, and often with marvellous rapidity. In the history of typhus in this country, you will find numerous incidental notices, such as the following, on the epidemic of 1819: " The disease has simulated the re- current type. The paroxysms were marked by distinct and often violent rigors, which were succeeded by intense heat, and increas- ed vascular energy, terminating occasionally TREATMENT OF TYPHUS. 299 in profuse sweating, but more commonly in a gradual subsidence of the exacerbation, without any relaxation of the surface. The paroxysms showed no obedience to perio- dicity, in some cases recurring in a few hours, and in others only after the lapse of many days." * Now, here we are pre- sented, clearly and distinctly, with the history of an irregular intermittent or re- mittent fever; and yet, Gentlemen, strange to say, this idea seems never once to have crossed the mind of the observer. As I well know how distasteful an array of cases commonly proves, both to hearers and to readers, I shall only trouble you with two or three on the present subject; but these are well adapted to illustrate, beyond all rational doubt, the justness of the principles, and the efficacy of the treat- * SHEPPAKD. Edinburgh Medical and Surgical Jour- nal, vol. xv. See, also, different accounts of the " Re- lapsing" fever, in this and other countries. 300 LECTURE VII. ment, which I have inculcated. The de- scription of the symptoms and treatment, in these cases, is divested of all minute detail, as I am anxious to place the broad facts clearly before you, in order the more firinly-to impress them on your memory, and in order that you may hereafter, as opportunity offers, submit them to large and careful experiment. I select these two cases of typhus chiefly on this account that they were lately received into our wards, and under your own eyes. One, you will remember, was admitted under myself; the other under my colleague, Dr. Scott; the notes were taken down by our intelligent house-surgeon, Mr. Evans; and the results have been observed by most of you. "CASE I. Cornelius Vincent, aged 26, was admitted on the 2d October, 1850, into ward No. 12, under Dr. Duiidas. Has been ill ten days. " October 3. Has severe headache; an- CASES. 301 xious countenance ; slight delirium ; hot and dry skin; the tongue is black, dry, and furred; the teeth covered with sordes. He has thirst; the urine is scanty and high- coloured ; the bowels open ; the abdomen pain- ful on pressure; pulse 100; respirations 28. " 9> Quinas Disulphatis, gr. xxx. " Divide in doses iii, quarum capiat i secunda quaque hora. " October 4. Convalescent. The pain in the head and the delirium have ceased, and the abdomen is less tender. The heat of skin is diminished; the tongue clean and moist; pulse 90; respirations 24. " |& Infusi Quassioe, ^iii ter in die. " No further treatment was resorted to; and from this date he rapidly gained strength, and was discharged well on the llth October." You are aware that our ordinary rule is, not to admit cases of typhus, but to forward them to the Fever Hospital; but the above case having been reported to rny colleague, 302 LECTURE VII. Dr. Scott, he resolved to give the treatment by quinine a trial. An opportunity presented itself in a few days, in the following case : "CASE II. Edward Donald, aged 23, was admitted into ward 14, under Dr. Scott, on 25th October, 1850. " October 25. He had been ill eight days. There was now great anxiety of countenance, and high delirium; dry, pun- gent skin; tongue dry, and coated with dark fur; sordes about the lips and teeth; great thirst ; the urine was scanty and high-coloured; the bowels open; the abdo- men tumid, and tender on pressure; pulse 108; respirations 30. " $k Quinae Disulphatis, gr. xxx. " Divide in doses iii, quarum capiat i secunda quaque hora. " October 26. At the morning visit, he was found reading a book in bed ! All the formidable symptoms of yesterday had dis- appeared. MODEKN OPINIONS. 303 " No further medical treatment was re- sorted to in this case ; and he was discharged well on the 5th of November." Yet we are told, on high authority, that, "in the continued fevers of this country, we believe it (bark) might with great safety be erased from the list of remedies alto- gether:"* and another eminent authority (Dr. Pereira), in his excellent work on Ma- teria Medica, lays down that "in febrile conditions of the system, attended with a hot and dry skin, aud a furred and dry tongue, tonics act as local irritants and stimulants, and add to the severity of all the morbid symptoms" (p. 208); and he illustrates these principles by the action of disulphate of quina in fever ! Whilst Dr. Tweedie whom we may fairly admit as representing the opinions of the highest authorities in this country on fever em- * Edinburgh Medical and Surgical Journal, vol. xv., p. 595. 304 LECTURE VII. phatically states of quinine, that " its exhi- bition in the early stages of fever, under any circumstances, is improper, as tending, by its stimulant powers, to keep up or increase the febrile action in the system; and when there is local complication, it is evidently so pernicious, that scarcely any practitioner can be so ignorant of the com- mon principles on which the treatment of fever should be conducted, as to think for one moment of its administration under such circumstances." * Such, Gentlemen, may be taken as the expression of the opinions of the most dis- tinguished men in this country on the pre- sent question. Contrast these opinions, not with mine, but with the facts observed by yourselves in the wards of this Hospital. * Cyclopaedia of Practical Medicine, vol. ii., p. 211. Compare these urgent doctrines of Dr. Tweedie with the results of the " quinine treatment" in the foregoing cases, and in the cases of " typhus with complications" in the Liverpool Fever Hospital. TRADITION V. OBSERVATION. 305 Yet do not, I pray you, misunderstand me. The physicians whose names I have just now, and elsewhere, cited, are men of un- doubted talent, nay, of European fame ; and whose works are, deservedly, in the hands of us all, and, for this very reason have I quoted them. My object is, not to depre- ciate, but to warn. In the course of your professional career and I speak from large experience you will find the great mass of the medical world disposed implicitly to rely on authority; it saves a world of care. But, Gentlemen, though conducive com- monly to our ease, and sometimes to our interest, this principle is dangerous to truth. Therefore, although I would have you to receive with all respect the opinions of eminent men, yet I would most earnestly exhort you to admit nothing on tradition ; " high though his titles, proud his name," resign blindly to no man the exercise of that reason vouchsafed to you by Provi- 306 LECTURE VII. dence for your own guidance, and for the benefit of your fellow-creatures. Now, I maintain that, did the before-men- tioned cases stand alone which they do not they would afford cogent evidence, not only in support of the quinine treat- ment in continued fever, but of the truth of the doctrine on which such treatment is founded ; namely, the essential identity of the typhus of this country with the inter- mittent and remittent of the tropics, modi- fied by climate, and numerous other influ- ences. I hold that in the present, as in numerous other maladies (delirium tremens, for example) the results of treatment will clearly identify or dissever diseases, which the most careful observation of symptoms, aye, and of pathological appearances, have utterly failed to distinguish. In fact, Gen- tlemen, the history of fever must, and will ere long, be rewritten* * Subsequently to the delivery of these lectures, the POWER OF QUININE. 307 The power of quinine, when duly admi- nistered, in controlling the remittent and intermittent fever, (and the yellow fever also, as stated by Dr. Blair), is now a well- established and important fact. But I to- tally dissent from the received doctrine of cinchonizing treatment has been adopted in several other cases of fever admitted into the Northern Hospital, and with equally good success. In one case, that of Ann Dobbin, one of the hospital nurses, the effect was highly instructive. Attacked with well-marked typhus, she was treated for three or four days on the ordinary routine system, by purgatives, salines, and diaphoretics. Under this treatment she became daily worse ; the cerebral disturbance, the lumbar pains, the heat of skin, and the thirst, gradually became more intense; the pulse more frequent, the tongue dry and brown, and sordes began to appear about the teeth and lips. Ten grains of quinine every two hours were now given, with the result, after the sixth dose, of arresting all the un- favourable symptoms. The pulse calmed down, the to ague became moist and clean, the sordes disappeared, the heat of skin, the thirst, the cerebral and lumbar pains, all moderated, and she rapidly improved without any further medical treatment, beyond the administra- tion of a little wine. 308 LECTURE VII. its specific action on the several specific poisons which are supposed to produce these fevers. Moreover, I have already demonstrated to you, in our own wards, that it displays an equal power in subduing the supposed animal poison of the typhus fever. The action of quinine is clearly not that of a tonic, in the ordinary sense of the term. Its action is obviously on the nervous sys- tem, whose functions it favourably and rapidly modifies, when they are depressed or exhausted by any of the numerous moral and physical agencies before alluded to; and thus it restores to the organic nervous system its normal influence over the animal fluids and the vital phenomena. Hence the curative powers of quinine in fever, as in many other maladies. The immediate arrest of typhus by quinine will, for ob- vious reasons, be more signally displayed in private patients than in the ordinary run of those admitted into hospitals. CAUSE OF FEVER. 309 EXCITING CAUSE OF FEVER. It would, Gentlemen, be altogether remote from the object of these lectures to enter into any lengthened disquisition on the nature of the exciting cause of fever a subject on which so many men of the first talent have laboured, and on which so much and curious speculation has been offered: yet I feel bound to submit, with great diffi- dence, a few observations on the idea, so rapidly seized on, especially in hot climates, of a malaria or poison acting on the animal frame, as in the supposed production of ardent, remittent, and intermittent fevers; while many of those causes are erroneously omitted, or held only as secondary, of which a most especial account ought to have been taken, and the concurrence of which, in more temperate regions, is unanimously allowed to be the efficient agent in exciting febrile diseases at one time of the idio- pathic, at another of the symptomatic form. 310 LECTURE VII. If we examine those instances which are especially put forward in proof of the action of a morbid poison on the system, we shall commonly find that they refer to soldiers and sailors engaged in hot climates, on detached or fatigue duty, in dockyards, on watering expeditions, &c., and exposed to the intense rays of the sun, rendered doubly oppressive by reflection from the sides of the hills, or in the deep valleys, where such operations are most usually carried on. The cutaneous system (both its nervous and its vascular elements) is brought into a state of the highest excitement by excessive heat and la- borious exertion, frequently accompanied by intemperance and other excesses. Extreme exhaustion of the nervous system necessa- rily succeeds, and is followed by a collapse. Night comes on, with a positive difference in temperature, t often more than thirty degrees, between the mid-day heat and the earth's surface, towards sunrise. The ner- NEEVOUS EXHAUSTION. 311 vous energies animal and organic being already profoundly depressed, and the faculty of evolving heat proportionately diminished, the men fall asleep, not only deprived of their ordinary protection, but with their light tropical clothing drenched in the chilly night- dew, and exposed to a brisk land or sea-breeze, to awake in all the horrors of ardent fever. A swamp, a mo- rass, a fen, a something unknown (for, even advanced as we are in the knowledge of the laws of nature, there exists in the human mind an inherent tendency to look to some secret, hidden, and unrevealed influence), is at once accused as the sole and efficient agent; and, thus satisfied, all inquiry ceases. Now, Gentlemen, this train of argument inferring a pre-existing cause from certain effects may be perfectly legi- timate ; but the cycle of logic is not equally correct, assuming that cause to be an un- known quality or essence, while it is matter 312 LECTURE VII. of observation to every one, that similar effects result from causes known and patent to all. For example, under the foregoing circum- stances, the influence of cold and exhaustion, positive as well as relative, on the sentient extremities of the nerves, and the rapid depletion of the vascular system by profuse tropical perspiration, seem to be altogether forgotten. In such cases, the depressed or exhausted energies of the cutaneous nerves will lower, and occasionally even paralyse, the capillary circulation, and thus deprive the nervous centres of the vivifying influ- ence of vitalised blood; for the activity or diminution of the circulation depends, as you are aware, less on an action in the heart than on an action in the capillaries. The energy of the peripheries of the incident nerves being thus depressed, and the respi- ratory movements lessened in proportion to the diminished activity of the organic ner- TRUE ORIGIN OF FEVER. 313 vous functions, imperfect arterialisation of the blood, with deficient circulation in the pulmonary arid systemic capillaries, and defective depuration, necessarily ensue; and are followed by an arrest of the evolution of animal heat, and of the normal reaction between the blood and tissues results highly deleterious at all times, but in some constitutions, and in certain states of the system, as fatal as the most deadly poison, and often with almost equal rapidity. Surely, under such circumstances, we need riot evoke the phantom Malaria, in order satisfactorily to account for the supervention of fever, or any other serious malady. *' Nee Deus intersit, nisi dignus vindice nodus." Moreover, as I have already informed you, I have myself been temporarily exposed, and have witnessed, largely, the exposure of others, in various quarters of the globe, to the most concentrated effluvia of marshes ; yet, in no one instance and I beg of you to P 314 LECTURE VII. bear this fact in remembrance in no one instance do I recollect having observed such temporary exposure followed by fever, in an individual whose general health was good, and where none of the depressing agencies, already alluded to, had been previously in operation. Neither has the influence of an occasion- ally large and sudden subtraction of the saline constituents directly from the serum of the blood, incident to over- exert ion and exposure to the sun in hot climates, been hitherto duly estimated by physicians. Physiologists teach, and pathology confirms the fact, that those elements are essential to the preservation of the circulating fluid from decomposition ; for the black and dis- solved condition of the blood, observed in the more rapid and fatal forms of tropical fever, is found almost invariably allied with great diminution or entire loss of its saline constituents. And this, I apprehend, EFFECTS OF DEPLETION. 315 is due, not to the exhaustion of these elements by the violence of the fever, but chiefly to their removal, which precedes the invasion of the disease, and greatly influences its course. Moreover, you must all be cognisant, from the experiments of Hunter and others, of the immediate and decided impression which the sudden loss of even a few ounces of blood exercises on the general system, and, through it, on the constitution of the entire mass of the blood itself. So, likewise, will the exhaustion of the nervous power, and the sudden depletion of the animal fluids, by the rapid and profuse perspiration incident to all laborious exertion in hot climates, often profoundly and immediately modify the whole animal economy. Thus, indeed, can we more satisfactorily explain the occurrence, from simple exposure to in- tense solar heat, of fevers similar in charac- ter to the most pernicious fevers of marshy districts, as observed by Dr. Murray; and 316 LECTURE VII. most medical officers who have served in hot climates must have witnessed, as I have, a perfectly healthy man walked into a per- nicious fever aye, and quickly, when the atmosphere has been humid, hot, and sultry. In offering a solution of the above and analogous facts, we are much aided by the evidence of Sanctorius and others, who have shown that, independently of its direct depressing influence on the vital powers, a drenching perspiration (never absent under the above circumstances) will arrest, or seriously interrupt, the elimination of those digested or effete elements which are alone removed by insensible exhalation, and whose retention in the system is ever attended by the most formidable results. * Moreover, the immediate influence of the * Sanctorius writes as follows : I. " That perspiration, which is beneficial, and most clears the body of superfluous matter, is not what goes off with sweat, but that insensible steam or vapour," &c., &c. Sect, i., aphor. 21. NERVOUS INFLUENCE. 317 organic nerves, in modifying the constitu- tion of the blood, is now placed, by direct experiment, observation, and experience, beyond all rational question ; nor can it be doubted, that such morbid changes can be suddenly impressed on the blood, through the nervous system, as to transform the healthy man of to-day into a mass of disease by to-morrow and that, too, independently of the introduction, ab externo, of a single particle of any morbid agent into the sys- tem. I need scarcely allude to the daily- observed fact of the influence of a serious nervous shock in morbidly modifying the animal fluids. An instructive case in point, of fatal "yellow fever'' following amputa- tion in consequence of accident, is given by Sir George Ballingall, and our own Hospi- tal affords numerous analogous instances; 2. " Sweat is always from some violent cause ; and as such, it hinders the insensible exhalation of the digested perspirable matter." Sect, v., aphor. 3. 318 LECTURE VII. whilst Dr. Hodgkin, in his interesting and valuable observations,* has shown that, in certain states of the constitution, even a slight lesion is adequate to the production of similar morbid results a fact to which I can myself bear testimony. We know, also, on the authority of Dr. Cheyne, that the most fatal cases of typhus fever will originate solely in anxiety and mental depression, without the individual having been exposed to any contaminating influence whatever; and I have repeatedly witnessed intermittent fever, of the most intractable character, originate under pre- cisely similar circumstances, and, on one or two occasions, apparently from accidental loss of blood. How, also, does it occur that careful attention to all those measures which pre- serve the general health, sustain the ner- vous power, and support the capillary cir- * Medico- Chirurgical Transactions, vol. xxxi. AFRICAN COAST. 319 culation, will completely annihilate the virulence of marsh poison ? This is clearly proven in numerous and well-authenticated instances on the coast of Africa, where, by careful attention to the general health and habits of the men, the use of woollen dresses, and protection by awnings from the sun during the day, and during night from exposure to the chill and humid atmo- sphere, ships' companies and boats' crews have been maintained in a state of perfect health, notwithstanding a long-continued exposure to all the ordinary exciting causes of African fever. Even so lately as July 1850, we are told on high authority, that with regard to the alleged unhealthiness of it (the coast of Africa), " so nearly have European skill, science, and care, baffled the climate, that the African station is now as healthy as the rest of our naval stations in the tropics."* * Eeports from the Lords and Commons. Edin- burgh Review, July 1850. 320 LECTURE VII. And we are indebted to that distinguished physician, Sir James Clarke, for the follow- ing important and analogous facts facts quite in accordance with my own experi- ence in different quarters of the globe, but utterly inconsistent with the notion of a specific poison. He says, that a person may sleep with perfect safety in the centre of the Pontine Marshes, by keeping his room " well heated by a fire during the night :" and again, that " the exemption of the cen- tral parts of a large town from these fevers (malarious) is explained by the dryness of the atmosphere, and by the comparative equality of temperature which prevails there." How, Gentlemen, does this occur? If there be a poison, it must be taken in either by the air*passages, or in deglutition, or absorbed by the skin. " Having his room well-heat- ed" certainly cannot prevent the access of the malaria to the skin, or to the lungs; on the contrary, from the current maintained THERE IS NO POISON. 321 by a fire, a greater amount of air, and con- sequently of the poison incorporated with it, must necessarily have access to the lungs at each act of respiration. Deglutition taking place only when we are awake, all access through this channel is necessarily denied. Can we then believe that simply warming a room causes the poison to refuse to enter the system by the skin or by the lungs, though extensively diffused through the atmosphere? or have we not, indeed, this obvious solution to the problem : THERE is NO POISON? De non apparentibus et non existentibus eadem est ratio. Is not the dryness of the atmosphere, as well as its warmth by means of a fire, an adequate protection against the reduced temperature of the night, and little swerving from that enjoyed during the diurnal heat? Thus are sustained, especially during sleep, the organic nervous power, and consequently the activity of the universal capillary and p2 322 LECTURE VII. respiratory functions, through which the normal reactions, so essential to health, are promoted and maintained. Such, Gentlemen, I believe to be a true solution of the foregoing remarkable and well-established fact, and explanatory of the invasion of, or the immunity from, febrile diseases, in all warm climates. In those countries, you will please to recollect, the capillary vessels play a much more im- portant part than in the colder latitudes, and are, consequently, more exposed to derangement from their excessive and in- cessant action, maintained by the perma- nent stimulus of high temperature. This important system, therefore, soon becomes weakened, as do also the peripheral nerves, whose energies, being exhausted or depress- ed from the same cause, greatly increase, if they do not indeed originate, the general mischief. Prolonged exposure to the sun, residence in humid and sultry localities, PREDISPOSING CAUSES. 323 excessive fatigue, debauch, the depressing passions, exhaustion from previous disease, &c., &c., will equally depress the organic nervous power and the capillary circulation, and thus establish a morbid sensibility and susceptibility to serious modification from such limited atmospheric changes as are caused by a strong humid sea-breeze, or other equally slight physical or moral influ- ences, which, in a different state of the economy, would be either unattended with evil, or would pass altogether unnoticed. Moreover, in hot countries, all the internal organs sympathise largely and immediately with the slightest derangement of the der- moid membrane ; and I am deeply convinced that such derangements constitute the im- mediate exciting cause of nineteen-twen- tieths of the diseases (including all the fevers) to which Europeans are subject in hot and tropical climates.* * While this sheet was passing through the press, my 324 LECTURE VII. The comparative exemption from fever enjoyed by the Negro race in hot climates is another well-established fact; and its solution, I apprehend, will be found chiefly in the peculiar structure of the dermoid attention was called to the interesting and valuable work of Dr. Bascome,* whose opinions in the following summary are, I am gratified to find, in perfect accor- dance with my own views and experience. " I take leave to reiterate my opinion-^-an opinion founded on a careful review of the foregoing history of epidemics that all epidemic pestilences or diseases are to be accounted for on the principle of natural causes, viz., that atmospheric disturbance, consisting of variations of temperature, by hygrometric influence, atmospheric pressure, electrical tension, c., are the exciting causes ; while, on the other hand, want of light, impure air, especially from defective ventilation, in which are included malaria and all other noxious vapours, from whatever source arising ; scanty diet, and habits in- duced by the irregular artificial life of many are the predisposing causes, which by enervating and otherwise spoiling the system, render it more susceptible of ex- ternal atmospheric impressions in the production of epidemic pestilence or disease." Chap. xi. * A History of Epidemic Pestilences from the Ear- liest Ages, &c. London, 1851, MARSH EFFLUVIA. 325 membrane of the black, in the abundant and often highly-offensive sebaceous or oleaginous secretion, with which the sur- face of the African is naturally anointed, arid which preserves him against the effects of sudden atmospheric changes. Also, the more energetic performance of the functions of the cutaneous system in the negro, as com- pared with the European, renders him less subject to exhaustion in the hot and humid atmosphere of his native climate. MARSH EFFLUVIA. There is obviously, Gentlemen, something too limited in the range of the speculations of those writers who assume marsh effluvia as the cause of remittent and intermittent fever. The ob- servations, indeed, of Ferguson, as I have already shown, tend materially to invalidate the common opinion regarding the agency of marsh miasm. He endeavours to esta- blish the proposition, that the only condi- 326 LECTURE VII. tion indispensable to the supposed produc- tion of marsh poison, on all surfaces capable of absorption, is the paucity of water where it had previously abounded; a statement which, if admitted as true, removes at once all idea of a specific organic poison, and places the theory of the origin of intermit- tent fever distinctly within the range of natural causes, as the atmospheric vicissi- tudes, the heat of a mid-day sun, the precipitation of dew, the condition of the individual, &c., causes always in opera- tion, arid the efficiency of which, in excit- ing other febrile disorders, is universally admitted. Still you may fairly put the question : If we are to exclude the idea of an especial poison from marshy regions, to what agency are we to attribute the acknowledged pre- valence of intermittent and remittent fever equally in Europe as in the tropics in all low, ill-drained, and swampy localities? STAGNANT ATMOSPHERE. 327 In addition to the observations which I have just submitted to you, I would further reply, that, in strong contrast to the un- healthiness of these localities, we have to place the admitted salubrity of dry and elevated regions, and their especial exemp- tion from intermittent or remittent fever, as well as from other diseases of an asthenic character. This exemption has been attri- buted, and I believe justly, to the pure and dry state of the atmosphere; which, in such localities, being rarely stagnant, permits the healthy changes to be more perfectly effected in the blood, and the functions of the exhaling surfaces and secreting organs to be more energetically and more efficient- ly performed, so that the vital and corpo- real energies are promoted and increased. On the other hand, in low and swarnpy districts we have an atmosphere often stagnant, and permanently loaded with moisture, whose influence on the animal 328 LECTURE VII. economy is attended by opposite results, as regards the necessary changes in the blood, the secretions, the exhalations from the surface, and the organic nervous power. Hence it causes the retention in the circula- tion, beyond their due proportion, of ele- ments which ought to have been eliminated, and whose retention in the system proves the predisposing, as well as the immediate cause of numerous and fatal diseases a broad general principle in pathology, now admitted by the highest medical authorities, and supported by the irrefragable evidence of chemical research. We have, moreover, the well-established general law which determines the prevalence of fever in all countries, temperate or tropical, namely, the occurrence of much rain, succeeded by a calm and sultry atmosphere; with the converse fact, that a dry and cold air arrests its progress. Moisture alone will not, indeed, generate fever; as is proved by COMPLICATIONS. 329 the history of our seamen ; but let the moist air become stagnant, and, if heat be super- added, how long would such immunity be maintained? especially if ever- fatigue, or any other depressing influence, be associated. The deleterious consequences just stated will the more rapidly and readily ensue, should one of the secreting organs, as the liver, the kidneys, or the skin, be, from any cause, incompetent to the efficient perform- ance of its healthy action, and consequently of those additional and vicarious functions by which one organ so frequently compen- sates the diseased or interrupted functions of another. If, again, to moisture and a stagnant state of the atmosphere be super- added high temperature, we shall find that the before-mentioned injurious agencies will be very seriously augmented, as evi- denced throughout the whole circle of vital manifestations.* * The deleterious influence of a warm, moist, and 330 LECTURE VII. The prevalence of the more intense forms of fever, the depression of the vital powers, and the adynamic character of disease, incidental to hot climates, have been com- monly attributed to the higher concentra- tion of terrestrial emanations, rendered more noxious by the abundant effluvia from dead animal matter, the exuviae of insects, &c., abounding in low and swampy dis- tricts. That such exhalations will render the atmosphere less pure, and deteriorate the general health, by acting on the ner- vous and secreting systems, I readily con- cede; but I do not admit that we are com- pelled to adopt the agency of an especial stagnant atmosphere, is now fully recognised by our latest and best observers, as the chief cause of those direful conditions, goitre and cretinism, so prevalent in some of the Alpine valleys in Europe. I have wit- nessed, in the mountainous valleys of Brazil, the same results, originating in precisely similar causes. In these cases, no doubt, the influence of great elevatioi acts as a modifying and determining agent. PERMANENT RESIDENTS. 331 morbid poison, in order satisfactorily to account for the frequency and gravity of dis- ease in such localities. Let us for a moment reflect on the condition of the parties com- monly exposed to these sources of disease. In the permanent resident, we shall find that a low standard of health almost uni- versally obtains; that the inhabitants are generally poor, and legibly stamped with the brand of poverty, badly clothed, badly lodged, and badly fed; an ill-developed physique; the abdomen prominent; the countenance care-worn, sallow, and usually indicative of suffering from some form or other of visceral derangement. In such districts, commonly low, we shall find the air warm, moist, and stagnant ; uniting, in fact, all those conditions most influential in impeding and deranging the secretions and excretions, modifying the organic nervous influence, and consequently contaminating the fluids, and depressing all the mental 332 ' LECTUKE VII. and bodily energies. Under such circum- stances, can we wonder that any sudden or slight atmospheric change, irregularity in diet, depressing emotion, debauch, fatigue in short, any, even the slightest, derange- ment of the ordinary condition of the indi- vidual, should be immediately followed by serious or fatal disease? The temporary residents will, on the other hand, be ordinarily found to consist of soldiers or sailors for what stranger would voluntarily sojourn in such localities? on detached, temporary, or permanent duty. Such persons are commonly ill- lodged, often crowded, and usually deprived of their accustomed comforts, as well as amusements, and almost necessarily sup- plied with food unsuited to the climate; a state of things, the truth of which will be readily admitted by any medical officer who has served abroad, or in the West Indies, during the last war. Under such TEMPORARY RESIDENTS. 333 circumstances, mental depression will be found pretty generally to prevail; often intemperance, harassing duties, and fre- quent exposure and fatigue. These dele- terious agencies will be resisted for a period of longer or shorter duration, varying according to the constitution, predisposition, habits, &c., of each individual. Eventually, however, the vital powers give way not, indeed, to the extrinsic impression on the system of a subtle, morbid poison, but to the intrinsic and united influence of all the above agencies, which depresses the nervous power, vitiates the vital fluids and solids, and thus deranges the whole animal eco- nomy, and ushers in the most formidable, dissimilar, and fatal diseases; the distinctive characters of each being determined chiefly by season, and by the constitution and pre- disposition of the individual. The cause is identical; the modifying and determining influences alone are different. 334 LECTURE VII. What influence the electrical condition exercises in this or in other constitutions of the atmosphere, the actual state of our knowledge does not enable us precisely to determine. But observation, and the re- cords of science, and my own personal experience, sufficiently demonstrate that electrical phenomena, and the changed relations between the electrical condition of the atmosphere and that of the indivi- dual, are closely allied with the amount of health enjoyed, and with the development of disease in the human constitution. * The foregoing evidence and statements, * Mr. Parker, formerly surgeon to H.M. 65th Kegi- ment, "whilst in charge of the Bahia Hospital, during my temporary absence in Europe in 1829-30, engaged in an extensive series of electrical observations. The results, although not conclusive, apparently proved the powerful influence exerted by electrical phenomena over the human constitution in hot climates. Mr. Par- ker's attention had been previously directed to similar researches, while serving with the army in India. BESULTS OF EXPERIENCE. 335 Gentlemen, rest on my own personal expe- rience of twenty-eight years in southern climates; and should they serve to direct the attention of our medical officers em- ployed abroad, and of our colonial practi- tioners, to what I believe to be the essential cause of tropical fevers, and thus transfer their anxiety from the visionary terrors of malaria to the true sources of mortality in our colonies, fleets, and armies, I shall have accomplished an object which has pressed upon my mind for many years. Of its importance, many of you now present will, probably, have the opportunity of judging in the course of your medical career. Unhappily, several of the causes alluded to are inevitable to certain of our colonial residents, to armies in the field, and to our royal and mercantile marine on different foreign stations. Still, the real sources of disease being once clearly ascertained, and 336 LECTURE VII. the visionary disregarded, we shall be able more efficiently to concentrate our efforts on the enforcement of such practicable mea- sures of prevention or cure, as reason and experience may suggest in each especial emergency. PROPHYLACTIC MEASURES. The precau- tions to be adopted flow so obviously from the premises, that it would be almost need- less to particularise them. Still, with reference to my junior auditors, I may perhaps be permitted to indicate, and merely indicate, the more important of these. Their application, and the necessary modifi- cations so essential in the ever-varying circumstances of individuals and bodies of men, we must refer to the judgment of those who may be entrusted with the responsibility and the power of enforcing them. In the first place, all the ordinary and HYGIENIC REGULATIONS. 337 well-established hygienic laws should be strictly attended to. The habitation, the barrack, or the camp, should be placed in a dry locality, on a moderate elevation, and well ventilated, but protected against all strong currents of wind. Lengthened or direct exposure to the sun's rays should be avoided, and all sudden vicissitudes of temperature guarded against. The use of awnings by day and by night, on board ship, should be strictly enforced. Light flannel shirts should be worn next the skin, espe- cially when the individuals are exposed to fatigue or night duty. Sleeping in the open air, or unprotected, should, if possible, be always avoided. Clothes should be changed after exposure to rain. After exhaustion by exercise, or from any other cause, collapse must be carefully guarded against, by avoiding, for a time, exposure to the cool breeze, or by taking some slight stimulant, as coffee, wine, or a little spirits. Q LECTURE VII. Spirits, otherwise, should be altogether avoided ; wine should be used in great mode- ration, and only at dinner, and by those accus- tomed to its use. Generally, animal food should be used only at dinner; no supper; and no stimulating drinks, however diluted, should be taken between meals. Ripe fruit may be used in the morning, and after the middle of the day ; but never after the princi- pal meal. Temperance, in every sense, must be maintained. When compelled to go out early in the morning, the individual should take some support, or a dose of quinine. In warm and swampy districts, over-fatigue, or prolonged exposure to the sun, must be carefully avoided, and the use of quinine, in moderate doses, should never be neglected. The cold bath, or cold sponging every morning, on getting out of bed, should be employed. The sleeping apartment should be dry, cool, and well- ventilated, but not exposed to strong currents of air. IMPORTANCE OF SLEEP. 339 Of all the foregoing principles, sound and refreshing sleep is the most efficient preser- vative to the European constitution against the inroads of tropical disease; but, unless the above rules are observed, sound and refreshing sleep in tropical latitudes is unattainable. The morale must never be lost sight of; and a calm and cheerful disposition of mind must be especially in- culcated. The foregoing principles being attended to, I am satisfied that the most formidable localities of southern climates may be braved with impunity at all events, for some years and certainly without the slightest risk to the individual from that hitherto dreaded, but visionary enemy, marsh poison. The question of the health of fleets and armies, in all its several details, would demand, not a passing notice, but a volume ; and has, moreover, been ably treated of by 340 LECTURE VII. others. The preceding principles, however, constitute the basis of all rational pro- phylactic measures in the intertropical or warm regions of the globe, whether as applied to individuals or to bodies of men. With these observations, I now beg leave to conclude my notice of intermittent, re- mittent, and continued fever, and my cur- sory remarks on tropical disease. I am little disposed to be the partisan of any particular dogma; indeed, the theory of marsh miasm (as formerly stated) is that to which I had almost religiously adhered as the only true and legitimate creed on this question. There is, undoubtedly, some- thing very fascinating, and commanding withal, in the broad and sweeping generali- sation developed under the hypothesis of the malaria doctrine ; but it is just this precipitate adoption of general principles that has led us to so much idle warfare, and CONCLUDING REMARKS. 341 has naturally induced us to overlook con- ditions from without, and actions from within, which are unceasingly in operation, and which daily and hourly, nay, every instant, display their effects; producing in one person acute inflammation, in another, continued fever, and, in a third, all the varied phenomena of intermittent, remit- tent, or dysentery. But facts. Gentlemen, and facts broad and well-defined, have compelled me to adopt an opinion on the subject of malaria direct- ly heterodox to that which reigns domi- nant in the republic of medicine. To detail these facts simply as they presented themselves to my notice, has been the chief object contemplated in this section of my lectures. If the inferences drawn seem to have been too large and sweeping, I may be permitted to urge, that they were such only as seemed capable of being drawn from the premises. As such, I now submit them to 342 LECTURE VII. you, anxious alone that the true source of the intermittent, remittent, and continued fever may be finally determined on a more precise and accurate basis than it seems hitherto to have rested on; and happy if I should have been fortunate enough to have relieved the inquiry from any of those diffi- culties which obviously encompass a ques- tion, as wide in its range as it is obscure in its character. LECTURE VIII. CAUSES OF SALUBRITY IN BAHIA EQUAL TEMPEEATURE COOL NIGHTS HABITS OF THE PEOPLE NEVER- FAILING BREEZE RELATION OF EPIDEMIC OR PESTI- LENTIAL DISEASES TO A STAGNANT ATMOSPHERE INFLUENCE OF RECENT POLITICAL CHANGES IN- CREASE OF CERTAIN DISEASES INSANITY MORE FRE- QUENT ELEPHANTIASIS AKABUM MORE BARE DE- SCRIPTION OF THE DISEASE ELEPHANTIASIS G-HJE- COEUM DESCRIPTION INCUEABIHTY NOT A CON- TAGIOUS DISEASE MOEE RARE INCREASE OF CON- TINUED FEVEES OF SUPPUEATIVE HEPATITIS IMFOETANCE OF MEDICAL HISTOEY OF BEAZIL. GENTLEMEN, I have already had occa- sion to comment on the peculiar salubrity of Bahia, and its special exemption from all serious epidemic or endemic diseases. This would appear to depend on a variety of causes moral and physical. 344 LECTURE VIII. CAUSES OF SALUBRITY IN BAHIA. In the first place, we have an EQUABILITY AND CIRCUMSCRIBED RANGE OF TEMPERATURE a freedom from atmospheric vicissitudes, un- equalled in any other region of the globe. How different is this from Italy, for exam- ple, or from America, where, while serving on the medical staff of the expedition against New Orleans, in 1814, I repeatedly observed, within a few hours, a variation of 40 of Fahrenheit ; while in Bahia, as I have already stated, the thermometer rarely de- scends below 72 in winter, or exceeds 82*5 in summer, the daily range being about 6. The heat, moreover, is never oppressive, being always tempered by a strong and never-failing sea-breeze, and by occasional showers at all periods of the year. The nights, too, are at all seasons cool and agreeable, with slight deposition of dew, the result of the limited range of temperature, and always admitting of sound HABITS OF THE BAHIANS. 345 and refreshing sleep. To this latter cir- cumstance I am disposed to attach the very highest importance, from having witnessed in other hot climates the direful results on the animal economy of a long succession of hot and sleepless nights, in predisposing the system to be impressed by the various and fatal maladies incident to climate. Farther, the HABITS, OCCUPATION, NATU- RAL DISPOSITION, and TEMPERAMENT, of the inhabitants, exercise a highly important influence in warding off or modifying dis- ease. As elsewhere stated, the Brazilians, that is, the masses are temperate, order- ly, cheerful, impressionable, never long dis- tressed by past, nor troubled by coming events. Chiefly occupied in agricultural pursuits, their wants are few, and those are abundantly and readily supplied. The mind is not over-exercised, and little dis- turbed by ambition or politics, religion or commerce. For a community thus consti- 346 LECTURE VIII. tuted, placed in such a climate, and under such peculiar circumstances, we might legi- timately infer, a priori, freedom from grave disease an inference fully borne out by experience. In addition to high temperature, the chief objection to be urged against the climate of Bahia is its great humidity. The deleterious effects, however, of this condition of atmosphere on the animal eco- nomy are tempered, if not entirely correct- ed, by the influence of a NEVER-FAILING BREEZE, so that a stagnant, or even a calm, state of the atmosphere, is utterly unknown. If this were otherwise, I am satisfied that Bahia, inundated with the most offensive and noxious animal and vegetable exhala- tions, with a total neglect of cleanliness, and absence of those police and sanitary regulations so essential to the public health in other countries, would prove a very Golgotha, modified, however, no doubt, by YELLOW FEVER IN BRAZIL. 347 the habits, constitution, and temperament of the people. Since these pages were written, however, Brazil has been desolated, for the first time in its history, by yellow fever, attributed by some to introduction from abroad, by others to epidemic influ- ence, originating in obvious and unprece- dented atmospheric changes as increased temperature, unusual rains, failure of the accustomed sea-breeze, &c.* The compa- rative frequency of ague in the more ele- vated positions or localities of the city, as compared with the lower, I have already noticed and explained. On reference to history, we cannot but be forcibly struck with the fact, that, in every account of an epidemic or pestilence, * It would, however, appear from the Portuguese historian Pitta, Huuiboldt, and others, that the yellow fever had already, in the sixteenth and seventeenth centuries, ravaged Brazil; and its present reappearance, after an interval of ages, affords certainly a singular anomaly in the history of disease and climate. 348 LECTURE VIII. either of ancient or modern times, we have, in addition to the ordinary details of war, famine, &c., one observation almost univer- sally recorded, namely, that all were pre- ceded by wet seasons or inundations, fol- lowed by excessive and unwonted heat, with a calm or stagnant state of the atmo- sphere. During the pestilence which ra- vaged Eome in 262-35 the air is described by Eusebius as having been so infected, as to cover all objects with a mould or dew, similar to that which arises from putrid bodies; in other words, the atmosphere was exceedingly humid, and hence produc- tive of those effects which are daily ob- served in all intertropical countries adjoin- ing the sea-board, where the breeze, other- wise perfectly pure and healthy, comes loaded with moisture, and rapidly covers with a mould (cryptogamic vegetation), such as described by Eusebius, all objects exposed to its influence. With its effects SOCIAL REVOLUTIONS. 349 on surgical instruments, every tropical prac- titioner is unfortunately but too familiar. POLITICAL AND OTHER CHANGES IN BRAZIL THEIR INFLUENCE ON DISEASE. Though the climate of Bahia, and the physical con- dition of the country, will probably never undergo any serious amount of change,* yet other great and rapid mutations are in pro- gress, affecting the social, moral, and politi- cal relations of the people, and which appear to have already exercised some influence on the character and frequency of certain classes of diseases. After a struggle of about two years, the establishment of Brazil as an independent empire was finally effected in 1823; and a political constitution, greatly unsuited to the intellectual and social advancement of the people, was conceded by the late empe- ror, Peter I. Since this period, Brazil and * Late events render this point doubtful. 350 LECTURE VIII. its population have undergone a series of remarkable and comprehensive political and social changes. From the strict and simple forms of despotic government, they have passed, at a bound, to one almost of licence, including household suffrage, popular legis- lative assemblies (imperial and provincial), open courts of law, trial by jury, local justices, and a national guard elected on popular principles. As might have been foreseen, this sudden and prema- ture concession of political privileges to a people yet in the infancy of civilisation has been attended by great and numerous evils, mingled, it must be admitted, with many advantages. In the intoxication of a new-born free- dom, the empire has anticipated and wasted the national resources in foreign wars, and an endless succession of intestine broils, one province being arrayed against another. Luxury has largely increased; the laws GOOD AND EVIL RESULTS. 351 have been inefficiently or corruptly adminis- tered, and a lax morality has but too gene- rally pervaded the whole community. On the other hand, an extensive and well-orga- nised system of national education has been established throughout the empire ; the slumbering intellectual powers of the nation have been aroused ; wealth and intelligence have been developed ; political and military ambition awakened; commercial enterprise created; agriculture revived; and, of all those mighty powers which advance and mould societies, the controlling influence of religion has alone remained stationary, if it has not retrograded. The priesthood, de- prived of wealth, power, or influence, has utterly lost its prestige, unless, perhaps, with the very lowest classes of the community a matter of curious speculation as regards the cause, and of vast importance as regards its future results on the character and insti- tutions of the Brazilian people. 352 LECTURE VIII. Coeval with these great and rapidly advancing changes in the social, moral, and intellectual habits of the nation, we can already discern some of those evils too commonly attendant on increased wealth, luxury, and intelligence. Anxieties, ex- cesses, passions, are largely multiplied ; and traces of that premature " wear and tear," so painfully characteristic of highly civilized society, begin to be distinguishable amongst certain ranks of the hitherto contented and indolent Brazilians. That such influences should effect some modification in the fre- quency and character of certain classes of diseases, we might reasonably infer ; and the justness of the inference is fully established by my own experience, as well as by that of my colleagues. Within the last ten years, diseases affect- ing the cerebral and nervous systems, pul- monary disease, and especially diseases of the heart and great vessels, have been of NEW FORMS OF DISEASE. 353 much more frequent occurrence than they were during the first ten years of my resi- dence in Bahia. Even while writing these lines, I have before me a letter from my successor at the British Hospital at Bahia, Dr. Paterson, intimating the deaths of three of my old friends and patients, viz. Dr. Paulo, dean of the faculty of medicine, and late secretary of state for the home department (a combination of offices which will sound oddly enough to British ears) ; Senhor Feital, the consul for Portugal ; and Senhor Joaquim Bento de Figueiredo, late chief of the provincial treasury. The two former died of apoplexy, the latter of dis- ease of the heart, and none of them were advanced beyond the middle age. INSANITY, formerly a disease of rare occurrence, has presented itself, within the last few years, much more frequently. This is shown by the results of my individual 352 LECTURE VIII. Coeval with these great and rapidly advancing changes in the social, moral, and intellectual habits of the nation, we can already discern some of those evils too commonly attendant on increased wealth, luxury, and intelligence. Anxieties, ex- cesses, passions, are largely multiplied ; and traces of that premature " wear and tear," so painfully characteristic of highly civilized society, begin to be distinguishable amongst certain ranks of the hitherto contented and indolent Brazilians. That such influences should effect some modification in the fre- quency and character of certain classes of diseases, we might reasonably infer ; and the justness of the inference is fully established by my own experience, as well as by that of my colleagues. Within the last ten years, diseases affect- ing the cerebral and nervous systems, pul- monary disease, and especially diseases of the heart and great vessels, have been of NEW FORMS OF DISEASE. 353 much more frequent occurrence than they were during the first ten years of my resi- dence in Bahia. Even while writing these lines, I have before me a letter from my successor at the British Hospital at Bahia, Dr. Paterson, intimating the deaths of three of my old friends and patients, viz. Dr. Paulo, dean of the faculty of medicine, and late secretary of state for the home department (a combination of offices which will sound oddly enough to British ears) ; Senhor Feital, the consul for Portugal; and Senhor Joaquim Bento de Figueiredo, late chief of the provincial treasury. The two former died of apoplexy, the latter of dis- ease of the heart, and none of them were advanced beyond the middle age. INSANITY, formerly a disease of rare occurrence, has presented itself, within the last few years, much more frequently. This is shown by the results of my individual 354 LECTURE VIII. experience, and by that of my colleagues, as well as by the admissions to a private hospital for the reception of Brazilian pa- tients of all classes, and with all diseases, which was established some years ago by myself, conjointly with my valued and talented friends, Drs. Persiani and Abbott, the latter surgeon-in-chief to the Miseri- cordia Hospital, and professor of anatomy to the Faculty. The most frequent character of the hallu- cinations bore distinctly on politics or com- merce rarely on love and, on two occa- sions only, within my long experience, on religion ; and one of these cases was a young Mahomedan slave. It is, moreover, suffi- ciently remarkable, that, notwithstanding an extensive professional intercourse with the religious orders, the convents and nunneries of Bahia, I have never yet met with a sin- gle case of religious mania, in either sex, among the numerous inmates of these insti- INSANITY ELEPHANTIASIS . 355 tutions. Another remarkable fact is, that there does not, I believe, exist at this mo- ment a single establishment, public or private, especially devoted to the reception of the insane, throughout the whole extent of the Brazilian empire certainly none in the province of Bahia. The " mad doctor ' is a species of the profession utterly un- known in Brazil; though I venture to pre- dict that the history of the next twenty years will tell a different and a sadder tale. ELEPHANTIASIS ABABUM, or the Barbadoes leg, though still of frequent occurrence, is now less commonly met with among the white population, than on my first establish- ment in Brazil. Its characteristic symp- toms and morbid results you will find accurately pourtrayed in almost every work on practical medicine ; and I notice it here chiefly on this account, that in Brazil it originates invariably from erysipelas, and never from inflammation of the lymphatic 356 LECTURE VIII. system, as commonly laid down by authors. The parts most subject to attack are, first, the lower extremities ; then the scrotum in males, and the mammae in females. Ani- mals are also apparently subject to the dis- ease, especially the horse; and the part commonly attacked is the scrotum. In nu- merous instances, the attacks become periodic, recurring monthly; and occasion- sionally, at the earlier periods of the disease, the inflammation may be suddenly trans- lated from one region to another; in the later periods this scarcely ever occurs. The natives of all countries are liable to be attacked, though seldom (unless from con- stitutional predisposition), until the system has been deteriorated by climate ; and when the European becomes subject to regular attacks of erysipelas, no stronger indication can exist for an immediate change of resi- dence. The constitutional and local symptoms, SYMPTOMS AND CAUSES. 357 especially in the early attacks, are often very severe; but they are purely those of erysipelas, and are to be met by the reme- dies appropriate to that disease. The causes are also those of erysipelas ; namely, constitutional predisposition, deteriorated general health, and sudden atmospheric changes. In the latter stages of the malady, constitutional disturbance is rarely mani- fest; and equally rare is inflammation of the lymphatic vessels or glands of the ex- tremity attacked ; while, on the other hand, these latter affections (inflammation of the lymphatic vessels and glands, especially of the groin), are of very frequent occurrence about the change of the monsoon, in April. They originate in some obscure constitu- tional disturbance, and often prove exceed- ingly tedious and difficult to deal with, the general health suffering, and the glands, notwithstanding every effort to resolve them, going on occasionally to suppuration, 358 LECTURE VIII. after which the health is at length re-estab- lished. In these cases there will be no local injury, nor inflammation of the skin or cellular tissue ; and in no instance have I witnessed such attacks followed by hyper- trophy. In the Barbadoes leg, I have found all specific treatment, as by mercury, iodine, &c., either useless or prejudicial. You can only hope to benefit your patient by im- proving his general health, on general principles, so as to prevent the recurrence of the erysipelas ; for each succeeding attack adds, by an additional effusion of sero-albu- minous deposit, to the morbid enlargement of the part. If your patient be European, urge change of climate ; this is your grand remedy, and, if resorted to in time, will be almost uniformly successful. Though sometimes counselled in such cases, the knife can rarely be resorted to with safety or advantage. A case in point FATAL OPERATION. 359 occurred not long since, in my own practice. Senhor Luiz Joze dos S., one of the princi- pal inhabitants of Rio de Janeiro, suffering from scrotal hypertrophy, came to London for advice, and placed himself under my care. I discountenanced an operation, for which he was anxious, and advised pallia- tives. This advice, I soon perceived, was unpalatable to a man who had travelled 5000 miles of ocean to have his scrotum diminished ; and I recommended that he should take the opinion of Sir Benjamin Brodie, to whom I accompanied him. Sir Benjamin also de- cided against an operation. Senhor S. remained a short time longer under my care, and then proceeded to France, accom- panied by his son, who subsequently informed me that the operation was, with- out hesitation, performed in Paris and he died. ELEPHANTIASIS GEJECORUM, or tubercular elephantiasis. This singular and fatal dis- 362 LECTUEE VIII. or to islands ; though I may observe, that I have never witnessed the disease in a native of Great Britain.* It is, moreover, worthy of remark especially as confirming the observations of others that a large majo- rity of the patients in the Hospital S. Lazaro were from the sea-board, or districts adjoining. * Since these pages were written, I have been con- sulted by an English gentleman who had long resided in hot climates, and in whom the disease is clearly developed. This gentleman had already consulted several of the most eminent practitioners in London, among whom was Mr. Erasmus Wilson, who employed an active and judicious treatment, but, I need scarcely add, without the slightest influence on the disease. I have put the patient on large doses of taraxacum, with liquor potassse, in the Vichy mineral water, vapour baths, sedative local applications, with strict diet and regimen. Under this system now some months in operation the disease has simply not progressed ; and, as the gentleman is still in the prime of life, and his constitution not seriously impaired, and as he has changed the climate and mode of living, it is just pos- sible that the disease may be arrested. I am not informed whether Mr. Wilson was cognisant of the LEPKA GK^ECORUM. 363 The disease attacks alike all ages, all sexes, and all colours the white, the mulatto, the aboriginal American, and the negro ; it affects all ranks the higher, however, more rarely; though in this there may be some fallacy, from not making due essential character of this most singular and intractable malady, so rarely witnessed in this country. Even at the Hopital St. Louis, in Paris, I never met with a single case, although a pretty constant visitor to the establishment, during a period of seven months, in 1842-3. Visiting Stevens' Hospital, in Dublin, in the winter of 1830, with Mr. Wilmot, I found a well-marked case in a boy, a soldier's son, about twelve years of age, and born in India. He had been in the hospital for several months, and his case had been the subject of much doubt and discussion. No other instance of true " lepra Gra3corum" had, I was informed, been observed in Dublin. In the spring of 1841, I also saw a well- marked case in the Military Hospital at Milan. The patient had never been out of Italy. And, in the autumn of 1845, I met with another case though not so distinctly marked in the great hospital at Vienna. This patient had been in hot climates. These are the only cases of this fearful malady which I have met with in Europe. 364 LECTURE VIII. allowance for the disproportion of the classes. In the Hospital S. Lazaro, I found, in some instances, the child diseased, while the parents were free: again, the parents were sometimes confirmed lepers, but the child- ren were unaffected. Sometimes the father was a leper, while the wife and children were clean; and sometimes the wife alone was leprous, and the husband and children healthy. In some instances, the grand- children of lepers exhibited the disease in its most aggravated form, while the imme- diate parents were perfectly free from the malady; and, finally, in other instances, the evidence for deeming the disease distinctly hereditary would appear irresistible. In the first glance at a leper, especially in the more advanced stages, there is that which supersedes all necessity for interroga- tion a something in his countenance and general appearance, distinct from anything CHARACTERISTICS. 365 to be found in any other disease to which humanity is doomed. The harsh and scurfy skin the small, red, and sunken eye the heavy, hairless, overhanging eyebrow the wrinkled and hypertrophied forehead the irregular tumid lips the enlarged, mis- shapen ears the swollen, tuberculated nos- trils the sunken nose the distorted or mutilated limbs with the husky, discor- dant voice and foetid breath reveal, at once, the presence ofHhe most loathsome and the most incurable of human maladies. Premature old age was visible in all; and life was rarely prolonged to the sixtieth year. Generally, the progress of the dis- ease is much more rapid. In every instance, the sexual passion was described as being at first weak; and, finally, at various inter- vals, totally extinguished. The mammae in the females had disappeared; and in the males, without a single exception, I found the testes much atrophied, and the genera- 366 LECTURE VIII. tive organs presenting a diminutive and shrivelled appearance. The libido inexple- bilis, noticed by authors, is a pure fiction. In a majority of instances, the approach of the disease is first distinctly manifested by numbness and loss of feeling in the fin- gers and toes, extending gradually to the extremities, but rarely to the trunk. A scurfy and unperspirable condition of the skin follows, with furfuraceous deposits beneath and around' the nails of the fingers and toes, by which they are soon elevated, and often drop off. Tubercles of different sizes, and in different parts of the body, but chiefly about the face and extremities, suc- ceed, sometimes rapidly, sometimes more slowly. Commonly, but not always, the general health suffers at the same time. The fingers and toes shrink, and become distorted by the permanent contraction of the integuments and flexor muscles. The skin cracks, and deep fissures form over the PROGRESS OF THE DISEASE. 367 flexures of the joints internally, on which unhealthy, fistulous, burrowing ulceration supervenes, unattended by pain or swelling. Tumefaction of the lymphatic glands fol- lows; the smaller joints drop away, and heal ; ulceration seizes the throat and fauces ; the bones of the nose give way ; the appe- tite, nevertheless, continues good. The large articulations are finally attacked ; and the constitutional symptoms now make rapid progress. Emaciation, fever, palpita- tion, oppressed respiration, and diarrhoea, ensue, shortly putting a termination to the most hapless state of existence that human imagination can conceive. The distinction attempted to be estab- lished by authors between lepra tuberculosa and lepra ancBsthesiaca is without founda- tion. They are simply different stages of one and the same malady, as indisputably proven by the patients in the Hospital Sao Lazaro, in whom I found the chief charac- 368 LECTURE VIII. teristics of both clearly developed at one epoch or other of the disease. This disease may be justly considered as altogether unmanageable. Every remedy which science, chance, or desperation could suggest, has been successively resorted to ; and, I must acknowledge, not only with no permanent advantage, but apparently with- out the slightest influence in arresting or modifying the progress of the malady, and often obviously hurrying on the fatal issue. The disease, in short, is mortal, and without hope; and the fatal termination, in the great majority of cases, is ushered in by some form or other of diarrhoea, or disease of the digestive viscera more rarely of the lungs. Neither has post-mortem research thrown the faintest ray of light on the essential nature, or proximate cause, of this fatal and singular malady. Every important organ of the body has been found in dif- ferent instances affected, and with almost CAUSES. 369 every species of disorganisation ; though, as might have been expected from the ordi- nary termination of the disease, the gastro- intestinal mucous membrane, with the Peyerian and mesenteric glands, have pre- sented the most constant evidences of dis- ease ; namely, numerous tubercles, softening and ulceration; cicatrices I have never myself observed, nor have I heard that they have been seen by others. In every case tubercles have been detected, to a greater or less extent, in the air-passages and lungs, often in the liver and spleen, more rarely in the kidneys, and still less frequently in the brain and its membranes. Causes. Having observed the disease developed in the most opposite states of the animal economy, under the most dissimilar conditions of rank, age, sex, climate, and diet, I cannot resist the conviction, that the causes ordinarily assigned by authors are purely imaginary. 370 LECTURE VIII. In regard to the highly important ques- tion, so often mooted whether the disease can be transmitted to the healthy, uncon- nected by ties of blood ? the following fact would seem to determine the question clearly and satisfactorily in the negative. Attached to the Hospital S. Lazaro are thirty-five servants, many of them slaves, and all in constant communication with the patients, as nurses, washerwomen, orderlies, &c. ; and, although no especial precautions had ever been adopted, yet, within the records of the establishment, or within the knowledge of the officials attached to it, not a single case of infection has been recorded among the servants or officers of the institu- tion. The important fact of their actual freedom from leprous disease, I verified myself, by repeated and careful examination, during the period of my investigations at the Hospital. It is gratifying to know, from my own HEPATITIS. 371 experience, and from that of my colleagues, that, within the last twenty years, this melancholy disease has been less frequently met with ; although the causes which have influenced it do not, in the present state of our knowledge, admit of any satisfactory explanation. FEVERS of the continued type the symp- toms being displayed chiefly through the stomach and intestinal canal are obviously increasing; they also partake more of the asthenic character, and are attended more frequently by fatal results than formerly. HEPATITIS, terminating in suppuration, though still greatly below the average of other hot climates, has decidedly increased in frequency within the last ten years; and this opinion is also borne out by the expe- rience of my professional brethren. Other modifications in the intensity and frequency of certain of the diseases incident to Bahia, have appeared to me sufficiently 372 LECTURE VIII. well marked; yet, as the evidence on which my convictions rest is in some respects incomplete, and liable, moreover, to certain sources of fallacy, I do not conceive myself justified in laying before you any statement on which a doubt may rest in my own mind. I would observe, further, that my chief motive for making the present cursory observations consists in the hope, that some of my well-informed and more talented brethren native or foreign now so nume- rous in all the provinces of Brazil, may be stimulated to fill up and extend the picture here so faintly and imperfectly traced. Judging from my own experience of profes- sional feeling in England, I would safely guarantee that their labours would be kindly and considerately received by the European profession; and I am, moreover, satisfied that the novelty and importance attached to any medical history of Brazil would command a full measure of public interest FURTHER INQUIRY DESIRABLE. 373 and support. In truth, it would be difficult to point out another subject of deeper or more legitimate interest to the great body of the profession. A climate unparalleled in the other tropical regions of the world ; the inhabitants peculiar in their moral, social, and intellectual relations, and pre- senting the rare and interesting spectacle of a large community in the condition of rapid transition into new forms and com- binations of social existence; the face of the country changing under the march of civilization and agricultural improvement; disease obviously and profoundly influenced by the climate and the character of the people; and as evidently undergoing certain and striking modifications under the in- fluence of the changed conditions before alluded to; all these circumstances taken into consideration, lead me to hope that, however imperfect may be the present sketch (and of its imperfections no person 374 LECTURE VIII. can be more fully aware than myself), it may eventually prove not entirely devoid of interest and utility, as a standard, at least, of comparison, to future observers. In my next, and concluding lecture, Gentlemen, I shall present you with a slight sketch of the medical institutions of Brazil, including those points in which th ey differ so remarkably from our own. LECTURE IX. RECAPITULATION OF LAST LECTURE MEDICAL EDUCA- TION IN BRAZIL COLLEGES AT BAHIA AND Rio DE JA- NEIRO CONSTITUTION PROFESSORS AND SUBSTITUTE PROFESSORS, THEIR DUTIES DEGREES, HOW OB- TAINED PHARMACEUTICAL STUDENTS MEDICAL SER- VICES ALWAYS PAID FOR BRAZILIAN CONSULTATIONS METHOD OF HOLDING THEM PROMINENT STATUS OF PHYSICIANS IN BRAZIL THEIR CHARACTER TONE OF PROFESSIONAL FEELING THE AUTHOR'S RECEPTION AND TREATMENT OFFICES OF STATE FILLED BY PHYSICIANS DR. LlNO COUTINHO, HIS POLITICAL CAREER AND CHARACTER QUESTIONABLE POLITICAL CAREER OF SOME OF THE PROFESSORS INSURRECTION OF 1838-9 CONCLUSION. IN my last lecture, Gentlemen, I submitted to you some observations on the peculiar salubrity of the climate of Bahia, and its especial exemption from all serious endemic 376 LECTURE IX. or epidemic diseases; and ascribed this sa- lubrity to a variety of moral arid physical causes ; to the singular equability and cir- cumscribed range of temperature, and a freedom from atmospheric vicissitudes, un- equalled in any other region of the globe the daily range of Fahrenheit's thermometer being about 6, whilst in other countries we often witness a variation of 40 in the space of a few hours ; to the fact, that the nights are, at all seasons, cool and refreshing, with slight deposition of dew; and to the never- failing breeze, which renders a stagnant, or even calm, state of the atmosphere al- together unknown. I directed your atten- tion to the social, moral, and political cha- racter of the Brazilian people, and its modi- fying influence on their diseases. I also glanced at those changes which increased wealth, luxury, and intellectual develop- ment, appear to have exercised in deter- mining the character and the frequency of RECAPITULATION. 377 certain maladies ; such changes being espe- cially manifested in the increased frequency of diseases of the cerebral and nervous sys- tems, pulmonary disease, and disease of the heart and great vessels. Fevers had par- taken more of the continued type and asthenic character, and had been more fre- quently attended by a fatal result. I pointed out that insanity, though still rare, as compared with other countries, had largely increased; and in pointing out the remarkable fact, that, up to the present mo- ment, there did not exist a single establish- ment, public or private, especially devoted to the reception of the insane, throughout the whole extent of the Brazilian empire, I ventured to predict that the next twenty years would tell a different and a sadder tale. In the hope that the subject may prove of some interest, not only to you, but to my professional brethren in general, I shall 378 LECTURE IX. conclude the present series of lectures with a few brief observations on the national medical institutions of Brazil, and on the position and standing of, and the tone of feeling which pervades, the medical profes- sion in a community placed under circum- stances so widely different from our own. MEDICAL COLLEGES IN BRAZIL. In the entire Brazilian empire, there are two national faculties of medicine, termed Es- cola Imperial de Medecina; one established at Rio de Janeiro, the other at Bahia the present and former capitals of Brazil. Both are constituted exactly alike in laws, forms, number of professors, modelled, with very trifling difference, after the constitution of the Ecole de Medecine of Paris. Each college consists of fourteen professors, and six substitute-professors, with a director and a vice-director, answering to our own dean and vice-dean of the faculty. The MEDICAL PROFESSORS. 379 latter are named by Government, from a triple list sent up by the professors every third year, and discharge the ordinary duties of their chairs, being only exempt from attending the examinations. They possess a limited controlling power over their college, and constitute the official channel of communication with Govern- ment and public bodies, on all matters re- lating to public health, prisons, &c. The duties of professor-substitute are explained in the name. When illness, or public em- ployment the latter not unusual in Brazil interferes with the duties of the professor, his chair is supplied by the substitute : both are appointed, as in France, by concours. Most of the older members have graduated in Portugal, Scotland, France, or Italy. Both classes receive a fixed income from the State, and derive no emolument whatever from pupils and examination fees, &c., which are applied to public purposes connected with the 380 LECTURE IX college. The income of the professor was fixed at twelve hundred mil-reis per annum (about three hundred pounds), when first established; and that of the professor-sub- stitute at eight hundred mil-reis. Both enjoy the right of retirement on their full salary, after twenty years' service, or when incapacitated by age or infirmities. A tra- velling professor is elected by concours, by the faculty, every four years, for the purpose of investigating, in the different countries of Europe, the latest improve- ments and discoveries in medicine and the collateral sciences, an account of which he regularly transmits, in formal reports, to his college. His expenses are defrayed by the State. The medical faculty consists of the fol- lowing chairs: 1, physics; 2, botany; 3, chemistry; 4, anatomy; 5, physiology; 6, external pathology; 7, internal pathology; 8, materia medica; 9, hygiene; 10, legal COUKSE OF STUDY. 381 medicine; 11, operations; 12, midwifery ; 13, clinical medicine; 14, clinical surgery. In addition to the professors, there is a secretary (medical), treasurer, librarian, and chemical assistant all elected by the faculty. The order of study is as follows: 1st year, medical physics and medical botany; 2d year, chemistry, and general and de- scriptive anatomy; 3d year, anatomy and physiology; 4th year, external pathology, internal pathology, pharmacy, and materia medica; 5th year, operative medicine and midwifery; 6th year, hygiene, history of medicine, and legal medicine. All examinations are public, and the sub- jects are drawn by lot. The titles conferred by the faculty are only three, viz., Doctor in Medicine, Apo- thecary, arid Midwife. The latter is spe- cially educated arid examined. In each chief city there are commonly 382 LECTUEE IX. three or four large hospitals the Mizeri- cordia, or Civil Hospital, possessed of ample funds from endowments, legacies, and cer- tain taxes; the Military and Naval Hospi- tals; and, in Rio, Bahia, and Pernambuco, Leper Hospitals. There are also infirma- ries attached to convents. Private sub- scriptions to institutions are utterly un- known. The academical session lasts for eight months from 1st March to 30th October lectures being delivered daily (with some exceptions) by the professors or their substitutes. The professors of clinical medicine and surgery have the right of selecting their cases from the Mizericordia Hospital. The student, previous to matriculation, must take his degree in arts ; and the cur- riculum is the same for all, viz., six years to obtain the degree of Doctor in Medicine. The examinations are conducted as in Paris. CLASSIFICATION OF STUDENTS. 383 For the degree of Doctor in Surgery which, however, is not essential a subse- quent and special examination must be undergone, as in France. All students are classified, on entering college, into medical and pharmaceutical; and both are obliged to obtain the degree in arts before they can be matriculated, and to have completed their sixteenth year. The pharmaceutical student obtains his diploma of pharmacy after three years' study; while that of medicine can only be obtained after six years. The student of pharmacy is obliged to repeat the courses of medical physics, botany, chemistry, phar- macy, and materia medica ; while one course only of each is required from the medical pupil. The pharmaceutical student is obliged to attend for three years in a pharmacy, after the conclusion of his aca- demical studies. He then undergoes an examination by the faculty, and publicly 384 LECTURE IX. defends a thesis to obtain his diploma. His duty afterwards, as apothecary, is strictly limited to the sale of drugs, and the compounding of prescriptions. He is never consulted professionally; and, did he attempt to apply a remedy for the cure of any disease, he would be immediately fined 50 mil-reis by the municipality, for the first, and an increasing fine for every subsequent offence; arid, did he still per- sist, his licence would be withdrawn. On the other hand, the medical practitioner is strictly prohibited from the compound- ing or sale of medicines, in any shape or form. STATE OF THE MEDICAL PROFESSION IN BRAZIL. The professors and substitutes are, like others, engaged in private practice, and not uncommonly hold some other public or medical office, of which there are a considerable number, and all paid PROFESSIONAL REMUNERATION. 385 honorary medical appointments being utter- ly unknown in Brazil. So deeply, indeed, is the system of pay- ment for medical services (under what circumstances soever rendered) interwoven with public opinion in Brazil, that, when the medical officers of an hospital the Mizericordia or Hotel-Dieu for example deem it necessary to call a consultation, the regular consultation fee is invariably transmitted to the consultants ; and I have myself repeatedly received it, through the treasurer of the hospital, who requires an authenticated receipt, in order to its formal insertion in the annual accounts of the establishment. The system of consultations, or juntas, as they are termed, prevails to an almost inconvenient extent in Brazil. No serious case is ever treated without repeated jun tas; and the number of consultants is rarely under three or four, and frequently much 386 LECTUEE IX. more numerous. The mode of holding the consultation, too, is peculiar, and, so far as I am aware, different from that pursued in any otjier country. After the patient has been examined by each in turn, the consultants seat themselves, commonly in a semicircle, around his bed, while, forming an outer circle, are seated the friends and relatives of the family. Silence being obtained, each physician successively, in hearing of the patient and his friends, enters formally into the history, symptoms, dia- gnosis, and treatment of the case; often, in fact, delivering his opinion in the form of an oration. And, on more than one occa- sion, I have heard, from the surrounding auditors, the appoiado, or parliamentary " hear, hear," of approbation, or the nao, nao, of dissent from the opinions of the speaker. In the event of disagreement, the treatment is decided by a simple majo- rity; or, should the votes prove equal, an BRAZILIAN JUNTAS. 387 additional physician is frequently called in, whose vote decides the question. This system, though by no means devoid of advantages, is, nevertheless, counterbalanc- ed by so many and obvious inconveniences, that, for the interest of the patient, it ought certainly to be abolished; and would be, probably, if the question rested entirely with the profession. To return to the public establishments. In case of accident or sudden emergency, an offi- cer of the hospital not being at hand, another practitioner is immediately summoned, and paid his regular fee. In fact, seeing that the barrister, the attorney, the priest, and every other class of the community, exacts remuneration and large remuneration too for time arid services, the Brazilian can- not be made to comprehend the grounds on which the doctor alone, after long years of study and expense, can be expected to devote his time, his health, and talents, 388 LECTUEE IX. gratuitously, to the people. The liberal and enlightened British public will, no doubt, open wide their eyes at such unan- swerable evidence of barbarism and defec- tive reasoning powers, in a nation making pretences to civilisation; and the proof will, I fear, be deemed too conclusive against my friends on the other side of the line, to admit of my advancing a single word in their defence. I may be permitted, however, to urge in mitigation, that people often view matters differently to the south of the equator. Be this, however, as it may, one thing is quite certain that the Brazilian is a much more independent agent than the British physician. The higher orders, too, of the medical profession, occupy a much more prominent position, quoad the public, than their bre- thren of Europe; and this, perhaps, may be accounted for by their superior educa- tion and knowledge of the world, as com- BRAZILIAN PHYSICIANS. 389 pared with the generality of the upper classes in a country circumstanced like Brazil. The Brazilian physician, especially of the old school, is generally well ac- quainted with European medical literature, especially the French. He is characterised by great liberality of feeling; is little dis- posed to jealousy, and altogether devoid of professional intrigue. His habits are usually simple and inexpensive, and per- haps another proof of Brazilian barbarism the public never dream of measuring his talents by the extent of his establishment, or the splendour of his equipage. In addi- tion to his private practice, he commonly holds some independent public appointment or professorship ; and, through the concours, he seeks to rise rather by the approbation and respect of the profession, than by those humiliating practices by which, on dit, his European brother too often mounts to noto- riety and fortune. 390 LECTURE IX. As regards the tone of feeling (a most important consideration) which generally pervades the medical profession at Bahia, iny own career will perhaps afford the best, being a practical illustration. An utter stranger, inexperienced, ignorant of their customs, laws, and language, I was received by my professional brethren from the first with kindness, and in time admitted to their confidence. I subsequently derived the most solid advantages from their sup- port ; and was finally honoured by the warm and unanimous public expression of their approbation and friendship, after a close and extensive intercourse of three-and- twenty years. Since the establishment of a constitution in Brazil, many of the highest offices in the state have been filled by physicians. In- dependently of provincial offices, the pro- fessors of the Escola de Medecina da Bahia DR. LINO COUTINHO. 391 have, within my own day, supplied nu- merous deputies and senators to the na- tional legislative assembly, besides two secretaries of state one, my friend Dr. Paulo, dean of the faculty of medicine, already alluded to; the other, Dr. Joze Lino Coutinho, a man prominently distin- guished in the annals of Brazil, and whom I knew long and intimately prior to, and during his elevation, and subsequently to his fall from power. On my appointment to Bahia in 1819, I found Lino Coutinho a simple physician, apparently absorbed in the duties of his profession. In February, 1821, the revolution burst forth in Bahia, and, after a brief and doubtful struggle, proved successful. The governor, Count da Palma, was deposed, and replaced by a revolutionary junta, to which my friend Lino Coutinho was not only secretary, but the very life and soul of the revolution. In 1823, the independence of Brazil being for- 392 LECTURE IX. mally acknowledged by Portugal, Dr. Lino Coutinho was elected deputy for his native province, to the general legislative assem- bly at Rio de Janeiro. He was subse- quently nominated to the senate ; and finally assumed the seals of office as se- cretary of state for the home department. He was long the idol of his party: like other idols, he outlived his worship, and returned to die in his native city, where, excepting his immediate household, the narrator of these brief remarks was the sole attendant on him who had so long swayed the destinies of millions. Sprung from the humblest origin, Lino Coutinho was unquestionably no ordinary man. In religion a deist, in principle a republican, and by nature profoundly am- bitious, he was eloquent, fertile in resource, and never depressed by adversity, nor elated by success. Many and grave defects he certainly had ; and, as certainly, many OFFICIAL PROBITY. 393 virtues. The present, however, is not the place to discuss either. I will, therefore, only add what his bitterest enemy cannot deny that, though he had long distributed the wealth and honours of the Brazilian empire with a lavish hand, yet Lino Cou- tinho himself like his colleague Dr. Paulo died poor, unpensioned, and untitled no doubtful epitaph, I ween ! and rarely to be found inscribed on the tombs of secretaries of state, from any other profession, in any country. So much, Gentlemen, for the honour of medicine; a regard to which influenced, in part, the introduction of this brief episode. As an impartial historian, however, I am bound to record, that the professors of the Escola Imperial de Medecina da Bahia have figured, from time to time, in other conspicuous, but more questionable posi- tions. Few, indeed, of the revolutionary attempts which, during the last thirty 394 LECTUKE IX. years, have so frequently shaken the Bra- zilian throne, are unconnected with the name of a professor of medicine. The last frightful attempt at revolution and plunder, in 1838-9, was led, if not organised, by Serihor Sabino, a substitute professor of the Escola de Medecina, and a man of daring arid desperate character. The horrors of Bahia during this attempt- ed revolution will not be readily effaced from the remembrance of those who wit- nessed them, and never from my own; for, during that awful period, I had charge of the Mizericordia Hospital, containing up- wards of five hundred patients most of the ordinary attendants and medical officers of the establishment (among them my friends Drs. Cabral and Abbott) having been compelled to fly for safety to the Imperial camp. The city, in a state of starvation, was blockaded by sea and land ; all legitimate authority was in abeyance; REVOLUTION HORRORS. 395 and the lives of the inhabitants were at the mercy of an infuriated black and mulatto mob. Money was valueless, as a means of procuring the necessaries of life; and, as regarded my unhappy charge in the Mize- ricordia Hospital, we were deficiently sup- plied with medical stores, and had no fresh provisions, no vegetables, no flour; and even the supply of salt meat and fish, towards the last, became scanty and un- wholesome. My heart sank within me as I daily approached the gates of the Hospi- tal; and, even now, I can scarcely repress a shudder, as I recall to remembrance the human misery I was compelled to witness, without the power to aid. Happily, my professional brethren in England are beyond the reach of scenes like these ! My friend, Dr. Paterson (now present), to whom, on quitting Bahia towards the end of the blockade, I transferred my melancholy charge, can bear ample testi- 396 LECTURE IX. mony to the painful reality of these remi- niscences. The foregoing brief outline will, I trust, make sufficiently apparent the broad dis- tinction which at present obtains in the relative position and range of occupation of the British and the Brazilian physician. Changes, however, are already shadowed forth in Brazil; but these I leave to be recorded by future observers. * I must now, Gentlemen, bid you adieu in my capacity of lecturer; and I have to thank you for the attention with which you have honoured my somewhat desultory observations. At the call of duty or inte- rest, it is more than probable, in the course of your professional career, that some of you shall visit foreign and southern cli- mates, and be there placed under circum- stances of inexperience and responsibility similar to my own. I have been, therefore? CONCLUSION. 397 anxious to lay down certain principles, based on personal knowledge, which may serve to guide you in the prevention and treatment of disease, until observation and experience shall have enabled you to deter- mine these important questions for your- selves. I could have largely extended the present series of lectures by the details of numerous cases; but this I have purposely avoided, convinced, by experience, that cases are useful to you, only in so far as they may serve to elucidate and establish sound general principles; and these prin- ciples your own judgment must apply to the ever-varying modifications of individual diseases. Should health and leisure permit, I may possibly recur, at a future day, to some of the more important questions involved in the preceding lectures; for man separates himself with difficulty from the recollec- tions of a country in which he has passed 398 LECTURE IX. the most active period of his career a country, moreover, endeared to myself by numerous associations British and Bra- zilian private and professional. APPENDIX. ON THE EFFICACY OF LAEGE AND FREQUENT DOSES OF QUININE IN ARRESTING/ THE COURSE OF CONTINUED FEVER. By ROBERT DUNDAS, M.D., Physician to the Liverpool Northern Hospital ; formerly Medical Su- perintendent (for twenty-three years) of the British Hospital, Bahia. (Published in ilie "Medical Times" ) EARLY in the present year, I delivered a series of lectures on questions connected with the Brazils, and on the diseases of persons returned to Europe after long tropical residence. In the course of these lectures, I laid down certain new doctrines on the pathology and treatment of tropical fevers, embracing likewise con- tinued fever as it appears in this country, and which I consider to be essentially the same in its nature as the fevers of tropical countries, and curable by the same agents. 400 APPENDIX. As the treatment which I recommended has heen tested at the Northern Hospital of Liverpool, as well as lately at the Liverpool Fever Hospital, and elsewhere, I am anxious to submit my views more generally to the profession, in order that their truth and value may be proved on a still larger field, and under every variety of circumstance. TYPHUS FEVER OF EUROPE. Acting on my conviction of the essential identity of the remittent and intermittent fever of the tropics with the typhus of Europe, and being aware of the specific action of quinine in every stage of the former diseases, I have for some time resorted to its administration in the ordinary typhus of this country, in all its stages, and commonly with the happiest results. In typhus, as in the remittent and intermittent of hot climates, the treatment by quinine will be successful in pro- portion to its early administration; also, as in the tropical fever, the doses should be large ten or twelve grains and repeated at intervals not exceeding two hours. Three or four doses will, in most cases, be sufficient to exert the specific influence of the medi- cine, which is displayed by dizziness of the head and tinnitus aurium, or in the rapid subsidence of all the urgent symptoms. In the latter event, three grains of quinine should be administered three or four times a-day, and the patient supported with good beef-tea, or APPENDIX. 401 other light nutriment, and wine if necessary.* Should the urgent symptoms return, the large and repeated doses of quinine must be again resorted to. Slops should be avoided, and purgatives also, unless obviously indicated ; but an emetic of tartarised antimony will prove useful at the commencement, and render the system more obedient to the specific influence of the remedy. Should the urgent symptoms persist, notwithstanding the administration of six or seven doses of quinine ; or should dizziness of the head and tinnitus aurium super- vene, the medicine must be discontinued ; and, after an interval of six or seven hours, small and repeated doses of tartarised antimony should be resorted to, until full vomiting is induced. The patient should then be allowed to rest for twenty-four hours, when the quinine should be recommenced as before. If the symptoms still resist, the remedies should be repeated in succes- sion, as above stated, for a period of four or five days ; and, unless the beneficial effects are broadly marked within that time, we can no longer reasonably hope for success from this treatment, and it may be abandoned. Still, in the great majority of cases of uncomplicated typhus, taken at the commencement, complete and rapid success may be calculated on; and, in all, the diseased chain of actions will almost invariably be broken no unimportant advantage in the treatment of any malady. In the advanced periods of the disease, * In Hospital patients wine, and often brandy, will be requently necessary from the first. 402 APPENDIX. the results will be much less certain ; but, in all stages, the large doses of quinine may be safely resorted to, and will commonly calm the patient, cool his skin, allay the headache, and reduce the frequency, and improve the character of the pulse. It must, however, be borne in mind, (as I have elsewhere pointed out,)* that any vital organ being seriously involved will prove a disturbing cause to the curative powers of the remedy, which are clearly exerted on the nervous system, through which the blood and secretions are favourably modified, and often with marvellous rapidity. In the history of typhus in this country, numerous incidental notices will be found, such as the following, on the epidemic of 1819 : " The disease has simulated the recurrent type ; the paroxysms were marked by distinct, and often violent rigors, which were succeeded by intense heat, and increased vascular activity, termi- nating occasionally in profuse sweating, but more com- monly in a gradual subsidence of the exacerbation, without any relaxation of the surface. The paroxysms showed no obedience to periodicity; in some cases recurring in a few hours, and, in others, only after the lapse of as many days."f Now, here we are presented, clearly and distinctly, with the history of an irregular intermittent or remittent fever; yet, strange to say, * In the course of the foregoing work. t Sheppard. Edinburgh Medical and Surgical Journal, vol. xv. APPENDIX. 403 this idea seems never once to have crossed the mind of the observer. As I well know, by experience, how distasteful an array of cases commonly proves, I shall only relate two or three ; but these are well adapted to illustrate, beyond all rational doubt, the justness of the principles and the efficacy of the treatment which I have just inculcated. The cases are divested of all minute detail, as I am anxious to place the broad facts clearly before the profession, so that they may be easily impressed on the memory, and in order that they may be submitted to large and careful experiment. The two cases now to be related were received into the Liverpool Northern Hospital, one under myself, the other under my col- league, Dr. Scott. The notes were taken by our in- telligent house-surgeon, Mr. Evans, and are given in his words : "Case I. Cornelius Vincent, aged 26, was admitted October 2, 1850, into ward No. 12, under Dr. Dundas. " October 3. He had been ill ten days. Present state : Severe headache ; anxious countenance ; slight de- lirium; skin hot and dry; tongue black, dry, and furred ; teeth covered with sordes ; thirst ; urine scanty and high coloured ; bowels open ; pain of abdomen on pressure; pulse 100; respirations 28. " $> Disulphatis quinre, gr. xxx. Divide in doses iij., quarum capiat unam secunda quaque hora. " October 4. Convalescent. The pain in the head and the delirium have ceased; the abdomen is less 404 APPENDIX. tender; the heat of skin diminished; the tongue clean and moist ; pulse 90 ; respirations 24. " $k Infusi quassise, ^iii., ter in die. "No further treatment was resorted to, and from this date he rapidly gained strength, and was dis- charged well on llth October." It is the ordinary rule not to admit cases of typhus into the Northern Hospital, but to send them to the Fever Hospital. The above case, however, having been reported to my colleague, Dr. Scott, he resolved to give the treatment by quinine another trial. An opportunity presented itself in a few days. " Case 2. Edward Donald, aged 23, was admitted on 25th October, 1850, into ward 14, under Dr. Scott, He had been ill eight days. Present state ; Great anxiety of countenance, and high delirium ; dry pun- gent skin; tongue dry, and coated with dark fur; sordes about the lips and teeth; great thirst; urine scanty and high coloured; bowels open; abdomen tumid, and tender on pressure; pulse 108; respira- tions 30. "9> Disulphatis quinse, gr. xxx. Divide in doses iij., quarum capiat i. secunda quaque hora. " October 26. At the morning visit, he was found reading a book in bed ! All the formidable symptoms of yesterday have disappeared. No further medical treat- ment was resorted to in this case, and he was dis- charged well on the 5th November." The same treatment has been adopted in several APPENDIX. 405 other cases of fever admitted into the Northern Hospi- tal, and with equally good success. In one case, that of Ann Dobbin, one of the hospital nurses, the effect was highly instructive. Attacked with well-marked typhus, she was treated for three or four days on the ordinary routine system, by purgatives, salines, and diaphoretics. Under this treatment, she daily became worse ; the cerebral disturbance, lumbar pains, heat of skin, and thirst, became gradually more intense, the pulse more frequent, the tongue dry and brown, and sordes began to appear about the teeth and lips. Ten grains of quinine were now given every two hours, with the result, after the sixth dose, of arresting all the unfavourable symptoms. The pulse calmed down ; the tongue became moist and clean ; the sordes disappeared ; the heat of skin, thirst, cerebral and lumbar pains, all moderated, and she rapidly improved without any fur- ther medical treatment beyond the administration of a little wine. The following valuable communication from Mr. Eddowes, the highly-intelligent house-surgeon of the Liverpool Fever Hospital, requires no comment : (Copy of Letter from Dr. Dundas to Mr. Eddowes.) "Canning-street, Sept. 13, 1851. " My dear Sir, As I understand from our house- surgeon, Mr. Weaver, that you have lately tested, in the fever cases at the Fever Hospital, the plan of treat- ment which I have recommended in my lectures, and 406 APPENDIX. carried into practice at the Northern Hospital ; and as I am about to submit this important question to the consideration of my professional brethren, I would feel greatly obliged if you would favour me with the results, briefly, of your experience of this plan of treatment in the typhus fever, as it appears in your hospital. I re- main, &c., " ROBEET DUNDAS. "To W. Eddowes, Esq., " House-surgeon, Fever Hospital, Liverpool." (Copy of Mr. Eddowes' Reply to Dr. Dundas.) '^Liverpool Fever Hospital, Sept. 17, 1851. " Dear Sir, I most willingly furnish you, in a brief manner, with the results of the fever cases where I have administered quinine. " I have used it, during seven weeks, in every case of typhus, giving five grains every three hours ; and the success has been most marked. " The day but one after its administration generally finds the patient better ; the petechise gradually fade, and the fever leaves its unhappy victim. " In diet, I give milk, arrow-root, and beef tea; also wine, if necessary. " The superiority of your plan of treatment consists, I believe, in the simple fact, that it either cuts the fever short, or prevents the accession or increase of the more formidable symptoms ; while, in the ordinary treatment, (the medecine expectantej, the physician only interferes APPENDIX. 407 when death is on the point of claiming the sufferer for his own. " The cases in which I have used the quinine have been eruptive typhus not a single case of typhoid fever. " The quinine frequently excites vomiting of a grass- green liquid ; but I do not discontinue it on that account. " If I have been too brief in the foregoing outline, I shall be happy to furnish any further particulars. I remain, &c., " W. EDDOWES. " To Dr. Dundas." I have subsequently had two interviews with Mr. Eddowes at the Fever Hospital, when he kindly per- mitted me to verify the results of the practice by a personal examination of his patients ; at the same time declaring, in emphatic terms, his sense of the importance of my system, and of its vast superiority over all others heretofore resorted to in the treatment of typhus fever. It will be remarked, that the improvement in the patients at the Fever Hospital was generally apparent only on the third day from the commencement of the remedy ; whilst, in my own patients, the improvement is generally established within the first twenty-four hours. Mr. Eddowes, however, it will be observed, did not push the remedy to its full extent. He 408 APPENDIX. administered only five grains every three hours, in- stead of ten grains every two hours, as I have recom- mended ; and this, I believe, will satisfactorily account for the slight difference in the results. He at the same time informed me and allowed me to state the fact that, from the high price of quinine, and the large number of patients in hospital, he was induced, by motives of economy alone, to try first the effect of the smaller doses. As regards the question of economy, very properly adverted to by Mr. Eddowes as a public officer, I am satisfied that if the plan of treatment in typhus, now laid before the profession, be adopted by public institutions, its superiority to all those systems hitherto practised will be at once manifested ; and not alone in the economy to human life and suffering, but what is scarcely less esteemed in this economical age by the vast pecuniary gain to the public, from the rapidity and certainty with which typhus may be arrested CUBED, malgre Pitcairn and the patient thus restored to his ordinary occupation, ceasing to be a burden on the funds of the community. Yet, we are told, on high authority, that " in the continued fevers of this country, we believe it (bark) might with great safety be erased from the list of remedies altogether."* Another author of acknow- ledged eminence, Dr. Pereira, in his standard work on Materia Medica, lays down that, in febrile conditions of Edinbwryh Medical and SurgicalJournal, vol. xv., p. 595. APPENDIX. 409 the system, attended with a hot and dry skin, and a furred and dry tongue, tonics act as local irritants and stimulants, and add to the severity of all the morbid symptoms," p. 208 ; and he illustrates his doctrine by the action of disulphate of quina in fever ! Whilst Dr. Tweedie* states, " We hold its exhibition (quinine) in the early stages of fever, wider any circumstances, improper, as tending, by its stimulant powers, to keep up or increase the febrile action in the system ; and when there is local complication, it is evidently so pernicious that scarcely any practitioner can be so ignorant of the common principles on which the treat- ment of fever should be conducted, as to think for one moment of its administration under such circumstances." Again, Dr. Watson, deservedly one of the highest (as well as the most recent) authorities in medicine, adopts, in its fullest extent, the well-known maxim of Pitcairn, " You may guide a fever ; you cannot cure it." When these high-vouched theories are measured by the facts which I have just stated, all of which have also been observed by others, I feel convinced that, however distinguished the names which have sanctioned these doctrines, they will be found to be utterly unfounded. So fatal, indeed, are they, that, when we take into account the extent and mortality of fever in all its forms, in every clime, and in every class, I question whether their application to the actual treat- * Cyclopcedia of Practical Medicine, vol. ii., p. 211. T 410 APPENDIX. ment of human disease will not outweigh, in danger to health and life, all the advantages to he derived from the more enlightened views of modern medicine. The cases which I have related, even if they stood alone, which they do not, would afford cogent evidence, not only in support of the treatment adopted, hut of the truth of the doctrine on which such treatment is founded, viz., the essential identity of the typhus of this country with the intermittent and remittent of the tropics, modified hy climate and numerous other influ- ences. In fact, I believe that the history of fever must, and will ere long, be rewritten. The power of quinine in controlling the remittent and intermittent fever, (and the yellow fever also, as stated by Dr. Blair), is now a well-established and important fact ; although I totally dissent from the received doctrine of its specific action on the several specific poisons which originate these fevers. Moreover, I have demonstrated, that, in sufficient doses, it dis- plays an equal power in subduing the supposed animal poison of the typhus fever. The action of quinine is clearly not that of a tonic, in the ordinary sense of the word ; its action is obvi- ously on the nervous power, whose functions it favour- ably and rapidly modifies, when depressed or exhausted by any of the numerous moral or physical agencies which act in causing fever, and thus it restores to the organic nervous system its normal influence over the animal fluids and vital phenomena. Hence the curative APPENDIX. 411 powers of quinine in fever, and in many other appa- rently dissimilar maladies. Liverpool, Tuesday, 30th Sept. On my return from London last night, I found a letter from Dr. Goolden, the talented physician of St. Thomas's Hospital, indicating the highly favourable results in his experience of the curative powers of quinine, as laid down above. He has kindly promised me a detail of facts, and I greatly regret that the time agreed on for forwarding this communication will not allow me at present to avail myself of them. In my work now passing through the press, I have entered more fully on the subject of fever, and I gladly seize this early opportunity of expressing my obligations to Dr. Leslie, now of Rio, and for many years my house- surgeon at the Bahia Hospital, for numerous valuable suggestions on the present and other medical questions. Since the publication of the above, my attention has been directed to a valuable report on the fevers of New Orleans, by Dr. E. D. Fenner,* who points out the efficacy of large doses of quinine in cutting short the yellow fever. Dr. F. observes, " The sedative powers of large doses of quinine, given during the early exacer- bation of our summer and autumnal fevers remittent, bilious, and yellow have been proclaimed by some of * Edinburgh Medical and Sut^gical Journal for October, 1851. 412 APPENDIX. the physicians of this city, by the army surgeons, &c. We perceive that these views are gradually extending to the north but it will require some time to prepare the minds of our northern brethren for such a revolution in therapeutics, as they must effect when established Quinine is given in five or ten- grain doses by a number of physicians in this city ; this is a great improvement but they will go farther after a while. ....... We saw twenty grains given at the Charity Hospital .... in the early stages of yellow fever." The London Journal of Medicine observes on the foregoing, " The experience of Dr. Fenner certainly gives additional strength to the im portant practical doctrine which Dr. Dundas has brought before the profession." P. 1142, No. xxxvi. ON THE ARREST OF TYPHUS FEVER BY CINCHONIZM. By ROBERT DUNDAS, M.D., Physician to the Northern Hospital, Liverpool ; formerly Surgeon to H.M. 60th Regiment ; and late Medical Superintendent of the British Hospital, Bahia. (Published in the "London Journal of Medicine") IN the Medical Times, I recently endeavoured to impress my professional brethren with the evidence in favour of the efficacy of large and repeated doses of quinine, in arresting the course of typhus fever. My observations have called forth several valuable com- APPENDIX. 413 munications from different correspondents ; to many of whom I have not the honour of being personally known. Some have fully admitted the soundness and the importance of the principles which I have laid down ; others demand more extended statistical proof ; and a third class state, that the quinine treatment had, in their experience, failed, in several instances, to arrest the disease. Such are the chief points in the corre- spondence with which I have been favoured. Instead of replying to each inquirer individually, I am anxious to be allowed to make the present explana- tory communication to the London Journal of Medicine, as an answer to all. I have reason to think that my observations on the specific powers of quinine in typhus fever have been to some extent misapprehended. I do not believe, nor have I ever asserted, that large and repeated doses of quinine will always cure or arrest typhus fever. I have stated the contrary. And I now ask Will quinine always arrest ague ? will calomel always sali- vate ? or will opium always induce sleep ? Assuredly they will not. Yet notwithstanding exceptional cases, who will question the general not universal specific action of these agents ? If we take, as an illustration of the failure of quinine in typhus, some unhappy patient from the noisome and unhealthy courts or cellars of a large city his constitution broken down by intemperance, by "poverty, sorrow, and dirt" what remedy, or what treatment, can snatch, with certainty, 414 APPENDIX. that wretched being from the grave ? What I say, and what experience will I believe confirm, is, not that quinine will certainly cure such cases as the above : no, nor those in whom, from a fatal trifling with worse than useless remedies, the vital fluids have already become irrecoverably vitiated, or some vital organ already irrecoverably damaged ; but I do distinctly state, that quinine will, generally, cure every case of typhus fever curable by medicine, including a large number of those who would sink under any other form of treatment. I say that quinine, administered as I have directed, will, in the vast majority of cases, stay or avert the symptoms that threaten life, will, in the forcible words of Mr. Eddowes, as proved at the Liver- pool Fever Hospital, " either cut the fever short, or prevent the accession or increase of the more formidable symptoms" And such also are the results in the hands of Dr. Goolden, the experienced physician of St. Thomas's Hospital ; of the practice at the Liverpool Northern Hos- pital; and in the private practice of myself and others. The dogma so tersely laid down by Pitcairn, and adopted, probably, more from its antithesis than its truth, that " you may guide a fever you cannot cure it" was obviously based on the hypothesis, that fever originates in a specific poison, and must consequently run a specific course. What wonder, then, that the efforts founded on such premises should have so satis- factorily issued in proving the incurability of the disease ? The prophecy ensured its own fulfilment ! APPENDIX. 415 Strange, too, that this generally received maxim, so far from being true, ought in fact to be precisely reversed ; namely, that you " may cure, but cannot guide a fever." No human agency can guide a fever : some of the symp- toms may Indeed be moderated, and death from certain complications may be averted; but the course of the disease will ever be fraught with danger, particularly if it be long continued, or if any system or any vital organ be predisposed, accidentally or hereditarily, to morbid action. Herein lies the chief danger in fever. The methods of treatment if, indeed, some of them deserve this name have been legion, and of every degree of activity. Irish patients, in their cabins, have been abandoned to cold water: distinguished physi- cians have, under other circumstances, deliberately adopted and practised the expectant method ; while the more heroic and imposing measures of bleeding, brandy, or mercury, have been pursued in clinical hospitals, or in the mansions of the rich. Typhus patients have recovered under each of these modes; but this fact only points out more strikingly the tenacity of life under the most disadvantageous cir- cumstances. As regards the demand for more extended evidence, and more numerous cases, I must at once confess, that, having observed how all new theories and modes of practice from Hippocrates, the father of rational medicine, down to the visionary Hahnemann have been ushered into life by a vast parade of successful 416 APPENDIX. cases, I have long regarded this kind of evidence with suspicion, and have avoided it on the present occasion, under the impression that many others might feel as I do. Moreover, when, as in the present instance, any principle admits of ready and conclusive proof, the cumbrous accumulation of cases is a downright im- position on the time and patience of the profession, supposing, which I much doubt, that they would be read. Is your principle sound ? one apposite case affords the illustration. Is it false? a thousand will not establish its truth. Let it be tested. Perhaps I may be allowed, in imitation of a celebrated northern surgeon, to introduce one other, though somewhat an unusual medical witness. An hospital nurse, E. McCartney, had been so employed for thirty years, and to her was entrusted the administration of the quinine to the patients in the Fever Hospital. Whilst I was discussing in the ward, with Dr. Gee and Mr. Eddowes, the relative results of the treatment, this woman voluntarily observed to us, " I don't know, but the patients that take the powders (the quinine) get well the fastest. I never saw the patients get well so fast before." So much for a " nurse's tale." Influenced by the considerations above stated, I have introduced only one case on my own authority ; and in that the notes were taken, and the treatment carried out, not by myself, but by Mr. C. J. Evans, then house-surgeon to the hospital, and now apothecary to the Liverpool Infirmary a, gentleman whose com- APPENDIX. 417 petency few will question. I may be allowed to add, that all the witnesses whom I am about to cite were equally impartial, and thoroughly competent observers. I shall now submit the valuable evidence of Dr. Goolden, who has also touched on some practical points, to which I shall afterwards briefly advert. In answer to my letter, requesting him to communicate to me the result of his experience of the quinine treatment in typhus fever, he replies : " I have only to state, that it is so satisfactory, that I should not feel myself justified in treating any serious case of typhus without it. Of eight cases admitted under my care in St. Thomas's in one week five adults and three children all with the characteristics of typhus gravior, with one exception, the effect was well marked. Each dose of quinine produced a sensible effect; ten grains in solution, every two hours, to an adult, produced some giddiness and deafness in about thirty- six hours, when it was discontinued ; and it was only necessary to give a few doses of nitre and a slight aperient, and nothing remained of the fever but slight debility debility varied according to the previous duration of the disease. In one case in the hospital, there was so much headache and excitement after each dose, that after the third time it was discontinued, but there was no permanent ill effect ; and I am satisfied the course is quite safe to adopt. " I have met with several opportunities of trying it in private practice. 418 APPENDIX. " In one case, a young gentleman had been travelling with his tutor in Germany, and, when at Giessen, was observed to be out of health ; he had loss of appetite, shivering, debility, thirst, and feverish nights. Still, he was able to make the journey home. When at home, he was attacked with severe typhoid symptoms, and I visited him with his medical attendant. I found him with a black dry tongue, hot dry skin, petechitz, pulse 140 and full, delirium, deafness, and diarrhoea. He had been in this state several days, when I sug- gested the large doses of quinine. After an emetic, he took eight grains every two hours. I saw him after the fourth dose, and found him sensible, but rather deaf, the skin bathed in perspiration, pulse sunk down to SO, and the diarrhoea checked. The medjcine was continued during the night, and discontinued the next morning, as the surgeon in attendance had had no experience in the quinine treatment, and did not like to carry it on upon his own responsibility. I saw him two days after- wards, and found that he had had no sleep, and the diarrhoea was returning. He took some opium, and repeated the quinine in smaller doses. After a good sleep he awoke much better, and was apparently going on well, when after some days I was sent for, in con- sequence of a congested state of the left lung, and slight cough. The apex of that lung was quite dull on percussion ; no respiratory movement was observed on that side, and bronchophony was distinct, and much large moist crepitation, which made me fear the result, APPENDIX. 419 as his mother was the only one of a large family who had not died of consumption. A blister was applied under the clavicle, and he was ordered port wine and nutritious food ; and I am happy to say that he is now quite recovered, and the lung perfectly sound. I do not attribute the congested lung to the quinne, but to the fever; but I should be wrong to omit it in making a report. " I requested the opinion of Mr. Hine, who has the care of the servants of the Great Western Railway at Swindon, including 2,000 families of artizans, &c., among whom typhus is prevalent, perhaps from want of drainage in the new town, and his report to me was, that for some time the result was most satisfactory ; but latterly he had found that the head symptoms had prevented his using it. He thought that there had been some change in the type of the fever. " The only drawback that I see to the use of the large doses of quinine, is the necessity for frequently visiting the patients, say several times a-day, which is almost impossible in country practice, and very difficult in town when one is much occupied; and patients may consider such frequent visits to arise from the nimia diligentia medici, when the danger is over, and perhaps hardly apparent." The above statement needs little comment. Of the eight hospital cases of typhus gravior, the treatment was conclusively satisfactory in seven ; the exceptional was also valuable, as proving the perfect safety 420 APPENDIX. of the remedy in those individuals where some peculiar- condition or idiosyncrasy interferes with its curative power. In one case, Dr. Goolden pushed the remedy, not only with perfect safety, but with entire success, beyond what I have ever done, or found necessary; and this fact is very important. The case of the private patient is highly instruc- tive, as proving, beyond all rational doubt, the specific power of quinine in arresting, within the short period of eight hours, the most formidable and alarming symptoms incident to typhus fever : and it is espe- cially important in another sense, had the fever been prolonged, considering the patient's constitutional tendency, fatal disease of the lungs was inevitable. No other form of treatment, I firmly believe, could have saved this youth's life. Though deficient in the necessary details, the report of Mr. Hine will fix attention ; and I trust that this gentleman, as well as others, who enjoy such extensive and favourable opportunities for observation, will favour the profession with the results of their future experience. I must not pass over the " only drawback" urged by Dr. Goolden against the quinine treatment of typhus and its practical difficulty is indisputable namely, the necessity for frequently visiting the patient. To ensure success, he should, undoubtedly, be frequently seen, whilst the large doses are being administered ; and this, as Dr. Goolden observes, is almost impossible in coun- try practice, and very inconvenient to the well-employed APPENDIX. 421 town physician. This difficulty, however, affects in no degree the intrinsic value of the quinine system, or the rationality and truth of the theory on which it is based. At the same time, it must be admitted, that the efficacy of this method of treatment cannot be fairly and fully tried, unless the practitioner, or some compe- tent substitute, exercise a frequent, even though an inconvenient, supervision. Neither in my own experience, nor in that of others, so far as I am aware, have the large doses of quinine caused congestion of any important organ. On the contrary, by cutting short, or moderating the febrile excitement, they prevent all such congestions, and in this consists the great value of the treatment ; seeing that the vast majority of fever cases are carried off by these local affections. In the event of any important organ being involved, I have, with great advantage, resorted to extensive dry cupping, either alone, or followed by a blister, or a large mustard poultice, fre- quently repeated. When the first large doses of quinine have failed to produce their usual curative effect, and the practitioner is obliged to discontinue them, an emetic ought to be administered, as formerly pointed out; and if, after this, the febrile excitement still continue, a full dose of the liquor opii sedativus, with a few drops of nitric acid, will frequently afford the most signal relief, and enable the patient to resume the quinine with every prospect of success. 422 APPENDIX. I would here observe, that the large doses of quinine are not only safe, but advantageous in every stage, and in every form of typhus fever, and that the action assigned to it by Dr. Pereira and others is altogether erroneous. The presence of intense headache, quick and strong pulse, dry and burning skin, dry, chapped, and black tongue, intense thirst, hurried respiration, abdominal tenderness, and diarrhoea, do not centra- indicate its use. On the contrary, under large and repeated doses, the headache will subside, the pulse calm down, the breathing become less frequent, per- spiration will return, the tongue will become moist, and the diarrhoea will be checked.* After the first decided impression has been made on the disease by the quinine, it is invariably necessary to support the patient's strength by good beef-tea, and a moderate allowance of wine. Purgatives, without some decided necessity, should be avoided. When the head continues much involved, a strong capsicum enema a drachm of the powder to ten ounces of water will often afford relief. The minor adjuvants in fever may also occasionally be resorted to with comfort and advan- In these observations I have confined myself to the exposition of general principles, and altogether avoided cases, as I entirely concur with that eminent physician, * For obvious reasons, the power of quinine in arresting typhus fever will be more strikingly displayed in private patients, than in the general run of hospital patients. APPENDIX. 423 Dr. William Stokes, whose Lectures on Fever are unexcelled in the English or any other language, " that you might as well expect to find two human beings exactly alike, as to find two cases of fever perfectly similar :" the varieties are infinite. I may here state, that I have repeatedly witnessed in Brazil, seasons of ague (for the disease prevails in seasons), when quinine, though always curative, appeared less efficient in controlling the disease than at others ; and similar modifications will doubtless occa- sionally occur in the fever of this country. Modifica- tions in the quinine treatment, and probably very important ones, will also, I am satisfied, be introduced through the more extended experience of the profession, though I believe the principle will be only confirmed by being tried and tested by different observers. I shall now briefly repeat the principles I have here, and elsewhere, laid down. The evidence on which I adopted them is embodied in my Sketches of Brazil, now in the press, and which in a short time will be laid before the profession. 1. Ague and remittent fever do not originate in malaria or marsh miasm. The doctrine of a special marsh poison I hope to show to be alto- gether unfounded. 2. Intermittent, remittent, and continued fever, are mere varieties of the same disease. The inter- mittent constantly merges into the remittent or continued type ; and continued fever assumes 424 APPENDIX. still more frequently (in Brazil) the intermittent form ; and all are curable by the same agents. By the same agents we can arrest them all. Could this be done if they originated in different specific poisons? or can we ever arrest, by any power, the course of a truly specific disease, as small-pox, &c. ? 3. The notion of typhus fever being unknown in the tropics, is altogether ill-founded. The intermit- tent, remittent, and continued fevers of tropical climates often run into genuine typhus. In Brazil, when the disease takes this course, it is popularly termed " maligna," or " malina," and, in some seasons, is very frequent and very fatal. 4. Bark, duly administered, will generally arrest the intermittent and remittent fever; and typhus fever being essentially the same disease, bark ought to, and will, generally arrest it. 5. Ague will occasionally resist, for many days, the most judicious application of quinine and fin- ally yield : the same remark applies to typhus. 6. Quinine is more certain in its results in propor- tion to its early administration ; but it is less to be depended on with the aged. 7. The administration of large doses of quinine in typhus, when not curative, is never followed by the slightest ill effects. 8. As typhus is, commonly, the more severe form of fever, and the subjects of its attack generally APPENDIX. 425 less favourably disposed, so we shall find con- siderable discrepancy in the several results. 9. Typhus will occasionally resist quinine, and yield to other remedies, and the same holds good with ague ; yet who ever associates the latter disease with any other remedy than quinine? And I am firmly of opinion, that the time approaches when the treatment of typhus fever, after ages of vacillation, will be established on the same sure and satisfactory basis as that on which the treatment of ague now rests. Mr. Eddowes continues to adopt the quinine treat- ment universally with the patients in his section of the Fever Hospital ; and Dr. Gee, in his wards of the same establishment, is now giving it a trial. From two such able observers, in such an extensive field, we cannot fail to obtain valuable and correct information. Since the above was written, my attention has been called to an interesting report, in the last number of the Medical Gazette, by Dr. Humble, on fever, as it appeared during the last year, in the Newcastle Fever Hospital. The symptoms, indeed, are pretty much those which commonly characterise the fevers of this country; and I notice the report, chiefly, from the "relapsing" type assigned to the disease.* After alluding to the different periods at which the * Upon Relapsing Fever, so well described, in 1843, by Dr. Cormack, and more recently by Dr. Fenner and others, I have made some remarks in my forthcoming volume. 426 APPENDIX. " relapse" occurred, Dr. H. goes on to state : " In general, this came on after convalescence had com- menced, and it did so in spite of any precaution which could be devised against it. ... A boy became conva- lescent, and -was ordered to keep his bed until the usual period of relapse had passed over. This was accom- plished with considerable difficulty, as he felt himself perfectly well ; but on the evening of the fifteenth day, the relapse, or, as it might be called, the second attack, of fever came on." Alluding to the class of patients, Dr. H. states: "A large importation of Irish were huddled together in great numbers, in a few lodging- houses, situated in the lower parts of the town In one family, fever seemed to have been occasioned, or at any rate aggravated, by the want of the common necessaries of life .... two of the children presented all the symptoms described as belonging to the famine fever of Ireland. Four cases, after presenting the usual symptoms of continued fever for several days, took on the character of regular ague; in one after twelve days, where the type was tertian ; and in three, after ten days, in which it was quotidian," precisely as continued fevers often terminate in Brazil and other southern countries. What, I ask, would large doses of quinine have done in these Newcastle fevers ? But the word " relapse" unhappily presents itself, and all reasoning ceases. Speaking of fever, generally, that most accurate of observers, Dr. Stokes, writes : " We seldom meet with APPENDIX. 427 a case of typhus without morning remissions ; and in some cases the symptoms are aggravated on alternate days, so as to bear some resemblance to double tertian." I have already stated what large doses of quinine would effect in these cases. I now subjoin a letter from Mr. A. B. Steele, late surgeon to the Liverpool Fever Hospital, and medical superintendent of Irish Quarantine and Fever Ships in the Mersey. I had learned, at the hospital, that Mr. Steele had tested the quinine treatment in typhus, and was anxious to obtain the opinion of an authority so competent to decide on its merits. This opinion was kindly and promptly given as follows : "49 Kussell-street, 24th Oct., 1851. " Dear Sir, At your request, I have much pleasure in furnishing the following brief notes of my experience in the treatment of continued fever with large doses of quinine, as recommended by you, and of which I was only informed a few days ago. " The first case was an Irishman, named Lawrence Connor, aged 40, living in 4 Court, Grosvenor-street, one of the very worst streets in Liverpool, and scarcely ever free from fever. I visited him here on Saturday the 18th instant, and found him labouring under the usual symptoms of the low type of continued fever; had been ill seven days; was lying on straw in a corner of the floor, destitute of all comforts, or even necessaries. " I gave an order for his removal to the Fever Hos- 428 APPENDIX. pital, but he did not go. On Monday the 20th, I was again called to him. He was now so much prostrated, that I should have considered it hazardous to remove him. There was great nervous and muscular debility ; skin hot and dry; suffusion of conjunctivas; pulse small and frequent; tongue protruded with difficulty, very dry and brown ; delirious, especially at night ; can scarcely answer questions. I ordered one drachm of disulphate of quinine in six powders, one to be taken every two hours. " On the 21st, I found the patient considerably better. The skin was moist ; pulse softer, fuller, and less frequent ; tongue readily protruded, moist, and whitish; the brown fur had quite disappeared; deli- rium stated to be quite removed; expresses himself better. The quinine in ten-grain doses was ordered to be continued, and wine and beef-tea to be given. These directions were not properly carried out during the following days, and a partial relapse has been the result ; the tongue becoming rather dry and brown ; the pro- stration returning ; but still the patient is now (25th) in a far more favourable condition than he was anterior to the administration of the quinine. " The second case, a woman named Galagher, 14 Collingwood-street, had been labouring under fever for several days. On the 20th, I found her in a state of great prostration, with well marked symptoms of low fever, with, I believe, pleuritic complication. The con- dition of the patient did not admit of auscultation, or a APPENDIX. 429 minute examination. General symptoms very similar to the first case. I ordered quinine in ten-grain doses, and a blister to the chest. The next day she expressed herself much better ; the symptoms had evidently given way. The quinine was continued, and she is now in a fair way of recovery. " 1 have tried the plan in a third case of low con- tinued fever, with dry brown tongue, &c. ; but un- fortunately, from the first, the medicine was not given regularly, or in the quantities ordered ; still, what would be considered a large quantity of quinine was taken, and with a decidedly beneficial effect, although not to the same extent as in the other two cases. " In the first case, the decided effect on the objective symptoms of the disease, in twenty-four hours, was so striking as at once to convince me of the value and importance of the remedy ; and this improved condition was produced without the collateral advantages of ventilation, cleanliness, nursing, nutritious diet, or stimulants, a fact which greatly enhances the value of this mode of treatment, in the hands of those who, unhappily, have to contend with the disease under the most unfavourable circumstances. " I have witnessed the results of various methods of treating fever, in several hundreds of cases, during the epidemic of 1847, in our Fever Hospital, and on board the Fever Ships in the Mersey, and subsequently in the town ; but I have never found any remedy, or remedies, which appeared to me to cut short the 430 APPENDIX. disease, or modify the symptoms, in the same decided manner in which the quinine has done, when fairly tried. " I hope shortly to be able to give you reports of more cases, as I shall continue to adopt your system, the importance of which cannot, I think, be overrated. " I remain, &c., " A. B. STEELE, " Late Surgeon to the Fever Hospital, Medical Superintendent of the Irish Quarantine and fever Ships in the Mersey." " P.S. I forgot to state, that Lawrence Connor had, by mistake, fifteen grains instead of ten grains of quinine for the first four doses." I have just received the following communication from my accomplished friend, Mr. Eddowes,* which, with his valuable cases, prevents the necessity of my advert- ing (as was otherwise my intention) to the very im- portant question of typhus with complications. By the kindness of Dr. Gee and Mr. Eddowes, I observed these cases whilst under treatment, and to both gen- tlemen I am, for this advantage, very deeply indebted. " Liverpool Fever Hospital, Nov. 8, 1851. "Dear Sir, In reply to your note of yesterday, I beg to state that my opinion of the quinine treatment is unchanged. " In one important practical point, I entirely differ from Dr. Goolden and yourself. I do not consider * The zeal, intelligence, and eminently practical mind of Mr. Eddowes mark him out as one of those men who are destined to advance the profession. APPENDIX. 431 that the quinine treatment requires, for its successful employment, any special supervision. For all practical purposes, one visit daily to the patient has been found sufficient in the hospital, where the ten-grain doses have been given every two hours, for many days, with- out any inconvenience. " I quite agree with Dr. Goolden (judging from the cases under Dr. Gee, and in my own charge), that the treatment appears to be altogether free from danger. " The quinine has been used here in fevers com- plicated with chest affections, &c. I enclose for your satisfaction the notes of two cases, (ex multis aliis), and should you desire any more, you can have them. " I remain, &c. " W. EDDOWES. "To Dr. Dundas." " CASE i. TYPHUS IN AN EPILEPTIC ERYSIPELAS SUPERVENING CONVALESCENCE ON THE FIFTH DAY OF TREATMENT. Richard Lewis, aged 30, a painter, has had colic and wrist-drop; has had epilepsy for seven years, having two fits a-month. The epilepsy occurred a month after the attack of colic. His general health is good. " Present Attack. Has been ill more or less for three weeks, but confined to bed for five days only : he had been under treatment, and had got worse. " October 18. Present State. He complains of deaf- ness and frontal cephalalgia; is propped up in bed, which, he says, eases the great headache. He passes 432 APPENDIX. restless nights; the countenance is flushed; the respi- ration hurried, 32; the pulse 106, jerking and weak; skin hot and dry ; tongue dry, and brown in the centre, moist at the edges : there is tenderness upon firm pres- sure over the hepatic region. He was directed to have ten grains of the disulphate of quinine every two hours ; four ounces of brandy daily; milk diet, beef-tea, and arrowroot. " October 19. He sleeps better; the head is easier than yesterday; is not propped up as before; the breathing is easier; the tongue as before; a dusky erysipelatous flush is appearing on the cheeks and fore- head. He was ordered to continue the remedies, and apply flour to the erysipelas. "October 20. The headache is less, but he spent the night restlessly ; the face is swollen ; the breathing natural; pulse 96; tongue as before. He says that he ' feels quite well, except the soreness of the head and face.' To continue the quinine, &c. " October 21. The deafness is nearly gone; the tongue moist; he was restless at night; headache quite gone; pulse 80, natural; skin cool, covered with a perspiration; the erysipelas is better. The medicines were continued. " October 23. He was convalescent; and was di- rected to take ten grains of quinine three times a-day. " CASE n. PETECHIAL TYPHUS PLEURITIS AND BRONCHITIS CONVALESCENCE ON THE FIFTH DAY OF APPENDIX. 433 TEEATMENT. October 23. Mary Malony, aged 15, of good general health, has been ill five days ; the skin is hot and dry, with petechiae ; she has great thirst ; rest- less nights; slight headache; tongue coated -with a white fur; loss of appetite. The pulse is 100, natural. $> Ipecac, gr. xv., antimon. potass, tart. gr. i., statim sumendus. Postea sumat quinae disulph. gr. v., se- cundis horis. To have milk diet, arrow-root, and beef- tea. " October 14. She is breathing quickly ; the pulse is 120, jerking and weak ; the tongue white at the base; she has pain in the left inferior mammary region. In front, the chest is clear on percussion; there is sibilus on the right side, also on the left, with occa- sional cooing rhonchi. To the left of the cardiac region is a dry friction sound, loudest during expiration. Behind, the left base is resonant, but less so than the right; the respiratory murmur is faint throughout. The friction sound is audible from the supra-spinous fossa to the base ; mucous rhonchi are audible over the whole of the right side. To continue the quina. fy Ung. hydrargyri fort, Jij., pulv. camphors 5ss., p. opii. 5j- M. Saepe lateri sinistro infricandum.* " October 15. The pain in the side is easier; the respiration slower; pulse 118; skin hot; friction sound behind as before ; no increase of dulness ; friction sound n front moister. Continue the quina. * From a formula recommended by Dr. Blakiston. 434 APPENDIX. " October 16. The breathing is easier; the pulse softer and more natural; the countenance improving. " October 17. Pulse 112, soft and natural; the skin moist ; no cough ; no headache ; breathing natural ; petechige fading ; she takes food, and says her tongue is sore. The quinine was continued. "October 18. She is convalescent; the tongue is clear ; the countenance natural ; pulse 84. She says she feels well. The friction sound is still audible. She had no relapse. " There were two other patients in the same ward with the same complication : the above treatment was adopted, and the recovery was as speedy. " Perhaps it may not be uninteresting to you to know, that there have been two cases of typhus occur- ring in pregnant women. The quinine was adminis- tered in the one case five, and the other ten grains every two hours. They both recovered without any ill effects." I have lately conversed with several able men of great experience Dr. Ewing Whittle of the South Dispensary, amongst others who have observed fever on a large scale, and who are of opinion that no re- liance can be placed on the " eruptions," to which many distinguished authors attach so much value, as diagnostic of the different fevers. They consider the character of the eruption as dependent on epidemic constitutions, idiosyncrasy, and atmospheric and other influences. All are aware of the numerous " rashes" APPENDIX. 435 which supervene on derangement of the digestive functions, from the use of certain medicines, articles of diet, &c., in different constitutions, and at different seasons. As regards the rosy lenticular rash, deemed peculiar to typhoid fever, all tropical practitioners must re- peatedly have ohserved these spots in protracted cases of dysentery ; and I have myself witnessed all the erup- tions described by authors as patliognomonic of the several fevers, displayed, in the same patient, at one period or other of his disease. There is now a patient in the Liverpool Fever Hospital, A. B., who presents an abundant " mulberry rash" which quite disappears on pressure. * There is also at the present moment, another patient in the Hospital (James Moore), in whom we have conjoined the mulberry rash, the rosy lenticular rash, and " true erysipelas" the latter classed by Dr. Watson, one of the latest and best authorities, with the contagious exanthemata as " a specific disease, running a definite course, and attended with an eruption." Now, in this instance we have, according to authority, three distinct morbid poisons the typhus, the typhoid, and the erysipelatous contending for mastery in the same unhappy individual, and all running their regular course, unchecked and unmodified in the slightest * This patient died, the rash continuing efiaceable. 436 APPENDIX. degree. Does the history of other morbid poisons pre- sent us with anything analogous ? On the authority, indeed, of Carmichael, a " plurality of venereal poisons" was at one time pretty generally admitted by the profession; but was finally exploded by M. Bicord of Paris, who, on one occasion, exhibited, with a smile, to Mr. Carmichael himself, his four dis- tinctive eruptions classically designed on one and the same patient. This argumentum ad hominem did not, I believe, prove altogether conclusive to Mr. C., but perfectly so to every one else ; and the " plurality of venereal poisons" soon disappeared. All must admit that our lot is cast in revolutionary times. I, however, as a loyal citizen of the republic of medicine, have now discharged my duty in handing over " the quinine system," and the principles on which it is based, for trial before the " legal and con- stituted authorities." Like other arch-revolutionists, the present doctrine is earnest in its promises to "benefit the public:" I have not, however, allowed its justification to rest solely on my own testimony to character naturally open to challenge but have adduced other and unimpeachable evidence, and I now await with confidence the verdict ; for although the profession be a republic, and its de- crees too often tinged by human infirmity, I firmly believe that its final judgments are never wanting in calmness, and justice, and truth. APPENDIX. 437 An incidental interest attaches to the doctrine now advocated, namely, that it will afford an opportunity for testing the value of the infinitesimal doses of homoeo- pathy with doses even larger than those commonly employed by regular physicians. Let an adequate number of fever cases be selected ; place them side by side in the same room; let six be treated on my plan; six infinitesimally ; let competent individuals (not in- cluding myself) be appointed on either side to take the notes, day by day, administer the remedies, and report the results; and on these results I am willing to stake, absolutely, my own professional reputation, and the re- putation of legitimate medicine, so far as that can be staked by such a humble individual as myself. I entertain no doubt that the authorities of the Fever Hospital, or of the Infirmary, the Northern or the Southern Hospitals, or the dispensaries, will readily afford the means of testing by direct comparison, that which I believe, with the rest of the profession, to be a dangerous delusion, but which has obtained sufficient extension to render its refutation an object of public interest. To this " experimentum crucis" no honest homoeopath can object. Canning-street, Liverpool, November, 1851. The following communications, recently received, will be read with interest, as emanating from gentlemen of great professional experience, and all of them enjoy- 438 APPENDIX. ing extensive and especial fields of observation. I may also state that cinchonizra, after careful and extensive trial, is now the established treatment in all forms, and in all complications of typhus fever, at the Liverpool Fever Hospital : Letter from Dr. Gee, Physician to the Liverpool Fever Hospital. " Liverpool Fever Hospital, " December 27th, 1851. " My dear Sir, In reply to your inquiry respecting my opinion of the cinchunizing treatment of fever, I beg to state briefly, that, in the first place, I have uniformly found it to be a safe method, even where there are severe complications, and that no unfavourable symptoms have resulted from its use. I may go far- ther, and speak positively in favour of quinine as ex- erting a decided and beneficial influence on fever this opinion has been based upon daily observations of the effects produced by the remedy in a great number of cases. " I can thus conscientiously and unreservedly speak most favourably of this new plan of treatment intro- duced by yourself to my notice. Mr. Eddowes and myself have recorded the results of our cases, and at some future time may, if spared, be tempted to lay them before the profession. I am, dear Sir, your's very truly, " ROBERT GEE. " To Dr. Dundas." APPENDIX. 439 Letter from Dr. J. F. Stevenson, Physician to the Birkenhead Fever Hospital. " Hamilton Square, Birkenhead, " January 4th, 1852. " Dear Sir, In answer to your note requesting my, opinion on the cinchonizing treatment of typhus fever, which you have lately introduced to the notice of the profession, the brief statement of a few cases will pro- bably afford the most satisfactory reply. " The first two cases in which I tested the treatment were hospital patients, and under almost precisely simi- lar circumstances. Eruptive typhus, and far advanced; face pale and sunken, but occasionally flushed; speech incoherent; hearing dull; delirium, with convulsive startings; great accumulation of black sordes on the lips, teeth, and gums ; tongue dry and brown ; pulse small and very rapid ; urine and faeces passing involun- tarily ; one of the patients had hoemorrhage from the bowels, with great abdominal tenderness. Prognosis. Both patients will sink. " I ordered 12 grains of quinine, with 6 m. tincture opii, in half a glass of wine every three hours, and watched the effect with the greatest care. The treat- ment was continued for sixty hours, when I reduced the dose to three grains every four hours. " On the second day all the symptoms in both patients were improved. On the third day the eruption had disappeared, and at the close of the fourth day, I considered medical treatment no longer necessary, 440 APPENDIX. the patients only requiring support. There was no relapse. " The two next cases presented no eruption, but had all the usual symptoms of low continued fever; skin dry ; tongue brown and parched ; pulse frequent ; slight delirium towards evening, &c. These I treated with ten-grain doses of quinine every four hours, without stimulants. " On the second day every symptom showed im- provement; the tongue moist and less brown, the skin softer and pulse less frequent, &c. On the evening of this day, reduced the dose to four grains, from a dis- agreeable sensation complained of in the head. On the third day this sensation had subsided, and the patients rapidly convalesced, evidently much more rapidly than they would have done under the ordinary routine treatment. " From my experience, the cinchonizing system, in continued fever, undoubtedly shortens the period of the disease; and if this prove to be the fact in other hands, there can be little question that it must become general, and that the ordinary doctrine of allowing a fever to run its course must, ere long, be exploded. I remain, Sir, " J. F. STEVENSON. " To Dr. Dundas, Liverpool." Copy o/Letterfrom Smith Glazelrook,Esq.,to Dr. Dundas. " West Derby, December 28th, 1851. " My dear Sir, In reply to your note requesting to APPENDIX. 441 be informed of the results of my experience of the cin- chonizing system in typhus fever, I beg to inform you, that on reading your publications I resolved to give your treatment a fair trial, though I must confess that I commenced it in hesitation and fear ; you will, how- ever, be glad to hear that its success has far exceeded all that I could have possibly anticipated. " I first tested it in the following case one of ex- treme danger, and in which I had trusted to chloric ether, carbon, ammonise, and liq. opii sedativus. " Mr. W , aged 36, typhus, complicated with delirium tremens, fourteen days in bed, under treat- ment since 9th October. " October 15. Deaf; stupid when spoken to, and answers only yes and no ; low delirium ; extreme ner- vous agitation ; sunk in bed ; singing in the ears, and headache ; skin harsh and dry ; bowels confined ; urine scanty; pulse 130, small, thready, and feeble; tongue dry, brown, cracked, and protruded with difficulty; lips quivered; rapid breathing. He was getting worse from day to day, and I, trusting to chloric ether, opium, and carbonate of ammonia, was waiting for a crisis. Such was the case when I changed my treatment to the following: $> sulph. quinines grs. xxx. divide in doses iiij, quarum capiat unam secunda quaque hora. " October 16. Was surprised at the change visible in the whole man. My anxiety ceased, and I felt a con- fidence in the treatment such as I had never before felt in any medicine. The tongue, the pulse, the skin. 442 APPENDIX. the nervous agitation, and the intelligence, had all improved. " October 17. Reptr. sulph. quininae ut h^ri. Had slept ; skin bathed in perspiration ; tongue moist and white; pulse under 100, breathing natural ; still head- ache and singing in the ears, but less severe ; the tongue, lips, and hands had nearly ceased to tremble. " Four o'clock p.m. Still bathed in perspiration ; con- tinues to improve; continue the quinine. " Ten o'clock p.m. Singing in the ears, and headache increased ; in all other respects continues better. Intr. quininae. beef-tea, &c. "October 18. Convalescent; had a good night; urine abundant ; bowels open ; appearance natural. Noticing that he was dressed and shaved, I asked, ' Who shaved you ? ' To my surprise he replied, ' I did it my- self ; no person would come near me, for fear of the fever.' " From this date my patient improved rapidly; in a few days left his bedroom, and went about and com- mitted great excesses in diet : relapsed, and was nearly as bad as when I first visited him. I prescribed 15 grains of quinine daily, to which the symptoms yielded ; though I now believe, that had I given the larger doses he would have more rapidly improved. No other treat- ment than cinchonizm would, I am satisfied, have saved the patient's life. " I have tried the larger doses in numerous other cases with equally good success. One family, mother APPENDIX. 443 and two daughters, attacked with fever. I shall only notice one, the other two being nearly similar. Miss , aged 34, ten days in bed, uncomplicated typhus. " November 20. Skin hot and dry ; pulse 120 ; tongue dry, brown and cracked, and protruded with great diffi- culty ; no sleep ; no food for ten days. On the third day, after having taken 60 grains of quinine, found her sitting up in bed, brushing her hair, with bright eyes, and laughing. Had slept ; skin moist ; tongue moist ; urine abundant ; bowels open, &c. "After an extensive trial, I am satisfied that the influence of cinchonizm in continued fever is an im- portant discovery. It seems to cut short the disease ; therefore, to lessen danger, to lessen mortality in fact, to remove almost all anxiety for your patient. I have also tried the system with good effect in erysipelas. " In this communication 1 have kept in mind that ' one grain of matter-of-fact is worth one pound of reasoning.' I remain, &c., " SMITH GLAZEBBOOK." Copy of Letter from Charles Lister, Esq., Surgeon to the West Derby Union Fever Hospital. " Fever Hospital, " 17th January, 1852. " My dear Sir, With reference to our conversation of yesterday, I feel great satisfaction, on the ground of humanity, in stating that I have extensively employed in this hospital the * cinchonizing system ' in typhus 444 APPENDIX. fever, which you have lately brought before the profes- sion, and that its vast superiority to all the modes of treatment hitherto employed in fever, in this country, was at once manifest. It effects that which has been hitherto deemed impossible by all medical' authorities ; it arrests the course of continued fever. The impor- tance of this principle will be at once admitted by every one, and therefore needs no comment. " As you have yourself seen several of the cases in my hospital, I shall not trouble you with details ; but should you deem it useful or necessary, I shall have much pleasure in supplying them. I remain, " CHAELES LISTER. " To Dr. Dundas, Canning Street." It may be well to place before the reader, briefly, and in juxta-position with my own, the views of several distinguished physicians on the treatment of continued fever ; and I cite these authorities not alone from their deserved eminence in the profession, but also from the fact that their opinions are almost universally admitted, and acted on in the treatment of fever, by the members of the profession with whom I have come in contact. These views are somewhat quaintly, but very clearly and tersely laid down by Dr. Southwood Smith: " Cold sponging, if the skin be hot ; acidulated drink, if there be thirst ; perfect quiet, a dark room, a silent nurse, affording prompt attendance, with a noiseless step, a cheerful countenance, and no words ; this, APPENDIX. 445 together with three tea-cups' full of thin arrow-root or gruel, in the twenty-four hours, comprises all else that will be required, or that will be useful, until the period of convalescence." Dr. Jenner states, "In no other sense in a large majority of cases at least than that in which we say a surgeon cures a fracture, can we say a physician cures a fever. The latter, like the former, places his patient in favourable circumstances," &c. " A large and well- ventilated apartment, fresh air, a cool, but not cold, atmosphere, quiet, abstinence from solids, and a free supply of cold water and weak broth these are the remedies on which, in a large majority of cases of typhus fever, the judicious practitioner relies for the safety of his patient ;" and such, in substance, are the views laid down by Dr. Watson the whole but a com- mentary on the text of Pitcairn, " You cannot cure a fever." Bleeding and stimulants are, indeed, strongly urged in certain cases ; but having never witnessed a case of typhus fever in which depletion appeared to me indi- cated, or where loss of blood appeared to have really benefitted the patient, I shall not dwell on this mea- sure. As regards stimulants, I have, in exceptional cases, employed them to an extent far beyond that commonly recommended by practitioners. For example, in a case of typhus Thomas Celeer attended with extreme prostration, lately admitted into the Northern Hospital, after the first large doses of quinine, I resorted 446 APPENDIX. first to wine, and then to brandy, of which he took twenty ounces in the twenty-four hours, and to which, I believe, the patient owed his life. My general plan of treatment is to administer, first, an emetic ; then give ten grains of quinine every second hour, until the urgent symptoms subside, or until tinnitus aurium, or deafness, supervene, when the remedy should be stopped. After an interval of about eight hours, give another emetic ; then rest eighteen to twenty-four hours, and recommence the quinine. If there be restlessness, or loss of sleep, give a full dose of liquor opii sedativus, with some drops of nitric acid. Support your patient well, from the very beginning, with strong beef -tea ; avoid slops ; avoid pur- gatives. Wine will often be necessary, and occasionally brandy, especially in hospital practice, immediately after the first impression has been made on the disease by cinchonizm. As regards stimulants, keep also in view the previous habits of your patient. Never bleed, and rarely, or ever cup ; but free dry cupping, followed by a blister, or by repeated large and strong mustard poultices, when a vital organ is involved, will often prove highly important. I believe that much larger doses, than ten grains may be often given with safety and advantage ; and, from his large experience in the Fever Hospital, Mr. Ed- dowes is of opinion-^-in which I fully concur that the supervention of deafness, or tinnitus aurium, does not always indicate a necessity for suspending the remedy. APPENDIX. 447 Cinehonizm has been tried in several cases of erysipelas, at the Northern Hospital, with good effect. It will also control gout. I have lately looked over with attention the cases so carefully observed, and so fully and ably reported, by Dr. Jenner, and I must confess that to me they afford no sufficient evidence to support the doctrine of distinct poisons in the different forms of continued fever. In most of these cases, certain phenomena will strike the most cursory reader namely, the intermissions or remissions, as indicated by the pulse ; the frequent rigors ; the copious perspirations ; the enlarged and softened spleens. Case thirty, and the fatal cases, twenty -three and thirty -three, afford good illustrations. The doctrine that rigors, in the course of continued fever, " invariably indicate" the establishment of acute inflammation, is altogether opposed to my own expe- rience, and case thirty disproves the doctrine. Case thirty-Jive has "typhoid fever," whilst her mother, aunt, brothers, and cousins, are all suffering from " typhus fever." Relapsing fever " the repetition of the rigors daily, for two or three days in succession, appears to approxi- mate certain cases to intermittent fever." What else are they? I am here unwillingly compelled to close my brief allusions to Dr. Jenner's highly interesting and valuable book. One word on the foregoing evidence. Having expe- rienced the extreme, perhaps the allowable, incredulity 448 APPENDIX. with, which, my proposition to arrest the course of typhus fever by cinchonizm was received by the great majority of my professional friends and brethren in Liverpool, I was anxious that the doctrine should come before the general profession, supported by such evidence as might obtain for the new system a prompt and impar- tial hearing. Moreover, as the doctrines advocated were so totally opposed to all the views of fever hitherto entertained by the medical authorities in this, and, I believe, in every other country, I was naturally desirous that the evidence adduced should be not only clear and conclusive, but free from all suspicion of bias. Under this impression, I have abstained from putting forward my own experience, or that of my relative, Dr. Leslie, or that even of my friends and colleagues of the Northern Hospital. I rest the claims of " cinchonizm in continued fever" to the confidence of the profession, on the positive, and necessarily impartial testimony of gentlemen, many of them personally unknown to me or to each other : men of undoubted talent and expe- rience, placed under widely different circumstances, in distant localities, and almost all of them in charge of fever hospitals. I know, moreover, that the majority, like Mr. Glazebrook, commenced the cinchonizing treat- ment "in fear and hesitation." In my efforts to introduce the " quinine system" into practice, though often disheartened, I could not observe without interest the confirmation of a fact noticed in every age namely, the different reception accorded to APPENDIX. 449 new views by the younger and by the more advanced members of all professions. In conclusion, I feel bound to declare my conviction a conviction founded on long, and large, and careful observation that " cinchonizm" will be found to con- trol, generally, the continued fever of this country, in all its forms, and in all its stages, and in all its compli- cations* * The frequently sudden improvement which occurs in typhus, when the disease, instead of death, terminates in recovery, has been noticed by all authors. Often, after a profound sleep, the Patient will awake with a soft skin a moist tongue the pulse moderated the delirium gone the conjunctivas clear improved strength, and some appetite. From a state of extreme peril, he has passed, at once, to convalescence ! Now, the nature and importance of this fact has never yet, I believe, been correctly interpreted by physicians. No accurate observer of continued fever will question the doctrine of crisis and remissions ; and close and careful calculation has satisfied me that these phenomena are as absolutely determined by the law of periodicity, as the best- marked case of tertian or quotidian ague. How often, indeed, is the so-called crisis distinctly ushered in by rigors, reaction, and perspiration, with deposits in the urine, &c. : the final parox- ysm in fact, (sometimes feebly, sometimes fully expressed) of the departing malady. THE END. C. RICHARDS, 100 ST. MARTIN'S LANE RETURN PUBLIC HEALTH LIBRARY 42 Warren Hall 642-2511 LOAN PERIOD 1 ONE MONTH 2 3 4 5 W ON L Nc TVDe nv anu UUHVMI i.vi. sxn ,. 7 ^ All RESERVES and JOURNALS ARE NON-RENEWABLE. All books may be RECALLED. Return to desk from which borrowed. 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